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HomeMy WebLinkAbout020-1309-20-000 3 0 00 ~F cG, w, n O N O i y 0 J C O N N O z C C i LL O Q 3 M 0 z 'vi rn c w co ° Z N y d a CO C,J 0 o z v w -CD Z o c ° H ~ M a) N ' _~J N N N co U o o Q w z co z o N z N W E N - C m > CO a m co co C C ca Mn ° O G a t o N N U) U) U) m 0) CD, 0 L_1_)Vl a EL LL z° o 0 0 0 0 o a a a o in o en M rn aa) -0 o o ~V J N '9 Q) c N N °X a O 64 f0 m C-L N p N N .y ca O rn 7 ~ M 'p - QI 1- (0 d O O H O N C ° ° > C E © O N In aO c _ U N ° 0 0 0 o Lo 3 w N c N n. 0 0 0 \ N F- i N Y a N N N v L. _ O O C c d L f~ N O 0 0 LO a; 0) '7N cUi> m E U 7 00 y' O 2 > N O N {n O ~ V L a ` a w 0 CL 4) ~1 A 0 a 2''' 0 U) V STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER Mlly,dal. ADDRESS S y LTV 'K 12 L-7- Z.4 i l~ Yol~ SUBDIVISION / CSM#_~1~CFS.~Z n/% yz6c~J LOT # /Z SECTION 44 T-~ f_N-R_L_W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VI W ► 2' SHOW EVERYTHING WITHIN 0d FE T OF SYSTEM 3D.5 163 ~ I ~ of ~5-5► l~ SS C Iii t INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: 7~ y~ier /op p i ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: mom Setback from: Well tiiy, r House ,2 Other - Pump: Manufacturer Mode Size Float seperation Gallon cle: Alarm Location SOIL ABSORPTION SYSTEM Width: /2 Length_ S 5 Number of trerrches .Distance & Direction to nearest prop. line: z s ' Setback from: well: House Other ELEVATIONS Building Sewer 6 ST Inlet: PZ ST outlet: PC inlet PC bottom Pump Off Header/Manifold y'3 9 Bottom of system gZ, Existing Grade y',gp Final grade ;'j.2! DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: 32 h q INSPECTOR: ~r L 3/93:jt ti Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) Sanitary PArmi" tNo. GENERAL INFORMATION 28415 Permit Holder's Name: ❑ City ❑ Village ® Town o : State Plan ID No.: WAXON, VERNON HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA I(AS-Ailil TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic (,v-0-c j , ! Benchmark P.m 3,OZ- ,;F pp Dosing-1 Opera,. j Aeration \ Bldg. Sewer 5 7, Holding r St/ Ht inlet 97 W TANK SETBACK INFORMATION St/ Ht Outlet ( TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic ZS NA Dt Bottom Dosing Header/ Man. Y, 3v j 1 Aeration Dist. Pipe 3 Hol Bot. System S 3 CZ iUMP / SIPHON INFORMATION Final Grade 10 Manufaciiuer- Demand w h "a 3.96 Model Number M ction System Ft TDH Lift Loss mead Forcema Length Dia. Dist. To Well SO ABSORPTION SYSTEM BED/TRENCH Width / Length ,F % I I No. Of Trenches PIT No. Of Pits Inside Dial. Liquid Depth DIMENSIONS DIMEN I N nu acturer-. \ SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHIN SETBACK CHA. R /in i n Mode Num er: INFORMATION Type 0 f t System: bR..: I A- OR UNIT E" do. DISTRIBUTION SYSTEM Header / Mad C Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia- Length 727 Dia. _LL Spacing ~O SOIL COVER x Pressure Systems Only xx Mound Or At-Grade' ystems Only Depth Over r ri Depth Over xx Depth Of xx Seeded / Sodded xx Mulched Bed /Trench Center Bed /Trench Edges laTopsoil C] Yes E] No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.)