HomeMy WebLinkAbout020-1019-40-100
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER '.r l~ ~yi ! L L C lZ
ADDRESS COY t)s
SUBDIVISION / CSM S- Z Z. LOT
SECTIONT N-R I q Town o f 1 ~1
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
E.~V 1
V
~tPa~ Y a7~
Byrn'
1
t WELL
,~QT E : i' ~s 779 4•
ri
tr~a E t. t VOTC. IN 5 H LC D
1 INDICATE NO~H ARROW
Provide setback and elevation information on reverse of this form.
1h ee v'Y'DIV --9-04,6
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: /47 NF_ CO21V4e2 r / /7.8/
ALTERNATE BM: 7&- 1~ Q (p oEv~ /ock 41A LL El =
(SE:PT:IC:T:AN:K:) PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: C
( Liquid Capacity:/,(}~°',-
Setback from: Well 56 House ZY~ (b Other 41
/ r
t Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
-:SOIL ABSORPTION SYSTEM
Width: S Length &0 Number of trenches Z
Distance & Direction to nearest ProP• line: '10
`~S Ei~J7 lam L/Alf
Setback from: well: 15-0
House Y ) Other t o
A4 z At Njr y, z Kf uc F
ELEVATIONS
I 10, z Building Sewer`,.. ST Inlet. 7 S I a ST outlet
PC inlet PC bottom Pump Off
Header/Mani fold I c"17r, r Bottom of system Z z
Existing Grade Final rade
lob, ~-S
DATE OF INSTALLATION:
PLUMBER ON JOB: LICENSE NUMBER: 60
INSPECTOR:
3 / 9 3 : j t
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations
INSPECTION REPORT ST. CROIX
'Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Permit Holder's Name: ❑ City ❑ Village [XTown of: State P an ID No.:
MILLER SAM
CST BM Elelev.: Insp. BM Elev.: BM Description: y Parcel Tax No.:
TANK INFORMATION ELEVATION DATA ~7
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 6644-11 Benchmark
/7 PZJ
i
Aeration Bldg. Sewer
Hold in St/ Inlet 26
/10( ~1 7, TANK SETBACK INFORMATION St outlet
fa' U 9~
TANK TO P / L WELL BLDG. Airi to ntake ROAD Dt Inlet
Ar I
Septic » ' 2 c2 c1 NA Dt Bottom
Dosin NA Header / Man.
Aeration A Dist. Pipe
Ap,
Holdin Bot. System o
PUMP/ SIPHON INFORMATION Final Grade' 0 lod /
Manufa Demand o- 5/~ S
Ly
Mod I Number GPM
TDH Lift F ' ion Sys TDH F
Force Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length / No. Of Trenches PIT No. Of Pits Inside Dia d Depth
DIMENSIONS o"l DIMEN I
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACH anufadurer:
SETBACK CHAM
INFORMATION Type Of /I.u,~ n Mode Number:
System: ,tek ~ USc. 57 2 41f OR IT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) i/ x Hole Size t:Holeng Vent r Intake
Length Dia. Length! Dia.^'' Spacing L
System I
SOIL COVER x Pressure Systems Only xx Mound Or At-Gir
Depth Over Depth Over 1'1 xx Depth Of xx Seeded/ Sodded x Iched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes
COMMENTS: (Include code discrepancies, persons present, etc.)
HUDSON.14.29.19W, NW, NE, MCCUTCHEN ROAD y /J
/I ~7
Plan revision required? ❑ Yes p-No
Use other side for additional information. ,I L:~ /X-- H
SBD-6710 (R 05/91) Date Inspector's Signa ure Cert No
01111-HR and Buildings Division
0101111-HR SANITARY PERMIT APPLICATION Bureau uilding WaterlSystems
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 ` n Q
than 8 1/2 x 11 inches in size. ~Y
• See reverse side for instructions for completing this application State Sanitary Permit Number
a6t.26 Z
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 INF RMATION
Property Owner Name Property Location
GL404 AWl/4 1/4,S T' 9 ,N, R./7 E
A
M
Property Owner's Mailing Address Lot Number Block Numbe
Re Z Z
City, State Zip Code Phone Number Subdivision Name or CSM Number
10 it Nearest RojlcP'
II. TYPE F BUILDING: (check one) ❑ State Owned
p
Public 1 or 2 Family Dwelling - No. of bedrooms s To~an OF =L-~L14 L 1~ G~ a
111. BUILDING USE: (If building type is public, check all that apply) arcel Tax Number(s)
l0 19_
1 E] Apartment/ Condo OZo - 00
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.tZ New 2. ❑ Replacement 3. ❑ Replacement of 4- ❑ Reconnection of 5. ❑ Repair of an
ystem 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
11E] Seepage Bed 210 Mound 30E] Specify Type 410 Holding Tank
12 KSeepage Trench 22 In-Ground Pressure 42 ❑ Pit Privy
13 Seepage Pit 43 ❑ Vault Privy
14E] 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
/ S /D S, 1W Feet 0 Feet TANK Capacity
VII. Fiber-
INFORMATION in gallonTotal # of Manufacturer's Name Prefab. Con Fiber- Plastic Exper.
