HomeMy WebLinkAbout026-1089-95-000
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER j/, NT J~1L a CN~SKr'~
ADDRESS Ll S7`,
44 asn-nAla, t a gya / l
SUBDIVISION / CSM# LOT #
SECTION -?(,5) T 3 DN-R/2 W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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Provide setback and elevation information on revs
Provide 2 dimensions to center of septic tank i
BENCHMARK: j ooh CB~Nr~/2 FF~c ,~os/ loop
ALTERNATE BM: -
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity ctvd
Setback from: Well dYf~ House / 7'#-Other-
Pump: Manufacturer Model# Size
Float seperation Gall cle:
Alarm Location...__
SOIL ABSORPTION SYSTEM
Width: l~ Length _?6 f Number of : e,P r hes
Distance & Direction to nearest prop. line: > 7S
Setback from: well: /1~dyiG House ti ' Other
ELEVATIONS
Building Sewer itIA?C ST Inlet: y78.7j r ST outlet: 18'. k6
PC inlet - PC bottom Pump Off
Header/Manifold pS,S Bottom of system Fyr~
Existing Grade 10,&0 Final grade yf, a
DATE OF INSTALLATION: L /
PLUMBER ON JOB:
LICENSE NUMBER:
SPECTOR: Gc
.jt
Wisconsin 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 284220
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
PROCHASKA, DANIEL/CYNTHIA RICHMONC
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
(117, 60 f ~ 5 i /0
TANK INFORMATION ELEVATION DATA c>1116 A G
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Benchmark
Septic
Dosin (r , 6,( S`7~
Aeration Bldg. Sewer
~
Hol St /A Inlet 9 7-33
TANK SETBACK INFORMATION St/$ Outlet 97,13'
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic ( d ) NA Dt Bottom
Dosing NA Header / Man., 30~ 9S S~
Aeration NA Dist. Pipe
Holding Bot. System 3p' fL~
PUMP/ SIPHON INFORMATION Final Grade
Manuf r Demand A le:a
s
Model Number GPM
TDH Lift FLoss riction System Head TDH Ft
Forcem n Length Dia. Dist. To Well
7-
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Lengt I No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
LEACHIN Manufacturer:
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM
CHAMBER
INFORMATION System: nom, X35 .2~ i C7 > 7 OR UNIT e u
S be.~(
DISTRIBUTION SYSTEM
Header/manifold Distribution Pipe(s/1 x Hole Size x Hole Spacin nt To Air Intake
Length Ai! Dia- Y Length 32 Dia. 7 ~ Spacing
SOIL COVER X Pressure Systems Only xx Mound Or At-Gr 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: R CHMOND.30.30.18W.N .,SE.CO,UN Y RD, =
i
Plan revision required? ❑ Yes Rr"No /
mt-lr I
Use other side for additional information.
1 ZLn-
SBD-6710 (R 05/91) Date Inspector's Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
Safety and Buildings Division
v~'■Lri : 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- CIZAZX
• See reverse side for instructions for completing this application State Sanitary Per it Number
7~I~
The information you provide may be used by other government agency programs ❑ Check it revision to previous application
IPrivacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
L C G u..) 1/4 z 1/4, S 3o T 3o r N, R/91 E (ora
Property Owner's iling Address Lot Number Block Number
City, State Zip Code Phone Number Subdivision Name or CSM Number
II. TYPE F BUILDING: (check one) ❑ State Owned city Nearest Road
E] Public 1 or 2 Family Dwelling - No. of bedrooms 3 j Town OF AZ ,WV J1Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo " A
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_____________TankOnly______----- Existiiqn System _________E----------
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,oSeepage 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
91 ro ,Z? 1.° 99, S" Feet .,O rFeet
VII. TANK Capacity
in gallons Total # Of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank j::;W t ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the6nsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No Stam %%4MPRSW No.: Business Phone Number:
I er's Address Street, City, State, Zip 96de):
IX. COUNTY / DEPARTMENT US ONLY
❑Disapproved SanitaryPermee (Includes Groundwater ate Issued Issuing Agent Si tamps)
Q ~JJCC~) Surcharge Fee) j~
pproved ❑ Owner Given Initial
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 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-
V11. 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 8 112 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.
