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HomeMy WebLinkAbout042-1059-70-000 2 -0 0 Q c ~ ~ ~ o o p v~ M 0. ~ 0 o N CV ~O ! ^ II X -0 N O N O U C N .C N O Y ~ U 0 LL p Z N I C 7 LL c C f6 O aI C O E Q N U CL N 2 « x O z d N C4 a co N I- O i c C7 ~ O z a c O mz~* m CD z c E •o M f~ -a m _ Na C O • AID CL -C C C ~ U N O O z w Z H• Z o C ~ N Z a N N C £ C 0 N _ 0 w N C d i M o a s EI r _ E N VJ V) V) O ~V? l_7~/11 O F- H F- 0 0 0 d Z z ~ o rn m a U ) 0) `D N U o rn rn 0 O N M 0) C) 0 N N r 0 0 E O N M > CL r r r m N 1rr1 p d `t } a lei L. co 7 Mid O ur (o U) C O O N U) Q 0 C N O W O M © U U) cn r- M O C_ C LL N N O O r \ LW C6 M co N Y Y V O 0 C N N 7 eM N In - W N M O 00 O O ~ N N N C N y (0 M tLj V ~ v~ d mI La 0 CL 4) l ,yam C L fn U A U a 0 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER a Q,~A ADDRESS F W'4- ~ SUBDIVISION / CSM# C S /r' LOT # SECTION T~N-R W, Town of ~c ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 30 .tsoX O~ a).c Alloy 37 x~• j 3 j g91 3 f1 , I~ J L~ -)I r l~/ I I ~ ,~d I 74 INDICATE NORTH ARROW D Provides ack and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: A - 0►,I DO ALTERNATE BM: 10 A SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: 1;2©0 q4b~ Setback from: Well /House Other oa.LeceB , - Pump: Manufacturer Model#Z4/_)~ Size Float seperation_ Gallons/cycle:_ hlb Alarm Location SOIL ABSORPTION SYSTEM Width: Length 7 Fa Number of trenches 2 Distance & Direction to nearest prop. line: Y7 >/0 0 Setback from: well: House_(_ OtherQ ELEVATIONS Building Sewer` ST Inlet 955. ' (7 ST outlet ~I I? S. 2 Z PC inlet PC bottom Pump Off JZ' Header/Manifold A `Z Bottom of system 89, 9 $ mar 9a, ~o -SY•7 / Existing Grade - Final grade 3 ? DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: D 3 S-~ INSPECTOR: 3/93:jt t ~ a liscon in upartme tofnsdustry, PRIVATE SEWAGE SYSTEM County: bor and Safety and Buildings Division INSPECTION REPORT ST CROIX (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 262361 Permit Holder's Name: ❑ City ❑ Village KJ Town of: State Plan ID No.: JONES, DARYL WARREN CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 00 Y A9600170 TANK INFORMATION EL VATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic fal7Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet Vent TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet Septic >SO ~o 02 ' NA Dt Bottom Dosing NA Header / Man. /p, 78 0 . Aeration NA Dist. Pipe 10,93' 90, yS' Holding Bot. System , PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand 30« Q ! 9 ' Model Number GPM TDH Lift Friction em TDH Ft Forcemain Length DDist . Towel SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS " 14~ DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION TypeO CHAMBER Model Number: System: y'~ ' loft -A) v' 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 Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: 21 . 29.1 r(8W,~S71, SW, 80TH AV' fiCr'4.~~"L./' ~lAv~ ~st~..: f ~.••iCYG ..r, t.-..., Plan revision required? ErYes ❑ No / Use other side for additional information. l 96,t d t SBD-6710 (R 05/91) Date nspector's Siqnature Cert No s `DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 ~ 8% X 11 inches in size. Check re sign p wous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION mod! $ -5 ai '/4 S lt~'/4, S -7:z / T p, N, R $ E (or PROPERTY O ER'S MAIL NG ADDRESS LOT # BLOCK # 2 0 v F_- I CITY, TAE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ~0 7!S 7Y9-3 11. TYPE OF UILD71*or • heck one CITY NEAREST R0 4D State Owned 41 J--LMWW OF. % ❑ VILLAGE - Q V ❑ Public 2 Fam. Dwelling-# of bedrooms M PARCEL AX NUMBER( S) III. BUILDING USE: (If building type is public, check all that apply) e-y- 7 d 1 ❑ Apt/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 PERMIT: ( ck o on in line A. Check li p if applicable) A 1. New 2. Re acement 3. a lacement of 4.0 Reconnection of 5.0 Repair of an System ystem Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Spage Bed 21 El Mound 30 