HomeMy WebLinkAbout032-1037-90-200
C)
y Co
o O
N y
bq N
4-; 4 O
r 0
C
Cam.
O
O
N
M
O
y
a
a Lr)
O x
C w
N
,n L
y U
y N
(n O i
N
O Y
6 Z cca
C
3 N-..
LL C (0
O m
O O
~ O
3 M
~ m
> r Z y
W E
Z C
Z y y I
0
c
0 z 2 :!t c
c
V ~ r
U -
O
It 0
h P y
a rn a~ M
7 N a
[if
~ c
N N
d O
C O U
Z I- Z p
O
Z
C (o
N
00 0 ~ N N
O N N >
O ~ R
v r C. ..R.. Y c
_ V N d E p
O D d
Q p w !n M _O U ;U
V~ Z r > a~ N
•rv o a a a
(~yl N j (O a) rn
N J U ~ rn ai
>
Q N O N
a 7-
O O O
N m d
N 'o co N
u) d Q Q
-n 7
R
C
O O N N i
O O C R
O CC N p O U O
O U m m
£i O E- N C C_ O
O Y Y O N
M 6 U c c U
CD V)
_ LO ro
Z' N
r.~ N M E N 7 L, E
C) U) 0 N In
O ~
r E
GC
✓1 `y t0 d
at a CL
CL w
• c~ m 2 a)
0 C)
) (L 0 v) 0
r A L
q..
STC - 10 4 AS BUILT SANITARY SYSTEM REPORT
~
OWNER_& , cfl t . :;.R:
ADDRESS
~'a~2+~YSe TZ~." Sf wit'
SUBDIVISION / CSM# GS/n LOT ~
SECTION T_?/ N-R W Town of
e~E---'Qlyi~'v
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
v1
O d
n ce-
o e
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
c
l `
BENCHMARK: e
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity: )/pd
Setback from: Well House /Y Other
r
t Pump: Manufacturer - Modell Size
Float seperation Gallons/cycle:
Alarm Location
-:SOIL ABSORPTION SYSTEM
Width: Length_S Number of trenches
Distance & Direction to nearest prop. line:_IF '
Setback from: well: House Other
ELEVATIONS
Building Sewer ST Inlet. ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION: PLUMBER ON JOB:
LICENSE NUMBER: INSPECTOR:_ 3/93:jt
sconsinDepartment of Industry, PRIVATE SEWAGE SYSTEM County:
ST. CROIX
aborand.iumanRelations INSPECTION REPORT
.,afet and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION
Pe&rpj$,~~ld r_S;arpE- ❑ City ❑ Village R Town of: State Plan o.:
C~tKCtf~'tu~i 11~V 7C Parcel Tax No.:
CST BM Elev.: Insp. BM Elev.: BM Description:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark Q o , r3r3
Dosing 2 /
Aeration Bldg. Sewer
Holding 77 St/ Ht Inlet (q S~ S
TANK SETBACK INFORMATION St/ Ht Outlet
ventto ROAD Dt Inlet
TANK TO P/L WELL BLDG. Airlntake
NA Dt Bottom
Septic S~
Dosing NA Header / Man. L/(. 7,5q'
y/
Aeration NA Dist. Pipe 5 4 7.
Holding Bot. System „Sy qL.~ t "
PUMP/ SIPHON INFORMATION Final Grade
Manufkare Demand
Model r GPM
TDH Frict ion Sstem TDH Ft
Forceength Dia. Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length? No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN I N DIMEN I N Manufacturer:
SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHING
SETBACK CHAMBER Model Number:
INFORMATION TypeOp,t, / =~D 3 OR UNIT
System:
DISTRIBUTION SYSTEM
[Hea-der /Manifold Distriuton Pipe(s) x Hole Size x Hole Spacing ngth Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over xx Depth Of xx Seeded / Sodded xx Mulched
[Bed epth Over Yes ❑ No
/Trench Center Bed /Trench Edges Topsoil 1:3 Yes ❑ No ❑
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: SOMERSET.13.31.19W, SW, SE, 210TH AVE
ti+,Ti ~ta ' =F,L'! " ~ Y~,' " -'r.•r°•~a~~ .~''...C•Y..e_) i`+~--CJ~r1~
ZZ)
Plan revision required? ❑ Yes ❑ No
sfa
Use other side for additional information. MiQ a~~
Date In a `or's Signature Cert. No.