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DEf'ARTMf N(°'- REPORT ON SOIL BORINGS AND r/p~ SAFETY & L1111lDINt
INr-GIRT'll ,,~fYI 171V1' I()fJ
LABOR AND z PERCOLATION TESTS (115) MADISON, IW'Ix53`7O`7
-HUMAN RELATIONS Z./ ,
(H .09(1) & Chapter 145.045)
l
' U SE~Ti(TN; TOWNSHIP UNICIPALITY: I_U1' NU.:BLI<. NO,:ISUBDIVISION NAME: /4E 'i4 N R A cd I,), (W 4
LW
COUNTY: UYER'S NAME: MA ADORES
USE LPrN DATES OBSERVATIONS MADE
NO.BEDRMS: COMM flZ`I/LDESCRTPTIUtT>l1-->='T[Tb-nTRfffTToNS: >sl'TTZ` LAI-I0~1 TESTS:
Resldence u f\j J _ ow ❑ nepioce n 0 /c?,g ~ AIA V Z 1 / 9 ~
~I< _ 5~ B - SgITTR L~
RATING: S- Site suitable for system U- Sits unsuitable for system
N
V ~fCSNA MOUND: IN-G MS DU :SU E]U CECOMMENDEDSYSTEM:loptional) ~S ❑U S JWS 011)1 (IS C U 1 CONVE NTIONAA - B JI
It Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area Is in the W, / A
under s.H63,09(5) (b), Indicate: C Loris ~ Floodplain, indicate Floodplain elevation: W, __--J
PROFILE DESCRIPTIONS
BORING TOTAL P'f TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH -rI-IICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH=F ELEVATION Q__ EST GHE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- / fo,o 6o,1"7 1(\ }o% ,~"$sscrs i4"$eNSrC ~8~8eNosrc~e 74''eo cs -
B- Z 14 z 912`7 ri > 64 z LsC-I S /c~~~ t4Rrj 1 3- 9 s~ 97 ~S > 7.sW 6"$(-LTS ZI'62iJStL Z4"'$zr,LCSf4 k 64,DafU Kl_c 5---
B 4 ,o0 7. r/oN~ > 9,00 11-• -1-~'(a~S,~ r~"8a~)Ms 66 ~8a►vcsfC>1~
B S /o,o~ S,6S its _ >10.0'6 9"9ctTS z 'B~NSI( rS~BeNM °$RrvCS~C_R---
B- - a„~ M 6
PERCOLATION TESTS
TES DEPTH WATER IN HOLE TEST 1IME DROP I WATER LEVEL-INCHES RATE MINUTES
NUMBER MUf t*S AFTER SWELLING INTERVAL-MIN. PERIQD,1-- 1, D2 ' i1Z5f5 PER INCA
P- 97-Z 2 > Z 3 -
P- E t (-(v 4 - s R V - - -
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitablo soil Brous. Indicate scale or distances. Doscribo what Bra the hoti
zontel and vertical elevation reforence points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION Qq -S-
IN
AT Cc~kmja - o5-- cio, F6N C~~ TOP IS 1~ ?9 Sc4Lz
PAINT~N 0t>, NC~~-- Yoh ~C. -I/
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNED
MAILING ADDRESS
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE Pr'fi~ 't}r , .r . , c
PROPERTY LOCATION / 1/4, 1/4, Section ~ T ' r N-R_LjW
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP d%r + , 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 y expiration date
SIGNED: / L_'
DATE: T I -7A A(4 -
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.
--------------------------------------------------/-y----------------
ownerof property
Location of property . 1/4,,,,q 1/4, Section ;'c. T W
IP
f~
Township Mailing address
i
Address of site ; .
Subdivision name ` Lot no.
Other homes on property? Yes L,. No
Previous owner of property
Total size of property 4.;
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 y No
Volume 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. ;-J 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.
S' ture of pplicant Co-Applicant
` r : S ...T.1.'+If~•7a3r`9:i917+s~`;9K~-Yt~
-im ilk -WIN
549586 STATE BAR OF WISCONSIN FORM 2 - 1962
WARRANTY DEED
DOCUMENT• NO. VK2000PApp16
Kenneth H. Gerhan and Joan Gerhan, REGISTER'S OFFICE
- husband an w e, ST. CROIX CO.. Wt
f e 1orAated
SEP IT T 1996
conveys and warrants to Daniel M. Prochaska an►nt a at 11:30 A. M
L. Prochaska, -husband an wife, as survivors hi 1
marital Droerty,
Ro*tw of Daeda
DM SPACE ME"D FOR RECONW40 DATA
NAYS MO AMOK A0!~0ffSS8, . .
the following described real estate in St. Croix
C~aaeX /D~`~"r'~
State of Wisconsin:
026-1089-95
PARCEL MENTW CATM NUMBER
That certain parcel of land located in HI12 of SE1/4 of Section
30, Township 30 North, Range 18 West, St_ Croix County,
Wisconsin, more fully described as follows: Beginning at
intersection of the North line of said S'EI/4 and centerline of
County Trunk "A"; thence South 89 degrees 30 minutes East along
said North line of 3E1/4 812.5 feet; thence South 52 degrees 59
minutes West 353.0 feet; thence North So degrees 45 minutes West
663.26 feet to centerline of County Trunk Highway "A"; thence
North 33 degrees 36 minutes East along said centerline 235.40
feet to point of beginning.
t~FER
This is not homestead property
XXl4XXXAijK
Exagiort towarramw Easements, restrictions and rights-of-way of record,
if any.
Dated dds- dal, of September 96
(SEAL) ! '2' (SM
• Kenneth H. Gerhan
(SEAL) (SEAL)
• Joan Gerhan
AUTHENTICATION ACKNOWLEDGMENT
Sigttatute(s} State of ICURVAM MISSO
s,.
~acKsati. counx
authenticued this day of . 19 Rnoaalfy came before "re this t ;L4-L, day of
September , ig 96, the ahove nowd
Kenneth H- Gerhan anti loan
Gar pan s hu URhanA and wi f a a
TITLE: MEMBER STATE BAR OF WISCONSIN
(d not,
authorized by 6706.06. Wis. Stats.) to or brow. to be the person t81Sre
instrr~n+t mid acknowledge the sarm \ ••••A vd
TM INSTRUMENT WAS DRAFTED BY I ' A • .4I9n iF°= 4. 1
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- Pm
468C
469E -~7 469D
' -469C
J
f N 4-S 4
469A
PARCEL 469D/468C
3.5 ACRES
COUNTY ROAD A BOARDMAN
$29,900 Aft
PRESENTED BY:
TOM NIELSEN
BURNET REALTY
(715) 386-9060
(612) 436-8756
I ball] ti