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HomeMy WebLinkAbout020-1321-30-000 y o 0 o M ° N ° O O y O Q C ~ I O O I ~ I Z C O ! M N z E rn o z `m a ,n0)Zi am ! o I o z d c u°i Fes- ~ m ~ z c o ~ y m I N N 0 U O co N N C N • a U) 0 O O Q Q z m z N z N N - d 1r~ > L ~i c G D a c ° o0 c N 8 C ° N 0 co ° o •►v aaa z a N 0 ! c ~o~ N J V y m (D CD CD } w T- M Q O - m o E ~ ~ m N W 0. `try' C: N E O C C) ~ c O R O co c O O O 7 0 f~ Om ~ E o. CL Q. OOi 00 V o N m c E E t co c G oU) - ° ° f a H Fes- aroi CN (0 (n N 7 N O N E E u • T~ O O iy O = N O U' U) = E m °i SL a w yv, r E U c a 2 O A U v STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER-51-71n 0/ 44~ e. ADDRESS 6"D u * z y"z /fva~- 0-,V (A-) SUBDIVISION / CSM# C,k1~IV4-e' LOT # 3 SECTION T 2-9 N-R~(WW Town of /~yvsoN ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTE PF rQ' ~ /aLTEQ &A7 2F A Z8 I\I ~ q~'1111 I ~ S° ~ ~a ~~ngU o R5~ v IO3 ~ ~ ixsra~cE0 e6A E+= 49,E ~o~TN- G-oT 4 /NE INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. r t BENCHMARK: TOP -X40 At A"7- SE C64-ONE= 2S-19Z a / ALTERNATE BM:- Top O 4-~ p lot k Fo dW OAT/o H Fl.-: ?P, D SEPTIC TAN / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: C!>,r /5.jF-, Liquid Capacity: Setback from: Well 50' House-0 /8, Other a6"' T° Nw ~ofi✓s,La~~~f Pump: Manufacturer - Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width' Length Ll O r Number of trenches / Distance & Direction to nearest prop. line: /0 3 7`- = vTf/ DoT LiiV~ Setback from: well: House--Z6 , Other Re 7o ELEVATIONS Building Sewer ST Inlet: ?,77-- gy ST outlet: ~~09' y5/' 3(0 PC inlet PC bottom ' Pump Off - Header/Mani foldpw/o,99 pe.y7 Bottom of system ~Z.oS Existing Grade Final grade' 7 1 i DATE OF INSTALLATION: PLUMBER ON JOB: ✓ ~Sp LICENSE NUMBER: INSPECTOR' 3/93:jt 'Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations MSPECTION REPORT ST. CROIX ` Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary 6Permit No-: 8676 Permit Holder's Name: ❑ City ❑ Village Cli Town o : State Plan ID No.: MILLER, SAM HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: P Parcel Tax No.: l J /~l , ' LSGz r~'JP QS TANK INFORMATION ELEVATION DATA A9600382 1 11)V 6 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic -~SQ r C~Ne . G Benchmark 3,35 166116b r Dosing Aeration Bldg. Sewer ~o Holding St/Yf Inlet s, OS r TANK SETBACK INFORMATION St/ Iif Outlet F 60 BLS` TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic}' -p r /g/ A4 NA Dt Bottom Dosing NA HeadertE M Aeration NA Dist. Pipe p SBA 22.2 2 ' Holding,_. Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand ° S~ O', Q r odel Number GPM TDH Lift Loss action Syste TDH Ft Forcemai Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width i Length0 No. Of T enches PIT Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE / STREAM LEA acturer: SETBACK INFORMATION Type Of `IQ 7~ , AMBER Model Number: System: ~,~I), ( ->50 d7/ 65 OR UNIT DISTRIBUTION SYSTEM Header /fAem(v+d Distribution Pipe(s)/ / r/ / x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length -31 Dia. Spacing (O SOIL COVER x Pressure Systems Only xx Mound Or At-Grade t nl Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed/ Trench Center Bed /Trench Edges Topsoil/ A' ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: ~WHUDI~SON.15.2 9 .19W ,NNW NW, QTY HWY A CL RLvm. 1 ,W G;rr~ rs can c7~ ~2 .iR GU•~ Plan revision required? ❑ Yes [2-116- Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signatu a Cert No. ADDITIONAL COMMENTS AND SKETCH - SANITARY PERMIT NUMBER: Safety and Buildings Division vi'•,,riR SANITARY PERMIT APPLICATION Bureau of Building Water System: 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 81/2 x 11 inches in size. sL - C )%y • See reverse side for instructions for completing this application State Sanitary Permit Number p vious application The information you provide may be used by other government agency programs E] Check it revision to7 [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location L64 OJ/4 U_)114,S jj T Z.N,Rjy E(ot W Property Owner's Mailing Address Lot Number Block Number .Clt City, State Zip Code Phone Number Subdivision Name or CSM Number vo o t.A.