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HomeMy WebLinkAbout038-1061-70-500 ~ O ~ $ O U u> N O 00 ' ~ 0 o C)) o o~ >U .0 id o~ ! a d oQ D oo 9 'a) 0 ~L ° N d xI V I O N ; Oa a Y N O ~ ~ ~(n f6 NN U u V) LI) N 0 C lL C CL u 0) 0 Z O O L L c ya3o3 LL O m 0 N O CF) m L O) 5 O 2Nm m 70 Q O aN N U f'J ~ I Z E co to = 00 z a in z I o z a c v r o v' d Z c N H O 4 N N N C H a O O O • N d (n O J jN N C) O Z c p Z m I N zzo I M n R Y d Q (D ~i Q Q CL E c o Z V > a U) 0) U) ~ U 0 3 3 3 a o 4i 1 • Laaa v J U Z O O } v ~rl 0 0 0 O p p a N N L p p 3 N O~ N co N C n M LO N N N Q .O. w M ~ _d ? ) ~ ~ hl O O 7 O O 3 r I~yl! C co ,pn LL O C ~ O h 0 O 0 0 ~ a N N C V a m o o r \ I~ N N O O- 'Y C 'O N N V L _ E c A N rn O O l0 cD f`6 M ` O N 7 N n N 4r M N tD H L M 2 -O MLn C7 O) V y N F- Z G N ~ O M N o 0 p t=p E ca U O r (n O N O Z N ~L (n ^r 0 `m € a # a ` a r A cia2 0U)UO 3 V STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ,F~~J- ADDRESS UBDIVISION / CSM#_ 'Z3 LOT # ECTIONT N-R D W, Town of ~9a -ra T. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTE 17` ' ,sue a p ~a INDICATE NORTH ARROW rovide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. t i BENCHMARK: J ) ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: 1A Liquid Capacity: / , Cj Setback from: Well House /2 -Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location -:SOIL ABSORPTION SYSTEM Width: Length - Number of trenches Distance & Direction to nearest prop. line: /_?o A),,L - Setback from: well House_ Other i ELEVATIONS Building Sewer ,/Oy ST Inlet. ST outlet PC inlet PC bottom Pump Off Header/Manifold er Bottom of system 97 / Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: 5 INSPECTOR: 3/93:jt W. Wisco*sin Department of Industry; PRIVATE SEWAGE SYSTEM County: Labor and Relations S INSPECTION REPORT ST. CROIX Safety and Buildings Pivivision (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI DODGE, DELBERT X STAR PRkIRIE CST BM Elev.: Insp. BM Elev.: BM Description: I" -L Parcel Tax No.: /lJ Dv . et_1 ;rte < J *9660823 TANK INFORMATION EL VATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic -pit ~ Benchmark Ac v. Dosing Aeration Bldg. Sewer i 6) -5 Holding St/ Ht Inlet 3e TANK SETBACK INFORMATION St/ Ht Outlet 7 . Vent TANKTO P/L WELL BLDG. Airito ntake ROAD Dt Inlet Ar Septic NA Dt Bottom Dosing NA Header / Man. , S 5 g8o0 S Aeration NA Dist. Pipe go 4 ,1, 7, 96 ' Holding Bot. System 49.1 PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft oss Fi Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~a J F DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type O Moe Number: System: oS 8 OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x 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 ~o Bed/ Trench Edges 0- Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: STAR PRAIRIE.15.31,10W, NW. SW LOT 4. H CC 1124 Plan revision required? ❑ Yes [Z/N0 Use other side for additional information. 171 SBD-6710(R 05/91) Date 66spdrtor'sSignature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: t ` j Safety and Buildings Division ~•G~~ 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 812 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number a35 y13 The information you provide may be used by other government agency programs ❑ Check if revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION Prop)i0y OiN er N me Property Location 1/4, S T , N, RIAI (or~ Property Owner's Ma ing % 1ress of Number Block Number Ci , State Zip Code Phone Number Subdivision Name orber I. TYPE F BUILD( G: (check one) E] State Owned El ity Nearest Road C] vil 1-1 Public 1 or 2 Family Dwelling - No. of bedrooms 3 Town OF ~7L ja,~Ojf /,P- Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo ®fg_ /ns,/ 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 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 112) 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 Require (sq_ ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./ ch) Elevation :L~ ] /1-5~ " Z Feet Feet VII. TANK Capacity gallonTotal # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks 11 1 Septic Tank or Holding Tank - - ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT 1, the ndersigned~ assume responsibility for i st Ilatio he onsite sewage system shown on the attached plans. Plum er' ame: Pr Plum er' Ign ur o St p MP/MPRSW No.: Business Phone Number: 15-9 Plum er's dress ( ree , ity, State, Code): IX. COUNTY DEPARTMENT USE ONLY ❑ Disapproved Sa Itafy Permit Fee (Includes Groundwater ate ssue Issuing A nt Si ture ( Stamps Approved E] Owner Given Initial / QD Surcharge Fee) 3/~~ Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR ISAP ROYAL: f Ze SBD-6398 (R. 07,94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber f 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 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- 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 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 1.983 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. i X~C ~~ffJ' ~O t~6.~ fVl~ Y~,SW Sze ~ s 1 1 1 ~ } y~ as , s Wisconsin Department of Industry, SOIL AND SITE EVALUATION Labor and Human Relations Page ~ of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. County Attach complete site plan on paper not less than 8 10,,x ti tz.. Eexmus t 5~ include, but not limited to: vertical and horizontaleme a point (BM), dihpercent slope, scale or dimensions, north arrow ar4)6cation ay+~ Ws*ce t road. Parcel I. D. # APPLICANT INFORMATION - Pleas int all r fornnation. Reviewed by Date Personal information you provide may be used for sect T@V purpooS i4Rrivacy It r4,r~ 15.0408r~)). Property Owner rty Loca' n Rl'cA, 12 STavT , 'gyn. t Nw /4 51V 1/4,S T ,E' -ox Property Owner's Mailing Address t # B ck# Subd. Name or CSM i3S3 AW,4TVejF_f- T•P- f~-~~`_~e~'~ / CsIy rAj G- /l 30YC) City State Zip Code Phone Number Nearest Road hFUpSo.J SSIOIco (7/S )Syy-(o73/ ity r F-1 villae / Town ~WY. CG L?J New Construction Use: ERIUsidential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: o 3 Code derived daily flow O ( ' Y ' Y gpd Recommended design loading rate 7 bed, gpd/it2 ' -0trench, gpd/ft2 Absorption area required bed, ft2 7~09 trench, ft2 Maximum design loading rate bed, gpd/fi2 • 8 trench, gpd/ft2 Recommended infiltration surface elevation(s) Jr 3 ft (as referred to site plan benchmark) Additional design/site considerations ' ZfSE ZOAJ6- Allf ,OW 7A0,5 (V-1 (S - ~,?Ved -V-v SLOE Parent material SLR C~ DU ~~if C/%j~ OUI`LrJ w Flood plain elevation, if applicable N14- ft S = Suitable for system Conventional ~M,ou/nd In-,G--r-,ouunnd Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system S❑ U 5❑ U S 1 1 U EJ S❑ U El S u El S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench 1 o-/& /OYR 31;k-- /W /X s ~vf y ; .s I 1e,--)71o0,31,3 i~ 2 f,s6.~ 4m71ie CS /!/f 5- ; - G Ground 3 ~7- PD /b Yip elev. ~f. P ft. Depth to limiting factor Remarks: q IC'f Of G' • A1524' PF" DESiIr.✓ /D ~¢OiN S /pi47iL D~ • S GPl~/ lril Boring # - ; . /o y Y/,~/ !s /.r►, sic- d~ C5 . 3 sy lo-,V/2 S - D . s cP '1 Ground elev. Depth to limiting facto in. Remarks: CST Name (Please Print) w (3 e r 1~ `n l GI., T a-lure ~l f Telephone No. -71S- 3 86 - ~/8 S Address Ulbricht & Associates Date CST Number Private Sewage Consultants e57'9' 1 PL_ 655 O'Neil Rd. Hudson, Wis. 54016 PROPERTY OWNER R' S1'~U SOIL DESCRIPTION REPORT Page? of .3 PARCEL I.D.# Ld 7- # Horizon Depth Dominant Color Mottles Structure 2 Boring Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench l 9 /o ye 31511 2'F sb,, n,,,fR s /Uf .S ; - (o 2- V- i y o y` S~/, 2 ^Nl s!~ ,►~f,~ 't 5, G of ,5 ' G Ground 3 f- /D S. d S Gt - 7 P elev. y~ W Depth to limiting ; factor AeLln. Remarks: Boring # ©-p Hoye 31y S,/ Z f sb& fA s /UF , s ; , 6 /0yR 2-f56,t 3 io x 11 S 0, S aQ - 7 .00 Ground elev. /00.0 ft. Depth to limiting factor 1&1-in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/fI? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench S Boring 2 3/ - 5//. ) f sbk m fa S a- is - s~ )fs6& f,~ a5 _ ,s;•L Ground elev. Depth to , limiting FT factor In. Remarks: Boring # Ground elev. ft. t Depth to limiting factor In. Remarks: SBDW-8330 (R. 08/95) IMPORTANT NnTR Tn nWRTTZRC JZ_ TXTemaT T VD. T„ L,.._ 1 < P/PO,oO S tv CVO • G o T . 1314!5r: Tod of3/y„.,mow 33 l' Pb~~E ~o ~o . J q ~ (o °10 1 , is 3 6,0 ~ 3 y ~ Z ~o y. zy' STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNERBUYER "I- MAILING ADDRESS q PROPERTY ADDRESS D l U (location of septic system) Please obtain fior^ fka niann;no r)Pnr CITY/STATE Lcl.,k I - PROPERTY LOCATION N K1 1/4, f w 1/4, Section W TOWN OF ti 1LCW`.~ SUBDIVISION CERTIFIED SURVEY MAP,-3 9026 , VOLUME]I, PAGE Svy 0 , 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. UWe, 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 expiration date. SIGNED: v 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 Q::gr Location of property /yW 1/4 .%W 1/4 ,Section /-5-_, T 31 N-JR__Lff_W Township C7-41- Mailing address 9W wy b Address of site 0 Subdivision name Afiolot no. Other homes on property? Yes-No Previous owner of property //.ZcK AN S*~uT Total size of property Total size of parcel 9-~0 X Y6~, Date parcel was created S Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house)? \,~,,-Yes No Volume and Page Number 4am 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. 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. Signature of A icant Co-Applicant i • rOCUMENT NO i STATE BAR OF WISCONSIN ACA ;r 2-1982 i WARRANTY DEED j -4 j ----II REGISTER'S Cri*'FiC7E - = - it ST. CROIX CTY ' _ Recd for - Richard O. Stout and Janet P. Stout, _ _ FEB 2 2 1996 j -flu- and and. wife surv_ivor.ship marital property, at 1:00 P&1 II conveys and warrants to Delbert. J . Dodge - I c / L'f 11 e~ (J~O~ I `ea.cwtn.4„f.- Register of Deed, i~ II RETURN TO /C pO i /P)k X ao L~ I-, following described real estate in _~~.-Cr01 x County, it SQ1y~ (~i/ $~/G+aS i State or Wisconsin: Section 15, Township 31N, ?ange 18W further described as: Tax Parcel No: Lot 4 of Certified Survey Map recorJed in tha office of the St. Croix County Register of Deeds on January 5, 1996, as Document ~ No. 538230 in Vol. 11, page 3040. I c I, I~ Ij ii i i I; II This- is not homestead property. (is) (is not) Exception to Warranties: easements, restrictions and rights-of-way of record, if any. Dated this 21St dayor February 1996 I (SEAL)<Yw (SEAL) Richard O Stout - Janet P. Stout j r (SEAL) (SEAL) 'i it AUTHENTICATION ACKNOWLEDGMENT ( Signature(s) STATE OF WISCONSIN I' St. Croix ss !i County. authenticated this day of . 19__ Personally came before me this-2I St _day of FQhri,ary 1Q4E-the above named -:3ir:a ti4__S - - -nut- Janet- P jI _~tQlt TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to -e to be the person S who executed the (i authorized by § 706.06, Wis. Stats.l fcrego, Instrument and acknowledge the same. ii THIS INSTRUMENT WAS DRAFTED BY, Jn~~r Sro.~ y OTA)q~, Z ✓ ll r , 538230 CERTIFIED SURVEY MAP Located in part of the NW1/4 of the SW1/4, Section 15, T31N, R18W, Town of Star Prairie, St. Croix County, Wisconsin. N OWNER Richard 0. Stout 1353 Awatukee Trail 0 3 Hudson, WI 54016 ~ -P Cq LEGEND U~ .°v viN 1 Aluminum County Section Corner Monument Found O 0 o N • 1" Iron Pipe Found 3 L b 1" x 24" Iron Pipe Set, weighing 1.68 lbs. per' L V) M linear foot 0 Wk Corner 4- 0 -0 L. o Section 15 100' Roadway Setback Line o v - - - - 12' Wide Utility Easement L. N E?..:.. N C 7 y O1•- N O C N V7 O m O O L. a..l O N M In Lr~ --j m3~ 96 - N f 0+1.I ' nW 220.7,8 v Sj~.~G~• S86°20 m 12.28'- - 208.5 r;,al data tt l sha;!! be 33' 3 3' 1 I ~ I I` Ir- i~ ~1-N I~~ cn I o I~ I I -1 t o i o I~I } IRl y ° F-I 1-I 0 NJ 0 0) c> C, LOT 4 I~ o N 2.32 Ac. Inc. R/W tj i 100,975 Sq. Ft. v ~W ' I~ 2.18 Ac. Exc. R/W 95,139 Sq. Ft. II'- c~i I ~ , ~ ° rn I1~ I c.~ I ICS i N I o I C _ E L 4 ' Q 6 6' I tt ~ V, 4 °