HomeMy WebLinkAbout020-1310-30-000
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNERS A M O(LL-fP,
ADDRESS R6 Z~ 2-
L2 DS®A~ Lk I S~O
SUBDIVISION / CSM#TAgKIEY LOT d
SECTION 2 TAN-R 1 W, Town of t~U G a N
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTE
Se,4 LE t/y e % /O'
rec A(6 Y A ; (OD
V
75
a7 70
73
T t /iya•
<ko Ce'4c~
L or
l T
INDICATE NORTH ~RROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover
BENCHMARK: /''P/yE oN SOa7hY 7
ALTERNATE BM:
=SEPTIC / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: I.cJF/Sfe
Liquid Capacity: /000 6,4e ,
Setback from: Well 70~
House Z- S/ Others, sek'f/i Lo-f L/1V,5
Pump: Manufacturer
Modell Size
Float seperation _
Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM _
Width:- Length
Number of trenches Z-_
Distance & Direction to nearest prop, line: 7S* to
Sau?~, GoT
Setback from: well: 7s- House -'-Z, 7 '
Bolt;,, Other To S T
Z - //Sow
ELEVATIONS
Building Sewer
ST Inlet: / ST outlet S . S`/
PC inlet PC bottom
Pump Off
Header/Manifold 43 p Bottom of s stem Y -7.yp' low
Existing Grade
Final grade .
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:r
INSPECTOR:
3/93:jt
County:
w scoasin Department of industry, PRIVATE SEWAGE SYSTEM ST, C$OIX
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division Sanitary Permit No.:
• (ATTACH TO PERMIT)
GENERAL INFORMATION
❑ City ❑ Village ,Town o : State Pia
Permit Holder's Name:
MILLER: SAM 096GN QA
Parcel Tax No.:
CST BM Elev.: !r lisp. BM Elev.: BM Description: t
TANK INFORMATION ELEVATION DATA s
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. /
Septic Benchmark
Dosing L t ~ 1'f?~ Cj SO
Bldg. Sewer
Aeration - -
St/of Inlet > e20.
Holding'"" i
TANK SETBACK INFORMATION St/ outlet ~.~5
FA ent to ROAD Dt Inlet
TANK TO P/ L WELL BLDG. ir Intake
ee ; NA Dt Bottom
Septic , /
Dosing NA Header' 9
Aeration NA Dist. Pipe
Bot. System 4~ .y S 11
Hold-61111i
Final Grade S/S /a%
PUMP / SIPHON INFORMATION
0/ /1 lr,9 3
3
Manufac r Demand
Model Number R.9-Z,
TDH Lift LOSS Ion System TDH Ft
Force Length Dia. Fi Dist. To well
SOIL ABSORPTION SYSTEM No.Of Pits Inside D d Depth
BED /TRENCH Width / Length / No. Of Trenches DIMEN I N
DIMEN I N rer:
SYSTEM TO P / L BLDG WELL LAKE /STREAM L ING
SETBACK CHAMBER Mo a Num er:
INFORMATION Tyem 1)2.w OR UNIT
Sysstem: ~--fCrc L
DISTRIBUTION SYSTEM
i To -1e Size x H pacing Vent To Air Int ke
Header /Manifold Distribution Pipe(s) is /
Length Dia. Length S Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Gr a Syste
p Depth Over `I xx Depth Of xx S lee ded /S ❑ odNo ed xx ❑ Mulched
De th Over Yes ❑ No
Bed /Trench Center Bed /Trench Edges Topsoil 171 COMMENTS: (Include code discrepancies, persons present, etc.)
. Nr7 ; SW ; LOT `O ; TAI NEY LANE
LOCATION: HUDSON.12.29.1aL'7 T - _es}' ~iCe c <I
Plan revision required? ❑ Yes 03 No
Use other side for additional information. 5 o'~c3
Inspector's Signat re Cert. No.
SBD-6710(R 05/91) Date
ADDITIONAL COMMENTS AND SKETCH -
SANITARY PERMIT NUMBER:
Safety and Buildings Division
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 u2 x 11 inches in size. 1 o /
• 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 ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
op
Property Owner Name, P operty Location
L. (~v4 1A, S ` Z T Z , N, R P_( E (orko
Property Owner's Mailing Address Lot Number Block Number
.iIr
d~ Z Z
City, State Zip Code Phone Number Subdivision Name or CSM Number
II. TYPE BUILDING: (check one) ❑ State Owned ity Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms - 0 Town OF vlJS u J4/~L
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo OZO - /3/0 - 30
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. R New 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 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 [B Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43E] 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) 4 111-r Elevation
YS-0 7
8 11-7,0 Fee Feet
VII. TANK Capacity
in gallons Total # of Prefab. Site Fiber- Ex er.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel Plastic p
New Existin structed glass App.
Tanks Tanks .