~V/'}S`e~: F~. A LOCATWX; HUDSON. 10629.18W,, W, SE, 1L P ROAy? _A ~,~-.yyit's7-yr+H"~ ~Zt~1~iYY'~1`~ !Z'L L'~•'-_C`" - _ G'L~-~ lo' p Plan revision required? ❑ Yes Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH r SANITARY PERMIT NUMBER: Safety and Buildings Division 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 8 112 x 11 inches in size. Sl: C/Z~0t • 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 ❑ Check4 f'eia/pplication (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location v w,~ w~'~l4 5& 1/4, S ~G T Z 9 , N, R /,,p E (or) 4C Property Owner's Mailing Address Lot Number Block Number /L City, State Zip Code T34fir") hone Number Subdivision Name offer tow ® 3 j ,9 /X II. TYPE F BUILDING: (check one) ❑ State Owned Ity Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms • F 4 Towan OF hrpSol~ L ~A. 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo p?-O 330 - 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. 0 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 1 1 0 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 Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation S--U 9-7,,o Feet y ?,,o / Feet VII. TANK Capacity site INFORMATION in gallons G lions a ks Manufacturer's Name Conc ete Con- Steel g Fiber- ass Plastic Appr New Existin structed Tanks Tanks Septic Tank or Holding Tank Gr El El 11 Lift Pump Tank /Siphon Chamber El 1 1:1 F1 I El 1:1 1:1 VIII. RESPONSIBILITY STATEMENT 0171E a.rcc ti~~ 12 ",or- Roc.K 4`1>6e ~T - /YI 4*f: y'f car TV S.+?-Xs F y r"^K • c/rP 71.4 r Lt e_ I, the undersigned, assume responsibility for installation ttye onsite sewage system shown on tle attached plans. Plumber's Name: (Print) Plumber's Signature: (No Sta . s) ir4PfMPRSW No.: Business Phone Number: !~6¢~,~ m~Ffzr r 3 - 3 r< Plumber's Address (Street, City, State, /Zip Code): v r /0~3 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (1ndudesGroundwater ate ssue . Issui g Agent Signature (No Stamps) Approved El Owner Given Initial 1/yD 11 Surcharge Fee)~~ Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD-6398 (R. 05194) DISTRIBUTION: Original to Counly, One copy To: Safety & 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: 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 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 p,-efix (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. E / 9VZ y"cal 1o7- i2 cRrs /02 ` 2 1 7,0 I F(-f - I _ X i I i i ~8 ~rac/c) X = /3s~G 70 ?0,0 Zq 7- i /YQ I ~ Q i i ZqV } I I, I s I I^ .2/f~ DAVE FOGERN PLUMBING Licen"dpark 3fe ~3~t89 plumber Heights Roed € MgONSIN 54023 r Phone 749.36 l /or WAY xso"'/ ' v z -J a of M~ .1 rC r M ~N«Z1fJ i i,b •r i t+9 dl r(~ }rl r r, Xnl 3 °c irr' ail r r- *1 Labor iwdn dtNpartmeleao~a5°ry, SOIL AND SITE EVALUATION REPORT Page of 3 W Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY ST. cRot'1~ Attach complete site plan on paper not less than 81/2 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.D. a)e dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION (WA100 E. 4V A X 0 A) GOVT. LOT wEST SC 1/4,S 4 7 2 9 N.R. 1 c,' E PROPERTY OWNER':S MAILING ADDRESS LOT 4 BLOCK t SUED. NAME OR CSM sY S 9 cry. 1zo. A /Z PIC4SAA3T U(C- CITY, STATE ZIP CODE PHONE NUMBER MCITY []VILLAGE OWN NEAREST ROppp vpsoA.) 