HomeMy WebLinkAbout020-1305-40-000
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 5 A /VI M l zi kW
ADDRESS /~D k & L8Z_
! u D S o N I. I I -c-
SUBDIVISION / CSM LOT # /7
SECTION T L? N-R_ Z9 W, Town of /4L/D So N
ST. CROIX COUNTY, WISCONSIN
PLAN VIER /V1. 1S! W. DoT
SHOW EVERYT G WITHIN-"100 FEET OF SYSTEM is - co,e yE,2 F = /000
7'c
1
GAtA6~ o
wcLC
yo
~3 N
So DoT iYE I N D I: CATE NORTH ARROjd
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover-
BENCHMARK: /yy dd•
ALTERNATE BM:
SEPTIC TANK___ PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: WTI _5EI2 Liquid Capacity: /Qdp g
Setback from: Well 7 2,'
House Other SZ o- Sccl~02,yF~o~ Neu
Pump: Manufacturer - Modell Size-
Float seperation Gallons/cycle: -
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length 4'0 Number of trenches
Distance & Direction to nearest prop. line: ',ISA T So~,C /o7L~NE
Setback from: well: $S House V4 , 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: LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, County:
Labor and Human Relations PRIVATE SEWAGE SYSTEM Spfety and Buildings Division INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
PeMILLERs Name: ❑ City C] village ❑_Town o : State Pla
X
CST BM Elev.:c Insp. BM Elev.: BM Description: Parcel Tax o.
led , C~ L a' ' cSa >-n aS i
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark 3, or, 102). 0"
Dosln
-D,oz 91 ,a3
Aeration Bldg. Sewer
Holding St/~ft Inlet
TANK SETBACK INFORMATION St! Outlet ,/a'
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic yJ NA Dt Bottom
Dosing NA Heade&l
8
Aeration N Dist. Pipe g7
Holding 136t. System a as
PUMP/ SIPHON INFORMATION Final Grade 7'
Manufacturer Demand
Model Number GPM
TDH Lift i tion System TDH Ft
Forcem Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width , Length No. Of Trenches PIT No. Of Pits Inside D' Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEA.Cllli G' Manufacturer:
SETBACK
INFORMATION Type Of pcv , AMBER Moe Number:
System:,?Gy- C OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) Hole Size x Hol sung vent To Air take
Length is Dia. 4L Length Dia. Spacing Co
,37 SOIL COVER x Pressure Systems Only xx Mound Or At- de Systems Only
Depth Over Depth Over ii i/ xx Dep xx Seeded/ Sodded xx Mulched
Bed /Trench Center 3/ '0 Bed /Trench Edges - Topsoil ❑ Yes ❑ No E] Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.} y c=,". ~ c {
LOCATION: HUDSON.1 .29.19W SE T~- LOT 17 TANNY LANE
r l f;
z2
Plan revision required? ❑ YesO
Use other side for additional information. S~019, 9
SBD-6710 (R 05/91) Date Inspector's Signatu a Cert. No.
ADDITIONAL COMMENTS AND SKETCH •
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION Bureasafetyu anofd Bildi uildiinng Water System!
s ter 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 1/2 x 11 inches in size. , ClQ
• See reverse side for instructions for completing this application State Sanitary Permit Number
X83 /7
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 Owner Name Property Location
5 A\ LL E2 SI_ 1/4 1/4, S T N, R /q E (o W
Property Owner's Mailing Address Lot Number Block Number
OLBZ-
City, State Zip Code Phone Number Subdivision Name or CSM Number
vbS0N w SYo&X(0)2 7G /V ► 6J
II. TYPE OF BUILDING: (check one) E] State Owned it Nearest Road
❑ Village
Public 1 or 2 Family Dwelling - No. of bedrooms 3 Town of &-hD SD 'rA 6+410
III. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/Condo Z - /3 O~ - 7
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. P New 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
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-Fil I
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
Sd (o ,7 Z C9 0,7 7, 5' Feet 9 O Feet
VII. TANK Ca acct
in gallons Total # Of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name concrete con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank X /000 SQL r_ ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
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) FrlMP/MPRSW No.: Business Phone Number:
I E CI~DIY~LL ~m~ mm5o 3%1-0a 3V--9'(.
Plumber's Address (Street, City, State, Zip Code):
Xd/ E'N M CLLA- E v1)Sow f _S~ O/
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Age Sig ature (No a
Approved ❑ Owner Given Initial Ife Surcharge Fee)
o~
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 015/94) DISTRIBUTION: Original to County, One copy To: Safety s 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 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 orefix (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 cc unty The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of Ii( lding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/vratc~r ser.;t, e, strear is ,-.r-,J lakes; pumo or siphon
tanks; distribution boxes; soil absorption systems; replacement system ai c<)s a the lo.:. iiol ( f the building served;
B) horizontal and vertical elevation reference points; Q complete specifications to- pumps arc r ont,ols; dose volume;
elevation differences, friction loss; pump performance curve; pump mode! an: ? imp Mei-)Uf, _ urer, D) cross section
of the soil absorption system if required by the county; soil test data on a 1 15'orm; and F) al sizing information.