Septic Tank or Holding Tank QUr Cl ❑ E 1:1 ❑
Lift Pump Tank /Siphon Chamber
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 Signatur (No Stamps) MP/MPRSW No.: Business Phone Number:
el 1,9~e5_-
Plumber's Address (Street, City, State, Zip Code):
6 G L 441411-1- SO
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved S nitary Permit Fee (Includes Groundwater ate Issued Issuing Agent qS'nat a (No Stamps)
Approved E] Owner Given Initial Surcharge Fee)
Adverse Determination C~ X
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05194) 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 permit maybe renewed before the expiration date, and at a time of renewal any ne,rj 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) tc. 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, 608-266-3815.
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 Dwfrling.
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, rec: :)nnection, 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.
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abo and Department Industry,
L Labor r and Human Relations SOIL AND SITE EVALUATION REPORT
'Page i of
Division 6f Safety 8 Buildings
• _ in accord with ILHR 83.05, Wis. Adm. Code
COUNTY ~n
Attach complete site plan on paper not less than .8 112 x 11 inches in size. Plan must include, but -S7 CA I k
not limited to vertical and horizontal reference point and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and dis 15'ta
.
y- r
APPLICANT INFORMATION-PLEAS I"1ALINFOR REVIEWED BY DATE
PROPERTY OMR: ROPERTY LO ATION
SA n7
L.L&R OVT. LOT /X~ 1/4SLA)1/4,S11 T'2-9 N,R / 9 E (or) W
PBQp.ERTY OW R':S MAILIN DDRESS
J OUT }~O>Afl OT# BLOCK# SUBD. NAME OR CS
CITY ST TE S ZIP Z PHONE c i 1Cwr< AJ N Y ' ' '4'6
~1j~ao 1-0 CITY ❑I LACE OWN EST ROA
%A S- i~ A'~bY
New Construction Use Residential /
$f r - UA~ [ )Addition to existing building
j j Replacement Public or commercial describe
Code derived daily flow gpd Recommended design loading rate ! "_bed, 2 o 7 2
Absorption area required bed, ft2 2 9Pd/ft trench, gpd/ft
trench, ft Maximum design loading rate bed /ft2 0_ 2
Recommended infiltration surface elevation(s) b end trench, gpd/ft
ark)
Additional design / site considerations ft (as ref rred to site plan benchmark)
L u,~tc~AT iDU 1 o60* W" Lk i APPP,6VA 2
Parent material Flood plain elevation, if applicable ft
S = Suitable for system 0 vVENTIONAL 11's, ND IN- ROUND PRESSURE AT- DQ U S_Y,SSEM 1 ❑ N U LL HOLDING T UK
U = Unsuitable fors stem ®S ❑ U ❑ U S ❑ U ~f
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure
in• Munsell Texture Consistence Roots GPD/ft
Qu. Sz. Cont. Color Gr. Sz. Sh.' Bed Trench
/&39 11)
es r o,~ o~
G
round 'l!~ /~yk~ S r 1dt
lev
i_ _sIt. 0,7
Depth to
limiting
>f t~z
Remarks:
Boring #
0 -rS t 6vs, 3-z 1 rti s 1 C S Z~ d,
!S S
Ground
elev.
11j. 7,- ft.
Depth to
limiting
ctor
3 5
Remarks:
CST Name: Please Print 14A kA <Ja . N Aj <-0 pi Phone:
Address: 4&&o
G~
Signatur
Date: 7 nS CST Number:
27 `j
SOIL DESCRIPTION REPORT Page? of
a
PROPERTY OWNER
PARCEL I.DA LaT 2d
GPD/ft
Depth Dominant Color f~otties Texture Structure Consistence Boundary Roots Bed Trend►
Boring # Horizon in. fvtunsell Qu. Sz. Cont Color Gr. Sz. Sh.
A -zo 0`t~ I I Yh s k toJ Z a. S
1
Ground
elev,,
119QS ft.
Depth to
limiting
f c6
7
Remarks:
Boring # S~ ~ /h S6Y~ /her CS Z~ D.~ 0~
A o-ZO /oy0h
Cw 16
Ground
elev.
jZL5$ft.
Depth to
limiting
Remarks:
S
Boring # 3 Z S L, /k Sb~ n,-Cr CS Z~ o,410
S~~ ~»~S~K r W J p,Z C)
$i 37
Ground
elev
Depth to
limiting
ctor
7
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
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13
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER _~S 4 /7/ 11Ll Z 6C
MAILING ADDRESS.D X 'Ir Z y- Z
PROPERTY ADDRESS 7 TAYNE,Y L A,Yj
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE _14 c,) D 5 ,.6 N 64// 5' y0 / is
PROPERTY LOCATION )V W 1/4, :S W 1/4, Section / ZZ- T N-R L7
TOWN OF 9 L )D J 0 N ST. CROIX COUNTY, WI
SUBDIVISION T A- Al N e Y R I D LOT NUMBER Z c~
CERTIFIED SURVEY MAP 5 3 / 9 y L , VOLUME PAGE LOT NUMBER Za
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.
