HomeMy WebLinkAbout036-1050-70-100
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS
SUBDIVISION / CSM# LOT
SECTIONA. ' T_ l
T N-R_L7_W, Town o f1-
d
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
S e 9-1
f
-o
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
. ~I
BENCHMARK: C ,9
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER /,HOLDING TANK INFORMATION
Manufacturer:Z')"'e<.e.r Liquid Capacity: ZQC
Setback from: Well House Other
t Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
:SOIL ABSORPTION SYSTEM
Wij*th: Length Number of trenches
°5tanc Direction to nearest prop. line:
Setback from: well: House Other
ELEVATIONS
Building Sewer l 5`7 ST Inlet.jj,_L~ ST outlet
PC inlet PC bottom Pump Off
Header/Manifold_L Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION: PLUMBER ON JOB:
C.-
LICENSE NUMBER:
INSPECTOR:
3/93:jt
a
-Wisconsir.PepartmentofIndustry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations
~ ° C'ft:3ZX
Safety and Buildings Division INSPECTION REPORT S'~
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 68513
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9600223 4/ Zke-
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
SepticS n/ / Benchmark}
Dosin C~ l . A , 31 -4,!2,7'
Aeration Bldg. Sewer 97: 7/
Holding St/ Inlet
TAIQIK SETBACK INFORMATION St/ Outlet
TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet
rl
Septic NA Dt Bottom
i
Dosing NA Headers k-7 eration
o A Dist. Pipe ~'lding Bot. System ~
PUMP/ SIPHON INFORMATION Final Grade
Mar,w turer Demand r
Model Numb GPM
TDH L Friction Ft
F rcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits on-side Dia. Liquid De h
DIMENSIONS DIMEN I N
SYSTEM TO P / L BLDG WELL LAKE /STREAM LEA IN anufacturer:
SETBACK C AMBER
INFORMATION Type O Q, Mode Number:
System: n~a. C R UNIT
DISTRIBUTION SYSTEM
Headers Distribution Pipe(s) d / x Hole Size x Hole Spacing Vent it Intake
Length Dia. Length S~ Dia. Spacing
SOIL COVER x Pressure Systems Only xx Moun r At-Grade Syste my
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded Ich
Bed /Trench Center Bed /Trench Edges Topsoil E] Yes ❑ No ❑ Yes No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STIAivTO- NE, NW, 2.10JP AV
17
Plan revision required? ❑ Yes No
Use other side for additional information.
SID-1110(R 05191) Date Inspector' Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH •
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION Bureasafety u o oand ff BuiluildiinWater Systems
g Water 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 1/2 x 11 inches in size. S' T.
• 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 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
GL ev ~►j~v4 y1jr,/1i4, S T 7/ , N, R,( E (or
Property Owner's Mailiir g Address Lot Number Block Number
7.7 g f GrA 141;v.
City, State Zip Code Phone Number Subdivision Name or CSM Number
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ !t Nearest Road
E] Village 5*74.,T
Public Ig-1 or 2 Family Dwelling - No. of bedrooms -LTown of o o21 /K
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 -E] Apartment/ Condo 6 ` / d
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. ppew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing 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
11 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 ❑ 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, . 7 9 Feet Pf'Feet
VII. TANK Ca
n g ant
alloS Total # of Prefab. Site Fiber- Plastic Exper.
INFORMATION i Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App.
New Existin strutted
Tanks Tanks
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑
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 Stamps) MPRSW No.: Business Phone Number:
Plumber's Address (Street, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved sa I ary Permit Fee (Includes Groundwater ate Issued Issuing Age Signature (N to ps)
,Z~Appro E] Owner Given Initial 7111,: R
10 Adverse Determination L Surcharge fee)
X. CONDITIONS OF APPROVAL / REASONS 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 maybe renewed before the expiration date, and at a time of renewal a=v n,e ~ cr~ a 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) tc De 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 13 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.
