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HomeMy WebLinkAbout020-1009-40-300 Q o ~ o I •o p E» I I I r, °o I c'V 7 a, N iy^ 00 y x zo o I cs c co N m 0 6 z N C ~ ro U. c w o N o I 3 a rn z o rn -Z ZC m m o H ~ ! a m o O Z ? 'a v U 30 p d V) I- Z C C 'O _~V 7 • M`ya o N O O Z m z N d E N 65 L _ 1 CL m m i In N O C m L c Y m D a E E c~ o tq to co 0 _ O o ~1 m co v F- H H LO 0 0 0 0 d m z° ~i • rv d G. a CL c o V) LO (D U) m 0 -0 0) a) a) o I O N O c m) w C O O N C O MQCO ~ r- o 3 0 o m c C m 0) o ° V O O_ C > N rn ~ F- E c m O O C N c) - t: c O 5 04 -0 a) N O 3 3 V f N E N 73 U • L O 2 Y N O y Cn r \ w~ C V E L dt _EL a w *Ali c E L m ' O U a M 0 (-n 0 STC - 104 f AS BUILT SANITARY SYSTEM REPORT N OWNER 'Sc o: Kt11Q ~ N ~9 4 1 ADDRESS F~4z y. LAW SUBDIVISION / CSM# ~WC KLAKAt STbtl aN LOT # SECTION 10 T_DN-R)_W, Town of ~upS00 ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~ Note ; rI'~a„1~1 e i s ' I~ ~Vef~ 0~,~'ie~ I i ► ~$k~~i ~cn I► 70' 34 S I PC 4 Beacom N T INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. ~ s BEf~HMARK• { 5tg I 1 I P N R~ 'VW I0j COrwt I4V VU,V ALTERNATE BI::,- SEPTIC TANK / BER / HOLD I RMATION Manufacturer:_ wt-kk s Liquid Capacity: Ia00 1 Setback from: WellOO Z S() House a Other Pump: Manufacturer N Model# Size " Float seperation Gallons/cycle: Alarm Location .SOIL ABSORPTION SYSTEM Width: 8 Length Number ofm-tA ~W_h" 3 Distance & Direction to nearest prop., line:Setback from: well:Wf SV House a~ Other ~epnglZ 9 1 5 7 -97-57 `Np 91' yo 7' VO ELEVATIONS Building Sewer ST Inlet. U-90 ST outlet PC inlet PC bottom --10-- I Pump Off Header/Manifold Bottom of system (0.S() Existing Grade IOU. $O Final grade 00."d0 DATE OF INSTALLATION: I a 3 ~44 PLUMBER ON JOB: g:~- Rjls1,Nran LICENSE NUMBER: 310V INSPECTOR: 3/93:jt r f-scohsinDepartment of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Pej&& ft's NM- ❑ City ❑ Village ( Town of: State Plan o.: F OTT CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark AX) Dosing 2 Aeration Bldg. Sewer Holding St/ Ht Inlet 9tso 90 TANK SETBACK INFORMATION St/ Ht Outlet Vent TANK TO P / L WELL BLDG. A irintato ke ROAD Dt Inlet Ai Septic >a5 >SU. ~,?s- NA Dt Bottom Dosing NA Header / Man. J3 7 5? Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade 5 ~aa, Manufacturer Demand" Model Number GPM TDH Lift Friction Syesatem TDH Ft oss Forcemain Length Dia. HH Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN I N 3 DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER Model Number: System:Vij,1'eU -'Ig, 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 '32 . Bed/ Trench Center Bed /Trench Edges 30 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson.10.29.19W, SE, NE, Lot 6, Zephyr Lane 109.0 act Plan revision required? ❑ Yes [](No Use other side for additional information. e~z-t,Z, SBD-6710 (R 05/91) Date Inspector's Signature Cert No. 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 8 112 x 11 inches in size. ' • See reverse side for instructions for completing this application State ~ nary P m u; m2 The information you provide may be used by other government agency programs ❑ Check if revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Li& .ii Property Owner Nam Property Location 114 AIE 1/4, S T , N, R~ E (or) W Property Owner's M g Addre Lot Number Block Number Cit Zip Code O/ Phone Number Subduouw Name or CSM umber ( ) II. TYPE F B ILDING: (check one) ❑ State Owned ❑ ityNearest Road Public 1 or 2 Family Dwelling - No. of bedrooms ❑ Village Town of _J:51) AJ 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo - 0140 /OO 05?_ ~~q '7o 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 online B, if applicable) A) 1. 