L/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:
DA'L'E:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
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 _51q 4 M /4
Location of property /(,y 1/4 S U,) 1/4, Section , T ? 9 N-RJ2_4:2D
Township N y J,, Lo N ...Mailing address Ro k-- z g
k v~ S o u w/ yo i~
Address of site 1097 TA NNi~-~' L fl/VE'
Subdivision name LAMA/EY 12/,y /t Lot no. Zp
Other homes on property? Yes XNo
Previous owner of property d AL 41
Total size of property 'l! o L X C
Total size of parcel p Z A c
Date parcel was created 9- 97
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? A Yes No
Volume D 3/ and Page Number SL 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. SD 9 -S , 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.
-So St-
r
!Sig ature Applicant Co-Applicant
Date of Signature Date of Siqnature
' DOCUMENT NO. STATE BA F WISCON$I ORM i-•19U T1416 tlrwcs essa"via FOR escoeolea awrw
a ARRANTY 0 D
504855 VOL 103inME 456
ACC t
C1STER'S OFACE
This Deed, made between CO.. %Z
Randall W. Synan, and Patricia E. Synan,._....___.
1803 }bir Record
........husband-- -and -Wife t
Grantor, ' SEP T 1993 '
and ...Sam.........Mi.:.er..............ngle person at 10'45 p ;'•M
~+r•+aCE.
7 e- Asa. o..o.
. Grantee,
WitliesSeth, That the said Grantor, f r a valuable consideration......
Randall W. Synan and Patr1Cia E. Synan
St. Croix"---' eaTOe"TO
- conveys to Grantee the following described real estate in
County, State of Wisconsin: ,
Tas Pared 40:....._
The SE1/4 of NE1/4 of Section 11; the SW1/4 of NW1/4, the N1/2
of SW1/4, and the South 53 rods (874.5 feet) of the SE1/4 of
NW1/4 except the East 74 feet thereof, all in Section 12; all in
Y' Township 29 North, Range 19 Nest, Town of Hudson, St. Croix
County, Wisconsin.
AND
A
.A A parcel of land located in part of the NE1/4 of SE1/4 of Secti8
'1 11, Township 29 North, Range 19 West, Town of Hudson, St. Croix
County, Wisconsin further described as follows: Commencing at the
E1/4 corner of said Section 11; thence S89 30100"W, along the
North line of the SE1/4 of said Section, 1212.32 feet to the point
of :.eginning; thence continuing S89 30100"W, along said North line,
66.00 feet; thence SOO 28103"E, 500.00 feet; thence N8Q 30100"E,
along the North line of Certified Survey Map filed in Vol. "30,
Page 722, 38.08 feet; thence N00 11133"N, 150.00 feet; thence
N03 58134"E, 351.07 feet to the point of beginning.
This i.9-AQ.t... homestead property.
(is) (is not)
r
Together with all and singular the hereditaments and appurtenances tuereunto belonging;
And..... RaftdAj.j.--VI-'.... Y.Dan,. AAA.. Patx-icia.. E Synan
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements, restrictions and rights-of-way of record, if any.
s
and will warrant and defend the same.
Dated this ................1.............................. day of AQQL18 119-9.1.
...(SEAL) ~C7alrt~~.4... 4~it.✓ ...........................(SEAL)
• Randall W. S ..nan Patricia . Synan
•
_ • .....................................................................(SEAL) ....................................................................(SEAL)
:a
t. AUTHNNTICATION AC=NOWLRDOMMUT
-r
A Signature (aSTATE OF WISCONSIN ~
r o. it
- St. Croix _b )
authenticated this ........day of 19
Poceowdy can before me • ..r[.I........day of
i August to do above named
ltadall ii.~Sx nan Patricia
i TITLE: MEMBER STATE BAR OF WISCONSIN Synan
(If not.. authorized by 1 706.06. Wis. stats.) AN .
1 to me known to be the person 6 Ay x e
'ADDITION TO TANNEY RIDGE SPECIAL ADDIT
IN PART OF THE SW I/4 OF THE NW I /4, IN THE NW 1/4 OF THE SW I/4, AND IN PART OF THE NE I/4 OFT HE SWIM, ALL IN SE(
19W, TOWN OF HUDSON, ST. CROIX COUNTY, WISCONSIN.
OWNER
SAY YllLr.
1011"TN 10"I 01 T"' S'AIi, 01 TK "WI/1, S[CTIOM Ir •O. g0. 141?
, I
$89'25`45"W 984.21 l4aM.a
- aoo oo' x64.21 .NOSOM
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'05 LOTS 39
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OA 4.8 2 SO.F'T \ \ ` \9~ `.y~► ~'n FT.
6~ P` LOT 36 ZD
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.26 ACRES LOT 34
I ,1 SO. FT. 2.61 ACRES N
113,6.0 S0. FT. y
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4310 . LOT 20 a~ \ ' s b 1
4.02 ACRES
175.310 SO. FT. LOT 3
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