HomeMy WebLinkAbout020-1301-70-000
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ~RP!1 Dla K k011 I C
ADDRESS UKO()Woo V 'W') 4
840SUN wlI c- Sj )01(0
SUBDIVISION / CSM# LOT
I
SECTION 7 _T D,9 N-RW, Town of ap ON
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SY TEM
N (8x 3 (o
ovex outlet 6r~=~1e a~' _ _ . _ .
tooo al
5! ►
(13311
3 8~~o n ~a n r.
I
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
L L I ,
BENCHMARK : U 'Post 5W lot CO K o e K S"\ r. he ~ Le U l CEO O
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: W Q Q I• S Liquid Capacity: U c 1
i
Setback from: Well MQ so House Q 91 - Other 33
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
VeWA rn~ rck S tiufi I.ya
-;SOIL ABSORPTION SYSTEM
LOWS,
Width: S Length 3 eo Number of treneh~--
Distance & Direction to nearest prop. line:
Setback from: well: 0V2IZ sv~ House Other
~N 9 ~ 3y - g y. 3 y COVOK
ELEVATIONS 97-08
Building Sewer ST Inlet, 95.'-13 ST outlet • 5
PC inlet PC bottom Pump QOff
Header/Manifold Bottom of system Io~. yo~
Existing Grade Final grade
DATE OF INSTALLATION: 9
PLUMBER ON JOB: V ~a0, Q-912 t-t
LICENSE NUMBER: 3 y V L)
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor ahjmawRelations
INSPECTION REPORT ST. CROIX
Safety alid B Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Permit Holder's Name: ❑ City ❑ Village QA Town of: State Pla .
FERKOVICH, JOHN & BRENDA X
CST BM Elev.: Insp. BM Elev.: 7_-'W-.~),e M Description: Huds ft Parcel Tax No.:
'60,'
60. 646", - - 0960009i
TANK INFORMATION ("I U ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 'ey
Benchmark
Dosing
Aeration Bldg. Sewer r7
Holding St/Ht Inlet IJ41 Crs,~7'
TANK SETBACK INFORMATION St/ Ht Outlet 95
Verit
TANKTO P/L WELL BLDG. Airito ntake ROAD Dt Inlet
Ar
Septic >d 5 >5o t C1 NA Dt Bottom
Dosing NA Header / Man. 9 y ter' yb
Aeration NA Dist. Pipe 9. S9' 93, 3 -
Holding Bot. System
gam?, V
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
9G, 0
Model Number GPM
TDH Lift Friction System TDH Ft -1 F
Forcemain Length Did. I f Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS / Ll DIMENSIONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM
INFORMATION Type O CHAMBER Moe Number:
System: -6-Z / 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: Hudson.17.29.19W, NE, SW, Lot 146, Brookwood Drive
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. 8 g q~ U , y
SBD-6710(R 05/91) Date spdctor'sSignature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
S Goo
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than as i~3 g 7
8% x 11 inches in size. ❑ Check if revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROP TY OWNER PROPERTY LOCATION
d N 4- I Q ~oVrlL N '/a ~'/a,S i TQ9,N,R 19 E(or)W
PROPERTY OW R'S MA(41NG ADDRESS LOT # BLOCK #
D0'6 I IsGOI~ f1nJ St , M + Iq~
CIR STATE r ZIP ODE PHONE NUMBER S DIVISION NAME OR CSM NUMBER
U0 lt~Is~~ S~ oIb ~/S $ -8543
;A,6
II. TYPE OF BUILDING: (Check one) 1:1 State Owned VILLAGE : #42 NEARE ROADY 4OWN OF: FOP KLa lab 0112.
❑ Public N1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMBER( S)
Ill. BUILDING USE: (If building type is public, check all that apply) ^ ~O
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 120 Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. Lf~New 2.E] 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 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 420 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
RE UIR (sq. ft.) PRO O (sq. ft.) (Gals/ y/sq. ft.) (Min./inch) F EVVATION
11~ v~ Feet Feet
VII. TANK CAPACITY Site
in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New istin Gallons Tanks Concr to structed glass App'
Tanks Tanks
Septic Tank or Holding Tank 00d WQ
Lift Pump Tank/Si hon ber, L1 I El
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~Signat : (No Stamps) MP/MPRSW No.: Business Phone Number:
)3 -g o~ Q
~s
J
Plumber's Address ~Stre$t, C~i y, te, Zip Code .
11 08 1~1, L h*~c Tsb N .S~ - N u ~s 00,~ 1 sc S o
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanit ry Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial TT Surcharge Fee) Q
Adverse Determination v `
X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL:
hh0 6398(R.08/93) 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 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 & 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 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 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% 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, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
R B, L 6 7 PA (.)I I
LOT 0 S S
[5 L
NAME
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P L A P A-----r-------
33, - ~eN~•~, ri~a--.
