HomeMy WebLinkAbout116-1000-80-300
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER JVA f.. 1 a h/~
ADDRESS to, feIt
er for
SUBDIVISION / CSM# LOT #
SECTION T 21 N-R _W, Town . ! fC.
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
42 / a
9
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
rt
BENCHMARK: I W F'a r ti
ALTERNATE BM: log
o~., ofd''
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: f,,J ~'.,~,1- S Liquid Capacity:
, `
Setback from: Well House Other
~
-60 4tr
Pump: Manufacturer Model#
Size
Float seperation Gallons/cycle:
Alarm Location
-:SOIL ABSORPTION SYSTEM
/ Ile
width: •_Z41;~j_ Length ';p Number of trenches
Distance & Direction to nearest prop, line:
Setback from: well:
House_ Other ,1 S"'r' tx "'JPIY1.~ ~
ELEVATIO
c
Building Sewer ST Inlet. iv_'~ST outlet
PC inlet, PC bottom Pump Off
o~~r► Sd
Header/Manifold ttom of system_, 01 41 -3)
Existing Grade Final grade g
tt
DATE OF INSTALLATION: _ ...1 56
PLUMBER ON JOB:
LICENSE NUMBER: R 6
INSPECTOR:
3/93:jt
4/v7";gDepartment ofIndustry,
PRIVATE SEWAGE SYSTEM
Labor and Human Relations County:
Safety and Buildings Division INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Permit Holder's Name: ❑ City ❑ Village aa~ Town of: State Plan o.:
NIEMANN, JAMES X
CST BM Elev.: Insp. BM Elev.: BM Description: ~ I DEER PARK Parcel Tax No.:
r
/00. /60. lbi~A_l A9600059
TANK INFORMATION LEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic / Benchmark /60. 11
Dosing ~~Qk 4,, ~ba"08
Aeration Bldg. Sewer a v S 99- 31
Holding St/ Ht Inlet
10,86' 4yy~"'
TANK SETBACK INFORMATION St/ Ht Outlet
Verit
TANK TO P/ L WELL BLDG. A
ir Ito ntake ROAD Dt Inlet
Air
Septic NA Dt Bottom
Dosing NA Header / Man. y/7
Aeration NA Dist. Pipe g/- 13
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
~ l rs~ sir. s
Manufacturer Demand
Model Number GPM
TDH Lift tion System TDH Ft
Force ma' Length I Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING manufacturer:
SETBACK
INFORMATION TypeO CHAMBER Moe Number:
System: ~l i4 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: VILLAGE DEER PARK.8.31.16W, NW, NW, MAIN ST W
♦ ~5.~ ~ ~..f'Lf..; fv " /real/
IA~Z
C
Plan revision required? ❑ Yes Q/No
Use other side for additional information.
SBD-6710 (R 05191) Date Inspectors Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
` 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
State Sanitary Permit Number
than 8112 x 11 inches in size. 51, • See reverse side for instructions for completing this application
Check Ie9viion fO pre4ious application
The information you provide may be used by other government agency programs ❑
[Privacy Law, s. 15.04 (1) (m)). State Plan LD. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location N R E (or 1/
! 1/4 ~(,tt 1/4, S T 3 r
}'U i~:. 4 to n
Property Owner's Mailin Address Lot Number Block Number
City, State zip Code Phone Number Subdivision Name or CSM Number
~-iC 00 ( IX-)A6,3 - ~aJ Nearest Road
II. TYP BUILDING: (check one) ❑ State Owned Ity
Vfllage
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF P-,--r r it
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1❑ Apartment/ Condo r 6` DD J 1!9 U
Q
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 C] 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
Tank Only______________ ExlstingSystem Existinq System
_ystem --------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 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./inch) Elevation
L77t_~Iv 6, y -3 1- 6 y? ~'7 D~3 Feet 1IY, S' Feet
VII. TANK CapautY site Fiber- Exper.
in allons Total # of r Prefab . Plastic
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass App.
New Existin structed
Tanks Tanks ❑ ❑ ❑ ❑ ❑
Septic Tank or Holding Tank ICJdL~' e, !
Lift Pump Tank /Siphon Chamber ❑ . El I El 1, 11 1 1:1 1:1
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No Stamps) MPRSW No.: Business Phone Number:
vs,
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sarr *tary Permit Fee (includes Groundwater ate Issued Issui g Agent Signatur No Stamps
Surcharge Fee) 04 A L
Approved E] Owner Given Initial
IX '111Vj_AX0_
Adverse Determination 0
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SOD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety 8 Buildings Division, Owner, Plumber
INSTRUCTIONS
r
re the expiration date, and at a time of renewal any new criteria in the
licable.
N Q M Q Vl Vl - by the permit issuing authority.
a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the.
aintained. The septic tank(s) must be pumped by a licensed pumper whenever
to sewage system, contact your local code administrator or the State of
L 08-266-3815.
mit application must include:
~0-`-' ress. Provide the legal description and parcel tax number(s) of where the
ily one and complete # of bedrooms if 1 or 2 Family Dwelling.
heck all appropriate boxes that apply.
4. Complete line B if permit is for tank replacement, reconnection, or repair.
depending on system type.