Gallons Tanks Concrete Steel glass App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank >C /000 I S -F -R ❑ ❑ ❑ ❑
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 Signature o Sta s) MP/MPRSW No.: Business Phone Number:
x) k F L!_ Mfe5 -d 3 4~
Plumber's Address (Street, City, State, Zip Code):
ILL C t4 N\ \ L Uk 5 o W( t
IX. COUNTY / DEPARTMENT USE ONLY
Groundwater ate Issue Issuing Ag t Sign r ps)
❑ Disapproved Sa tary P,eerr~miitt Fee (Includes Surcharge Fee)
?6/
Approved E] Owner Given Initial /
Adverse Determination
X. CONDITIONS OF APPR VAL / REASONS FOR D!~APPRO A
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety a Buildings Division, owner, Plumber
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, 608-266-3815_
To be complete and accurate this sanitary permit application must include:
L 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.
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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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
La-r,ind Human Relations
Division of Safety & Buildings in accord With ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less Than 8172 x 11 1 1 ze. Plan must include, but St. Croix
not limited to vertical and horizontal refe r16e point (Bf~p);, directio 6 of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and locatio dista 66arest roa pending
APPLICANT INFORMATION-PL IF~E PA~'ALIINRM REVIEWED BY DATE
PROPERTY OWNER:, PROPERTY LOCATION
Kernon Bast GOVT. LOT NW 1/4 NE 1/4,S14 T 29 N,R 19 *(or) W
PROPERTY OWNERS MA!I_ING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
948 LaBArge Rd. r~ 5 na csm pending
CITY, STATE ZIP CODE HOt =-7775-- ❑CITY ❑VILLAGE ®t•OWN NEAREST ROAD.
Hudson, WI. 54016 Hudson McCutchen
New Construction Use Residential / Number of bedrooms 3 [ J Addition to existing building
j ] Replacement ( ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate • 7 bed, gpd/ft2 •8 trench, gpd/ft2
Absorption area required 643 bed ft2 563 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2_8 trench, gpdt t2
Recommended infiltration surface elevation(s) 105.44 ;t (as referred to site plan benchmark)
Additional design / site considerations na
Parent material outwash Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK I
U = Unsuitable for system EIS ❑ U El ❑ U I EIS O U I EIS ❑ U I ❑ S M ❑ S 19U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth I Dominant Color Mottles Texture Structure Consistence IBourtdary Roots GPD/ft
in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. Bed Trends
1 0-12 10 r3/2 none 1 2ms. d(fr gw 2f .5 .6
.1......2 112-31 10yr5/4 none sil 2mbsk mfr gw if .2 .3
Ground 3 31-47 10yr4/4 none sl 2msbk mfr na .5 .6
1081!44ft 4 47-10 7.5yr4/6 none co s Osg ml na na .7 i.8
.
Depth to
limiting
factor +156
Remarks:
Boring # I
1 -10 10yr4/3 none 1 2msbk mfr 2f .5 .6
2 110-20 10 r4 4 none sl 2msbk mvfr if .5 .6
2 Y /
Mai
3 0-10 7.5yr4/6 none co s Osg ml na na .7 '.8
Ground
elev.
109.64 ft.
Depth to
limiting
factor
+100"
Remarks:
CST Name _Please Print Gary L. Steel Phone:
715-246-6200
Address: 1554 0th. AVe., New Richmond, Wt. 54017
Signature: Date: CST Number:
5-12-95 cstm 02298
PROPERTY OWNER K. Bast SOIL DESCRIPTION REPORT Page%? of.Ir
PARCEL I.D. # pending
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence 8ourxfary Roots GPD/ft
i I
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed iTrench
1 0-13 10 r3 3 none 1 2msbk mfr 2f .5
32 13-26 10yr4/4 none sil 2msbk mfr gw if .2 1 .3
Ground 3 26-10 7.5yr4/6 none co Osg ml na na .7 1.8
elev.
107.94 ft.
Depth to
limiting
factor
+100"
Remarks:
Boring #
1 -10 10yr3/3 none 1 2rnsbk mfr gw 2f .5 .6
4 ' 2 0-17 10yr5/4 none sit 2msbk mfr gw if .5 .6
Ground 3 7-30 10yr4/4 none sl lmsbk mvfr gw na .4 €.5
elev. 4 0-80 7.5yr4/6 none co s Osg ml na na .7 .8
105.64 ft.
Depth to
limiting
factor
+80"
FT
Remarks:
Boring #
1 -10 10yr3/3 none 1 2msbk mfr gw 2f .5 .6
5 2 0-24 10yr4/4 none sil lfsbk mfr gw if .2 .3
1~3 4-31 10yr5/4 c2p 7.5yr5/8 sil M na gw na np .2
Ground
elev. 4 1-50 7.5yr4/4 none is Osg mvfr gw na .7 .8
106.1{
5 0-84 7.5yr4/6 none co s Osg ml na na .7 .8
Depth to
limiting
factor -
+84"
Remarks: H-3 less than V
Boring #
Ground
elev.
ft. ~
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel Kernon Bast 1554 200th Ave.
