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HomeMy WebLinkAbout020-1313-80-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ///7~ 4571 ADDRESS e SUBDIVISION / CSM# ;~Ie LOT # SECTION ~Z T_!_N-R /f W, Town of ` ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET F SYSTEM o I F \ h (off h n T 1 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tan}: manhole cover. BENCHMARK: oG ' -V f ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Well_ House Other Pump: Manufacturer Model# Size Float seperation Gal eyc Alarm Location ,..SOIL ABSORPTION SYS 1M Width: L Length_ ,5 ,S' Number of Z L Distance & Direction to nearest prop, line: /o ~/fSl Setback from: well:/14g4_ House---Y Y , Other ELEVATIONS Building Sewer ,Z ST Inlet. j? J~. ST outlet PC inlet PC bottom Pump Off Header/Manifold- 1G,3 Bottom of system 1r.3 ,~,ua~~ - Existing Grade_~ Final grade fSe DATE OF INSTALLATION: PLUMBER ON JOB: fig/ LICENSE NUMBER: INSPECTOR- 3/9 3 : j t ' V017PNsin•Department ofindustry, PRIVATE SEWAGE SYSTEM County: Saffetaety a andnd H Bumauildinngs D Divisi Reivisi son INSPECTION REPORT ST. CROIX ` S (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION Pe~Drn~L~Ider'CONSTRUCTION [I City village XTown of: State PIA %M 4 CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: G .6 , ' o xt- TANK INFORMATION ELEVATION DATA U y' TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 'led. Dosi n ~~1114 , (/y( / 3S~ 10-2, Y71 Aeration Bldg. Sewer 3 G ea, 6,:2 Holding St/I, Inlet 'S~sy 7, ' TANK SETBACK INFORMATION St / bf~ Outlet 6s TANK TO P/ L WELL BLDG. ventto ROAD Dt Inlet Air Intake Septic >a/ Cr 3 NA Dt Bottom Dosing NA Header t tb= /3' i Aeration NA Dist. Pipe Y, 161 Holdin Bot. System 9 S3( ' PUMP/ SIPHON INFORMATION Final Grade , Man cturer Demand Model Number TDH Lift Friction System TDH Ft mead Force in Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length 1 No. Of Trenches PIT No. Of Pits Inside Di id Depth DIMENSIONS Z 1 0 LAKE /STREAM LEAC Manufacturer: SYSTEM TO P/ L BLDG W SETBACK INFORMATION Type o C MBER Moe Number: System: ,(cp( ~j OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) / x Hole Size x Hole Spaci Intake Length (I ' Dia. Length -5L Dia. Spacing SOIL COVER x Pressure Systems only xx Mound Or At-Gra ystems Depth Over It epth Over „ xx Depth Of xx Seeded/ Sodded xx Mulched 11 Bed / T~h Center _ 3D 7"/1, ed / T-amh Edges -1) R ?o Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) fps LOCATION: HUDSON.22.29.19W, SW, NE, LOT 8, ROSS ROAD_/HWY 12 i l_J ,(.~c,C~l QGc.~p /!1.[.~.~9 .~?o-~ ~ /_.t;1,%f~-`.~'`` Z`i ;~Y1E'~`~/~ ~-n ~ ,v'+2_ ~~L(irr( E .Y tt.,E I n r'.n d v f1~ -G _ O, 6 S LGy1oC ve~I, Plan re is required? ❑ Yes [4-IQo Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH `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 12 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number a.6 q 40 The information you provide may be used by other government agency programs ❑ Check if revision to prey us application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Propert Owner Name Property Location r W1i4 1/4, S 2.2. T , N, R Idy E (or Property Ownprj Mailing ASWress Lot Number Block Number A" S7- 607 1 City,te 7~I • Zip Code Phone Number Sub ivision Name or CSM Number - 1 ) / 14N 11. TYPE BUILDING: (check one) ❑ State Owned 0 !t~ Nearest Road ❑ VII age t 1 Town OF Public 1 or 2 Family Dwelling - No. of bedrooms rif III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 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. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an __System System Tank Only______________ Existing System _________Ex 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 1 ❑ 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) 01 Elevation B Feet , 7 Feet VII. 