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HomeMy WebLinkAbout038-1173-10-000 o O 3: 0 va U co C ~ i C r. o I N O i O y x o U O U I I co co Y (CD JS U C N 7 LL c C (0 O O) p0 q ~ I I a Z E °o ~ v E u~ co a z m 0 c z o O 2 d' c u o ) _ a o I ti FZ- c E '2 m m ` M I N a O N O N ~ c I ^ d L L ~ I U ® Lo z H Z O co -a m C > O N ~ !mil c E ` y CL C) O co s 0 a 3 c c a E N N Q Z F- F U CV 3: 3: X0 0 0 n 3 w z° • c ►v m Q)aaa a Q I = Q0 (o rn -j cU rn 0) } Lo M O O O M ~ E O O ~ U d C a N Q) v ,N vi m m d~ O I O p c ui c E rn n l O E ~ j a) Y co CL O° a) C) G n E (D p o 4.i W O N O O M M d U In co W p M U N c) a) CD vc c E U • y' O r (n d N O 2 f a a m a • ca a. a 9 4) y iV +E L c c A 0 a 0 N 00 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER_RC~. ADDRESS~d~~f~? LLB r' SUBDIVISION / CSM LOT # SECTION / T---,-/ N-R W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 1;20 h ti P INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: Q,g /1.6_ ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION i manufacturer: Liquid Capacity: j,?a d Setback from: Well House &;u' Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location :SOIL ABSORPTION SYSTEM Width: Length../ _ Number of trenches ,3 Distance & Direction to nearest prop. line: A` „2C> Setback from: well: .rG House ~g 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: "7`-- r LICENSE NUMBER: j INSPECTOR: 3/93:]t Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.- 262357 Permit Holder's Name: ❑ City ❑ Village IA Town o : State Plan ID No.: P C COLLOVA BUILDERS STAR PRAIRIE CST BM Elev.: Insp. BM Elev.: / BM Description: Parcel Tax No.: U/) s du 1 G6 r' G; A9600167 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. i Septic 7 Benchmark Dosing ' Aeration Bldg. Sewer a9' Holding St/ Inlet 1W 5, TANK SETBACK INFORMATION St/ Outlet s TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet rl Septic -21j 1~4 NA Dt Bottom Dosing NA Header / Man. Aeration A Dist. Pipe Holding Bot. System i` PUMP/ SIPHON INFORMATION Final Grade Manufact Demand Model Number GPM TDH Lift Lriction T Ft Fordmain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH width Length 1 No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION S Z/ S DIMENSIONS SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM ING Ma u~ _t CH rer: INFORMATION Type Of Ctp~- "rr~ i i CNHA Moe Number: System: -ao DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length &6/ Dia. Spacing,/ SOIL COVER x Pressure Systems Only xx Mound Or At-Grad stems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed/ Tr nch Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc:) LOCATION: STAR PRAIRIE. 15.31 .1 8W, NW, SW, LOT 1, HW~j Plan revision required? ❑ Yes Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signatur Cert No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 7 zs' 7 ~a' p. 3z' der ~d~~ a Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water Systems 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. • 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 E] Check if revision to previ us application [PrivacyLaw,s. 15.04(1)(m)]. State Plan I.D. Number 1. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION Property Owner Name Property Location C 4® va- e, 4111464) 114, S l.f T,3/ , N, Rl E (or) W Property Owner's Mailing Address Lot Number Block Number Ile_*- LI~lf l City, fate Zip Code Phone Number Subdivision Name or CSM Number 1 t r aov l~L II. TYPE F BUILDING: (check one) ❑ State Owned ❑ City Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms 2~ C1 gown of rr ' .v C III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax N~yum7ber(s) 1 E] Apartment/ Condo (1 ~ g X 73-1 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. aNew 