SBD-6710 (R 05/91)
Safety and Buildings Division
r"~r■Li SANITARY PERMIT APPLICATION Bureau of Building water systems
201 E. Washington Ave.
t 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. V- Q l
• See reverse side for instructions for completing this application state Sanitary Permit 7.0 eJ The information you provide may be used by other government agency programs
❑ Check it Ion papplica Ion
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
T , N, R E (or
4) 114 O!F 1/4, S I
3 3/
Property Owner's Mailing Address Lot Number Block Number
G
City, State Zip Code Phone Number Subdivision Name or CSM Number AN' ( ) i-30FF
II. TYPE BUILDING: (check one) ❑ State Owned ❑ it( Nearest Road
Vila, Public 1 or 2 Family Dwelling - No. of bedrooms ig Town OF S'd/~eYSa? d / D?/I 14,
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
0-70
1 E] Apartment/ Condo Q lT2Ja ~7~7~~ a00
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. S New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System
System System Tank OnlyExisting System Existing
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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 IA 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/da sq. ft.) (Min./inch) Elevation
y~e SG 6- 1 ?d' .vG~- 97 Feet dd e C Feet
VII. TANK Ca
in galloacitns Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existin structed
Tanks Tanks
Septic Tank or Holding Tank X ~d M; d A)e v;,10,p„ V ® ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans.
Business Phone
Plumber's Name: (Print) Plumber's Signature No Stamps) P/ PRSW No.: Number:
/ 'sc m ~G a ~k~d G3 2 711' G l2 l
Plumber's Address (Street, City, State, Zip Code):
D f d
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved S~rtitary Permit Fee (Includes Groundwater ate Issue Issuing Agent Signature (No Sta ty-~
Qj l `
Approved ❑ Owner Given Initial Surcharge Fee) A,j Adverse Determination 4
I Y14-
X. CONDITIONS OF APPROVAL / REAS NS FOR DISAPPROVAL:
SOD-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.
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.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than8 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.
~yo h► /G7-4 a Ue s~wv
fl~ ~ha~ kat~
Y
V
3
h
R
IA/a
~'ea D
senor.
i
3 ~
D % / Xv
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of
Labor and Humap Relations
Divisiop of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but ✓ , "
PA)7. #
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or b I _ ~ t;.0
dimensioned, north arrow, and location and distance to nearest road.
j1q _
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION R EDB!.L` 1 TE
PROPER WNr PROPERTY LOCATION
GOVT. LOT J 1/4 1/4, '14 F
PR l TY OWNER':S MAILING ADDRESS LOT # BLOC # SUBD. NAME 0 ti
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY VILLAGE ®f WN r N
y`
~f New Construction Use [)(J Residential / Number of bedrooms [ ] Addition to existing building
Replacement [ ] Public or commercial describe
Code derived daily flow °~S~ gpd Recommended design loading rate ed, gpd/ft2_trench, gpolft2
Absorption area required Z_ bed, ft2 ,5~3 trench, ft2 Maximum design loading rate ~---"bed, gpd/ft2_trench, gpd/ft2
Recommended infiltration surface elevation(s) ~y ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM Al FILL 7 HOLDING TANK
U=Unsuitable fors stem ®S ❑U [CIS ❑U CIS ❑U [ZS ❑U ❑S U ❑S ®U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
v:;4
Ground 3 - ,
elev.
Zal ft.
Depth to
limiting
factor
Remarks:
Boring #
6-
_41 'Z L2
Ground f
elev. - -
,meal ft.
Depth to
limiting
factor
Remarks:
CST Name:-Please Pri Phone: _
Address: ~°p S i-, 1
L'
Signature: Date: CST Number:
PROPERTY OWNER SOIL DESCRIPTION REPORT Page of
PARCEL I.D. # f
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. nt. Color Gr. Sz. Sh. Bed Trench
,a
Ground
elev.
l
j,:5) .4J
-
Depth to
limiting
factor
L
Remarks:
Boring #
/iw
Ground 3 s /
elev.
/~22zft. - 7
Depth to
limiting
factor
Remarks:
Boring #
al Jill
Ground
elev. _
Depth to
limiting
factor
Remarks:
Boring #
10 i!~01
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
"Ile
oSf~~'•OsJ AT .S/TK O ~le ~/~J~
(~-Efln-tom'
0
i
- I`~/_actlS~
r
n
F
Q
p
l
33'
=./11 1991 13_ 3E. ?151,1,361 PERP,`:' TE NI 1 F?Ef1LTV PAGC
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWN-ER/BUYER
5~' SllrCny'a-7` ~~4_~
MAULING ADDRESS
PROPERTY ADDRESS 76-12 I6 4y e-
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION 01) 1/4, ~ 1/4, Section T- J L N-R_l C?W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION eS___ - LOT NUMBER
CERTUUD SURVEY MAP qxp , VOLUME IPAGFr , LOT NUMBERT, _W
I) 3o9a
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)
tite 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.