El Specify Type 41 El Holding Tank 12 2 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 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) Q0. ELEVATION 7 5-0 st s peoweq, I eet 3-3e' Feet VII. TANK CAPACITY Site in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New xistin Gallons Tanks Concrete strutted glass App. Tanks Tanks Septic Tank or Holdin Tank «©o Lift Pump Tank/Si hon Chamber r VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plum er's Signature: Stamps) M /MPRSWs. Business Phone Number: I Or ig A Plumber's Address (Street, City, State, Zip Code): IX. OUNTY/DEPARTMENT USE ONLY Li Disapproved Sanjpry Permit Fee (Includes Groundwater a e ssue Issuing Agent Signature (No Stampsf Approved ❑ Owner Given Initial (7N6) /Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: .41313-6398 (formerly Plb-67) (R. 11/86) 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 may be renewed before the expiration date, and at the time of renewal an j 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 (SBf1 6391) 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 & 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 Dwel ing. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in 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 in ##1-7. VII. Tank information. Fill in the capacity of every new and/or exii', tank, list the total gallons number of tanks and manufacturer's name. Indicate prefab or site construe and tank material. Complete `or 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% 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 rnain-dwate, service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; repl.~?cement system areas; and the location of the building served; B) horizontal and vertical elevation referercee 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 116 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, ground- water contamination investigations and establishment or standards. SBD-6398 (R.11/88) liv N C o T,. -U W O F-HI v. RT o~eruE d►_ 9a.o s lp, N 00 G _ ~ t rn Wisconsin Department of Indust Labor and Human Relations Industry, SOIL AND SITE EVALUATIOi~~ . Pa ! of 3 Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis :C k Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must Coun include, but not limited to: vertical and horizontal reference point (BM), direction and FFiCi= percent slope, scale or dimensions, north arrow, and location and distance to nearest road. parcel I.D. APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location _D4R11 JO~~s Govt. Lot :j;W 1/4 _4W 1/4,S Z/ TZ f N,R 18 E (or& Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# //z & Bo t- Au97 n0 C$r1 city State Zip Code Phone Number Nearest Road F o Q R rS s yo1Z ( 713 )7,l/ - 314G ❑ City Village Town eD Aut ❑ New Construction Use: esidential / Number of bedrooms _ Addition to existing building E9,11epiacement ❑ Public or commercial - Describe: IVOT Ar4P.y.N E.cX7E7~ Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2 ' B trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate" bed, gpd/ft2~trench, gpd/ft2 Recommended Infiltration surface elevation(s).-5-et- ~~t 3 ft (as referred to site plan benchmark) Additional design/site considerations Parent material SAS JP e4 'F_- A Flood plain elevation, if applicable y It S = Suitable for system ~Conventional 2`9' MMound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system LAS ❑ U El U a 's 1:1 U 21- El U [rs'-❑ U ❑ S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench is ye y/L zfsb,~~,e S 3-F- , s : , 6 Ldw 1 -,Z Z /2 /e is y~ 3 3 - s~/, ~f sfe s ~y~ .3. . G Ground d.C 00%i 0. Q s ~f . S ' • G elev. 93. eft. 45M ; / / a4 CS , '7 , S -5 ~6 o io s s. O s Depth to limiting ; factor Remarks: Boring # ley 57 2-11 5// fS AA Ground - 7. S t /.S Ck.,7 7 elev., ft. -s /D s - 0 S Gt~ - • 7 , 8 Depth to limiting factor Ic in. Remarks: CST Name (Please Print) Signature Telephone No. 7r 316 V/ 0.5 Address Date CST Number PROPERTY OWNER