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HomeMy WebLinkAbout020-1009-40-000 Q ° 3 0 d O E» m v a p' p o C 4) OO O N U ~ N U c c ~ c co i T a a OL p 0(0 v p x O aafin E 0 > N 'a V co L O ~O > N C ` O 3 a) (0 f6 $ p O ~ .r a) E cu O m -0 co 6 z 0) C > C U U. o .5 U a .0 co Q) CL , -p N > N Q U ~ L ~ M 3 z rn w E Z " o d z m o CN Z (L c 2 c t9 p z d c d 'z z c Q) E -a "O 0) 1U.. 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CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Noe,-114 p `f azi tf J/V £ o llEw ~ PQo Po s E~ ~'°~e~Y L,.uF WEST " 3 p 40 ' 7 Sctf cI0 S~wEQ ~ ENE " sJ~P 35 PvC ~fu 4--Aj r 4,,vE INDICATE NORTH ARROW ~c7 S~d1~~ Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank BENCHMARK: os T O!e ccP~loub E~~✓ /t~c~ , cam' ALTERNATE BM: J1,4 SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer:_ • Liquid Capacity: /vow Setback from: Well 7 _ House la?, other Pump: Manufacturer Model#Size Float seperation Gallons/cycle Alarm Location SOIL ABSORPTION SYSTEM Width:- Length ~ Number of trenches v7 Distance & Direction to nearest prop. line: /av' h/ oerr► - wts~ Setback from: well :rO _ House Other ELEVATIONS Building Sewer ST Inlet. ST ST outlet PC inlet PC bottom Pump Off r-- Header/Manifold 16', 1,,7 1-_Vv tBottom of system 9~•~s~ Existing Grade 10e) •,?S" Final grade DATE OF INSTALLATION: PLUMBER ON JOB: ~J LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor andHuman Relations INSPECTION REPORT ST. CROIX • Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 268569 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: JOHNSON, BRIAN & SUSAN HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: ~GU , ~1J 1UJ GIB TANK INFORMATION ELEVATION DATA A9600278 X129 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 3,~ /~e1. L-~) D n-9- Cb 4, , "~T a,5$~ 16,), Aeration Bldg. Sewer Holding St/Ht Inlet TA ETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosi pg- NA Header -7,7, / SS Aerati NA Dist. Pipe 37' 7,20 olding Bot. System { PUMP/ SIPHON INFORMATION -F+' I'Grade Manuf Demand ps!' Model Number PM TDH Lift Friction System TDH Ft Loss Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width 7 Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEA Ma cturer. SETBACK Mode Number: r /,4- OR UNIT DISTRIBUTION INFORMATION Type 0 ~ h , System: CQgs r~S d `JPQ CHAMB SYSTEM Header / KUv%daUr V Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length --112 Dia. Length 6,-3 Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Gr Systems Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed/ Trench Center Bed /Trench Edges Topsoi - ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON.10.29.~19W, NE, /NE, ZEPHYR LANE -XiGQ C'JO- r'r Gv Z~l Plan revision required? ❑ Yes to Use other side for additional information. o- SBD-6710(R 05/91) Date Inspector's Signat re Cert. No. ADDITIONAL COMMENTS AND SKETCH , SANITARY PERMIT NUMBER: _DILHR SANITARY PERMIT APPLICATION N In accord with ILHR 83.05, Wis. Adm. Code Co rN STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 0?10g9(0 I 8% x 11 inches in size. 1:1 Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION 6r~an 4 SlknZy) _'S6VV1S0Y1 NE '/4 NE t/4, S 10 Tag , N, R Iq E (or W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # GS-6 ze_h r Lane- L4 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER, u„G~SOr1 ~ l.J~ 5401Co f~c..~rl~lno,rd-}- ar1 -171 11. TYPE OF BUILDING: Check one CITY NEAREST ROAD ja 4QWN OF: -1 ( ) State Owned VILLAGE : -8s nv 1 Ze. r Lav)P- ❑ Public ®1 or 2 Fam. Dwelling-# of bedrooms 3 PARCEL TAX NUMBER( S) III. BUILDING USE: (If building type is public, check all that apply) 0x10 - I oo9- Lic 1 ❑ Apt/Condo 20 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 80 Mobile Home Park 120 Service Station/Car Wash 50 Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ® New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # _ Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ® Seepage Trench 22 ❑ In-Ground 420 Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION L-I SO coy 3 sq. IF--t Aso sq. F'-+. .7 - q5. a5 Feet q$ • 75 Feet CAPACITY VII. TANK Site in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New xistin Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Holdin Tank 1000 IoQC~ I BSc r Lift Pump Tank/Si hon Chamber Vlll. 