Loading...
HomeMy WebLinkAbout040-1193-40-000 U ~ STC - 10 4 ST CPO* AS BUILT SANITARY SYSTEM REPORT COSY ~Di}/P~EGL ~M ~tSo t~ 4.0 f- 2 OWNER PA4 o -ooo s,•j~2., ADDRESS' f Z ~4,e,~, utEc,J JJ12. . P_ i V-~. ~¢-(•QS l•S 502 Z SUBDIVISION / CSM# CPO('Y P-r06"-S'-- -LOT 2- q SECTION 2-~_T Zk N-R 2-0 W, Town of T1z y ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. ► r c STS ~3.~f - Ty BENCHMARK • 4*D.v C-tz ALTERNATE • BM: T~ p " _ / ~(o Yo , 2 Ta~wkS . CZ) SEPTIC TANKS / cKAMBER fAa, ?60 Manufacturer: `0 • Liquid Capacity: 7pfa.Q Coco p~ . No 4>E/ , o Setback from: Well PX1114C House 12z Other Pump: Manufacturer N//+ Model# Size i Float seperation Gallons/cycle: Alarm Location / 1} SOIL ABSORPTION SYSTEM ' 1 3 Width: ~ Length 63- Number of trenches Distance & Direction to nearest prop. line: 20 'f o P4- RICO Setback from: well: RIO House 30 Other , W ell ELEVATIONS Building Sewer ST Inlet: ST outlet: 21049 ST " 57- " 1040 000 ` PC inlet PC bottom / ump Off Header/ManifoI- Z Bottom of system s~ Pd 2 Existing Grade Final grade pis f D je ?4-L l3 - t DATE OF INSTALLATION: h PLUMBER ON JOB: 'Z0 5 a7 t LICENSE NUMBER: / O;4/Or 330 INSPECTOR: -4-4 to Sv 'j 3/93:jt S ~t)C TOp a~ ID,rJ &Il e 4a4/I /o 6, ' yz 3oltr I,--, q , IG ~q~ 14s-1 , 0 T ID44IJ Sc-,O 12- SEp7ic /3 -rIf / Ulbrlcht 8 AsaocCon NRaa Consultants ~~l r-v1 I I I Cl li I ds n. Wis. 54015 y ~v .yG ' I SS I I I I 31Jv 57 I iq I I I I I I I I ~ U i i ~I I I I C I I I I i I I W sy5 T ~ . ssG~ ~ sysr • 9~Ga : = zp 'fop o~ spy syy~ 53' sC4 Ze IA 77 Pl~~~ cL - GT~ COVC e SPA aV-;e -12I s % • 49/1 yb 3 Wisconsin Dtpartmentof Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284341 Permit Holder's Name: ❑ City ❑ Village Z:I Town o : State Plan ID No.: ANDERSON, DARRELL TROY CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: /mod , /Gr1 I a_s 040-1193-40-000 a-In-e ] TANK INFORMATION ELEVATION DATA X5%7 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic u ) 0 Benchmark Dosing f vm.V3 ~1' Aeration Bldg. Sewerko' ,I-(" ,~'r= Holding St/.lit Inlet TANK SETBACK INFORMATION St/0E Outlet .97 Vent TANK TO P/ L WELL BLDG. Airito ntake ROAD Dt Inlet Ar Septic >$Q~ L 13 NA Dt Bottom Man- Dosing NA HeaderP Aeration NA Dist. Pipe f_J Holding. Bot. System PUMP / SIPHON INFORMATION Final Grade -17 lag -1 S_ Z1 /42. ' C) Man rer Demand X.46 Model Number GPM TDH Lift Friction stem ;T DH Ft Loss Force, ain Length Did. Dist. To Well y, SOIL ABSORPTION SYSTEM BED /TRENCH Width / Length I No. Of Tenches P No. Of Pits Inside Dia. Liquid Depth DIMENSIONS l~ DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHI M acturer: -Mt INFORMATION TypeO r) 30'+ OR UN_ BE Model Nu e_ System ~ln! Emil ~a DISTRIBUTION SYSTEM Header/ Dl6iwi#6kk- , Distribution Pipe(s) x Hole Size x o Air Intake Length e~6 7 Dia. Length _!~iz Dia. Spacing SOIL COVER x Pressure Systems Only xx _9,Gr t-Grade Systems Depth Over Depth Over , , xx De Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed/ Trench Edges Topsoil El Yes ❑ No [I Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY 24.28.20.870.SE, W 212 PLAINVIEW IVE LOT 24 Plan revision required? ❑ Yes 'g"No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. 'AA ADDITIONAL COMMENTS AND SKETCH S SANITARY PERMIT NUMBER: 7~P P . ~ 44- .gas _ n 39~/,Zoo , C~ ~C~o ~c~( J~ ot+ ClCn~ ° 9 , G 5 /o, 7,3 ~1# 3 12- r Safety and Buildings Division ~•i~i•~i i SANITARY PERMIT APPLICATION Bureau of Building Water System: 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O_ Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County CIQO /X than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit '71er 43 The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number / 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION N/*- Propert yy Owner Name Property Location ~4R Q iL AAJ DIEFR$ &,0 