SOIL DESCRIPTION REPORT Page Z of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 0y 1fs6,t 1W 2 / o e 3/3 5./ ;4"5& e;, ~ 4 s /-f •s ; ,6 Ground ?J S-2 AO Me 60 . S , . Co elev. Go ft. 1 r S / 60CAR C-5, Depth to J -57 O s - 7 • C7 limiting factor 77 Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots FD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Ground , elev. n. ' Depth to limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) ~ m 7~7 -U w -1 o L _ j-- sysr, 2, s - - - • N 40 'X7 Z I ' rn I (YIN Ll\ r STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER MAILING ADDRESS g Q & t~ F PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE We, h f' ?~S W _ PROPERTY LOCATION S ul 1/4, -5 W 1/4, Section T ` N-R TOWN OF ST. CROIX COUNTY, WI SUBDIVISION Az 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. SIGNED: DATE: I G 1 G 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 0 I;IFs Location of property ZC~ /4 g ut 1/4, Section ; , TAN-R l W Township JtJc,aw~'.1 Mailingaddress Address of site subdivision name Lot no. Other homes on property? ~tYes 1/No Previous owner of property ~;~liliol~'7 Total size of property / ;z 57- Total size of parcel ( 'A e.xc.K~ Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes ~No Volume 4,57,0 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. 3,62-7-3,77 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. 1 Signatur of pplicant Co-Applicant P-- D t of Signature Date of Signature 451T E1i118 III& DOCUMENT NO. ~+c~ /R I STATE OF WISCONSIN-FORM 11 _ VOL 62O PA~[156 1112 tMCE 1931019 FOR IltGietlN SATs REG.STt~RS OFFICE lop da.~~>~ Aie.•s ST. (-rOIX CO., WIS. T= flMETrUFA Made this Y - a~~~r A. U.19 ADL, bet,w Kathleen K Monson Jones formerly Rec'd. for Record *is 31PtMpn X_ Monson Oct. i - day at IV D. 19_ at 8;30 A part Y- of the fast part, and Der YsZnnp ` for s pact V of the second part. R T 0 A N TO w i t n e s s e t h, That thr. said part V of the first part, for and in consideration dtbewma[ One Dollar and Other Good and Valuable ,Considerat-'on Dollars, to - hP r in hand paid by the said part .x-of the second part, the receipt whereof is hereby ecehased and acknowledged, ha S_ given, granted, bargained, sold, remised, released, and quit-claimed, and by these presents doe S give, wok bargain. self. remise. release and quit-claim unto the said part _y_ of the second part, and to his. heirs and assigns forever, the a lbllowim described real estate, situated in the County of St roe X and State of Wisconsin, to-wit: r That certain parcel of land located in the SE4 of the Swh of Section Y` 21-29-18a Town of Warren, further described as follows: Beginning at a'point on the S line of said Section 21 a distance of 982 feet W of the `-SE corner of said SWU; thence V perpendicular to said section line a dis- stance of 165.0 feet; thence W parallel with said section line a distance of 330.0 feet; thence S perpendicular to said section line a distance of ➢,"165O,feet to said section line; thence E a distance of 330.0 feet to the point of beginning, containing 1.25 acres, more or less. 4" 1 '.HOMESTEAD PROPERTY F To Have and To Hold the same, together with all and singular the appurtenances and privileges thereunto belonging or in anywise thereunto appertaining, and all the estate, right; title, interest and claim whatsoever of the said part Y of the first port, either in lp o equity, either in possession or expectancy of, to the only proper use, benefit and behoof of the said part y of the second part, n heirs and assigns forever. 10th_ EsWitae~s Whereof, the said part Y_ of the first part ha s hereunto set her hand and seal -this dsyof OCtOber , A. D., 19 80 SIGNED AND SEALED IN PRESENCE OF (SEAT-) Kathleen K. Monson J nes (SEAL) (SEAL) (SEAL) STATE OF WISCONSIN, Pierce Ias' County- 1 10th ~ ~ October A. D., 19 80 Personally came belore me, this theabovenamed Kathleen K. Monson .ones to me known to be the person--who executed the foregoing instrument and acknowledilthf 4amA