~
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1"=40'
BN--top of 3/4"pipe by power pole at el. 100'
alt. BM= top of blacktop at road edge at el. 100.51
dm 210
24' 30' 1 g ►,o~ sup-n'42 ~o Pei.
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
µ COUNTY
St. Croix
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. 036-1050-70
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
Dale Swazsrn GOVT. LOT NE 1/4 NW 1/4,S21 T 31 N,R 17 A (or) W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
1641 210th. Ave. na na na
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE MOWN NEAREST ROAD
210 th. Ave.
New Richmond WI. 54017 (71$ 248-3787 Stanton
New Construction Use [x* Residential / Number of bedrooms 3 [ J Addition to existing building
j ] Replacement [ J Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate • 7 bed, gpd/ft2 •8 trench, gpd/112
Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2 •8 trench, gpd/ft2
Recommended infiltration surface elevation(s) 94.00 ft (as referred to site plan benchmark)
Additional design / site considerations na
Parent material outwash Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable for system IBS El U M❑ U 91S O U ®S ❑ U S ®U S M
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed T
1 1 0-3 10yr4/4 none is Osg mvfr cs if .7 .8
..02.0% 2 3-84 7.5yr5/4 none co s Osg ml na na .7 .8
Ground
elev. h w
97.85 ft. Depth to
limiting
factor 17 2 119 y
+84"r
ru-f y'
A7 I
Remarks:
Boring # to
1 0-3 10yr4/4 none` is Os mvfr cs if .7 ~.8
2 2 3-84 7.5yr5/4 none co s Osg ml na na .7 .8
n
Ground
97..70 ft
Depth to
limiting
factor
+84"
Remarks:
CST Name:-Please Print Phone:
Gary L. Steel 715-246-6200
Address: 1554 200th. Ave., Ne Ric ond, WI. 54017
Signature: Date: CST Number:
6-16-94
I- 1
PROPERTY OWNER Dale Swenson SOIL DESCRIPTION REPORT Page ? of 3
PARCEL I.D. 4 036-1050-70 a
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ITmnch
>.,.,3.,..> 1 0-26 7.5yr4/6 none co s Osg ml cs if .7 .8
<:'< 2 26-27 5yr4/4 none sicl M na cs na np .2
Ground 3 27-84 7.5yr5/4 none co s Osg ml na na .7 !.8
elev.
97.05 ft.
Depth to
limiting
f
Remarks:
Boring #
1 0-82 7.5yr4/6 none co s Osg ml na na .7 .8
kj 4
Ground
elev.
97.05 ft.
Depth to
limiting
factor
+82"
F
Remarks:
Boring #
1 0-12 10yr4/4 none S Osg ml gw if .7 .8
5<..: 2 12-8 7.5yr4/6 none co s Osg ml na na .7 '.8
:ii:;4H:i+;?:j;:y`:
Ground
elev.
96.75 ft.
Depth iu
limiting
factor
+82"
Remarks:
Boring #
Ground
elev.
ft. `
Depth to
limiting f
factor
i
Remarks:
SBD-8330(R.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel 1554 200th Ave.