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 r V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30E] Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 In-Ground Pressure ❑ 42 ❑ Pit Privy 13 ❑ Seepage Pit 43E] Vault Privy 14E] 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) Q~"r d Qg, 57jevatLpn 64d O Feet °!ra Feet VII. TANK Capacity INFORMATION in gallons Total # of Manufacturer's Name Prefab. Site Fiber- Ex per- New Gallons Tanks Concrete Con- Steeglass Plastic App Takks strutted Septic Tank or Holding Tank (JeJ ~P c/Ve->-P ❑ O ❑ ~ 0 Lift Pump Tank /Siphon Chamber ~ 1:1 1:1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: o Stamps) MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zi C de): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Issuing Agent Signature (No Stamps) )(Approved ~40 Surcharge Fee) ❑ Owner Given Initial 6 Adverse Determination GQ&h 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 maybe 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 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. zed l f Y v L!'L ~ce cG p~ C i I I I I i I ~i f I S ~-e S e i Wisconsin Department of Industry, SOIL AND SITE EVALUATION / 3 Labor and Human Relations ri ~r, ae of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 Inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and x percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. If 6 APPLICANT INFORMATION - Please print all information. Reviewed by "tvly ate Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (t) (m))./' E' Property Owner Property Location ~1 Gffi4R D STOUT Govt. Lot N40 1/4 S W 1/4,S T E (or~ Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 1353 ACV AT U ItL & T12 • AplocRi ~E-vb City State Zip Code Phone Number Nearest Road u pSO "J W 1, S Y 01(0 El city s villa I Town New Construction Use: 21esidential / Number of bedrooms 3 \ / Add ition to existing building ❑ Replacement ~S ❑ Public or commercial Describe: W = O 7- EGO H /t L~~ L~ d ' Code derived daily flow 6 0 0 gpd ~ Recommended design loading rate bed, gpd/ftz trench, gpd/ft2 Absorption area required bed, ft 2-trench, ft2 Maximum design loading rate/U%p bed, gpd/ft2 gpd trench, /ft2 Recommended infiltration surface elevation(s) S pI 3 ft (as referred to site plan benchmark) Additional design/site considerationsw/s'E - 'mi l S D2oe ~8X / S Tlel t~l'I O J Parent material SC S I ~hL~ ©/V'~'~ Flood plain elevation, if applicable ft S = Suitable for system ~Conventional Mound In-Ground Pressure AT-Grade System InFi~ll - Holding Tank U = Unsuitable for system L g5 El U R"S 1:1 U ~ El U B<❑ U ❑ S a ❑ S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/rye Texture Consistence Boundary Roots - in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Dya y~2 5 / -2fSb>k A-PQ Z O-.0 ,0 I Ground 3 -S I 2 .S It Pk Q kJ elev. ff. 2-5-ft. 1 /O S. 0, S .-7 - Depth to limiting factor %in. Remarks: Boring # -r- S •6o o ye Y1_3 s z~s ~,v,e 6? 4v 3 ~ Ground elev. /05. Depth to limiting factor y t_9 In. Remarks: CST Name (Please Print) Signature Telephone No. R01!1'F1>_T- 7,tCQ~f'GG►T' ?/S -386 -618 S Address Date CST Number PROPERTY OWNER SOIL DESCRIPTION REPORT Page 2 of PARCEL I.D.# lO T PPLE7 i~'%U R Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots Mft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench -3 0- x0a s 1 s6~ 'hjli't Ground gle eft. ~ Depth to limiting factor 7 r7 in. b Remarks: Boring # -io /o s,/ fs4✓& 1114 f e i04-f y s , f sd~e fie 2 s /G f , s : , -3 s, © ~s :,b Ground elev. ` c0 Jos. ff. Depth to limiting factor Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots PD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # 0 Y/3 - $ 2f.P~iC nM-fjQ CS 2-,r- G S Z - 31/ z s',e -?ee 4- S 3 / S .s. 0, Sw Ground Depth to limiting factor 7 8-6-'n' Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) ~,U~'GtJ " • ~ti~~,,, S 7 ~ v ~ T'/O,J C L. _ ~ y~v pry . ~ If 3 - .6 t D pi's rvR e ~~iU~-troas - Q 9~ 75- /05- z yz FS3 00, 90 QQ Wr i~ 9 kJ ~ 41 13 O , G *0 'I 0 oil VARIABL 51 w ZI . 