'TANK Capacity site in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION Gallons Tanks Concrete glass App. New Existing structed Tanks Tanks Septic Tank or Holding Tank 40W 4000 1001e_k_~ ❑ ❑ ❑ ❑ El Lift Pump Tank /Siphon Chamber r El ❑ El El VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation oft nsite sewage system shown on the attached plans. P ber's Name: (Print)Plum rs Signa yre-(#o Sta s) MWMPRSW 4No.: Business Phone Number: I ber's Address (Str et, y, State, p ode): O Z 2'j, IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued sluing A ent ignat re o Sta S) AApproved ❑ Owner Given Initial Surcharge Fee) 1:~~~ Adverse Determination OCJ X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBO-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS r` 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. f 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. 12- i NG R08Ef4N 54023 phone T49-3656 -17 L aks~ r 4) 0 ~ ~c st. © I /D , ~y a f o ~SF ~ ~r`OTr'F- ~ r X2.7' C~UtcS .zof (rr 7 CQLG /r e© / ~,rff~ sr ,~wf~ ~'BtE ,Sr anm2 i~ = 13it4 7o/,> of Al re .47- f o F w~c~ ©f 7 M E 4 ~Lld . i s a~ . 14 1 N Li N o f W x 'Cob h ~c o' ti -~coR~ i~ Laboad Department ndusvy, SOIL AND SITE EVALUATION REPORT Page l of 3 Labor and 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 8 1/2 x 11 inches in size. Plan must include, but • eearx not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION F (G'V GOVT. LOT 5", 1 1/4 ~ 1/4,S 22T 1 N,R E (a((V PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME ORIG&W Y?' .2- - ff 'y 41W CITY, STATE ZIP CODE PHONE NUMBER- LJCITY ❑VILLAGE DOWN NEAREST ROAD rv'- s o (?8/) 11,66 /2o S New Construction Use Residential / Number of bedrooms fr Addition to existing building j) Replacement Public or commercial describe Code derived daily flow. ,600 gpd Recommended design loading rate , 7 bed, gpd/ft2 , .p trench, gpd/ft2 Absorption area required e.5", P bed, ft2 7s _~;y trench, ft2 Maximum design loading rate ___,~bed, gpd/ft2_.ltrench, gpd/ft2 Recommended infiltration surface elevation(s) f'S.3 ft (as referred to site plan benchmark) Additional design / site considerations /V 06yr Parent material Flood plain elevation, if applicable ft 17S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM 1N FlLL HOLDING TANK U= Unsuitable fors stem EIS El U ❑ S I Z U OS ❑ U ❑ S O U ❑ S U U [3S JOU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft Texture Consistence Ba#x~ty Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tw& o T o Z - SStL ©2F'.J FR024t/ 17S - - L ~,Zo2E~e.J F)eo2c`vU S T 2 .3 Ground 3 p- f/ 6 5 e2~ L !¢s 7 elev. 2Z ft. `lr y S3 - 6 LS t r~,, Tf S B Depth to - a limiting F IA factor F~ Remarks:/ /1fo ~L TlE/,~T d © SL r Co Hf~ o pt.~/V~. Boring # 3 Ground 2~- - s ©S~ L elev. pg. ift. Depth to limiting factor Remarks: CST Name:-Please Print Phone: yr 50 CC /Z T Address: Signature: Dat : CST Number: PROPERTYOWNER -I)EL7-fi2 ro s'l. SOIL DESCRIPTION REPORT Page 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 1 b - OLD 24V S ? - - p.G 7y Z 2-? to - 6 - c F o24 oL,~- S , Ground 3 _ S p L - ,7 .B a 7- elev. 9~ft. Depth to limiting factor Remarks: Boring # -<Z- F/70z6-ju F,9vZAW 145 ?r> 7 z o^ ^ 6 -<1 C- F/ZO o2C01 S - . 2 ,2 _ ~vt .7 .B Ground elev. ~P•7 ft. Depth to limiting factor Remarks: Boring # y s 2- G SG /FIZo2EA/ vZF J 951. z 3 _ s O sG L - 8 Ground elev. 9~ 2,ft. Depth to limiting factor Remarks: Boring # \~5 Ground elev. ft. Depth to limiting factor Remarks: r j ucw Tester g Plumber Roed Rp F t4 54023 phone 749-3656 ~I f t 368 l! ~vC ~V1/ N vy i 4 Go ~ y l ss l s f I If ~ C Lo f i , -,04A, npp &F PAXL *7- 9,fSol Or j'ncvE2 ?6LF, r ~-S5'U1~rt (mO. D ~ 109 ` = t N~ • = F©I4ND LOT CoRwF- R ; f ~j = .usp Pow EJZ POLE E , . ifs#~~ ~ . `.st f ~ y ~°i: .2dY ,?Fr?1', 4. ?fir:. I ~ ~ i e STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BV R e7-- /osT1 MAILING ADDRESS _ ;Le F , Ve /X LA/ r PROPERTY ADDRESS 4L (location of septic system) Please obtain from the Planning Dept. CITY/STATE fJ~Cw10GL.