I
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of reaulated 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 1 of
Labor. and, Human Relations
Division cfSafety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
rx
Attach complete site plan on paper not less than S 1/2 x 11 inches in size. Plan must include, but C vo
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to n
t ~ ' REVIEWED BY DATE
APPLICANT INFORMATION-PLEASE PRIN ~L I~FF1 A~L ~
PROPERTY OWNER:
llsli~ ERTY LOCATION Q
ILLa rte' LOTS 1/41/4,S T 29 N,R 7 E(or)W
TAkle
PROPERTY OWNER':S MAILING ADDRESS BLOCK # SUBD TAME OR CSM #
CITY, STATE ZIP CODE NE NUMBER,., ❑V L GE OWN NEAREST ROAD
®SoIJ I-rAjjfjJkN LAN
New Construction Use DC'] Residential / Number of bedrooms Addition to existing building
j J Replacement [ ] Public or commercial describe
Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2 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) It (as referred to site plan benchmark)
Additional design/ site considerations EyALu.4i 1Q+.aS L6/jt ~'o~P-LjtT AP,'-46yAL
Parent material Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL OUND Ili-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING K
U= Unsuitable fors stem as ❑ U S ❑ U ER S❑ U S❑ U S❑ U ❑ S o U
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 Trench
A 0-% 1 C)y k- *3 3 5 c. I h S b r C S Z rFf O .S O .c
3 is; /cry 3A. SL 1 M Sb< rite C S 1 CA .S
Ground $ /s~ /0`/ 3 S G't u 0.7 0-
elev.
gz,saft. 6 SZ-IZ$ /OYk 4 4 _ S nil
Depth to
limiting
factor
Remarks:
Boring #
10-7 16-43 3 SL n, Slob rn4'r C 5 Z M o 5 0.~
[3 8, VZ4 i&yr,-~A SC -"bK QA 6,S
Bz 4 - /ovIe 3 s rV l c Lv
Ground
elev. ~S3 -12 141,e 4 5 n-, o 0.1
9L.Z0 ft.
Depth to
limiting
factor
? 6, L16
Remarks:
CST Name: Please Print Phone:
74~ ~~Y SIN Sd ~
Address: . $dJ~ 9 ddtJ W)
Signature: Date: 1 / A CST Number:-34V
PROPERTY OWNER SAA M)UEp- SOIL DESCRIPTION REPORT Page Z of
-PARCELI.D.9 LOT 17 `rANNL~y Rihce
GPD/ftZ
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundery Roots Bed Twit
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
n oy~ 3 L. s b o.s
L A Sb< ,vft'f C W
Ground ~2 2 bb O 4- 3 n'►' C ~.7
elev.
9~sA ft. iz~ 0 4 4 rn 0 . o
Depth to
limiting
~ factor
OOH 6
Remarks:
Boring #
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0
4
x, I/V
TIA JT-
4 8) 9-,z4 lnpiO L 'Z eh
Ground 4-S 'd` R 4 A S" !1, C W I O.Z O
elev. 14-
I! I ~~7 d
ft.
Depth to
limiting
? f c~ t~._
Remarks:
Boring #
~4 -1 I aYi2 3 3 5 m r r ~ 5 Z~ .S d6
1 /dv~ 4 3 -7 Gv) C, tv
Ground 7- fZ bye. 4 S 1'~ Q .7 Q
elev.
ril$1ft.
Depth to
limiting
factor }
Remarks:
Boring #
y+tti,
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 5 4 M Aj jL L F f
MAILING ADDRESS 60X 0 z r il/ w l
PROPERTY ADDRESS (b.SS 7-AhI e' 4,4411=
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE y y S o)U w 'L
PROPERTY LOCATION 5 E 1/49 N E 1/4, Section I , TAN-R. / W
TOWN OF #U D,5 CA( ST. CROIX COUNTY, WI
SUBDIVISION -AA1 0 /Z/,0G-F_ LOT NUMBER ~ 7-
CERTIFIED SURVEY MAP T Z;- 9 S-4 , VOLUME (,o , PAGE o2 S , LOT NUMBER /7
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.