3~ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an SystemSystemTankOnlyExisting 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 114~*eepage 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 0 Req re (sq. ft.) Prop s d (sq. ft.) (Gals/da /sq. ft.) (Min 'nch) / Elevation V 9 \o Feet G d• U Feet VII. TANK Capacity INFORMATION in gallons Total # of 's Name Prefab. Site Fiber- Plastic Exper. New Existin Gallons Tanks Manufacturer Concrete Con- structed Steel glass App. Tanks Tanks Septic Tank or Holding Tank W4Q S ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ 1 11 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. P ber's Name: (Print) Plu is Signatur : (No Stampsil MMP/MPRSW No.: Business Phone Number: Plumber's Address ( treet, City, Statt Zi Code): J IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Age S' nature (N tam pproved E] Owner Given Initial Surcharge Fee) -0 Adverse Determination /O(J~~ X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to county. One copy To: Safety & Ruildings 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 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.y, 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. Q. L. 7 _ P OTA I', R 0 S P 0 J I I l{ N A Ivl _ wN A M ) M ou rnQ_e l. L o A 10 p -I; M AID _ . (05 B~ 0 b gy SO' T 0133 S 7a ys. 001 raw Pt' ~ 1a v c~.Q ~1 ci~ 0 RN e i~ s _ i~eNCQ I INe i .Nye; qd• AC~w~ ARp ~aR 1~c s' ~^1e I s- (ZOM tkA}V - Note ; WO 11 'is fiN P _ ti lll• lt,Ll:'tS AND ODSEJtV11f1pN CROSS SECTION Approved Vent Cap Minimum 12" Abovc I wnl ~(Zp~ Find C:raS~C'~- ~ Above Pipe Cast Iron To Final Gradr- Vend Pipe Marsh Ilay Or ~Synthetic Covcri ncj Min. 2" nygr.cr.jl,il i Over Pipe Dis tribu L Pipe F Y io~ ~1) Tee C?/ S~ Aggregate rerf.aratad Pipe C1clot-, Teo A3c,ricath Pipe \ __Courl.ing TerminaLing' r Rol•tom. of System, WOO" "I. ~Vl~}onsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page ~ of r 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 81 must include, but not limited to vertical and horizontal reference poi erection and % 1 scale or PARCEL I.D. # dimensioned, north arrow, and location and dist c~ nearest road`, J APPLICANT INFORMATION-PLEASE PR TILL INFORMI REVIEWED BY DATE t ~C F ~ ..f 'I PROPERTY OWNER: PR LOCATION G T j T 1/4 yU r2, 1/4,S /a T Z nl N.R r) 19 10-A A PR(pOPERTY OWNER':S ILIN ADDRESS BLOCK# SUED. NAM OR CSM h 5?-j - - - 21 A 1,116IL-1 r> CITY TATL ZIP CODE PHO NUMB J;JCITY []VILLAGE [VOWN NEAREST ROAD Oh p -11 oe- j VNew Construction Use Residential / Number of bedrooms 3 [ ] Addition to existing building j ] Replacement [ J Public or commercial describe Code derived daily flow L gpd Recommended design loading rate '2 ed, gpd/ft2 . S trench, gpd/ft2 Absorption area required bed, ft2 ,4 3 trench, ft2 Maximum design loading rate _.L2 bed, gpd/ft2,_,~ trench, gpd/ft2 Recommended infiltration surface elevation(s) 973 3 }v 9 4. S It (as referred to site plan benchmark) Additional design / site considerations Parent material ~r c~ d i~ / arvr "'~Q plain elevation, if applicable AIA ft S = Suitable for system ONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem INS E: U ®S El U Lis 1:1 U POS El U 'RS ❑ U ❑ S ,;N SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed tench 10 ti<:i::i:<~1i:i: -9- b Y9 3 olltc _/7 lb Yrt -7 714 /07 Ground 3 5 ~-x rr C+~ - , 7 , elev. 01, 0 J _ . q _7 ,l v S S S r C_ W Depth to S yob L zp C 5, ; ,/QCs '0 G rN - limiting dZ „ factor -~l p S Q,n S - s , FP r~ 1x Cdr SOi ,'~s yf ~cc~ t ~c.t oe S Remarks: Boring # S 0 lo yje 'y ^ Y. i Ground / 3a-52 /0 YK Cs C y / G~ ,1 Depth to 52`- 73' 10 Y9 1 S ®lM Sc N~ $ limiting factor '73" Remarks: CST Name:-Please Prin;01414 / Phone: g VGhJ,)e 7>S ~yC' ~~Zo Address: /0 7,9 S~~ Q Signature:A _ Dat CST Number: PROPERTY OWNER SOIL DESCRIPTION REPORT Page? ot43 PARCEL I.D. I Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tw& o- S' a n i 707 l Y r" s Ground 3 //-z3' /OVA, y 43°3y O SO- d~ s G~ Depth to s 3 y 'loe G O c S" M , j limiting 0 ye, r Remarks: Boring # }C N ~t D n Uj 1 .rte 1~ ~ / r~ 2 iY~ y x v Ground Depth to 6:5"_, 74 y Sri- ©k" s m l - S limiting >t7,„ Remarks: Boring # ,S /0 911 3/1 ALO 1-61-6 7, Ground