4atS. SYo/~ (7r5) 94, 3'13.0 HU OSo,J cry. ~O .4- (New Construction Use [ Residential /Number of bedrooms 3 ~40 q Addition to existing building [ J Replacement ( ) Public or commercial describe fl-qo Code derived daily flow &0 gpd Recommended design loading rate bed, gpd/ft2 ' IrerA, gpd/ft2 Absorption area required bed, 112 trench, ft2 Maximum design loading rate • ? bed, gpolft2 ' trench, III Recommended infiltration surface elevation(s) -eiAa PS • 3 ft (as referred to site plan benchmark) Additional design / site considerations oT~ 5 I~.C ( b to Parent material SCS Y t *1110rf 57/. Flood plain elevation, if applicable N ' . ft S = Suitable for system CONVENTIONAL Mode IN~G UND PRESSURE AT GRADE S~YSi~w FILL FIOLDgVG TAW U= Unsuitable fors stem BS ❑ U [3S O U O U S O U C7'S p U O S olT'- SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Con, Color Gr. Sz. Sh. Bed ionch ( 0-11- /v ,e 211 o i 2 s K _75- s7 3 •f- . S .6. Z- Z - 23 A 9 N , 313 s 2,m 5XIIr a°s a s 3 of . S • G Ground elev. 7 It. 3 3-38 to yR 'U~y 4/ S Depth to • y(P 75 ye y`lP •S d' limiting . factor Remarks: Boring # -/3- /o ye ?-/z z ~Z 'LS /o yR 3/3 s/ .2 Yd-r oes qes 3L'S~ Sr /f! Ilk Y/e, C.~. ©1 J cs 'CJ Ground eIt. g ,o y Depth to limiting factor~ Remarks: CST Name:-Please Print Rp OE 2 r IAL 13 R i c k r Phone' 715- 3 AM ~ 18 5 ress: & 55 0' Nei L 'k D. t+u0Sono [.v t S . Sg01ly - j 7 - cSrh 2y ?2L Signature: Date: CST Number: PROPERTYOWNER e SOIL DESCRIPTION REPORT Page 2. of 3 PARCEL I.D. If Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bot -day Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed ranch M 2/1 z S LM•l '541t S cs 97 •S •G 3 t a 40 Ground 3 7- 37 /D y/~ S/ C'. S. o, s Q/~ Ct S . 1 •1P sG.~tt. / 2- s y S16 z , s, VJQ -5 Yle Depth to 5 /D s • d~ GQ • 7 limiting y (actor ~ Remarks: A~4 V111'" 7i~ Boring # d / y /D yie ! 1 ~eS, f - C -S/ 2tin S/I S Or 3t e--, y 2- r,. 23 /o Ke J13 Ground io' y 3 ' y z •S s~6o" c' ~s 5d. ~f 5-k eeX It. limiting factor Remarks: Z Ike e P C i L7O A 0 r2 i. 2- Boring # : Sl 2A, sj,.C C s 3~ . S 1.~ 100 713 15 ele, • . 36 7 s y12 //G . S O. S a°-Q at 5 --7 00 Ground _ y~ S y l S' s K ~t `i Q elev. Z. S 4 S' A 51/ . S • rf I- s Depth to S to " y/e Y/L C',S• C~ S Gt~iQ • d' limiting faM If s Remarks: Boring # i Ground elev. ft. Depth to limiting factor Remarks: cIon enenio ne,nn. o ~ 3 ~v CIO o^ ' z° ~y ~ o. Q o Q boo ~ U.J c ro o r 1` t a ••-r v.Q N S'1'C-105 SEI'TIC TANK MAINTF,NANCI? AGREEMENT' St. Croix County O WNERfB++ i+1R W MAILING ADDRESS sy' Grc~ 04A) /76k &4N oe 't'C -W1r_ zJ6 _ PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE pim ~yD~6 ' 7 PROPERTY LOCATION - 1/4 y~ 1/4, Section -1'~N-IZ , W TOWN OF ~ Sdh ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP , VOLUME-- PAGE - , LOTNUMBER 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 Jul), 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. lAkle, 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. S I G 1\ ED: t DAIT T - \ St. Croix County Zoning Office Government Center 1101 Carmichael Road 11193 Hudson, \\'I 54016 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 yCM A,,Ik% 41,14 Location of property_AL.