~)/ Ol (3 >L7G 1~.4AlAE V#LL,Ey II. TYPE F BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road ❑ Village Public Cgr 1 or 2 Family Dwelling - No. of bedrooms -3 Town of 11v 1)s 0 N C7`"iS~ '9 III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 0 Z (5 3 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. fo New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ 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 11 W Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ 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 5. Perc. Rate 6. System Elev. 7. Final Grade 5~0 Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation q -7 Z-0 f`lr ~o Feet 98r, Feet VII. TANK Capacity Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank coo ❑ ❑ ❑ ❑ ❑ 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: (No Stamps) MP/MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): /070 140 rir-A- R WG.,lc v s® O~ IX. UNTY / DEPARTMENT USE ONLY ❑ Disapproved Spa{-Itary Permit Fee (Includes Groundwater ate Issued suing ent Si nature (No amps Surcharge Fee) A ~ pproved ❑ Owner Given initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SOD-6398 (R. 05/94) DISTRI81.11TION: Original to County, One ropy To: Safety a Buildings Di-,ion, 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 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: 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. IL 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. Chec< 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 8 112 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. SCAC~ 1(y/t" to, S~,~ILE 40 Alotcr/t CoT L/NE 3 Z 2,00' i P6 A/4 / Ala i As A* I MT- 1 C 60 ~ Lot#~ l0 D ~ LoT y ~ IV v LdTz 3 S T . l~ B-y - i- s .s _ ° ~ IJ ~ F7 . ~,r1 -7s ' /~I-fir M1 \ 0\~ ~ p ~,~~~c 3~X31r ~B L M ~ ~/Rod/ ~ WE LL A7' DoT ~oR~yEIZ 9 9, V 2c~ ~ ~ ~ REV C9 z a L w a ~1 L1 a w o cr zd . j O~ Q w = ^ ~Y o o 41 S~ r T o o = X .-d I` J I ✓ w a M m 0 T o ~I W ~ 1 a I z_ I a © d I M I I I p I oz I I I _ ~ ' z O I N CL CWL F-- I I j a I LJJ W I j j I _ I I I ~ I I co I I M I ~ I w I I I ~ CL a I I I I U9 I I I 3 ~ o k► ~ I o U o CL , I U I a~ JiL ca/~ z ,Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page ! of . Labor and uman Relations Division ofSefety & Buildings in accord with ILHR 83.05, Wis. Adm. Code • COUNTY S-T C~a ► ~ Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but PARCEL I.D. # not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. REVIEWED BY DATE APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION PROPERTY OWNER: PROPERTY LOCATION q 111 1LL 0 GOVT.LOTIV{,J 1/4/vW 1/4,S/S T 29 N,R /9 E(or)W PROPERTY OWNER':S MAILING ADDRESS =[3CITY[]3V11LLAGE BLOCK # SUBD. NAME OR CSM # 4 , LL. CITY, STATE ZIP CODE PHON; NUMBER OWN NEARAS` ROAD [4 New Construction Use Residential / Number of bedrooms AN+C [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe - O% trench,gpd/ft2 bed, gpd/ft2, Code derived daily flow gpd Recommended design loading rate T Absorption area required bed, ft2 trench, ft2 Maximum design loading rate 7 bed, gpd/ft2CL S trench, gpd/ft2 Recommended infiltration surface elevation(s) ft as referred to site plan benchmark) Additional design/ site considerations-so l l vALC,~A , #o, hn -j L yn o WT A _P Pk6 y 1_ Parent material Flood plain elevation, if applicable ft t uitable for system CONVENTIONAL M2UND IN ROUND PRESSURE AT 9 -GRADE SY TEM IN FILL HOLDING TANK U S U nsuitable fors stem S ❑ U INS ❑ U 9S ❑ U S ❑ U 2S ❑ ❑ SOIL DESCRIPTION REPORT Boring # WD Depth h Dominant Color Mottles Texture Structure Consistence Bax>dary Roots GPD/ft Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench n1 y r c w ~ o r~ s b1~ M V r C t~ 6 ..7 ~ :3~ I6yo~4 Ground 9- d Ib-YR4 ~ S ~►t ~r th O7 67 elex. ~`1 ft. Depth to limiting factor 710 y0 Remarks: Boring# L ri,S~ AiyV y- LO r' OA 0' w S~ L b r ~ oZ 0.3 .76 z A /bYk 4 4 1 r Ground -elev. CPA ft. Depth to limiting e;Rr3 y . Remarks: CST Name:-Please Print) QuN N Phone: q~$a Address: fX l alD~S~>v Date: CST Number: Signatur ry (_j PROPERTYOWNER '!!