5E'114 SW 1/4, S 2 y T 26 , N, R20 E (or (p Property Owner's Mailing dress Lot Number 1Bo D~ Rv R~ Number z Ci,ty,State Zip Code Phone Number Subdivision Name or CSM Number Ki"vE1e SyOZZ ( 7i5 ) 112- 5 s93 1C,1 C R/olrE- I. TYPE OF BUILDING: (check one) ❑ State Owned it v p v Nearest Road Public or 2 Family Dwelling - No. of bedrooms ~ Vown of / P//¢1N 41f4rW PA10- III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo ~7 -//f3 ' y6 • D 6 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church / School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel / Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. ER,~'ew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank OnlyExisting System Existing System B) ❑ A Sanitary Permit was previously issued- Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 210 Mound 30 ❑ Specify Type 410 Holding Tank 12 E eepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill 7~'E.JGI~lS 64G4 X (0 , VI. ABSORPTION SYSTEM INFORMATION: 9Z,20 - gc/ 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7' fi'n'%Grade .7 Re r ddsq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) y/• 30 Elevation a • 9 • ~ 157 ' y0 Feet !`'.3 d Feet VII. TANK Ca in gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin structed Tanks Tanks Septic Tank or Holding Tank ?00 /6 d0 Z tV _4r0❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber Wig ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps) /MPRSW No.: -----]Business Phone Number: 08 9Ri r ?4113 R I•C4r r336-, 7js • 38(0 • ~f tJ~ Plumber's Address (Street, City, State, Zip Code): 9So~ / I w / 6i SS 0'~v IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved sa¢~dry Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) ,~4X., AApproved E] Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS ti. 1. A sanitary permit is valid for two (2) years. << t 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly m'aintainedr~The septic tank(s) must be pumped 'by a Irtensed"pumper vJh¢neve~ necessary, usually, every 2 to 3 years- . ~ A 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the Statizof Wisconsin, Safety and Buildings Division, 608-266,-3815. _ I `Tb be compfete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. ll. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information- Provide all information requested for numbers 1 through 7. VII- Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII- Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only- X. County / Department Use Only- Complete plans and specifications not smaller than 8 1/2x 11 inches must be submitted•to.the county. The plans-m- ast include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks,- distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county;-E) 'soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which'can effect groundwater- The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. CS T'37 ~All, F.0 Tod aF ~i1SC of ,p~~ Cf& 10& Iq rte` 3 -4 T~~~~ 5 ysr= i3L c ' eA) 51' k~-q 44, Aq 7- 96 4 • P~3` 1 S p AC !,v 6- . 1pp IDFO? RC SSOW 0 s 30 o , t~N PAapos~v /U~T~J s~ o lu ;~usT t~E ~ F"/ow To -1irE^oat S ~.o r , nor Lo 7- l y CRO tX R► Sv~31~ . so nor - Fresh Air Inlets And Observation Pipe Approved Vent Cap Minimum 12"Above , 11~ll Final Grade `l Y37-76 it 4 4" 3.2- Above Pipe _ Cost Iron 'to Final Grade Vent Pipe Synthetic Covering min. 2" Aggregavo_ Over Pipe Distribution - Tee pipe 0 0 0 0 tr p * Aggregate 0 Perfbroted Pipe Below Sentoth Pipe o -Coupling Terminating At Bottom Of System Fresh Air Inlets And Observation Pipe rR~~ 4V Approved Vent Cop tf Minimum 12" Above Final Grade Po 30 "Above Pipe 4" Cast Iron - . 