HomeMy WebLinkAbout038-1172-90-000
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AS BUILT SANITARY SYSTEM REPORT o
OWNER cJC/ s61L .,e
ADDRESS ^L~r Ad
~`J~_
SUBDIVISION / CSM#LOT
SECTION T_~'/ N-RW, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF S STEM
,sue'
i
1s'
INDICATE NORTH ARROW
Provide set "ac and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
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BENCHMARK: 'Lz r 5,1 - / C9
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: G Lk-e~Liquid Capacity:
Setback from: Well N~ House ,-,2~ Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length Number of tren hes
i
Distance & Direction to nearest prop. line:
Setback from: well: House Z~9_ 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: -~72 -9Z
/
PLUMBER ON JOB:
LICENSE NUMBER: ® 2
INSPECTOR:
3/93:jt
Wisc(nsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Y Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) sanita168641
Permit Holder's Name: Cit Mile Town of: State Plan ID No.:
ODELL, TODD ~Tc PRAI E
CST BM Elev, : Insp. B~ev.: BM Description: Parcel Tax No.:
U ~I
TANK INFORMATION ELEVATION DATA A9600336
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic CJ l ZC~ Benchmark
Dosing G) A~w, . 15 IGj- 0"
Aeration Bldg. Sewer 97 <3'
Holdi St/,W, Inlet
S,
TANK SETBACK INFORMATION St/ I Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic > O NA Dt Bottom
Dosing NA Header. 0
Aeration NA Dist. Pipe Y3 5, 7~
Holdi+tg" Bot. System 75 9 S/,~~,
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand 4 32 "
Mode Number M
TDH Lift Fricti System Ft
L H
Forcemai n 11Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length / No. Of T enches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMIEN
SYSTEM TO P / L BLDG WELL LAKE / STREAM NG nufacturer:
SETBACK
INFORMATION Type Of xevi- _SV~ O NIT Mode u
A
system: ,
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipes),,/ / x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length l0 Dia. Spacing -az SOIL COVER x Pressure Systems Only xx Mound Or At-Grad ystems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) ,r
LOCATION: STAR PRAIRIE.29.31.19W, NW, NE, NIGHT HAWK DRIVE ~D
Plan revision required? ❑ Yes Vol,
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signatu a Cert. No.
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ADDITIONAL COMMENTS AND SKETCH `
SANITARY PERMIT NUMBER:
Safety and Buildings Division
~.■~r■r. SANITARY PERMIT APPLICATION Bureau 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 Per~r,it umberr,
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 o per Name roperty Location
1/4 1/4, S T , N, R (or
Prope ner's Mail g ddres Lot Number Block Num r
I / ti J
City State 1` e 1` Zip Code Phone Number Subdivision Na or CS N mber
( ) 1 )
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ C ty Nearest o d
❑ Public 1 or 2 Family Dwelling - No. of bedrooms W Tolwnn o I '
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) .100 - X0
1 ❑ Apartment/ Condo
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. 0 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
------System ___System__---- __Tank_Only- Existing System ExistingSystem
❑ 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 A 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 h ch) Elevation
Feet Feet
VII. TANK Capacity Total # of Prefab. Site .
App
INFORMATION ingallo Gallons Tanks Manufacturer's Name Concrete Con- Steel Fiberglass- Plastic Exper
New ExistiInstrutted
Tanks Tanks
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned ssume responsibility for i tallatio he o ite sewage system shown on the attached plans.
Plu s Nam (Pr nt Plum e' Ign o Sta ps) MP/MPRSW No.: Business Phone Number:
Plumber's Address (Set, ity, Stat p Code)
S4 e k s
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stam )
P(Approved ❑ Surcharge fee) „ 94
Owner Given Initial ~
Adverse Determination 7-
X. CONDITIONS OF APPROVAL / REASONS OR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to county, One copy To: Safety & Ruildings Di-,ion, 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-
11. 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.
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach-complete site plan on paper not less than 8 1/2 x 11 inches in size. Pla M-~u tgIb I
not limited to vertical and horizontal reference point (BM), direction and %op, PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. of
"y "VIEWED BY DATE
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMA`' s
PROPERTY OWNER: i' PROPERTY LOCH F3 ti•
COT 1/4 4, T N,R E (00 WO
G61i
: li4 ",O.?j
PROPERTY OWNER':S MAILING AD RESS n LOT # ! CK # S R E OR CSM
CI , , STATE ZIP CODE PHONE NUM ~A VILLAGE.:, 9 N NEAREST ZRAD
. t'
New Construction Use [od Residential / Number of bedrooms [ J Addition to existing building
[ j Replacement [ j Public or commercial describe
Code derived daily flow gpd Recommended design loading rate ~~bed, gpd/ft2 trench,gpd/ft2
Absorption area required ~ ,/3 bed, ft2 trench, ft2 Maximum design loading rate 7 bed, gpd/ft2 trench, gpd/ft2
V_ )q 0j 7 )
. ft (as referred to site plan benchmark)
Recommended infiltration surface elevation(s)
Additional design / site considerations 5y' 9
Parent material ,.s~t► Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL UND I GROUND PRESSURE gGRADE SYSTEM Ian FILL HOLDING NK
U=Unsuitable fors stem ~S ❑U jXS ❑U NS ❑U ®S ❑U ❑S ®U ❑SU
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Bourxiay Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tw&
o-~ /d V1a
S4-
Ground
91elev.
ft.
