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HomeMy WebLinkAbout020-1313-40-000 C c a) i-. O v 0o Sc a~ ` y o a r,. 0 0 N ~ I N O N M x N_ ~ O ~ Y z C 7 t6 C f6 U. O O) 00 Q 3 Cl) VI N z rn z o v z ~ m a~i a m N I- ~ c O C U O Z d c U d Z d' i' c fA I- r O N z c ~ 'o Cl) N O O m 6 Q. N N O N CL) C • Fy a (A o m Q ° m z z o N c z 'a y c C N i N C: m c LO v N (O N_ y i O T O O O L_ (0 O G G a -0 N N l7 /l Lc LO ~ I~ O O O a v a as `a a 0 0 ° z O O O •►v ~aaa N t!J J U T } p N (O T) 0 C) O ~ O O O O C CL M 'D N m n O ~ p Q c0 O 0 (D O O O O N C O O RR+ O C IS O y O O O O O C:, CO O 1; O C a IL N N N y Tr O ( E N O m v rr m C U 00 0) o L ro I~ M H N N CO _LO O Z. F" O O O 7 N N E U y' O N= D N O N =i cO ~ - E L v~ d a #t a L a w • c~ CL d .V d C £ i c c 3 `r1 A aa2'I',0U)00 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS SUBDIVISION / CSM# 5;,fV7 ,(BOA) LOT # SECTION 2Z... TAN-R / q W, Town of I~tiUSt~Ir/ ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM /l I I y 1 I i ~a 3 rF~E v _ o v r Lrw r / ~ ~ci ~ r /no IN CNORTH ARROW Provide setback and elevation information on reverse f this form. Provide 2 dimensions to center of septic tank man ole cover. r BENCHMARK: l 2 ALTERNATE BM• SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: A1,1 -e A1 Liquid Capacity: 3 Setback from: Well Allye House Other Pump: Manufacturer Model# Size Float seperation Gallo cle: Alarm Location SOIL ABSORPTION SYSTEM Width: 12 Length ~d Number of hes 2-- Distance & Direction to nearest prop. line: .a-- .ZD Setback from: well: House Sy Other I ELEVATIONS Building Sewer ST Inlet: z ST outlet: PC inlet - PC bottom Pump Off - Header/Manifold 9G f6 Bottom of. system l60 Existing Grade Final grade 1f:.0 DATE OF INSTALLATION: 2 f~ PLUMBER ON JOB: LICENSE NUMBER: .7 INSPECTOR: 3/93:jt Wiscorisin Department of Industry, PRIVATE SEWAGE SYSTEM County: ' Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284158 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: DELTA CONSTRUCTION, INC. HUDSON CST BM Elev.: Insp. BM Elev.: B Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA / /G1196 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing,( Aeration Bldg. Sewers. Hold' g St/pW Inlet 94 TANK SETBACK INFORMATION St/oOutlet TANKTO P/L WELL BLDG. Airito ntake ROAD Dt Inlet Septic X56 NA Dt Bottom s i Dosing NA Header 9K Aeration A Dist. Pipe 2/ 9~0 7t` 7 G~3 r Hol ng Bot. System (03' 9G, PUMP/ SIPHON INFORMATION Final Grade nufacture 7::mand °fJ OZ/ 99. dot` Model Number PM TDH Lift Lriction System TDH Ft Forceim 3i n Length Dia. I f Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length No. Of T enches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION {Z SS DI L NG =fe : SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM INFOR MATION TypeO ,e , - CHAMBE mbe System: o. 6c_d 5 4 o, OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length sb Dia. Spacing ~-P SOIL COVER x Pressure Systems Only xx Mound Or At-Grade S e my Depth Over Depth Over xx Depth Of `xx Seeded/ Sodded Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes o COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON.22.2)9~~.19W, SW, NE, LOT 4, HIGHWAY 12 Ot C& I /_1 ~bJ~Q 0 cr , O o - I Y- ) 3 Ian revislo required? Yes No Q r Use other side for additional information. /a /lO K SBD-6710 (R 05191) a ~c ate / Inspector's Signatu a Cert No r ADDITIONAL COMMENTS AND SKETCH ` SANITARY PERMIT NUMBER: ^:pE~ Safety and Buildings Division v■~r■r,t 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. 571-. c7o • See reverse side for instructions for completing this application State Sanita; yPgrmit umber The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION PLEASE PRINT ALL INFORMATION Property Owner Name Property Location o T T $W 1/4 1/4, S~ Z T 2 , N, R E (orj~ Property Owner's Mailing Address Lot Number Block Number X7 `l City, State Zip Code Phone Number Subdivision Name or-ESMber wa= Nearest Road LDING: (check one) ❑ State Owned ❑ Cityge II. TYPE BUI illa Public 1 or 2 Family Dwelling - No. of bedrooms pV Town OF /lziosvN Z III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 3 r 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 SystemTank 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 110 