~Alh /VMrUE2 SOIL DESCRIPTION REPORT Page Z of PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench M.M Ground 6-12 1&1014 0.7 6 $ elev. 9_•7 ft. Depth to limiting facto Z Remarks: Boring # 0-a 16W-VI L_ l msb< m CS /47 D,~ 0 bYR4L Ground - in p- S !Lt r A f 63 P 't I v~. M,y ft. Depth to limiting factor Remarks: Boring # /p Q F~'s , g~32 R4 5, L r C~ OZ 0 3 M r 's0~ 14 S Q 9 Ground 2'1 IdY~4 elev Cg L ft. Depth to limiting factor :f Remarks: Boring # :hC Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) • • : ` >PALC 3 of 3 i n ~ i - - - - ~ I / 60t I S3 i ~ \ I 1 - STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER S.4 rr1 /17 / c L 6:7rc MAILING ADDRESS x Z Y Z_ PROPERTY ADDRESS kC A-,6 (location of septic system) Please obtain from the Planning Dept. CITY/STATE f yy p o r C.2J / S Yo / PROPERTY LOCATION ffk/ 1/4, Wk/ 1/4, Section / s T~N-R /9 TOWN OF #ybSON ST. CROIX COUNTY, WI SUBDIVISION ,C /f-ff LOT NUMBER S' CERTIFIED SURVEY MAP S o 2 , 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: 6--) Z ^ l~~ St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 1 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 51:1-17-1 /yj/LL E/L Location of property AEG 1/4ct/ 1/4, Section/s , TAN-R : Township /-f-aq So N Mailing address eok iht Z.9 Z._ ~l) sdy Jt Sy0/6 Address of site ~e0 ? ~;fe# "E rep /f°/-j Subdivision name 6,C,¢kloc. Vo4Lct 5e' Lot no. Other homes on property? Yes J,- No Previous owner of property Aoy6 "A S k-,S 7-,&F L Total size of property r-, r 9 Ae, Total size of parcel 2. rf A e- Date parcel was created /o - z - Se, Are all corners and lot lines identifiable? k Yes No Is this property being developed for (spec house)? X Yes No Volume ZZ4Z- and Page Number 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. r 3 clypp A 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. s3 ~yoa t7- i atur Applicant Co-Applicant 2 Date of Signature Date of Signature r Stale Ric of µ',v onvi+t (+inn 2 1982 r3 Yale / ' 1 WARRANTY Dt:::U ' w DOCUMENT NO AEG'61 t~KS Ovr:"E _ i p STf Q101n CU , W! R c'd for Fz Douglas C. Katner, Bernard J. Net: ti-an, SEf' 2 9 jy;05 - -and Chris P. -Neuman- t 0 P.M 12: 3 conveys and warrants to Sam E. Miller SPACE nESEnVLD rOR RErOMnhG DA'A ftA.VE ANN RE TURN ADOnESS I~ I the following described real estate in --St.-- Croix County, State of Wucoasin: I' ['RAC'1 ' II t;' (Paiccl Identification Number) s NW1/4NW1/4, Sec. 15-T29N-R19W, except Certified Survey Map recorded in Vol. 5, P-ge 1418 as Doc. No. 393288, and except Certified Survey Map recorded in Vol. 6, Page 1761 as Doc. No. 420627. ~I TI 1 This__- is n0thomestead property. it (is) (is not) Exception towarra,;tici: easements, restrictions and rights--of-way of record, if any. 4A September 95 Dated this __-------.---_l~Q1 _ day or 19 i -C - (SEAL) (SEAL) Douglas C. Katner Bernard J. Neuman (SEAi.) - _ •wr^ _ _ (SEAL) Chris P. Neuman AUTHENTICATION ACKNONN'LEDGME.NT I' Signature(s) STATE Of %T;U"' !W,1.`F Chris P. Neuman SS. County. + authenticated this'" ~ d y of September _ , 19_95 r, l1y unj betorc me this x`'day of ri-d 19 ~as C. Katnpe Kristina and it TITLE: MEMBER STATE BAR OF WISCONSIN fit (It not, - r authorized by §705.96, Wu. Stet;. pr Va„:., exec++rt.¢ ) to me knry n to be the rwn t- foregoing in,irni;t and acknOwledfie.~ 3 THIS INSTRUMENT WAS DRAFTEO By y i Kristina 0gland