CSTM2298 Dale Swenson New Richmond, WI 54017
MPRSW 3254 NE4Nw4 s21-T31N-R17w town of Stanton (715) 246-6200
t
N
1"=40'
BM=top of 3/4"pipe by power pole at el. 100'
alt. BM= top of blacktop at road edge at el. 100.51
3z`
24' 30' t 1 0 ~D{~UYn`~2 ~o'UEi P"ih
13'
30
° a-/d
loo- t-1
Gary L. Steel
6-16-94
522832
CERTIFIED SURVEY MAP
Located in part of the NEh of the NA of Section 21, T31N, R17W, Town
of Stanton, St. Croix County, Wisconsin. N
NC L
9 FILED °
+ v- N
O -
5 O CT 2 6 19940- 1 =o
e z a+
JAMES O'CONNELL
wt z
Register of Deeds a
St. Croix Co., WI e o
w e+
UNFI_,-71-TCC LANDS
210TH_ AVENUE L
~
~ b
North line of the NW; CS e a
N89059'28"W
- N89°59' 28"W 316.79' N89a59' 28"W
9.0
1307.10' 8
M
ZNW Corner of 990.31'
U7
Section 21 N89 5912811W 316.79' N4 Corner of
Section 21
LOT 1
z 3.99 Acres Inc. R/W
173,805 Sq. Ft. 01
C71 t ro
~I + M - M 0 x
L 1 0 `n 3.75 Acres Exc. R/W RJ I1 '941
J~ - 163,351 Sq. Ft. M N
O iv i°n ST. CROiXWE1f;. t U I - N
Z
00 ►Nn N lJ I ~Ornprsha iae Via; :r
I-I C o - - 00 <i Parks Ce~rnrrilft
rn Jr
QI - o CLI If not half -ji m LI
CLI within30ifti q
~I 1 approval dfeiLe
nun ,9 • Wnlr!
4' Scale in Feet
291-1211E 117 0 50 100 200
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
, ~j
OWNER/BUYER f IV
MAILING ADDRESS ~Qr/~ /iG✓ /~c~~••~~••l w' s`1a/7
PROPERTY ADDRESS / Z ~U ` ti c
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION 1/4, ()~L_ 1/4, Section , T_3L_N-R__W
TOWN OF C ~ ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
1 a~3~
CERTIFIED SURVEY MAP , VOLUMEPAGE, LOT NUMBER I
C_
Improper use and maintenance of your eptic system uld re~su t 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 expiration d e.
c°
r' n
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
i
• 8TC- 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 eoun
Location of property_N_E,.~1/4 NW 1/4, Section T_3j_N-R 1 -7 W
Township ~tQr1~f Mailing address
Address of site _ l6 J / Zi
Subdivision name Lot no.
Other homes on property? Yes No
Previous owner of property te, F , gw&Wn 0(nd n o , & ~On
Total size of property
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 _'~-_No
Volume 110~1- and Page Number 67 ,
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. 5693ysi , 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.
5n,3 (ArA
Signature of Applicant Co-Applicant
_ ok r %3
6 Date o 'Signature D t of Signature
y DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
STATE BAR. OF WISCONSIN FORM 2-1982
523459
REGISTER'S OFFICE
Dale E. Swenson and Neoma P. Swenson, husband and ST. CROIX CO., WI
; Recd fvr Record
ia%fe
NOV 14
.0.......5 ..A.
10.:0"0'-5..J.99
conveys and warrants to Z`-racey._L._-Ellevold• and-Michelle M. at M
4
-Elleyold_,._husband_ and wife, s
f;
Re$istorofDa.9d3
41-4 Vi
Er~ To ~V1~11P 1~~..
- %~Glo~ o k r
.
the following described real estate in St.__CrQiX......--... m~rSa Z St(OZ~
...........County,
State of Wisconsin:
Tax Parcel No
Part of the NEA of the NWT of Section 21, T31N, R17W, Town of Stanton,
St. Croix County, Wisconsin, more fully described as Lot 1 of Certified Survey
Map October 26, 1994, in Vol. 10, page 2836, as Doc. No. 522832.
try ~
This is not
homestead property.
-
(is not)
Exception to warranties: Easements, restrictions and rights-of-way of record,
~M . if any.
Dated this l ~w-------------•---------- day of ---------November ---------------------------------------1 19.. 94-.
---------•-----------(SEAL) .---.I , ------(SEAL)
* Dale E. Swenson
(SEAL) ---------(SEAL)
* * Neoma P. Swenson
AUTHENTICATION ACKNOWLEDGMENT
Signature (s) Dale E. Swenson Neoma P. STATE OF WISCONSIN
-
Swenson as.
County.