_ e 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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Labor oraridHuman Relations use' SOIL AND SITE EVALUATION REPORT Page ~of~
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY t, 1'Q 4+
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCE LD;
dimensioned, north arrow, and location and distance to nearest road. ; ,'.IrY
REV _ . D BY DATE
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION _
O
PROPE TY OWNER: PROPERTY LOCATION
GOVT. LOT SAJ 1/4 1/4` T i,, )(qf
PR PERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. AME
+r=t•~
Cl STATE ZIP CODE PHONE NUMBER _-]CITY VILLAGE off OWN I
( )
I AZ
~(J New Construction Use NJ Residential / Number of bedrooms [ ] Addition to existing building
j J Replacement [ ] Public or commercial describe
Code derived daily flow( gpd Recommended design loading rate gybed, gpd/ft2-I-X-trench, gpd/ft2
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate 'L7 bed, gpd/111:2_,'~E_trench, gpd/ft2
Recommended infiltration surface elevation() ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material - Flood plain elevation, if applicable ft '14 1 S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM
I FILL HOLDING TANK
U = Unsuitable fors stem 21 S ❑ U E9S ❑ U aS ❑ U ®.S ❑ U ❑ S ~ U ❑ S S U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. 22nt Color Gr. Sz. Sh. Bed Trench
Ground
elev.
2-f -Ot•
Depth to
limiting
factor
Remarks:
Boring #
2 s
Ground /
elev. 1
ft. Z 9Z '//9 ".0d'ik All c d 6,21
- -
Depth to
limiting
factor
9Z
Remarks:
CST Name:-Please Print Phone:
Address:a
S-
Signature: Date: CST Number:
9
PROPERTY OWNER SOIL DESCRIPTION REPORT Page PARCEL IA
Depth Dominant Color Mottles Texture Structure Consistence Bourxiay Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. nt Color Gr. Sz. Sh. Bed Tw&
M;. ~
Ground / - - - S~
elley.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev. - -
41, Z
Depth to
limiting
factor
Remarks:
Boring # ,
411,1
Ground C
eley.
W9 ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER (4- f o Y,,n k v- t'1 ` t -4, ,,r
A
MAILING ADDRESS '7
PROPERTY ADDRESS 71, S'T KJ Pate.- P4r Cy S-z/oo 7
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION W 1/4, N U~ 1/4, Section T 3 I N-RW
'SOWN OF ~J 4 ~ I Q 1 P "")c' r ST. CROIX COUNTY, WI
SUBDIVISION LOT NUM133ER
CERTIFIEDSURVEY MAP , VOLUME PAGE2 , 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 (I)
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:
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 'Na w ` i
Location of property N \A)1/4 N W 1/4 , Section, T 3"1 N-R W
Township Mailing address V~o lS
Address of site 37 ST Jy. D~~,- p~,~lTt.,.J,' SYoo7
Subdivision name \J0 Lot no. N~
Other homes on property? Yes No
Previous owner of property o a~~~ P `K Or- -5,n- Y-i
Total size of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? _Yes XNo
Volume 11 71 and Page Number 4 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 decd 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. S$ 9/ c/ 3 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 ~o-App licanY_
A" A ~Q - - - l4 -
DrIte of Signature Date of Signature
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541.91 State Bar of Wisconsin Form 2 -1982
WARRANTY DEED FRE~T. GISTER'S OFFICE
DOCUMENT NO. 01..1171PAG: ~ROIx C~ ,
Recd for Record
APR 9 1996
Roland W. Thompson and Janice Thompson, g,0o M
his wife
I
conveys and warrants to James G. Niemann and Bonnie e
N emann, husband and wife, as survivor-
ship marital property-
Is SPACE RESERVED FOR RECORDING DATA
1 NAME AND RETURN ADDRESS
the following described real estate in St T•oi x
County, State of Wisconsin:
II Part of the Northwest Quarter of
Northwest Quarter (NW 1/4 NW 1/4) per''' of-"116-1000-80
11 Section 8 Township 31 North,-Range (Parcel Identification Number),
16 West in the Village of Deer Park
described as follows:
1 Commencing at the Northwest corner of the Northwest Quarter of
Iit Northwest Quarter (NW 1/4 NW 1/4), Section 8 Township 31 North,
Range 16 West as the point of beginning; then East along the North
Section line 279 feet; then South parallel with the West Section
line 239 feet; then West parallel to the North Section line 279
feet to the West Section line; then North along the West Section
line 239 feet to the point of beginning;
SUBJECT to the right-of-way of State Highway 46 along the West side
of the above parcel AND FURTHER SUBJECT to the right-of-way of
County Trunk Highway "H" along the North side of the above parcel.
Tr ANQ FER
j This is not homestead property.''
(is not) FEE
Exception to warranties: Subject to municipal and zoning ordinances and
recorded easements and restrictions of record, if any.
Dated this day of April 19 96 .
I
(SEAL) (SEAL)
I' * Roland W. Thompson
Ili
(SEAL) (SEAL)
~I
it Janice Thompson
jll AUTHENTICATION ACKNOWLEDGMENT
STATE OF WISCONSIN
I Signature(s)
ss.
j POLK County.
day of
Pnrennally came hefnre me this