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 p 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 y.570 ~ 3 , 7 .7 OA .0 Feet . D Feet VII. TANK Ca in gallons Total # of r Prefab. Site Fiber- rExper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic New Existin strutted Tanks Tanks Septic Tank or Holding Tank pD Qga ❑ ❑ ❑ ❑ ❑ 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 Sta ps) r /MPRSW No.: Business Phone Number: T P umber's Address (Street, City, State, p ode): to ©3 &04 / .3 o c 1- 74. IX. COUNTY 1 DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued I ing Agent Signature (No Stamps) OApproved ❑ Owner Given Initial $ Surcharge Fee) -C~~ - Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) 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 may be renewed before the expiration date, and at a time of renewal ar.y nevv criteria in the Wisconsin Administrative Code will be applicable. 3. Al! 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 subm tted 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. 1X. 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. Nil ~ D v ~r N C i r I' e IT, 1N a Rr fr b J ~ y 0 ~ ` 1 t x r ~ h l y iz, o VN o v 1 / , - _ _ / U ~C n 0 p , IQ t -n t h • ( w _2 TIN 1 I I aL, 4 in ~N Z y~Z fhM y cv~ ~ ~ 1 myN ~'II vN=3 c i . HI a • • v IW6 E I 14 } I 3 Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page Of Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code FPAL TY 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 I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION WED BY DATE PROPERTY OWNER: - PROPERTY LOCATION L O GOVT. LOT 114 1/4,S. T 2 N,R E (9LjV 0 ERTY WNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # ~l ^ ES .vT- CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE [MOWN NEAREST ROAD ©6 ( ) Plots 2 [ ] New Construction Use Residential/ Number of bedrooms [ ] Addition to existing building j J Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate _bed, gpd/ft2 trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate 7 bed, gpd/ft2 . Q trench, gpd/ft2 Recommended infiltration surface elevation(s) 2 e n123 ft (as referred to site plan benchmark) Additional design / site considerations 41R Parent material Flood plain elevation, if applicable It S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U=Unsuitable fors stem ❑S ❑U ❑S ❑U ❑S ❑U ❑S ❑U ❑S ❑U ❑S ❑U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. Bed Trer>ch .7 X 0A< ~ L 3 577 ; Ground 3 s-- 0i 7._5 -S 6 S~ /Yt L elev. ~t• Depth to limiting factor Remarks: Boring # ~ Al l¢ C'o 3 / - SG 2- ~0 C ..2 31SL 42 Y 3 -~6 7. _-S S O dr- L - - Ground elev. /a26ft. Depth to limiting factor Remarks: CST Name:-Please Print Phone: vz' c )e i-y Address: / d 2 77 colt ©-a Date: CST Number: Signature: ,o .L 3 PROPERTY OWNER /~FCJ SOIL DESCRIPTION REPORT Page 2 of 3 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 v~ •4.v4v;.. vvv:y hv:• A0 - Z c .z c o z a- is - / S-9 X AA - s Ground 3 -led 7. F L elev. A Depth to limiting factor Remarks: Boring # SoD It -_j \i; Z 117- 9y,~ 3 z-s -VA/ 4a c s IF Ground elev. -Z. S- V 3 c 3 _T - .3 ~ft Depth to - s o L - - • 7 . limiting factor Remarks:- Z4c; y ('trT 7" > -.uZ Boring # " Z- z 33 0 - Sc F S Z .3 3 33- 75 -s a S6~- 4 - - Ground • 9 elev. /OLD ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) a e a , k r K a ~ w fi ~I a V ~ p N Gwlefi ~ ~ p CIA wwm 02 d, to V u' ow ut LLm > a 1 ti ~ o ~ S'I'C - 105 SEPTIC TANK NIAINTF,NANC1; A(;REh;Nl1,"NT' St. Croix Count)' OWNERIBUYI?R ~ - MAILING ADDRESS ,261le -Nojig PROPERTY ADDRESS fiy ,cars d~~ Z YOAr (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION 06L) 1/4, A!R 1/4, Section 2.-L T A f N-R Z f TOWN OF hfeL' , ST. CROIX COUNTY, WI SUBDIVISION ?fj~,6rA'tIr/l' / LOT NUMBER CERTIFIEDSURVEY MAP , VOLUME j, PAGE 2$W7S, 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 properly 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. UWe, 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 ust be completed d returned to the St. Croix County Zoning Officer within 30 days of the three year xpiration da e. 1 SKJNFD: - St. Croix County Zoning Office Govenlment Center 1101 Carmichael load Hudson, \VI 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 l ~ .rte Location of property ,E 1/4A/,,91 1/4, Section 2.,?