HomeMy WebLinkAbout020-1316-10-000
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 7e V - 1 P412,S012
ADDRESS 3 03 4ke, Xy
SUBDIVISION / CSM# ~7&*7 L Z74-l-- LOT # T
SECTION T N-R W, Town of
ST. CROIX COUNTY, WISCONSIN
P 41M VIEW
SHOW EVERYTHING W HIN 100 FEET OF SYSTEM
t
/Y
t
1 ~
~ v
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: 4
ALTERNATE BM•
SEPTIC TAN / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: 6~-,'Ce /I 5 Liquid Capacity: /0dm
> 4;01
Setback from: Well House
f
,lam ,3® f other ~ A~, ~s
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width:- 1a _ Length i7 Number of trenches
Distance & Direction to nearest prop. line: 9!9
Setback from: well: !cvv~ / House-'5V_ Other
ELEVATIONS
Building Sewer t~ ST Inlet ;?LZ L ST outlet
PC inlet ---PC bottom Pump Off
Header/Manifold a7- Bottom of system 7
_Z
Existing Grade- ell$ Final grade DATE OF INSTALLATION:
PLUMBER ON JOB: ~y~ph ~r~..G! r
LICENSE NUMBER: ,3 .3 /:J~
INSPECTOR: -12
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
"'Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division ST CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
262390
Permit Holder's Name: ❑ City ❑ Village g Town o : State Plan ID No.:
JOHNSON STEVE & MARY HUDSON
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
TANK TO P/ L WELL BLDG. A
ir Ito ntake ROAD Dt Inlet
Air
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
oss Head
Forcemain Length Dia. f Dist. To Well
SOIL AiSORPTION SYSTEM
BED / T ENCH Width Length No. Of Trenches PIT No. Of Pits Inside Liquid Depth
DIMEN 1 N DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING manufacturer:
SETBACK
INFORMATION Type O CHAMBER Model Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header /Manifold Distribution Pipe(s) ix Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON. 24.29.19W, SE, NW, LOT 46, BENDY DRIVE
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No
ADDITIONAL COMMENTS AND SKETCH "
SANITARY PERMIT NUMBER:
i
4
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 8112 x 11 inches in size.
• 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 ❑ Check If rbvision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATI N INFORMATION -PLEASE PRINT ALL INFORMATION
Property One ame ~ P operty Location
/4 4, S ,?,-3/T , N, R/~? E (or W
Property Owner's Mailing Addres Lot Number Block Number
City, Sta a Zi ode Phone Number Subdivision Name or CSM Number
p ~ Village Nearest Road
If. TYPE F BUILDING: (check one) ❑ State Owned
Public ]Rri or 2 Family Dwelling - No. of bedrooms own of ✓i- V-
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1❑ Apartment/ Condo 45~2 o 3 0
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_ ______TankOnly ______________Exlsting System__________Exl-- --System
B) Q 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 eepage Bed 21 C] Mound 30 E] Specify Type 410 Holding Tank
❑ Seepage Trench 22 E] 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" t Elev. 7. Final Grade
Required (sq. ft") Propos7d( q. ft") (Gals/day/sq. ft.) (Min./inch) Elevati
U o Feet et
VII. TANK i Can altoacct5 Total # of Prefab. Site Fiber- Exper.
INFORMATION New g Gallons Tanks Manufacturer's Name Concrete struttedCon- Steel glass Plastic App
Existin
Tanks Tanks
Septic Tank or Holding Tank ~U ❑ ❑ ❑ ❑ ❑
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.
PI 's Name: (Print L Plumb gamps) MP/MPRSW No.: Business Phone Number:
~
s- - Ze~ -15
Plu er's Ad ress t , City, State, Zip o
IX. COUNTY/ DEPARTMENT USE O LY
E] Disapproved Sanitary Permit F (Includes roundwater ate Issued Issuing Agent Si tamps)
rgefe
7-/
XApproved ❑ Owner Given Initial
i . 54
Adverse Determinati n
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety 8 Buildings Division, owner, Plumber
INSTRWC-TIONS
i. 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 ne~~ 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.
111. 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.
