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HomeMy WebLinkAbout038-1061-70-500 (2) ~ o h ° d N y o CE g c 'o U a c o y'ma N D )o 0 > V cr) ¢s a a.- .0 Q. -0 GO w p N x v (D U C rNi1 O It; > d C O a Y O « U) N O N V7 U V Mn Ln c-4 0 LL C O O U L C Z N N 'O L C O 3 7 6 N 3 LL o m w (O .N N (1) CD B O L ` N V C 'a :3 N ¢ O CL H V M Z E U Y o u, c) a m Z o z c O N d 2 c N H ! ~ v 2 N N O O ~ O- Q' C N O O O aO '1 • d L V U O Z m Z O N Zzo 4 M r E E a ( N d o o a E v Z v > o F~ FN- FN- E 0 0 0 a 0 caaa j U) o (D 0) -1 CD ai y 00 o Q (V (V .0 E N O 1[,~ t Mp r- (D (L m O rn M ~n 04 v r) d ¢ cn ~l ~ 0 3 o y c li LL o C o c :3 O r- o CD m I-- a m ° c v ° ° (D a CL C N O N Y O N N O C E C a N r O O V O N 3 r N W (O O M L j G O 0' rn q y N F- Z, C N M • roi LO c0 o u> O N E 10 to U S O r (n III 0 N O z 2 d C t`1V E 2 c t A 0 (L M 00 0 a1 U 3 1• V STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER sC /J.CI~E ADDRESS UBDIVISION / CSMW 1113 LOT ECTION T N-R 19 W, Town of T. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTE or, 17 IS-1 a 8 g ~a t~ o, S'C.J 1~ INDICATE NORTH ARROW trovide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. t BENCHMARK' J n 1 ALTERNATE BM: T SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity:, C-i Setback from: Well House 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: Setback from: well: House- Other ELEVATIONS Building Sewer /6-5/ ST Inlet. ST outlet PC inlet PC bottom Pump Off Header/Manifold e Bottom of system Existing Grade Final grade DATE OF INSTALLATION: o PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt Wiscowsin Dep4rtmentof Industry; PRIVATE SEWAGE SYSTEM County: aboa rc Human Relations Safety and Buildings s Pivrvision INSPECTION REPORT ST. CROIX (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI DODGE. DELBERT X CST BM Elev.: Insp. BM Elev.: BM Description: STAR PR*IRI Parcel Tax No.: TANK INFORMATION EL VATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic "-0 h Benchmark /c;p 0. Dosing 0 .7 Aeration Bldg. Sewer Ot7l o'11,53 Holding St/Ht Inlet 3a11' TANK SETBACK INFORMATION St/ Ht Outlet 7 . Verit . TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet Septic NA Dt Bottom Dosing NA Header / Man. , 55 98o0S Aeration NA Dist. Pipe ge y' 7' 96 ' Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Head 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 S~ DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type Of CHAMBER Moe Number: System: 1_ `5 0~(o 8 /v 1,,4 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 [Bed pth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched /Trench Center Bed /Trench Edges Topsoil E] Yes ❑ No El Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCAATION: STAR PRAIRIE.15.31..18W, NW, SW LOT 4. H CC aJ- Plan revision required? Y ❑ es [2/No / b . !o Use other side for additional information. 9C , 6 SBD-6710 (R 05191) Date s64ctor's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH •►t SANITARY PERMIT NUMBER: I I I t 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 81/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number a~95~13 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 L APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Prop Oyv er N me Property Location( 1/4 1/4, S T , N, R or Property Owner's Ma ing i,Yress of Number Block Number It ,State Zip Code Phone Number Subdivision Name or C~ er ( ) I. I Lo hI 's-21-11 TYPE F BUILD[ G: (check one) ❑ State Owned ❑ it~ Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms IF ° Town of 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo ©zg ~Q 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 S ❑ 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 11 M 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 Feet Feet VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank /zw - ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the ndersigneck assume responsibility for i st lIatio he onsite sewage system shown on the attached plans. Plu7mer' ame: Pr Plum er' Ign ur o St MP/MPRSW NO.: Business Phone Number: 91 Plum er's dress ( ree , ity, State, Zin Code): 6~4COLUNTY DEPARTMENT USE ONLY ❑ Disapproved Sa itary Permit Fee (includes Groundwater ate ssue Issuing A ntSi ture ( Stamps Surcharge Fee) Approved ❑ Owner Given Initial 3~ Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR ISAP ROVAL: SBD•6398 (R. 05194) DISTRIBUTION: Original to county, One copy To: Safety & Buildings Division, Owner, Plumber 4 INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe renewed before thee xpirati on date, and at a time of renewal any neuv 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 E! 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 tr+rough 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. s , IVW Y7 SZE- s 9 ~r~,rs•~ ~z.s-9 I \ i ~ - I'Ce~s,ta ~ ` ~ ~wHll ,(~pi1k,JTy '/OV5/: ~~E'.OGti V V J Wtsconsin 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. Attach complete site plan on paper not less than 8 10,)c V~.. must County include, but not limited to: vertical and horizontal (ete. a point (BM), di~rec` "n d 57' C4PO K percent slope, scale or dimensions, north arrowan¢J6cation ay+' ' ce to rte t road. ~Parcel I.D. # APPLICANT INFORMATION - Plea int all iIformation. Reviewed by Date Personal information you provide may be used for sec}Tivagr purpoS~s vacy IC' w. Property Owner ~o rty Loca ' n / R/2 57007'- 1/4sW 1/4's/ 7 T 31 E (or~ Property Owner's Mailing Address ` t # B k# Subd. Name a CSM / 3!5 3 14 w,4 T wee-, TP. i~AJG- j / 3 o yv city State Zip Code Phone Number Nearest Road if UQSo.J GcJ/- SSIOICo (7/S )ff~~'(o7'31 ity r El village Town ryw~/ CG -5fQ If /X 9 New Construction Use: residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial -Describe: Code derived dail flow (Oc)o ( o " ~ (3 3 ` Y Y gpd Recommended design loading rate - 7 bed, gpd/fit '00 trench, gpd/ft2 Absorption area required bed, ft2 trench, It2 . 7 Maximum design loading rate bed, gpd/ft2 8 trench, gpd/fl2 Recommended Infiltration surface elevation(s) 5 3 ft (as referred to site plan benchmark) Additional design/site considerations IfSE LG~~ N/ /f°4f'.t1 TipE(iGL* l S - ~it~UEl~ ~ti SLOpE - Parent material ✓~iG~ C-fV ~~/%j~ OUT4Jl~ Flood plain elevation, if applicable ft S = Suitable for system Conventional Mounnd In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system 2S ❑ U 2-s ❑ U 2-6- ❑ U El's ❑ U ❑ S EMU ❑ S EJT] SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 Texture Consistence Boundary Roots Bed , Trench in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. P 1 o-/& ioYR 31.;,- / S,4e X X s /vf . Y , •S /0Y X3/3 Si/ 2f,s6.~ ~,fif' CS LUf S; -G Ground 3 Z 7-,PD /o yip x// b elev. y q. kO f t . Depth to limiting factor > in. Remarks: Aoe'P i; K 'Peel G~/ /D.LOAN s R47i~ b~ • SGjol~/ 1 Boring # 10-// 1,00 3W f -5 z L #--w/o o Y/'Y es ' . 6,r 3 W io le t; ~ - S o . s dam- -7 . ~ Ground elev. ft. Depth to I\ TG1 limiting V Vin. Remarks: CST Name (Please Print) Signature Telephone No. ~013 T Lt 't3 P r- -713'_- 3 8G P/8 s Address Uibricht & Associates Date CST Number P rivate Sewage Consultants _ e_ FS C'57-9' i 4(P2 655 O'Neil Rd. Hudson, Wis. 54016 R ' S To J T' SOIL DESCRIPTION REPORT PROPERTY OWNER Page ? of ` PARCEL I.D.# LO7- # Horizon Depth Dominant Color Mottles Structure 2 Boring Texture Consistence kunclary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench t o- y ,o y,~ 31 si 2-f sbk (w,fR s huf y/ Si/, 2 S, j e.4-rg- - s G 4,) -F ,5 ; G Ground 3 y-~ S rl 'e- 7 elev. y~ W Depth to limiting factor , T- Remarks: Boring # o-~ /oYR 31y - S// f.sbk ~V,fR Z -le /OY14 .2 f5At AU -~FR 3 ~-y io Y S 0,54 aQ .Q - • 7 ' • P Ground elev. /00.0 ft. Depth to limiting factor chin. vv Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # D--/C3 /O 2 3/ - 5//. )fsbk iw.fa 5 ~U~ . 