HomeMy WebLinkAbout014-1063-90-000
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ~J C n 'i:t V
ADDRESS UA4_ 6 ~ I
S
SUBDIVISION / CSM# LOT #
SECTION D T N-R_L5' W, Town of rorQ-A;t
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
L ~ a
p O a
L~ ✓
f~ ~~r 4 qb Cr~N~
Ue A*
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of thi'; form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:
ALTERNATE BM: C11 /10 A JEC,~~
EPTIC T / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: C,(~~p , Liquid Capacity: 00
;z5ON o-- j
Setback from.'- Wel]NV Will House Other
Pump: Manufacturer Model# _ Size-
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
i
f Width: l8 Length 6 Number of trenches
Distance & DireScton to nearest prop. line: 750e NaZ
Setback from well: ~House~ Other
ELEVATIONS
Building Sewer ST Inlet: ST outlet:-
PC inlet PC bottom ~ Pump Off Header/Manifold r Bottom of system /,423
Existing Grade Final grade O~
DATE OF INSTALLATION: 9 - 7
PLUMBER ON JOB: LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wiscwsin Department of 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 268698
Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.:
VOELTZ, SCOTT FOREST
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA AQgnnAnl
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
ir Ito ntake ROAD Dt Inlet
TANK TO P/ L WELL BLDG. A
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction Syestem TDH Ft
oss
Forcemain Length Did. II ff Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O CHAMBER Model Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil E] Yes C] No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: FOREST.30.31.15W, SW, SE, HIGHWAY 64
,7" IV Aa
a~"--
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
,Safety and Buildings Division
v~i~'r'■~' SANITARY PERMIT APPLICATION Bureau of Building Water Systems
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 ,
than 8 v2 x 11 inches in size. :!5-
r
ombe
• See reverse side for instructions for completing this application state Sanitar P mit N
The information you provide may be used by other government agency programs ❑ Check if revision to previo47
-
us application
[Privacy Law, s. 15.04 (1) (m)]:
State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Nam Property Location
3
, N, R l~ j E (or W
j .SG~4 1 /4, S 3D T
Property Owner's Mailing Address Lot Number Block Number
12 4 6 'K
City, State Code ___tPhone Number Subdivision Name or CSM Number
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ City Nearest Road
Public '1 or 2 Family Dwelling - No. of bedrooms ❑ vollageOF
Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) O.3! , L41M ]
1 ❑ Apartment/ Condo
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 -ew -_-_2.-❑ Replacement 3, E] Replacement of 4. E] Reconnection of 5. E] Repair of an
------System System Tank Only ___Existing 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
1 ?E3 leepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
1 Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade
Required sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
I CJ 9 , 411-:1 Feet _ !Feet
VII. TANK Capacity
in gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel lass Plastic ANew Existin structed g pp
Tanks Tanks
Septic Tank or Holding Tank
21~ El El El El
El
Lift Pump Tank /Siphon Chamber I -I I 1~ ❑ El 113 1 El 1 1-1
VIII. RESPONSIBILITY STATE-MENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumb is Signature: (No Stam MP/MPRSW No.: Business Phone Number:
Able -
lu tier's Ac[d res (Stree city, to , Z Code): GAG/ / J~IX
IX. C UNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Age t Sign N tam
A roved Surcharge Fee)
pp ❑ Owner Given Initial
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
1. A sanitary permit is valid for two (2) years.
2. Your sanitary perrnit may be renewed before the expiration date, and at a time of rerewrai a iy ie, criteria in the
\Nisconsin 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 'oe 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, 608-266-3815.
V
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.
11. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
Ill. 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, re(onnection, 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 1/2 x 11 inches must be submitted to the county. The plans must
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.