FLU I FLAN
PROJECT_ ADDIRESS
1 /4 /l/~rJ1 /4/ lT N/R/y W TOWN CO TY , - a >c
MPRS Byron Bird Jr. 3318 ATE
BEDROOM CLASS PERC CONVENTIONAL IN-G ND PRESSURE
CONVENTIONAL LIFT_ MOUND_ HOLDING TANK
SEPTIC TANK SIZE /;;2 0 U LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE-
ABSORPTION AREA ~5-(g PERC RATE , -7 BED SIZE A~2 -7 12
` ► Benchmark V.R.P.' 'Assume Elevation 100'
Location of Benchmark %
R, ,
0 Borehole Q Well Sca et
O Perc Hole System Elevation
Uent
12"
Grade
TYPAR COVERING..
N
2
1 2" 3' ` 4 6' 3'
I 6" Sewer Rock
i 12'
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m 46. 00 W ~LINE OF SECTION 24, QE-"
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page - of 3
Labor and Human Relations
Division of Safety & Buildings in accor HR 83.05, Wis. Adm. Code
COUNTY
~ 8 ~ ST C&001')(
Attach complete site plan on paper not less tha 1 inchii1"hM, an must include, but
not limited to vertical and horizontal referenc M), directio,A and"' , ope, scale or PARCEL I.D. ff
dimensioned, north arrow, and location and Coto r6,wst road
REVIEWED BY DATE
APPLICANT INFORMATION-PLEASE P$t ALL INF-Okl' 11O
PROPERTY OWNER: j~ ' , r P PERTY LOCATION
c7i f f /f'I /v y if IJSG , `1? \ LOT 1/4 1/4,0-11T Z9 N,R 1/` E (010
PROPERTY OWNER':S MAILING ADDRESS T BLOCK # SUBD. S ME R E
1yl6, 3R0 S T- y~
CITY, STATE ZIP CODE P 40, tdy18~R! OCITY OVILLAGE [ffOWN NEAREST ROAD
(fup.5 0~ W 5~lO I Co (-715) - voso,v BE.voy
[q'New Construction Use (k4,'Residential I Number of b6drooms 3 -to ~ [ ] Addition to existing building
[ ] Replacement [ ] Public or commercial describe File if~Pi ~~f Ir3 t ' - Q s O ..j U/
yse -
Code derived daily flow (&o0 gpd Recommended design loading rate NA bed, gpdAt2 -.J(I- bench, gpolft2
Absorption area required ! - & bed, ft2 trench, 112 Maximum design loading rate 41114, bed, gpd/ft2 ' 4O trench, gpolft2
Recommended infiltration surface elevation(s) 3 ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material $CS Sq SA rT E- Lo, c Si ~ TS Flood plain elevation, if applicable It
p N
S = Suitable for system CONV IONAL MOUND KGROM PRESSURE 7AT-GRADE SYSTEM M FILL FIOLDING TAM(
U= Unsuitable fors stem LA'S O U ❑ S U ~S O U ❑ S ❑ U [IS o u fi S C}li~
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistencce Barhtary Roots GPDIft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed iendh
0-07 /0 vl~' 3~~- 5-11, f s~k A- fie s s
z /~/l y aye 3/3 Si 1 + Q /IM-F,e CS ! f N N
Ground 3 ~7-3/ o 3/y et S S~ , G
elev. eS Q S
F7.2-0 it. x-10 7's ye ylY
Depth to
limiting
factor
Remarks:
Boring # [ ' ~l 5
16 Yid 313 Jr// f s h& 4.1-F1101 CS
P- J I a ye 3/zl -)-ill h,r 444 -ICI ' a s l U
elev Ground FS. GS ft.
Depth to
limiting
factor V
Remarks:
CST Name:-Please Print i2p (3 E-R -r u 1J3 p- I-C 1,,T- Phone: 71-,5-- 3,96 • 9/ 8S
Address: _ Z 2 -1-5 6'S'T,A'1 .2- y4, L
Sinnature . .,_~.....e aghwaea consultants Date: CST Number:
PROPERTY OWNER RV S SOIL DESCRIPTION REPORT Page? of 3
PARCEL I.D. I LOT y~o S(i,y2 /DG
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
Bed tench
V4 1-0be 313 -FAD (T ,5
-F1 /U f S-
Ground 3 - ys ~b ye Y y s~ ~-~s6,~ t/ ~,e Q w , y , s
elev.
It. e57
D S G~IL
Depth to
limiting
~
factor
i
i
Remarks:
Boring #
7 Z 5"-55 /o t j ~i'/ ~.w► J nM f i' 2 S / f , S .
Ground S ,S ~s f> S' G~ 17
_
elev.