CSTM2298 Nw4NE4 S14-T29N-R19w New Richmond, WI 54017
MPRSW 3254 town of Hudson (715) 246-6200
lot #5
N
1"=40'
BM.= top of NE lot stake at el. 100,
12-1
4
24-, 3
f ~ F
Gary L. Steel
5-12-95
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNERBUYER r-, A rw W t rA
MAILING ADDRESS t° 14 M Z g, -t__
PROPERTY ADDRESS -2 S C C U L (f E /V
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE I-~ V 't S to t,[ W ~ S y0 I G
PROPERTY LOCATION ~l(w 114, ~JE 1/4, Section t~ T, 9 N-R
TOWN OF N V D S 0 N , ST. CROIX COUNTY, WI
SUBDIVISION C S M S~ -7 4 LOT NUMBER
CERTIFIED SURVEY 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)
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: a
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 5
Location of propertyl/4`1/4, Section /Y , T_t-'7N-R 17(IP
Township V C) S a ti Mailing address /a cv/
1901> 5 o N l,t> l yo
Address of site -7 .S $ 191 U TC 1f E /V 4~ dL
subdivision name C 5 /y1 S' Z. q/ 7r., Lot no.
Other homes on property? Yes No
Previous owner of property DO /p SPjF~' L~h'S7-
Total size of property Z 7 Z-
Total size of parcel od r
Date parcel was created
Are all corners and lot lines identifiable? x Yes No
Is this property being developed for (spec house)? Yes No
Volume //?C/ and Page Number r? ir 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 z q 7 5/j~p , 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.
S2.
v
o pplicant Co-Applicant
Date of Signature Date of Signature
FILED
MAY 2 2 1995 0-
KATHLEEN H. WALSH
Register of Deeds
529176 SL Croix Co., W11
CERTIFIED SURVEY MAP
Located in part of the NWk of the NEa, Section 14, T29N, R19W,
Town of Hudson, St. Croix County, Wisconsin.
d
~4,~ba asps OWNER
e Ray Brown
+ C/0 Kernon Bast
L C 948 La Barge Rd.
N HAG ~
Q Hudson, Wi. 54016
j DSON,
Qo I10 SURD 'off Icy
®~~0levees OI~~~ i M
S88054122"W 494.50' ix II
251.20' 243.30' 1 - I J
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s I ) o cv I Ti I(/)
I-I ~ Ir) IL
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'00
LOT 6 o LOT 5 In
fi un_ a) I
2.73 Acres Inc. R/W z 2.72 Acres Inc. R/W
N Corner 118,894 Sq. Ft. Inc. R/W 118,681 Sq. Ft. Inc. R/W w
0 of Sec. 14 - 2.51 Acres Exc. R/W co 2.51 Acres Exc. R/W T
v> 109,431 Sq. Ft. Exc. R/W o 109,434 Sq. Ft. Exc. R/W I> If-
CD 0. 1 _0
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ao
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I 238.71' r 243.28 „
N8903713911E 481.99' W
N8901215211E 243.28'- _ - W
N890121 5211E 480.86' W
169.81' Lj - a
1 I L South Line of the NW} of
PJI"C' la + 1^11@Il ~.QC1d VED the NE} of Section 14. m
I
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W 1~JA ! KY22:`95 I~~,~~,I
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F ♦ DOCUMENT NO. WARRAN'Ty DEED TNI! SPACE Rl9ERVED Pon RECn RDiNo DAIA
STATE BAR OF WISCONSIN FORM 2-1982
C t
C
529'46 a
von 1? ~s,~. 85 -
ST. CfLu rj.,Iq
Donalda J. Speer-Bast, a married woman Reedio; rL1M
JUN S 1995
- st 8:00 A. l
conveys and warrants to jjtI ier ~~*h.
the following described real estate in 5t.,--rroir....................... County,
State of Wisconsin:
Tax Parcel No:
A Parcel of land located in part of the NWk of the NE}. Section 14,
T29N, R19W, Town of Hudson, known as Certified Survey Map Lots 5 and 6,
recorded May 22, 1995 in Volume. 10, page 2921, Document Ntm+er 529176.
IOU-
This s-•not............ homestead property.
(is) (is not)
I
Exception to warranties:
Easements, reserictions and rihts of way of record, if aNT.
Date-) this n.9..--•-- day of 19.951....
June.
..............................(SEAL) 7
Donalda J. Speer-Bast
•
(SEAL) (SEAL)-
.
- •
AUTHENTICATION ACSNOWLBDOMBNT
Signature(s) STATE OF WISCONSIN p
ss.
- -
.St.l;.rni County.
Personally came before me this nday of
authenticated this day of _10
June 1~5 the above named
-----•-Donalda 1• weer-Bast..---------------------------
- --IS..
TITLE: MEMBER STATE BAR OF WISCONSIN'
(If aot............
authorized by 1706.06. Wis. Stats.) to me nowti who executed the
fore ingi i aNt the
THIS INSTRUMENT WAS DRAITED BY -
• . :7•-••--..........