~ S M 6 01 PROPERTY LOCATION _,E~V 1/4, 1,loe!' 1/4, Section 2- Z , T_ N-R - W TOWN OF ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER g CERTIFIED SURVEY MAP - , VOLUMF,24_PAGE 2 OT 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 a piration d te. SIGNED: J DATE: 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 Location of property,2Cr/_114~_1/4, Section 2 2 , T 2' N-R --L----W Township - /54 Mailingaddress 7B,y 4r- 46*-0 r~. -ni Address of site 2 Subdivision name Lot no. Other homes on property? Yes ✓ No Previous owner of property Total size of property Z. ~r Total size of parcel _yd o~,c~J Date parcel was created Are all corners and lot lines identifiable? _-V'Yes No Is this property being developed for (spec house) ? Yes ✓ No Volume zzr and Page Number Y641 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. oand wn the proposed site for the sewage ~disposal tsystem ) orr I e(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. Signatu f Applicant Co-Applicant Date 3f' Signature Date of Signature WARRANTY DEED DOCUMENT NO. They ip- 2-:-j Fl. Aecoru ing nary THIS DEED made between DET TA CONSTRUCTION ~.d COMPANY, a Minnesota corporation a/k/a DELTA SAN 2 1996 CONSTRUCTION, Grantor and DELTA CONSTRUCTION, 10:10 A. INC., a Wisconsin corporation, Grantee, Witnesseth, That the said Grantor, conveys to Gr3•we the following described real estate in St. Croix County, Star of W iscc n.in: /o Lots 2, 3, 4, 5, 6 and 8, Pheasant Run Addition to The Town of Hudson, St. Croix County, Wisconsin. F This is not homestead property. TOGETHER WITH and SUBJECT TO reservations- restrictions, easements and rights-of-way of record, if any. Together with all and singular the hereditaments and appurtenances thereunto belonging; t And Delta Construction Company warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances, and will warrant and defend same. Dated this 29th day of December, 1995. DELTA CONSTRUCTION, INC. f Virgil Fe or nko, Individually By: V'wgm orenko, President STATE OF WISCONSIN ) ) ss. ST. CROIX COUNTY ) Personally came before me this 29th day of December, 1995, the above-named Virgil Fedorenko, to me known to be the person who executed the foregoing instrument and acknowledged the same. ~4- CLS~1n~lY ~ . Notary Public, State of Wisconsin My Commission Expires: February 1996 1 ~ M , U. S. la. I L W N89059' 16"E N A 9 59'1 CE 719.34' " 14 181.93 355.00' 364.34' - + (D '2 - OBI 13 r z G LOT 2 6 a LOT I °m m 2.23 AC. w 97,10 4 SO. FT. I C7 C I ''f~ /1VJ~ I I✓ 6 PG. 1481 C I F I LOT 8 - S89°59'16"W 323.18' 2. 41 AC. 1 126,914 SO. FT 4.07 ACRES 0 01 f~,~• v/~ ~ u Z 177, 498 SQ. FT.0 U 2.54 AC. EXC. ESM 3 UN vN 1 110,739 SQ. FT. 8 LOT ro ~ C~Nlon~ I cr 2.27 AC. ~ ~ ~ ~ • n~ 98,849 SQ.FT. 2.21 AC. EXC ESMT. 10 I 96,348 SQ. F'' ~9 I Q5 \ I e EASFRE FOR • ~ / ~ crrc;RLS S AND EGRESS 9'16"E 355.00' F(-R rU%URE uSE y~ C~I • / 33, / I /1 9%/ i i33, / 66' WIDE ROAD - - --I - LOT 1 \•r \ \ . I Q/ - EASlEMENT FOR FUTURE ROAD 2. 10 AC. 91,450 SQ. FT N88009'52"W 266.01' EXC. ESMT§ ~5 y' 7 6 / SQ. FT. S83'19' 194.9E-- 69 72~"F 58141 4,9 NG EASEMENT ~i ~ / ` LOT 7 p 3.19 ACRES Og'08 138,990 SO. FT. C- A _ _ hP N g /JL . 1141 'G. 7/4 Ol5 W 'v -a 2.00 AC. ! I r.IE. , l I i 17,16 6 SQ. FT. 1 1 ,C. EXC. ESMT (f) 2.33 AC ~ I ~ 272 SQ. FT, G 2975 ° c~i O 1 ~s w N89 30'00"E tv-