- , T,7,r_N-R__Zf_W Township 114A. ct Mailing address _ Address of site 8'A/ 42SS lz!>. fctrp'sLit, Grwc 'rYe91,6' 40 Subdivision name s^,rAc,wT RKA/ Lot no. Other homes on property? Yes ✓ No Previous owner of property Total size of property Z./ Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes A/ No volume ([S"Srand Page clyrf 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. 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. C.a Signat re of Applicant Co-Applicant Date of Signature Date of Signature y 5 5 j VV V `giT , V'11-1) DOCUMENT NO. r TIFI;; I)I'I?,Ts maile b tus, n P1-;UF' k COQ; S. 1 CTIC), JpaN 2 199r= CO ~1~'~~ti a )Minnesota corporatir~n a' -a I)I;1 T A i` CONSTRUCTION, Grantor ani(l Ml" .TA CONS't 1=ti"C"f i io: to A.A INC., a Wisconsin cCfporation, Grantee, 0-_"c,3 dirtness-►lo, That , they st.~c1 Grintor, conv„ys G~.~rx :t th;e following described real estate in St. Croix County, Stsrrc of Yl.. A Lots 2, 3, 4, 5, 6 and 8, ?peasant Run A,.lditio i to Gifu Town of Hudt on, St. Croix County, Wisconsin.` I t.,is is not hor te,,Lcad pi •pcrty. r ~CT 10 reser~.d'.rnl, rc,iri;.ti.~n~, case_ !macnts and rights of-way s TOGETHER R WITH aiad St1#i3- TOGETHER , of record, if any. To Wier with all and singular ti ' ht'red tarp lots a~~' brlon-111g; - And Delta Construction Covipany warrants th.4the title- Is gt>_ d, lndlcfedsiblle in fee Siniple and free and clear of encumbrances, and will Warrant a n Dated this 29th day of December, 1995. DELTA (70NS r CYIO$, INC. ~ . F STATE OF WIS`'ONS:l N ) ss. ST. Ck()'kX COUNTY 296h d t I~ rn 19')3 tirF aiuoti'e nar ~d Virgil: _ a} Fersorial,y came N-fore r7' this a. FedJr~T> U, to me known to tip tL' lk:rSon who exmacJ the - fofc- *ng iristiufnent aild acknoMedoej the •ai~~c. ~ NI-Ai- 1-7-1 S1 C' WI: C Q' 1 n I1"~ C134 .tSii 5+. A.} I'~1:.'u ,•y, !~191£7 n N O y v n v M ~ 'D 07 A t O • • to Cn ^ . to O N 0 = N 0 ~1 • C7 3 N w A (D C N O =r -1 c ~ ra N r.. R o m m CO ZZ co O W -4 Q O N ? 0 W"' C 1 co o a ro a 3 o 00 00 00 r M 'N N n c CO W 6 aD .A N 3 C 7 O O 7 O rt O 7 N p ~ O C O w fD OD CY) Iv ~ a A ro (D i vOi N cD O I~ N O N y O O ~Q N 0) U1 a to m c M (n O c N rn rn o O O O < G G A A O C A 0 C 0 O ( r y N N m m o o m m 0) j v 0 cn m (D N - 7 a Z N ° z W z Q D m o C) O a v tr. o (D N N CD N (O N' C (D (D W (U a 3 ET z N (6 -I N . O .O» p Z ~D .o' N Cl) W ( N a z 3 i> 00 z m z y CD A Cl) r N 000 Q 7 0 0 a c 0 - G ''n N l0 O _ O' N N ~ -1 N C 7, (D O 3_ O O_ G 7 CD N O (A Q I O O X 7 cn t CD ~ W cl) a O(D O v cr ~o °o (D a R -0 N (D CL O N 7 O O p A O :3 b w q (D p rp Efl b r b I O O b m } 0 C' 1 V - bao- 1313 BOLDT s 17V L1J 1 daV LAJ 1 Ali %.A, JL PLUMBING & HEATING INC. "Serving You Over 45 Years" 820 Main Street Baldwin, WI 54002 (715) 684-3378 Fax (715) 684-3144 Date: Oct. 31, 2001 Pr>G✓ious owner off' horhe To Whom It May Concern; An on-site investigation of the septic system on the Lon Gilbertson property, located 864 Ross Road, Hudson, WI was conducted on 10/30/01 At the time of the inspection, the sanitary system appeared to be functioning property for the existing use (See exception * below). The inspection of this sewage disposal system was based upon a surface inspection of said system and did not involve any excavating or chemical analysis. Accordingly, there is the possibility of hidden defects in the system not discoverable by this inspe.!;fion. Therefore, it is understood and agreed that there remains the possibility of hidden defects in the system which are not discoverable by a surface inspection and this inspection does not ire any way warrant or, guarantee the continued proper functioning or operation of this system. It is recommended that the system should be purnped once every two to three years. Therefore, the prolonged life of this system is totally dependent upon proper maintenance of the system and can very depending on the number of people living in the residence, the age of children, wont outside the home, and use of garbage disposal. Should you have any questions regarding this subject, please feel free to contact this office. Sincerely, Dale E. Hudson Master Plumber / Certified Soil Tester #220853 "SPECIAL NOTATIONS: Vent cap missing on ispection riser.