elev. `l sr1 rn 5 r' ! ~ft. y 1134,2 " In Y/? Depth to Z -b7 d ' O C S y►' '7 1-T limiting L 67-74 b /1 y S~ Y N~ S 1 7 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) , . Seel Ape, 6y~' ® 6 o 0 v D 5-71 ~e. 1 r STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 45' a -11 i~ rl e MAILING ADDRESS PROPERTY ADDRESS ] 9 Ze . / / a x ho (location of septic s stenj Please obtain from the Planning Dept. CITY/STATE "J_,1:6A,) Z,~z2 7- ~2 LO / PROPERTY LOCATION 1/4, A 1,C Section Ir , T N-R _W TOWN OF ST. CROIX COUNTY, WI [.t n LOT NUMBER SUBDIVISION 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 expirati n date. SIGNED: _zj DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 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 .5Co4-~ Location of property -$F 1/4 4/,~- 1/4, Section /~_W Township 1-171adf,0 I Mailing address q 3 4 voll A/4 Address of site , 9-9 Z~4'Ayi- L AJ dzu) Z2Jr Subdivision name Z"'kilal;V / Lot no. Other homes on property? Yes V' No Previous owner of property e. % rl LirfiLo-r Total size of property 3''2q- 0"-4-e6 Total size of parcel Date parcel was created Are all corners and lot lines identifiable? V"' Yes No Is this property being developed for (spec house)? Yes ✓ No Volume //13 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. J~,3 7 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 Duds as Document t+o. Signa e of A plic, Co-Appli nt Date of Signature Date of Signati-are fit, I- 5 a 4 -s r 171w STATE BAR OF WISCONSIN FORM 1 1982 ii 11WR GcN ED IDOCUMENT NO. REGISTER'S OFFICE _ ST, CROIX CO., WI Reed for Record This Deed, made between Dale G. Wucher and OCT 6 1995 j' Sandra S. Wucher, husband and wife ~t 2:40 P. M - Grantor, b'~.t1. C, - '!'l and Scott T. Kuehne and Tracy L. Kuehne, huusband_ RegistarofDeeds and wife as survivorship marital property Grantee, Wltnesseth, That the said Grantor, for a valuable consideration TH S SPACE RESERVED FOR RECORDING DATA !ICI NAME AND RETURN ADDRESS conveys to Grantee the following described real estate in St. Croix - Heyw d & Cari, S. C. F~'r t"om"`'. County, State of Wisconsin: 204 Lo St Street Hudson, 54016 Lot 6, Burkhardt Station, Town of Hudson, St. Croix County, Wisconsin #020-1009-40-300 ii (Parcel Identification Number) 'II Ij II'i jI J I I too T7 V i l Il ii is not This homestead property. (is not) l Together with all~rantgul r the hereditaments and appurtenances thereunto belonging; And - - - warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except j easements, covenants and restriction of record, if any. i III and will warrant and defend the same. i I 3rd day of October 1995 Dated this II I~ (SEAL) da 'v'(SEAL) - ' -D Glu~h- (SEAL) ~ ) . e (SEAL) -Ha-nd r--a-S--Wuc her AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ss. St. Croix _ County. a thffnticated this day of 19Personally came before me this 30th day of - - September - - 19 95 _ the above named Dale G. Wucher i Sandra S. Wucher Husband & Wife TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Scats.) to me known to be the persgns who executed the f otng strument and know dge he same. THIS INSTRUMENT WAS DRAFTED BY ~3Pywnnd & .a i, S.C. by Walter Hodynsky JPe rkelsen 204 Locust St. Hudson, WI 54016 - N tar St. Croix County, Wis. (Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration date: necessary.) May 9 l9 99 _ JANE TERKELSEN - •Namcs ul' person signing in any capacity should be typed or printed below their signatures. Notary Public ; WARRANTY DEED STATE BAR OF WISCO State of Wisconsin Wisconsin egal Blank Co., Inc. FORM No. I - 1982 Milwaukee, Wis. i 9 J L v w _0 ~ V a D J u ` a u u a o ~ ` c n p y_ I 4 w w Y O E T 3:' CVVVyy y l~ ' $ . a N U ✓ S o N h ' . U U N jog d u a I$ a n ~i9 Z N E r ° S N - Y z lo ~V N i Y L c uoy~ $ w N~q ~ $ q V) U° O y • 4 z O y E y 0 3 SN 8 x w x y Q o °vc y o . ° O' o H o• o G C Y Y 4 a E o = i c50~ & ~N• S . 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