Depth to
limiting
factor
3, d
Remarks:
Boring # 02 , n
-n owr rVi7k-el -7
Ground
le
ft.
Depth to
limiting
for
Remarks:
CST Name:-Please Print rV i Phone: 6.
f
Address: ~J) All e~- 1
Signature: O Date: CSJ Number:
27 ~Zc)
PROPERTY OWNER SOIL DESCRIPTION REPORT Page,of
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
77
Ground
elev.
ft.
Depth to
limiting
Remarks:
Boring #
i r)
kv / V
Ground
e
9S~ ft.
Depth to
limiting
y i I I ILL]
Z., Remarks:
Boring #
or 714
Ground `S /
elgv.
q-5') / ft.
Depth to
limiting
f ctgL,~
c2`.6 Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
Soil Test Plot Plan
f.
Project Name Charles Borgstrom Byron Bird Jr.
Address 2033 Co. Rd. C 4~L~
Somerset Wi 54025 M #3479
Lot 13 Subdivision Country Livin Date 8/31/94
NW 1/4 NE 1/4S29 T 31 N/R19 W Township Star Prairie
Boring O Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft.Base of Wood Stake Red Ribbon
System Elevation 93.8 * H R P Same as Benchmark
620' 30 300' to Property Line
'
6% 4 0,
Slope
z
J310'
B-5 30, Rep A
x -1
B-3 30'
C7 30' Pri A Pro 3 Bed
c' Room House
c~ Area
B-2
Scale 1/4" = 10 Ft/ When dimensions aren't stated
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER W I
MAILING ADDRESS,_..,
PROPERTY ADDRESS _ oaly 1011W ,90 ~5R 41
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE 11-n <e
PROPERTY LOCATION Section a T_ N-R~
TOWN OF S ,744 ~k4,%e/e ST. CROIX COUNTY, WI
SUBDIVISION 0a_/P/"iey / 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 expiration date.
SIGN-81):
DATE: 741~'
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
{
f
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 - TUDlD -T oQr-, (i
Location of property 1/4 1/4, Section o ,';_I/ N-R_,"
Township Mailing address S/ /icy 3S`/6¢
Gt]zy
Address of site Ala) % Al Ste!, Z:37/ IFA1,X /'Y GCS
Subdivision name 42&d,~,fe / MIA)<y Lot no. 13
Other homes on property? Yes X No
Previous owner of property
Total size of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? 5Z-Yes No
Is this property being developed for (spec house)? Yes XNo
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.
Signature of Applicant " Co-Applic t
Date f -Slig'iiature Date of Signature
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WARRANTY DEED
548896
Document Number REGISTER'S OFFICE
ST. CROIX CO., WI
Field br Recpd
Return Address -AUG 2 9 1996
at 11:00 AM
- KAQ" . `R JAk.
Register of Deeds
Parcel I.D. Number: 038-1172-90
A9
Charles H. Borgstrom and Dolores Borgstrom, a/k/a Dolores S. Borgstrom, husband and wife, conveys
and warrants to Todd R. Odell and Tammy L. Odell, husband and wife, as survivorship marital
property, the following described real estate in St. Croix County, State of Wisconsin:
Lot 13, Plat of Country Living in Town of Star Prairie, St. Croix County, Wisconsin.
This is not homestead property.
Exception to warranties: Easements, restrictions and rights-of-way of record, if any.
Dated this 7'Vt' day of August, 1996. 6 Alp FER
Charles H. Borgstrom Dolores Borgstrom, a/k/a D ores S. Borgstrom
AUTHENTICATION
Signature(s) Charles H. Borgstrom and Dolores
Borgstrom, a/k/a Dolores S. Borgstrom, husband and
wife, authenticated this day of August, 1996.
Kristma Og d
TITLE: MEMBER STATE BAR OF WISCONSIN
THIS INSTRUMENT WAS DRAFTED BY:
Attorney Kristina Ogland
Hudson, WI 54016
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
11 M N 11 M N M 1111 M1..6 ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 540 1 6-771 0
(715) 386-4680
November 22, 1996
To Whom It May Concern:
On October 23, 1996, a sanitary septic system was installed on the
Todd Odell property. The property is located in part of the NW-, of
the NE4, Section 29, T31N-R18W, Town of Star Prairie, St. Croix
County, Wisconsin.
The system was inspected by James K. Thompson, Assistant Zoning
Administrator, St. Croix County Zoning Office, and was found to be
code compliant for a four bedroom home.
Should you have any questions, please contact this office.
Sincerely,
Mar kins
Y
Assistant Zoning Administrator
cc: File