HomeMy WebLinkAbout042-1098-60-001 (2)
STC -
AS BUILT SANITARY STEM~T
- 1 121-97
OWNER
ADDRESS 4_C~31t0ICE
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SUBDIVISION / CSM# LOT #
SECTION~T Z:LN-R ~LW, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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NON-CONFORMING
TREATMENT TANKS SHALL
n BE ABANDONED PROPERLY
FOR ILHR 83.03(2).
a~
13 AV
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this -form.
Provide 2 dimensions to center of septic tank manholo cover.
/p~ ~F Ct1 EGG C~S~ ~1~r • = /DD-~
BENCHMARK'
7'd19 OF O M0,1-1 4Uti/7iC-_ Tire -41 e4epe a,=
ALTERNATE BM: iv
SEPTIC TANK nHAMB R HO nTN TANK TNyngHATjQX__
Manufacturer: 116, 57 ~d~Gcl7{~- Liquid Capacity:
Setback from: Well 7 Z House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
.:SOIL ABSORPTION SYSTEM
Width: Length Number of trenches
• Distance & Direction to nearest prop. line: 2 3
Setback from: well: 0_0 House Other
e 7 6 1A_1 1, tz ' TD 5P2
~J CT~ ? ELEVATIONS i
~X I,$
0 31
Building Sewer / ST Inlet; ys` `s7 , ST " outlet.
S PC inlet PC bottom Pump Off
Header/Manifold 9a,7l. Bottom of system PF• P-9 ,o
Existing Grade 93. Sd Final grade s3•S•O a Q014.
s~ mk S .
DATE OF INSTALLATION:
PLUMBER ON JOB: A D015e ' 7 7
LICENSE NUMBER: 330
INSPECTOR'
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
Safety and Buildings Division INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary~i§gl o
Personal information you provice may be used for secondary purposes [Privacy La S.15.04 (1)(m)].
KEMHolder' ART Name: & MARY [:41yRRE/lage Town of: State Plan ID No.:
CST BM Elev.: I Insp. BM (10~: BM Descriptio c Parcel T L-1098-60-000
c c(t A;
TANK INFORMATION E EVAT10N DATA A9700500
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ~e K 05D Benchmark if/ C~(o jOl
Dosing 6M k
Aeration Bldg. Sewer
Holding (91* Inlet e-
,55
SETBACK INFORMATION / Ift Outlet 41-7 '992-61
Vent
TANKTO P/L WELL BLDG. A
irito ntake ROAD Dt Inlet
Septic (PO, ~2~l L/S NA Dt Bottom
Dosing NA Header / Mayoloptol-
q
1 oy~o p0&
Aeration NA Dist. Pipe 0"OK 9 41-1
LaW ✓ /0-71/ C16.72--
V r o-Sn ,0
Holding Bot. System Pf r/
n S, 15-
PUMP/ SIPHON INFORMATION Final Grade P '2' s
CoN 7 S 42 &7
Manufacturer Demand M 0 96.91
Model Numbe GPM nlirf v~~~ C42f
TDH Lift Fri Sys m TDH Ft
oss ea
Forcemain Length Dia. H Dist. Well
SOIL ABZRPTION SYSTEM
BED T Width / Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 7 q:~' 2 DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEA RING cturer:
SETBACK
INFORMATION Type O t T CH 0,
Model Num er:
System: Cfinj tW OR UNIT
DISTRIBUTION SYSTEM ki Z~2 q
Header/Manifold Distribution Pipe(s) r x Hole re e x Hole Spacin Vent To Air Intake
Length Dia. Length l0 Dia. Spacing , / o0 -11
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx De f xx Seeded /Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges I T Yes ❑ No ❑ Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: WARREN 35.29.18.545,NW,NW 695 130TH STREET
sf`~10~r two ke5
/n
Plan revision required? ❑ Yes No 1~ ~11~
?
Use other side for additional inform ion. IZ [dLI 1'( F aA*
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SBD-6710 (R.3/97) Date Inspector's Signature
F
ADDITIONAL COMMENTS AND SKETCH -
SANITARY PERMIT NUMBER:
Safety and Buildings Division
`Mscons/11 SANITARY PERMIT APPLICATION 201 E. Washington Ave.