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 Sign ure: (No Stamps) MP/MPRSW No.: Business Phone Number: I~0,r,q Za►(ppo. ~ rV`►PPtS 33) 71b 34fo- a, so Plumber's Address (Street, City, State, Zip Code): -7115 Coth -st• No. + FAi;.AdSa/ . 'Sy01(cl IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sani ry Permit Fee (includes Groundwater a ssue Issuing Age Surcharge Fee) Approved ❑ Owner Given Initial Adverse I?~_ Determination (J X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber t INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at tha time of rerj;Y al 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 rD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) mist be pump. 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 & Buildings Division, 608-266-3815. 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 in 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 informaJon requested in #1-7. VII. Tank information. Fill in the capacity of every new and/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 Epproval only A 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'/2 X 11 inches must be submitted to 'he courty. The plans must include the following: A) plot plan, drawn to scale or with complete dimension:, ocaticn of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water r~ai -'water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems, re: z cement system areas, and the location of the building served; B) horizontal and vertical e1w ation n>ferer : + points; C complete specifications for pumps and controls; dose volume; elevation d fferences, fri:t on loss; pump performance curve; pump model and pump manufacturer; D) cross section of the sc°i abs.rption system if required by the county; E) soil test data on a 115 form; and F) :iii sizing informatio+s. GROUNDWATER SURCHARGE 196:3 '-Visco sin Act 4"0 included the creation of surcharges (fees) for a nurnt,- -~r r " regulated practices which can effect groundwater. The rwnflps collo, ted tl touga the.<.e surcharges are LISE ed for monitoring ormin -.r,der, grourld water contamination investigations and establishment of standards, SBD-6398 (R. 11/88) )J LO S, , i COO,,) R'f~olps I_CEI y Labor and D=Relations nt of Industry, SOIL AND SITE EVALUATION REPORT Page Labor and HDivision of Safety 6 Buildings in accord with ILHR 83.05, Wis. Adm. Code C r~ Attach complete site plan on paper not less than S 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I. dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY AWNER- S °Y5S PROPERTY' ATION A% GOVT. LOT 1/4,Z~1/4,S 10 T Zf N,R If E (o Wt PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # /2 8 H o R 'D~ &eWehfiiPfT S7~Tia.v CITY, STAT ZIP CODE PHONE NUMBER CITY q~ILLAGE NEAREST ROAD own j~il~ ~ GU/, 5yo 2Z - (7/5) y.15 'lo /~✓~J~ UYS o ;ii ~ h~/E/E' [ New Construction Use [ Af'Residential /dumber of bedrooms 3 f~ [ j Addition to existing building j j Replacement [ ] Public or commercial describe Code derived daily flow (oDZ7 gpd Recommended design loading rate bed, gpd/ft2 ~trench, gpolft2 Absorption area required bed, ft2 14~1 trench, ft2 Maximum design loading rate bed, gpd1ft2 ' to trench, gpd4t2 Recommended infiltration surface elevation(s) -150e 3 It (as referred to site plan benchmark) Additional design / site considerations 5.e-2 A-c-hQ- (oc Parent material 1110- S1 7, o r&1A3W Al fl,~ Flood plain elevation, if appli6able ft S = Suitable for system CONYWIONAL MOUND IN-G~enFD PRESSURE AT GRADE S~YSpU AV FILL HOLDING TANK U =Unsuitable for stem ©'S ❑ U ❑ S g1j U~'S ❑ U ❑ S O'S ❑ U [3 S 2, SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundah/ Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed lunch 0-/2- lee 211 -F '-ZP A3P 51. 