I
PLOT PLAN
PROJECT Scott Voeltz ADDRESS2668 Hwy 64 Emerald Wi 54012
SW 1/4 SE 1/4S 30 /T 31 N/R 15 W TOWN Forest COUNTYST.CROIX
MPRS BYRON BIRD JR. 3318 DATE 10/12/96 BEDROOM 3
CONVENTIONAL IN-GROUND PRESSU E CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE j$QO Gallons LIFT TANK SIZE DOSE TANK S~Z>F
Q'
HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA BED SIZE 18'X
l
BENCHMARK V.R.P.Top of White Stake Red Ribbon ASSUME ELEVATION 100'
❑ BOREHOLE (DWELL *H.R.P. Same as Benchmark
VENT SYSTEM ELEVATION 94.0
12" GRADE
TYPAR COVERING
12" 3' 6' Q 3' 3'0 3'
I SEWER R K
12' 18'
Pro
Bedroom
House
0'
1% Slope
25' T 170' >C 7
760' 200' B-4 60' B-5
2 ' r I
0
B.M.
30' '40'U
20, Rep A B-3 Vent
B-1 B-2
Wisconsin Department of Industry, SOIL AND SITE EVALUATION
Labbr and Human Relations Page of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION - Please print all information. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
GO f7 Govt. Lot 1/43, 1/4,S3~ T N,R E
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
6 6 6
City / State Zip Code Phone Number ❑ City ❑ Village ,IGy\ Town Nearest Road
/7'J rte C D/`;?- ~71 _5V, -7- JIM
New Construction Use: residential / Number of bedrooms Addition to existing building
Replacement Public or commercial - Describe:
Code derived daily flow. gpd Recommended design loading rate! ~bed, gpd/ft2 ' '16 trench, gpd/ft2
Absorption area required bed, ft2 trench, ft2 ,Maximum de i n l ding rate 16 bed, gpd/ft2trench, 9Pd/ft2
Recommended infiltration surface elevation(s) ► (as referred to site plan benchmark)
Additional design/site considerati s
Parent material M414, ) Flood plain elevation, if applicable ft
S = Suitable for system Con entional M and In-Ground Pressure AT-Grade System in Fill Holding Tank
U = Unsuitable for system S ❑ U XS ❑ US ❑ U ,eS ❑ U ❑ S U El S X U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
S~
Ground 10 00,
ft
42v
Depth to
limiting
~c r
✓ Remarks:
w`
Boring # -4
Ground
ft
~ t
Depth to
limiting
fact r
-Mo . Remarks:
CST Name Please Print) a ~Siature Telephone No.
/7/ - 6
Address Date CST Number
6 01 J ~d tc-
l,~ ~r SOIL DESCRIPTION REPORT
PROPERTY OWNER ~ ~r✓ Page of
PARCEL 1.D.#
Boring # Horizon Depth Dominant Color Mottles Structure 2
Texture Consistence Boundary Roots
in. Munselllll Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
O - / I
tom. r J ' >
I/< L2
r5 S r -C
Ground
e' AA* r~ r
o- S ' 4
Depth to
limiting
n.
~c
5' 0)- Remarks:
Boring #
y a
S r
14_ Ground / j 49
Depth to
limiting
21Vy in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # 0~1_ , .
' vn/~' s
Ground -
wuw
e
Depth to
limiting
~-to~y7
~~l n Remarks:
B r,J #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
SBDW-8330 (R. 08/95)
Soil Test Plot Plan
Project Name Scott Voeltz Byr ird Jr.
Address 2668 Hwy. 64
Emerald Wi 54012 6%fM'#3479
Lot Subdivision Date 6/18/96
SW 1 /4 SE 1/4S30 T 31 N/1315 W Township Forest
Boring ()Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of White Stake Red Ribbon
System Elevation 94.0/93.6 * H 13 p Same as Benchmark
x Pro 3
Bedroom
House
rn
1% Slope
25'
760' 200' B-4 60' B-5 hy-d 120 Pri A
30' B-3 40' MB.M.
Rep A 40A -
B-1 60' B-2
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNERBUYER('~,
MAILING ADDRESS 6 GcJ
PROPERTY ADDRESS
(location of septic system) Ple ob in om the Planning Dept.
CITY/STATE
PROPERTY LOCATION 1/4, Section 360, T_,Z/ N-R W
TOWN OFv ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP - , VOLUME AGE , 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 W' consin R.
Certification stating that your septic has been maintained must be completed and returne to t St. oix
County Zoning Officer within 30 days of the three year expira
SIGNED:
DATE: 6
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
_ a `1` C: - 10 0
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_ a
Location of property ~X1/4 r 1/4, Section ,T7/N-R__Z W
Township A0 Mailing address
:5 2
Address of site- a, 6 7O y
Subdivision name Lot no.