Department of Commerce 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
than 8 112 x 11 inches in size. .5'7( / X
• See reverse side for instructions for completing this application State Sanitary Permit Number
The information you provide may be used by other government agency programs 2019 /9✓
[Privacy Law, s. 15.04 (1) (m)). E] Check if revision to previous application
State Plan 1.0. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION N
Property O[1er Name
~ ` N I
K Q M ~/EA' Property Location
wr` D~ 1 is 1 ia, S ~S TZ N R E o W
Propert Owner's ailing Ad ress Lot Number
3 • Block Number
Ci , State • Zip Code Phone Number Subdivision Name or CSM Number
S~10~ ) 33
II. TYPE F B ILDING: (check one) E] State Owned E] it
Public or 2 Family Dwelling - No. of bedrooms -3- g W-4A v Nearest Road 404 ❑ Vila e
wn OF ~00 J.-iiii
III. BUILDING USE: (If building type is public, check all that apply) Parcel TaxNumbell
1 ❑ Apartment/ Condo 0q.2-/u / 9 ' d
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11
4 E] Church/ School 8 E] Mobile Home Park E] Restaurant Bar/ Dining
12 Service Station/ Car Wash
5 ❑ Hotel/ Motel 9 ❑ Office/ Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check ly one box on line A. Check box on line B, if applicable)
A) 1. ❑ S Sw 2. eplacement 3 ❑ Replacement of 4 Reconnection of
❑ 5. ❑ Repair of an
_y_em SystemTank 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
11E] Se age Bed 21 ❑ Mound 30E] Specify Type 41E] Holding Tank
12 eepage Trench 22E] In-Ground Pressure
13 ❑ Seepage Pit 42 ❑ Pit Privy
14 ❑ System-ln-Fill i~; _46 43 Vault Privy
VI. ABSORPTION SYSTEM INFORMATION: ® 1r d
, 9'3 ,So
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System v. 7. Final Grade
//,07 Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) c Elevation
l/ 1 47117) % 2'~ Feet gill Feet
VI1. TANK Capacity
INFORMATION in gallons Total # of Prefab. Site Fiber- Ex per.
New Existing Gallons Tanks Manufacturer's Name Concrete Con- steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ 11 El ❑ ❑ ❑
Vill. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) umber's Signature: (No Stam
0-T ZtLQI~ p NFP/M3PRSW No.: Busin~es^s Phone Number: /
Plumber's Ac dress (Street, City, State, Zip Code): } 6/`~ •~L~~
SS r (,6 S11 i'S
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permiye (includeswoundwater ate ssue Issuin Agents i nature (No Stamps)
XApproved ❑ Owner Given Initial 0 Surcharge Fee) 1
Adverse Determination NO 0 62` r{' 97 /OQ
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBO-6390 (8.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
7
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
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 maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608-266-3151.
To be complete 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.
II: 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. and VII. Tank information. Fill in the capacity of every ite constructed and tank
material. Complete for aN eptic tpumsp/siphon and
manufacturer's name, indicate prefab o s
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR
VIII. Responsibility statement. Installing plumber isto 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 1/2 11 inches must be submitted to the county. The
to scale or with complete dimensions, location of hold ng t nk(I) sept cst
include the following: A) plot plan, drawn
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
performance curve; ppumppmodeland pump manufacdtu~ertrD) ;caoss set ones
elevation differences; friction loss; pump p
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.
Fresh Air Inlets And Observation Pipe
.r
Approved Vent Cap
Il~~~~ r► Minimum 12"Above
Final Grade '
_ 4" Cost Iron
Above Pips '
1o Final Grade Vent Pipe'
Synthetic Covering
Min. 2" Aggregate
Over Pipe
Distribution - Tee -0. 1 L PIPS 0 0 0 0 0
s Aggregate
~o o Perfbroled Pipe Below
Beneath Pipe 0 -Coupling Terminating At
Bolcom or s.y:tem
Fresh Air Inlets And Observation Pipe
Approved Vent Cap
Minimum 12" Above
Final Grade /y ' Above Pipe _4 Cost Iron
7o Final Grade Vent f1ps'
Synthetic Covering
min. 2" Aggregate
Over Pipe
Distribution - Tee
P1pe 0 0 0 0 0
Ai:4 * Aggregate o Parfbraled Pipe Below
Y' Beneath Pipe 0 - Coupling Terminating At
Bottom Of System
Fresh- Air Inlets And Observation Pipe
Approved Vent Cap
Minimum 12" Above
f#.0_1 Final Grade r r r ~
/30 ok ST.