5 . •G Ground elev. / G /•~ft. Depth to limiting L factor in. Remarks: Boring # Ground elev. j. ft. i t Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) TMPnPTANT ATr1T1: Tn r)whTvnc c TATOM XT T Tr % P/~oaostp .vo . [.v T- ~ . 1314 5er : Toy of 3/f/ STEAL ~/t?Jif loo -J = /d D • d V 33~ f0 yQ! ~ ~Z. b !o Pb ~o 90 Pn o3a,,~q v v ' 0 • !3 3 B t~Z y zy, goo. d STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER Ir. MAILING ADDRESS PROPERTY ADDRESS ~~~--T~ f D 02- y (location of septic s)stem) Please obtain fror^ fka Ulann;nn nP.nt CITY/STATES PROPERTY LOCATION N H/ 1/4, S V✓ 1/4, Section " W TOWN OFti SUBDIVISION CERTIFIED SURVEY MAP:K3 9:9Z0 , VOLUME I , PAGE3vy D , 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 year expiration date. SIGNED: asd 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 Location of property fvW 1/4 $lw 114, Section T 31 N-/R W Township r- r,41- Mailing address lV 6W N wz ~y i Address of site Subdivision name C5h'I .aI_ I of no. Other homes on property? Yes_X-No Previous owner of property Total size of property Total size of parcel 0-200 yd~a Date parcel was created S =Q Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house) ? \<-Yes 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. 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. / om~ Signature of A icant Co-Applicant - 02a-76 4 4- II i~ 2-1982 DOCUMENT VO. STATE BAR OF WISCONSIN FOP'.? l WARRANTY DEED 9S~d7 I - i REGISTER'S Gr~i. ~tlsem~- j; $T• CROIX CTY. V t Richard O. Stout and Janet P. Stott . I FEB 2 2 1996 _hu~ band and, wife survivor-shiptnarital. I 1.0011 Phi II gropertY conveys and warrants to Delbert J DOd e i ~ i Reg;ster of Dee ~ , I RETURN TO /VP)t x t,.-- following described real estate in _ St-C QI x County, State of Wisconsin: Section 15, Township 31N, ?ange 18W further described as: Tax Parcel No: Lot 4 of Certified Survey Map reco=ued in th3 Office of the St. Croix County Register of Deeds on January 5, 1996, as Document No. 538230 in Vol. 11, page 3040. c ii !i I i. This is not homestead property. (is) (is not) Exception to Warranties: easements, restrictions and rights-of-way of record, if any. I I Dated this 21 t day of February 19 96 'i ~I (SEAL) (SEAL) • Richard O Stout Janet P Stout II f I~ (SEAL) (SEAL) I ii I, it - u it AUTHENTICATION ACKNOWLEDGMENT j I i Signature(s) STATE OF WISCONSIN l ss St. Croix County. authenticated this day of 19-- Personally came before me this-21 s tday of Fg-hrnary 19 C) the above named _ S_tnnt and TanPt P_ i~ u TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to ^e r- «n to be the person s wno executed the it authorized by § 706.06, Wis. Slats.) 'creGa instrument and acknowledge the same. THIS INSTRUMENT WAS GRAFTED BY~,~ '9j Jaln<< Sto.s oTARr Z . - . - 538230 CEPLI_FIED 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 LEGEND Hudson, WI 54016 t •rN N -P r 0 +JOCN Aluminum County Section Corner Monument Found 0 0 o 0 • 1" Iron Pipe Found L N 0 1" x 24" Iron Pipe Set, weighing 1.68 lbs. per' W14 Corner linear foot wa~~o L- Section 15 -P o 100' Roadway Setback Line 04- -P - -12' Wide Utility Easement c. o v M a~ N C 7 (/1 IM.- N O C to Ln O to O o L d.1 O N M N 4) Q CO 3: -P '9 6 N Iv I:~:,I ~f/11~ : ar~fta~ g Prh,~ 5~-~c{• K S86°20' 1"W 220.7.8' r,~ J r s I.--- CD 12.28'- - 208.5 '3,0 days of ,,val date :wial sha7 be I 33' 33' i r I` I • I1 r Ln I~ I~~ I CD Iy I I. I -I t o i r o I~ C) 0 IRj i o II I C~ N 0 I 1 ~c> LOT 4 N = tv 2.32 Ac. Inc. R/W tq LL 100,975 Sq. Ft. v W 71 Ir' I 2.18 Ac. Exc. R/W l y Lq 95,139 Sq. Ft. Ir' l z3 ICS o I` I C N E L i i N N el,4k 616 I I • N. 45.• + r-V . .5