Other homes on property? Yeses -No
Previous owner of property
Total size of property 5
Total size of parcel
Date parcel was created Aa-la.lA/J~ I/
Are all corners and lot lines identifiable? Yes No
Is this pro party being developed for (spec house)? Yesx No
Volume ( and Page Number e~" 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. 411/61V7 , 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 ounty Register of Deeds as Document No.
Signature of Appl'cn Co-Applicant
t16 -/C/ 4~
Date of Signature Date of Signature
r 52645 VOL OPAc
WARRANTY DEED
STATE OF WISCONSIN - FORM 2
DOCUMENT NO. REGISTER'S OFFiCE
51 CROIX CO.,'WIj
This indenture, Made this day of Reed for Remd
A.D., 19 96 , between Diamond K Farms, Inc.
a C6rpgr~tioneZ towanized NOV 2 6 1996
and existing under and by virtue of the laws of the State of itmcn,' located at
Emerald Wisconsin, party of the first part, and A P M
Scott A Voeltz and Lisa M. B: Voeltz, husband'
I gester of Deeds
and wife, as survivorship marital property 1Re
part ies of the second part.
Witnesseth, That the said party of the first part, for and in consideration of the
sum of $1.00 and other valuable consideration THIS SPACE RESERVED FOR RECORDING DATA
to it paid by the said parties of the second part, the receipt whereof is hereby NAME AND RETURN ADDRESS
confessed and acknowledged, has given, granted, bargained, sold, remised, released,
aliened, conveyed and confirmed, and by these presents does give, grant, bargain, sell, FIRST NATIONAL BANK OF GLENWOOD
remise, alien, convey, and confirm unto the said part ies of the second part, 204 East Oak Street
h i r heirs and assigns forever, the following described real estate, P.O. BOX =
situated in the County of St. Croix GI@f11N00d City, W
State of Wisconsin, to-wit:
Southwest Quarter of Southeast Quarter (SW1/4 of SE1/4) of Section Thirty (30),
Township Thirty-one (31) North Range Fifteen (15) West, EXCEPT the East 255 feet of
of the West 1038 feet of the South 342 feet thereof.
$ TRONSFER
1 00
FEE-
(IF NECESSARY, CONTINUE DESCRIPTION ON REVERSE SIDE)
Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining; and all the estate,
right, title, interest, claim or demand whatsoever, of the said party of the first part, either in law or equity, either in possession or expectancy of, in
and to the above bargained premises, and their hereditaments and appurtenances.
To have and to hold the said premises as above described with the hereditaments and appurtenances, unto the said part ies of
the second part, and to their heirs and assigns FOREVER.
And the said Diamond K Farms Inc
party of the first part, for itself and its successors, does covenant, grant, bargain and agree to and with the said part ies of the second
part, their heirs and assigns, that at the time of the ensealing and delivery of these presents it is well seized of the premises
above described, as of a good, sure, perfect, absolute and indefeasible estate of inheritance in the law, in fee simple, and that the same are free and
clear from all encumbrances whatever, reserving and excepting, however, all walnut trees now
standing, growing or lying upon said property and subject to the necessary rights of
way incidental and necessary for the removal of the walnut trees located on the property.
and that the above bargained premises in the quiet and peaceable possession of the said part ies_ of the second part, their
heirs, and assigns, against all and every person or persons lawfully claiming the whole or any part thereof, it will forever WARRANT and
DEFEND.
In Witness Whereof, the said Diamond K Farms, Inc
party of the first part, has caused these presents to be signed by Douglas L. Karau
its President, and countersigned by Murten G. Karau , its Secretary,
at Minnesota mmja, and its corporate seal to be hereunto affixed this
day of , A.D. 19 96
SIGNED AND SEALED IN THE PRESENCE OF iamo K F s , Inc.
Corporate Name
President
4 ~ooi,ne_ Douglas L. Karau
COUNTERSIGNED:
Secretarv
rt ws ~r rn
µ
5
CIO t ~ /$3
43
US
00
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