~32-0 It.
Depth to j
limiting i
factor i .
Remarks:
Boring #
I ye 2-11- fe nM f i2 S /vf ~u
;G -f ~o VA 31-1- Si / Z,k~ Sh,~ n-►► 4 S /~f , S . G
75 y y Ground eS d a - - d
elev.
y. yo it.
Depth to
limiting
factor 1i
Remarks:
Boring #
Ground
elev.
it.
Depth to
limiting
factor All
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
c St. Croix County
oWNER/BUYER c~ -ke vC n Cr . 4 Ma r E. Jo ~ k o
~urrt ►1 a rtSS
MAILING ADDRESS SS~ I3{ n U o L,, r~So_~ w
PROPERTY ADDRESS ~6 r vi 1 b~
! II (location of septi system) Please obtain from t e Planning Dept.
CITY/STATE X7101)90A/ W
PROPERTY LOCATIONS 1/4, 446/'114, Section, T,=;? N-R.~W
TOWN OF 14u D SO N ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP ,VOLUMEAGE , 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.
i
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 retu ed to the St. Croix
County Zoning Officer within 30 days of the three year a ration date.
SIGNED:
DATE: V YI ~e_
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 S-IeVev? .
Location of propert C 1/4_1/4, S ctionc52 T9 fN-R W
Township i4y'bs od Mailing address 30Lip -erg
~v~S6iU ,WT S'~O~~
Address of site 5
Subdivision name 5uyj k' Lot no. 41(0
Other homes on property? Yes -No
J
Previous owner of property Ja M e_ ¢ I'Y2 a V RV Soh
Total size of property 3. oo V armC
Total size of parcel
Date parcel was created lL~-
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes )LNo
Volume Z~and Page Number /Z/ 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
warrant deed recorded ~h 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.
ignature of Applic t Co-Applicant
Date of Signature Date of Signature
_ 0(l tir.\IE BAR OF '%1ISCO',SIN FOR`.! i 1992
J'i`tV~sJ WARRANTY DEED
-
DOCUMENT NO. l it
This Deed, made between Greenwood Entarpr ise . , Inc.
a Wisconsin corporation '.SAY 1
-
3:"~5 P.
and Steven C. Johnson and Mary E. Johnson, hush '
and wife as survivorship marital property
W itnesseth, That the said (irann•r, for a valuable ~'un> ieraui~a 'D ne r1W, WA( E E, CIE/CR'D , i`A' A
-
dollar and other good and valuable consideratica %A1.1E."j7)kEr,t,J,7„cHe ,
consevsto Grantee the followingdescribed real estate in St. Croix Greenw0 Enterprises, Inc.
County, State of Wisconsin: 1416 hird St-2et
I1 scan, 141 54016
1 ~~7J j _ t G
( Parcel Identification Number)
Lot 46 of the Plat of SunRidge III, filed in the -Iffice or the Rel;istcr of Deeds
for St. Croix County, Wisconsin on January 2, 13'-6 in Volume 6 of Plats, at
Page 46, as Document Number 538046.
is not
This homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances t!ac_unto belonging:
And ...__Greenwood_Ente_rprise,s,_Inc.
warrants that the title is good, indefeasible in fee simple and free and clear of c sc+ mbrances except
easements, restrictions and reservations, if 3-v, of record
and will warrant and defend the same.
-i`t May 19 96
Dated this - - - - - day of
GREEN OD ENTERPRJ~ES, INC GREE'_<l: OD UTERPRISE NC.
i
BY:~~ (SEAL) 3Y~
SE,\Lt
Jame3 E. Rusch, its president ia~rg- usch, it secretary
(SEAL) - (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) James E. Rusch, its president STATE -;f WISCONSIN
- ST_ CROIX
County.
au his/ d of May 19 96 Personally came before me this day Irt.
19 96 the above
usch its secretar
Tar' R. R
- - - I
is A. M(TEE: MEMBER AR OF W CONSIN
(If not,
- - - -
authorized by§ 706.06, Wis. Stats.) -x':n,,
'n to he the perulfi who executed the
r ec!ror strument d a nywl ge the s;.mc.
THIS INSTRUMENT WAS DRAFTED BY YLI
Lois A. Murray, Zilz and Etitreen V
621 Second Street ~t1