VWe, 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 hm been maintainer) mint he. r.nmpleted and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED- Aj~ XAtl A4%',
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, W1 54016 11!93
1,?=44 1_,.=: =F ,1"':' 4, 1EArl 1 r-LAL 1Y PAQiE lit
~ly, r.,,cY .FU c AU,
• s •r ~ - ioo
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.
o f re r t _ - - J Wa-~ J~.,lt/1'1~11i1~. _ - -
owner pop y
Location of property.~U✓ 1/451/4, Section Ly T3/N-RL_W
Township __211 --Mailing address tie., y
Address of site
Subdivision name Lot no. /
Other homes on property? Yes No
Previous owner of property
Total size of property s -
~"5~(
Total size of parcel
Date parcel was created X94
Are all corners and lot ines identifiable? -Yes No
Is this property being developed for (spec house)? __X_Yes No
volumeJt and Wage Number as recorded with the Register
of Deeds. 348$
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 DEED::. In addition, a
certified survcy, if avail,abla, would ho 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 (ol.ir) knnw1 PdgP that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded it) the office of the County Register of
Deod-_ As Document ?Jo. 12L and that I (we) presently
own the proposed site -or -the sewage disposal system or l (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 c,-)f the County Register of Deeds as Document No.
Sig ature Applicant Co-Applicant
171- TFWA I RFAI TV PAGF n7
W C~ 71
v ~ 7
0
5'2882 ~
0
o ~
~ a
FLED ~.1
Bearings are referenced to the
9 APR 2 9 1996 1 south line of the SEA, of section 'd
13, assumed to bear $69'09'02"E a
KKVLEEN 01
Ragiswr of Dleds rr
> .crolxCo~wf 0
M
R
1
d \1\T~ ro
Q ~ O e ~ O ~
n g o IH IQ- M+
Kk~ n
~ er► t~ y,J w
O W. W• 0
A, w ~ ~ sY
D
A
301.07150"W 545.561
S 12.96'
-33.W n y
m o %R •s
j 0
c kv O
v
z I~ w w N
I ~ f1
I P J -34.81;' 511.96' a; w W
c I- Q 301.07'30"W 547.77' v+ CO S y0 r~ a m
ICJ ~ ilA V O N O 4 n O f~ O F.+ ~i
. W Q lNl. W K.- ~1 v~ Z1
-1
rn
> N -36.63 512.96'
,l{89.0910211W N01007'50"E 549.59' :h <
M tgt 66.001 S01 °0715011W 550.06' T
w b ' 7 512.96, pw ON `.Z..
t4 4"
g
S -a i -37.10
T vie >N
n ; k i O N Y~1 NW ty f (oho tf O OH
A b n d r _
n A
x rn r 3O
A
513.21' cn
n IC/) Ir o N02.21152"E 552.10' 0
7 ~ ~ IS IQ ~
%0 r ( N
°D I It may' ~ --I I
po 'r"fR En
, r+
tt 11i 1' 94 ii;: 6 15'24736:''2' FEP14>; TE91'4 1 FEALTY PAGE 06
J~~J a a y WARRANTY DEEP---z
'DOCUMENT NO, VOI. 1-147FAU 273 REGISTER'S OFFICE
ST. CROD(CO., WI
IF- j Lyle P. Klink and Marie A. Klink Redd for Record
us an an NOV 2 X995
>.i: is A. M ~
conveys and warrants to -Michael J. _ QpyMain and
Michelle M. Germain, husband and -llq, 4RR e~Qky tay ra'tp, t>t~ I'
I
I
THIS SPACE 1119ERVt4b FOA AECOADING AtA
NAME AND RETURN A00REss
I~
the following described real estate in St. Croix
(i
County, State of Wisconsin:
I:
i II
(Parcel Identlfieation Number)
I I II
SW1/4 of SE1/4 of Section 13-31-19, St. Croix County, Wisconsin.
SUBJECT TO a 66 foot easement for ingress and egress over the
~I! above described parcel, at a location to be determined and
CI described by a surveyor within one year of the date hereof. The
Grantor and Grantee hereto agree to execute an amended easement,
~i if necessary, upon surveyor's completion of the legal description
for such easement.
i
This i S homestead property.
(is) XXilnY,}X
Exception to warranties: Easements, restrictions and rights-of-way of
record, if any.
{ Dated this l' day of Ue t o be r 19 95
(SEAL) (SEAL)
Lyle e. Klink rtarle A. K1Y k
i i
(SEAL) (SEAL)
i
f
AUTHENTICATION ACKNOWLEDGMENT
`
Signature(s) Lyle P. Klink, STATE OF WISCONSIN
-
Marie A. Klink ss.
5•~r _ County.
i authenticated thi day of October 19_ 95~ Personally came before me this w..~ day of
I, V~~a/ h i , . , 19 the above named