1,7e, OX ef-V-41"e2) e5 Z L /Z Z/ o Y/ 56k 1"7/ 5 Lf , Y .S Q S S Ground 1-3 M Si/ 1741714'e ~g~ Depth to limiting factor Remarks: c'Tl~ 457 . Boring # ( a w / V / $i CS f l f3 5 3 y 75 yR Ground cl~ elev. 6 2- ft. Depth to limiting M110%1 1A1 factor , f> LT/_ Remarks- PROPERTY OWNER SOIL DESCRIPTION REPORT Page of3 PARCELI.D.! a L)R-k--A 7dWT s Ti~O'J Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bound3y Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed rends , 3 l o g /oY Q s /t PD , 1) -4/1 149M _57 Ground 4-0-5e ACS ~F y s elev. 100 ,30 ft. 31- 7,51ve Gs d S. 4 . 01 Depth to limitng = factor Remarks: Boring # 2 N z -/f yr? 2-11- If sj/(~ fr~e e~ Y s Si1 2- f S/f~ f~ • S ; Ground elev. Depth to limiting Remarks:/ Boring # 3 16 ?a 4e 41141 L ~ ~ s/ s! ~ f ~s z f- y s Groundt / Z holy 5 G elev, Zo-J / 7~o 61-6 .c.7 it. Xe J 6- 4- Depth to N /ZD-JS le Za '907?) D limiting factor Remarks: Boring # f Ground L O r yea ioo.o' C,4, ZEPA y 4,. ry ~a Cc/zU~P-T~o,J S .13z /3.3 100,3e 7a ' l~11 /3 ley 2 ~o , l3 /33 S c9 6C~ ES TAD -T"R ~NC.(,L l ~-y~t-T-iou S STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER r 1 ~h ltd 5n r% 1xy\66n MAILING ADDRESS (D g G a r L a h e- PROPERTY ADDRESS ( V Lck ii (location of septic s ste lease obtain from the Planning Dept. CITY/STATE - A S LI U 1 co q PROPERTY LOCATION ~J 1/4, v 1/4, Section T_2-q N-R l I W TOWN OF _~Alip A S o v-\ ST. CROIX COUNTY, WI SUBDIVISION GU-,r ~_h Q ,r St " u LOT NUMBER CERTIFIEDSURVEY MAP, VOLUME , PAGE , 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) s 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 ex iration date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 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 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 Location of property-'-->' 1/4 WE 1/4, Section T.Z(3 N-R [ Q W Township Sort Mailing address _t 1 `?S z P nh,, r- 0.n e Rud sov) E LXi ) 5uU l (o Address of site _(A 3 ?-evk u r Lap e., Subdivision name 13AA.)rk 6.0e S+a+ibVN Lot no. Other homes on property? Yes_X_No Previous owner of property "1~ € CT \AeL, C. \ na, Total size of property _ 2, 2 _acres Total size of parcel _ 2, C V- R-,; Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes _X No Volume _ and Page Number as recorded with the Register of Deeds. Pj~_LV Y)WKu k s a vi 0,-, INCLUDE WITH THIS APPLICATION THE FOLLOWING: J~. 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. 5 3j6-p<0P(o , 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. r Signature of Ap cant Co-Applicant- Date of Signature Date of Signature n Y I~ Stale Bar of Wisconsin Form 2 - 1952 53808G it WARRANTY DEED DOCUMENT NO. I' VOL ' 1156PAG: 31 Michael J. Vodinel ic_h and Christine T. Vodinelich. t/k_la_ Christine T I1cCorma_ck. JAN 3 1996 husband and wife - 10:15 A.j,j Ban E. Johnson and Susan M. \ , conveys an~l yvarrants to JONnSOn, husband an wife, TmIS SPACE RESERVED FOR RECORDING DATA %AME AN;` RETURN ADDRESS the following described real estate in St. CrOi x - r County, State of Wisconsin: -22Q--1~Q9-4Q _ 0 Parcel Identification Number) If Lot 4, Plat of Burkhardt Station in Town of Hudson, St. Croix County, Wisconsin. ~j i gFER This is not homestead property. XXKKKDWM ~I Exception to warranties: Easements, restrictions and rights-of-way of record, if any. 29th December _ 19 95 Dated this day of fI ___1r" _ (SEAL)` 1 (SEAL) Michael J. Vodinelich Christine T. Vodinelich, a ristine . t c rmac-k- (SEAL) (SEAL) ' II II AUTHENTICATION ACKNOWLEDGMENT jI STATE OF WISCONSIN Ij Signature(s) ~ u• ~I St. Croix County. Personally came before me this 29th - day of j' authenticated this day of , 19- i pacthPr _ 19_-4r1 the above named icliael J-Vodinelich_and_Christine-T, Vodinel]_Ch,_Illc/a-Chric into T - II TITLE: MEMBER STATE BAR OF WISCONSIN -McCormack>--husband- and_-wlfP. (If not, - authorized by §706.06, Wis. Stats.) to me Lnown to be the person - - who executed the SUSAN M. GENSON Irrtrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY NOTARY PItRt If` --r- II