1o Final Grade Vent 'Pipe' Synthetic Covering min. 2" Aggregate Over Pipe Distribution - Tee pipe 0 0 0 0 0 Aggregate Beneath Pipe ° PerfOrat'ed Pipe Below o - Coupling Terminating At S'yST' 9--"J1 Bottom Of System f/•30 -Fresh Air Inlets And Observation Pipe-- - Approved Vent Cap t /1 Minimum 12" Above Final Grade DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 53707 HUMAN RELATIONS (ILHR 83.0911) & Chapter 145) LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME: 4. 10W 'e 11~1t't 1er)yt'*'e COUNTY: OWNER'S/BUYER'S NAME: AILING ADDRESS: ©rt 3 o USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Eknesidence EPNew ❑Replace I /rsl9'/ 1~~It RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: JIG TANK:RECOMMENDEDSYSTEM: (optional) ~s❑u as au [es❑u OS RA IJs❑u If Percolation Tests are NOT required D ESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B r ./Z .s ' B- L 71 , 73 's" IM/ S ` B- ? po.9 77 y` ! '6'r "e ' B- > 71 me __j FB- TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PER1001 PERIOD 2 PERIOD PER INCH P_ 2-1-70 3 S %8 P- P- s r* s- .s 1G P- P- 3 N 04 3 Pd - PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. ~je f 9',3..A 1 SYSTEM ELEVATION Pz. w 3 Dr. ;yY. # r - TT OT C K, E X k ti z ' i e i 'R., ~,i S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER YV/P~ ADDRESSl el PleY 2 a,,-- FIRE NUMBER CITY/STATE R Uhl, fs G(' ZIP -s~b~ PROPERTY LOCXTION: SE 1/4 , .S1~)1/4 , SECTION, T LO N-R i0 W TOWN OF_ I-FEZ St. Croix County, SUBDIVISION_ D , LOT NUMBER Zy Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed septic tank pumper. What you put into. the system can affect the function of the septic tank as a treatment stage in the waste disposal system. 'St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix Co. Zoning officer within 30 days of the three year expiration date. SIGNED: ' i2h~r2~?✓ ~v~.G~r~ ' f DATE : __ir~s r►~~ , St. Croix co. Zoning office 911 4th St. Hudson, WI 54016 S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/ contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. owner of property " ^'Ve sex) Location of property s 1/4yw 1/4, Section Tjo N-R .20 W Township 7"edy Mailing address Address of site fQ/7~-fig. e . Subdivision name GieDl')L (~%176"E" Lot no. L~ Other homes on property? Yes No Previous owner of property f%N f Total size of property 2 t i4 GK S Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes No Volume I2-03 and Page Number X72-- as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. S~~d L and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. Signature of Applicant v- Co-Applicant Date of Signatifre Date of Signature VOL 1203Pei-17*7 s 55o 7v II STATE BAR OF WISCONSIN FORM 2 - 1962 WARRANTY DEED F EC DOCUMENT NO. - - - S - a' Vil ~I Martin L. Hanson and Donna T- Hanson, husband alld_ i _ - wife. 'OCT 11 1996 ~I at 9:00 A M I _ erson and Barbara J. ij wit +w _ ~1A, Derrell L. And tal QK conveys and warrants to F Anderson, husband and wife, as survivorship maxi _.a j Property,- THIS - ~ I , i SPACE RESERVED FOR RECORDING DATA - - I' .ICI ''I NAME AND 9ETURN ADDRESS / St. Croix the following described real estate in Stale of Wisconsin: 1193-40-000 PARCEL IDENTIFICATION NUMBER Lot 24, Croixridge in the Town of Troy, St. Croix County, Wisconsin. S a TRANSFER i I C it it This is not homestead property. e (is not) is-of-way of record, if any. Exception to warranties: Easements, restrictions and rim October A.D., 19 96 I 10th day of Dated this y (SEAL) i .•.s~ (SEAL) Ii I)ottna ns Martin L. Hanson (SEAL) (SEAL) 1 • i1 I is ACKNOWLEDGMENT ij AUTHENTICATION I I State of Wisconsin, i ss. Signature(s) jj St. Croix Cut day of i p~aIfy came before me this lot] y authenticated this day of 19- rjctcber . 19-gfi-. the above named t ancnn aryl flnnna -T- Nancnn_ h TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to be the perwho executed the foregoing l authorized by §706.06, Wis. S[atsJ me ac owl e~ht~me. it ...cut weA nRAPTED BY