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION Page of 3
Labor and Human Relations
Division of Safety and Buildings in~ac r a %Mth s. ILHR 83.09, Wis.
f
Attach complete site plan on paper not less than 8 9)1 inches Qwze. ~Plr ^ u County sr. C/e0 x
Include, but not limited to: vertical and horizontal r ce po ction
percent slope, scale or dimensions, north arrow, d lpcation to nea st-r ad. parcel I. D. #
.Wn A- 1, 0
L~~f
0 199
APPLICANT INFORMATION - Please t all inwTAW. ~o. Rev wed b Date
Personal information you provide may be used for second oses (P~~ s. 15.04 ( l
Property Owner -t' 4A I?Vph rty Location Q
dR Lf(fR J • / AR l LYI`-~ vt. Lot Alto 1/4 vtJ 1/4,S s T Z! N,R & E (or W
k I
Property Owner's Mailing Address rTock# Subd. Name or CSM#
City State Zip Code Phone Number Nearest Road v
RDI3~i~'TS Cv. ,S-YO23 (71S) ~yl~•33 7 [:1 city w vne p Town 70 , 130 ST.
❑ Uew Construction Use: Residential / Number of bedrooms 3 Addition toe fisting building
Replacement ❑ Public or commercial -Describe: IV /P = NOTF E~O.~IiyE'N~~1~
Code derived daily flow gpd Recommended design loading rate -Abed, gpd/ft2 ' S trench, gpd/ft2
Absorption area required bed, ft2 q" trench, ft2 Maximum design loading rate bed, gpd/fl2 -.57 trench, gpd/ft2
Recommended infiltration surface elevation(s) 5-4.1- ft (as referred to site plan benchmark)
ZIS~Lo vG- ~'e4 t c9 .P.~ c 5 ~v/ 1~/edp .BOX d/'s'Tit'i%3 v7zo,J
ti
Additional design/site considerations
Parent material -5"c57 6$ s4TTAiF- 16,414Y Flood plain elevation, if applicable N~ ft
S = Suitable for system CConv~entional Mound In-Ground Pressure VGr de System in Fill Holding Tank
U = Unsuitable for system 03 s ❑ U ~ ❑ U ~ ❑ U ❑ u ❑ S ❑>S
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
1o!Z /bY 3/3 L ffshAl Iw►1/r? CS 2-F q s
S1L. Z-Fs he /4q 1Z c s / . s
Ground 3 •q 7.5 AM 74
elev.
Depth to
limiting ;
factor
Remarks:
Boring # 0-7 /DY,e 3l3 L. /7'ASA4 fe eS 2 -f ' . S
z 7 • L /o YR y/3 51Z_ 2-f She A--6e Cs
3 3 161 75-R 1q%Xfut,c o ZIC5 /f IV a -o s •
Ground G S / r►+ Uf . S ; . ~o
elev.
y 3.2z-ft. ~ S-
8r• 2 nil Ile
Depth to
limiting
factor .4A.IZ> ems' I
y f-6-in. Remarks: EaIt:ST>N~ SYST iS iy T ~,4, va.~.~
CST Name (Please Print) Signature Telephone No.