-(1/4, Section TI _.Z N-R1 W Township 4~pso-k Mailingaddress .s!V9 C. f, Address of site f,; 4",k$-07-7 IN ~f~ti'SOh ue .SYO/G Subdivision name ~Ltf,~s~vP !/,cEuJ Lot no. Other homes on property? Yes_,---' No Previous owner of property Total size of property .2,0/ Total size of parcel Date parcel was created Are al.' -No Is this 3 _L ---No Volume Register of Dee, A WARR AND PAGE NUMBER lition, a certif to avoid delays scription refere irvey Map shall 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. Z5-j1_5-P1 , 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. .2 S`f, S-J-/ 4- `U Signature of Applic nt Co-Applicant Date of Signature Date of Signature . ' N a \ rlX :m 12 N 00 I I c ~ •O ~m to ` a 0 A e` 1J O a M ~2 °p~~'~ ` cn c "w's 38°• s9 I \ I NN O co n N 1 \ ~m I I \ ` \ cn ss e \ )b ha m< -1 M'\ \ c 4 r o r coN '/8 \ I a O' Z 4- \ b 0 C 2 n1 O I 2 \ \ \ N -4 \ C 00 S \ \ `v ti cz l m /00' y ti (A 30 Z \ \ (A / co O~ 16 * I 1 0.? 0 \ ti m w .y to (A 0/0 m ? O /it 160 SOD \A e l G~ I `A N89°56'57I E 325. 91 / N 0) N Cn Cf o C O N % WARRANTY DGF.D 0`,orzaer Statutory Form). IB00KTATL.. ',0NSI ? Miller-Davin Co., hfinneatrolis, r;inn. 3 S Form No. 8 W. 911;ta Inbruturr, Made, by St. Croix County Public Welfare Department ~~;rolltor , of 5t'.-,Croix County, Wisconsin, hereby convey ood warratit to Vernon Fiaxon-,and Irene Maxon, husband and wife as ;joint ten.:nts and, not a?, tenant in common tt~ rl s, 01 St. Croix .l Wiscolkin. for the suln ofOne Dollar and other good and valuable consideration thr followiu_s tract of land in St. Croix Co;enty, State of Wiscoiisin- The West One-half Q) of the Southeast Quarter (SED of Section Sixteen. 16), Township Twenty-nine (29), North of Range Nineteen (19) West, excepting the railroad right-of-way of the Chicago, ST. Paul, Minneapolis and Omaha Railway Company and excepting a conveyance of lands to St. Croix County for high~;ay purposes as shown in Volume 11336" Deeds, page 65 in the office of the Register of Deeds for St. Croix County, and subject to an easement to the Wisconsin Telephone Company as shown in Volume "295" Deeds, page 371, in the office of the Register of Deeds r for St. Croix County. J 9 i fl:_ GI~,TC'f:' i OFFICE= - ST. CROIX ~'t~„ 1TJIw. Rec'd for R!cc,rtl this - 30th d,.Y of_S~ ten;bur A.D. 19 59 y~ ; M1 at_ :OD - A., N,. 1 i " IH 3:I7 lI 1. In Ulitur" 1111jerruf, The, said grantor ha 8 hereunto set his It,nul t n tl ;cal t lr i : 28th day of September a. 1). 19 59. SIGNED AND SEALED IN PRESENCE OF St. Cr x County Publi We are Dept.. - ~✓tccXff~ - 4/', I L 1 Kenneth H. Hake - - Sumner S. Brigh ire or _ Mary Ellen- Marlette .4tatr of Msronsin, ss. St. Croix County Pe)sotiall j cane before me, this 28th day of September J. D. 1959 the above named St. Croix County Public Welfare Department Rv 3umnwr R_ Srivht_ Director