50 1 = ~ X11 ~ JI 0 H w 0 I U I t cD o , M UNPI A ~I W C]i z1 3 NN I I I N ; C SZ2~~ D (V z 0 ~ 0 S86 2021 W 318.02 wl 1- 1-1 M DEDICATED - 2 J1 M - 334.83 - i ,rd_ 50- 1 12.28' rn 208.49' 114.06 35 ` I N86020211'E- 220.77 - - DI z Q, T c w23 4 o LOT I i~ . - II Dai N N v. S. M. It 2.20 AC. M LL CY o w 95,726 S0. FT. o ~ 1✓~~. z~g o c,1 w N ~ W. W :I W 2 m J P . 904Q ~ W 'Lj W L O W N 41 a' a: 0 pp 3 (0 C.4 W k NZ j O z °1 t, J o z y N ww 3 rn u S89058'40" E 200.00' 208. oo' S 8 90 58'A BENCHMARK NAIL SET IN POWER POLE APPROXIMATLY 30' r SOUTH OF SW COR.OF LOT 4 C.S.A. VOL. 11, PG. 3040 _ a ' ELEVATION = 915.98 i 2 3 USGS DATUM N N 04 - a - STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 0" 4,4-6VA L' kJ1-1. j r :r",/<_ .d -7 MAILING ADDRESS /02 S 7S' l e //e a, IV-d PROPERTY ADDRESS 11&4.5" 0212 -rA JyIJ&57--dto 1)2e' e_ (location of septic system) Please obtain from the Planning Dept. CITY/STATE PRA '01 I r PROPERTY LOCATION I)a 1/4, 45reV 1/4, Section , T 31 N-R W TOWN OF ~54 Ate ' 1 1 ST. CROIX COUNTY, Vn SUBDIVISION Aoyl,~:_ /f LOT NUMBER CERTIFIED SURVEY MAP , 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 year a iration date. SIGNED: DATE: (2 3 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 • S T C - 100 S4,9K 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 ( • C- 0o k ,(-0I/A 6011 op-. f - Location of property~1/4 50) 1/4, Section f T3J _N-R~W Township s,4,~ 2A(K(4 Mailing address Address of site d®S '('e- subdivision name Apat F- let UC54 /3 'i~ 4 Lot no. other homes on property? Yes No Previous owner of property RN C- LA ,.&C ~+D Total size of property Total size of parcel c«c Date parcel was created 12~4ty Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? X Yes No Volume and Page Number 50 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. 6"44 q , 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 Applica t Co-Applicant 6-3-`& Date of Signature Date of Signature F:1VLk VHLLEY' HB::Ak::H(_ T Fax:: r 15-:3n6-x'664 Awl 15:`l F. 02 iNG DATA DOCUMENT N0. STATE BAR OF WISCONSIN FORM 2-1982 Trrl$ SPACE RESERVED FOR PECOHO WARRANTY DEED 544697 vr~.~ g~PAC: r REGISTER'S OFFICE ST. CROIX CTY, WI tpatdlxn~oerll - I JUN 3 1996 a: o P. M conveys and warrants to p . C . C O 11 o v a Builders Inc. S MI1neso a rpora ion petal Doe* AETuRN TO /O the following described real estate Inr ('rn tX County, state of Wisconsin: Tax Parcel No: Lot 1, plat of Apple River Bend in the Town of Star Prairie. J!RA ~ I This, iS-.not w-hornestead property. (is) (is not) Exception to warranties; Easements, restrictions and rights-of-way of record, if any. . Dated this `3t-h day of May (SEAL) (SEAL) jchar n. Stow F. C. Collova. Builders, Inc. (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signaiure(s) STATE OF WISCONSIN ss. ,,St . CmodX County. ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 - - (715) 386-4680 October 27, 1997 First Federal Bank Attn: Tammie Hudson, WI 54016 RE: Septic Inspection for P.C. Collova Builders, 1105 212th Avenue, Star Prairie, Wisconsin, St. Croix County Dear Tammie: An septic inspection of the above referenced property was conducted on August 30, 1996. This property is located in the NWY4 of the SW1/ of Section 15, T31N-R18W, Lot 1 of Apple River Bend, Town of Star Prairie, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a four (4) bedroom home. If you have any questions regarding this, please contact our office at (715) 386-4680. Sincerely, 9 es Thc; so Zoning Specialist sm