~E oI 'T" Zllhwi~7_ 7!S• 3,?6 • e19S
Address Date CST Number
Aeo . S - 5F 7 25lP2_-
Private Sewage Consultants
PROPERTY OWNER SOIL DESCRIPTION REPORT `
Page 2-. Of ,3 1
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Morales Structure z
in. Munsell Qu. Sz. Cont. Color Texture Consistence Boundary Roots
Gr. Sz. Sh. Bed Trench
/ 0-/0 /o YR 3 /3 L 1-1s ,&4& nM ~2 C'.S' 2 f
2 0 *149 /o y/? Y/ SC. /]'C f 4" 7/e ccv A , S
Ground 3
elev. 7-.5 S/I e yl G' LS /7C /t+r Uf~ G~ s . S '
ft. Ll q: .5
Depth to ,v
limiting
factor ~'v fly U S S
7 m. ,
Remarks:
Boring #
Ground
elev.
ft. ,
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Structure
in. Munsell Qu. Sz. Cont. Color Texture Consistence Boundary Roots GPD/
Gr. Sz. Sh. Bed Trench
Boring #
Ground
elev.
n. ,
Depth to
limiting
factor
in.
Remarks:
Boring #
Ground
elev.
ft. ,
Depth to
limiting
factor
in.
Remarks:
SBDW-8330 (R. 08/95)
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
owNER '
MAILING ADDRESS & ~-s 130 d7/1- s I
sY02
s( PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE C ,Q
PROPERTY LOCATION Nul 1/4, P144, Section T 2l N-R l" W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION 1014- LOT NUMBER
CERTIFIED SURVEY MAP /,///4-, VOLUME LOT NUMBER
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 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
County Zoning Officer within 30 days of the three year expiration date.
SIGNED~
DATE:
St. Croix County Zoning Office
Government Center
'4:101. Carmichael Road
Hudson, WI 54016 11/
8 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
develdpment 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.
-------------------------------------------------~J------
owner of property
Ldcation of property NLG) 1/4it1W 1/4, Section 3 S ,T2 f N-R W
Township 10,410eA-) Mailingaddress
~ t S /3 d d'~ s ~ . iPD.B ~ r~ Gf~/.S . SY o z.3
Address of site
Subdivision name Lot no.
Other homes on property? Yes No
Previous owner of property
'T'otal size of property yU 46►-t-
Tota1 size of parcel R&Lf 7-LfJ~ 44tt S'
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes L--1140
Volume q0 and Page Number ~ 2- 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. L -j!R 177 r , and that I (we) presently
own the proposed site for tie 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.
S i grtattur of Appl ica Co-Apple nt
0
11 --~42.- -
Date of Si.gnattir.e Date of Signatt -e
DOCUMENT NO. l :!n t < r
I VOL 408 PA E382
.
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27817
THIS INDENTURE Made by _ Harold J. Kempf, and Nora ricG{STER,L~ C) 171 ~z-;.
Ce Kempf,-husband and wife, as joint tenants, 5T. CROIX Cry VJ;S.
- Recd for Record ties 6th_
day 64
grantor _s or tCroix_County, nnSK. aereby 7: n-;,ys :ant+, to --Arthur J. Ke at__ .
p 9_--and Marily Kempf ! boo P i;1
, husband /
and..wifeg__as 3Aint__tenants,
RegIsto o De)e.,iti
I
Richard P. Rivard
ratutW S
Couuty, Xisccnsin, for the sum of
One ($100)--
Dollar
and other -valuable--Consideration, Glenwood City, Wis.
the following tract of land i❑ .----$t-.__.Croix County, State oC l-viacon=in;
'I
I~
The West (W 1/2)0 of the North West Quarter (NW 1/4) and the
North West Quarter (NW 1/4) of South west
. Quarter (SW 1/4), Section
l 350 Township 29 North, of Range 18 West.
r
o ,
A Y,
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IN WITNESS WHEREOF, the said grantor Sha _._ve hereunto : et their hand s wid <(-Al s Uu; 4th
day of _ November , A. D., 19 6 4
S 'NED A SEAL ESENCE of 1 e~ . Y ti ¢
Harold(J~., Kempf ~ c
f! / SEAL)
Ri d P. Rivard-___ Nora C. Kempf k~
f
;SE _U,)
> I
I
R y._C_._ 4i ~SIEAL)
j ~
STATE OF WISCONSIN, 1 I~
1 } SS.
-----its-Cr-oi-?C County.
! Personally came before me, this __~itL.__-_____ riay of November _ A. D., 19 64
rho ~hr,- -.A L.T-1 d .T Ye __4. -A TT..- , 0 Tl___, F -A Fo - ~