0
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 b a mater restricted plumber, journeyman plumber, 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: Z _ Z O ' `1
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 _ 5 p. m M I L L F ~Z
Location of property5j 1/4 IYE 1/4, Section If T z!~ N-R / W
Township AU D S oA/ Mailing address OoK z sz
_A' Vp .5ed wt s yo
Address of site 1osr Tx yllr z,4A1--
Subdivision name 7`fi~l/iVY~2/06E Lot no. / 7
Other homes on property? Yes X No
Previous owner of property ,P,¢NQ,4LL SS #A#
Total size of property Z Z AC,
Total size of parcel Z. 2- 1/1-L
Date parcel was created 10-1-173
Are all corners and lot lines identifiable? Y Yes No
Is this property being developed for (spec house) ? Yes No
Volume D 3J and Page Number y S~ 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. S0y~y S
and that I (we) presently
_S_ I
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.
.so~flSS
Signature of Applicant Co-Applicant
Z C) S-
Date of Signature Date of Siqnature
1 ~ Tf '
• + DOCUMENT NO. STATE BA F WISCONSI ORM 1-1983 T"la araCS aeaa"vaa ,on a/Carol"o DATA
ARRANTY D D
504855 - YOL 1031►QGE r
r._C1ST,.. S OFFICE
This Deed, made between ► CO..%AA
....RandAi.i..W-. Synan..and- Patricia E. Synan, ,ech:r Reaxd
.....husba............................................ and wife _
. Grantor, SEp T 1993
and...Sam E.•...Mil:~er........_...._....?:e...Pe .rson of 1.21ou:45 A.M
t/ ~+►+~X~,
Grantee, I @- ~s~ n10ae4
Wit~lesseth That the said Grantor, fqr a valuable consideration...... l~
s,. Randall W.'Synan and Patricia E. Synan
conveys to Grantee the following described real estate in ...St' CrO~X To
County, State of Wisconsin:
Taz Pared No:
to ° °
The SE1/4 of NE1/4 of section 11; the SW1/4 of NW1/4, the N1/2
of SW1/4, and the South 53 rods (874.5 feet) of the SE1/4 of
NW1/4 except the East 74 feet thereof, all in Section 12; all in
Township 29 North, Range 19 West, Town of Hudson, St. Croix
County, Wisconsin. FF _ wj
}DIY
AND ~
'A
A parcel of land located in part of the NE1/4 of SE1/4 of Secti n +
11, Township 29 North, Range 19 West, Town of Hudson, St. Croix
County, Wisconsin further described as follows: Commencing at the
re E1/4 corner of said Section 11; thence S89 30800"W, along the
North line of the SE1/4 of said Section, 1212.32 feet to the point
~j of :.eginning; thence continuing S89 30'00"W, along said North line,
66.00 feet; thence SOO 28103"E, 500.00 feet; thence N8q 30100"E,
along the North line of Certified Survey Map filed in Vol. "30,
" Page 722, 38.08 feet; thence N00 11133"W, 150.00 feet; thence
N03 58134"E, 351.07 feet to the point of beginning.
This ..........i.$..AQt.... homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances titereunto belonging;
And..... R, . aa1.l... if _$yndn.. and__Pa. . E,.--Synan
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
t, easements, restrictions and rights-of-way of record, if any.
ai
and will warrant and defend the same.
i
Dated this 5) day of ALU9.U.9t-....................................... 19..9.1.
a rt GJ, ....!?fit.~J---(SEAL) _ t~Ai.GC- !ht! .........................(SEAL)
Randall W. Synan Patricia Synan
...(SEAL)
(SEAL)
a •
i
't. AUTURNTICATION AC=NOWLSDOM11INT
Signature(s) STATE OF WISCONSIN
i
816
St. Croix
......................................County.
j authenticated this day of 19..__.. P"nally came before me .../-1......._day of
August 19 the above named
Randall W. Synan, Patricia E'._....._..
TITLE: MEMBER STATE BAR OF WISCONSIN Synan
.
(If not, A ~Ct. '0,~,
authorized by 4 706.06. Wis. Ststa.) to me known to be the person ..,g....... 1)swf10 tz e
gong instru nt and n wle
I
THIS INSTRUMENT WAS DRAFTED BY '
.r Kristina Ogland 6
Alice Joy orfhors
Atcamep..at f;aW
5t.....crol x---------------------------------
Notary Public ...............------.......-.CountY, Wis.
r (Signatures may be authenticated or acknowledged. Both My Commission is permanent. ((jf not, state ezp. ation
are not necessary.) date: lA•.~• 7.)
-Names of person, sicnlne in any capacity should be typed or printed below their siSnawrs.
WARRANTY DIED STATE BAR OF WISCONSIN Wiscon.in Kral Blank Co. Ina
FOQY No. 1 - 1911 Mil Waukee. Wis. ~