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Node: Ad1~~~, u s e VACW -
Not.: W411 ,1S
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N
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FRESH All' INLETS AND ODSERVA'f1QN I I.PE
C110S'S SECTION
Approved Vent Cap
Minimum 12" Above I 9~- 7a F) N0 Gt-pw
Fi nil r~~fle___~
~A-x
4" Cast Iron
Above Pipe Vent Pipe
To Final. Gradc-
Marsh Ilay Or -Synthetic _
Covering
Min. 2" Aggr.e(J.111 o _ I
Over Pipe
Dis tribu Lion Tee
. Pipe I ..t ,
Aggregate rer- ora Led Pipe Be low
gaga ,.,4) ncaa h Pipe Coupling Terminating r
_ . 'Hot tom. of, System...
wsr^nsinDepartment ofIndustry , SOIL AND SITE EVALUATION REPORT Page of
t aboAnd 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 81/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OW PROPERTY LOCATION
v F e_ GOVT. LOT /t 1 /4 S ~ 1/4,S T 2 N,R /9 E (orjfj,)
PROPERTY OWNER :S MAILING ADDRESS ~ LOT # BLOCK # SUBD. NAME OR CSM #
/v 1,~4&
CI STAT ZIP CODE 146
PHONE NUMBER - ❑CITY ❑VILLAGE WN NEAREST ROAD L 56L6 )6
New Construction Use Residential / Number of bedrooms -3 [ ] Addition to existing building
] Replacement [ ] Public or commercial describe
Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2 , trench, gpolft2
Absorption area required 3 bed, ft2 .J 3 trench, ft2 Ma)amum design loading rate _Z_bed, gpd/9_ trench, gpd/ft2
Recommended infiltration surface elevation(s) t7.2,412' _ ft (as referred to site plan benchmark) /
Additional design / site considerations ~ ~ Lt_ ' L. 4- cL~Z , vb ¢ 4
ur~H~~/ ~L
Parent material Flood plain elevation, if applicable It
S = Suitable for system CONVENTIONAL fi?ND GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem S O U S❑ U ❑ U S❑ U ❑ S jov ❑ S TI?!W
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 Tna'&
g
=Z7 G? '//J~ S~ tn 5-4/c
Ground Z 7
sir s~
e1411
fV
Depth to
limiting
Remarks:
Boring #
sb/C c~ . S
.
ZA'
Ground 3 V o S QGh s i~ -
Depth to
limiting
or
Remarks:
CST Name:-Please Print ale Phone: 7l S 3b-~r~~ ,1
Address: 3s
Signature: ` Date: a CST Number:
1
PROPERTY OWNER SOIL DESCRIPTION REPORT Page of
r
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourdery Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
j" in Ir
Ground 3 p6 ° l
ev.u "
Depth to
limiting
fact.
Remarks:
Boring #
Ground ke'-191f2eZzw-V41 5- 7
Depth to
limiting
factor
i
Remarks:
Boring #
t' 3' O /e 3 Z ~~~ye, S I S" Nr v ~i v Y IM,
Depth to
limiting
Tt~
Remarks:
.Boring #
Ground
elev.
ft
Depth to
limiting
factor
Remarks:
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STC- 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER Sala i,, 4- t~Yek-,da Fe-r O di
MAILING ADDRESS ~9 $ I'S rV' a i ai'c osoh/ , ZV/' 67YO/ 6
PROPERTY ADDRESS &Okwooj b 9 a4-
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE [/1~56{lI, I d clUl
A -1 _N-a~W
PROPERTY LOCATION /~I W I/4, s' V`/ 1/4, Section T ffa"Q
TOWN OF A IO~~Sr'j ST. CROIX COUNTY, WI
SUBDMSION-~JYk UI&,J C S t a l k s J IA4' HIM -4-~ LOT NUMBER ILRo
CERTIFIEDSURVEY MAP , VOLUME I , PAGE LOT NUMBER / y a
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.
UWe, 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
c
SIGNL-:D
DA FF _
St. Croix County Zoning Office
Go,,'ernment Center
1 101 Cann chael lZoad
I1/`~'
I Judson. AV'I 54016
S T C - loo
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 o f property ~o h d- ~By u-"do_
Location of property-k0-1/4 1/4, Section T9) N-R I W
Township .b tnj Mailing address c~b f s . N~ 07 I
- sa
Address of site
Subdivision name ail, _ U~ C~53}c e S Lot no.
Other homes on property? Yes No
Previous owner of property( r~ a a2 eir l V Q
Total size of property b Pr
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 No
Volume IWO and Page Number 110 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 t office of the County Register of
Deeds as Document No. t)9'1' f' , 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.
S' nature of Applicant do-Applicant
5-5-95 S-5-~S
Date of Signature Date of Signature
DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
STATE BAR OF' WISCONSIN FORM 2-1982
524396 VOL 1106PA ,f 170 ....._.S
REGISTER'S OFFICE
Darrel E. Wert and Beverly A. Wert, husband and wife r ST. CROIX Co., WI ;
individual l and each in their aan right
- Recd for Record
D EC 1 6 1994
conveys and warrants to John R. • Ferkavich and Brenda J. 10-.5'6--- -A. M
Ferkovch,--husband-and-wife-as-survivorship-marital-.--..-
--p4pp2rt---
tiagiscxotue.ds
- GVgil'& Wertheimer, S.C.
430 Second St. R O. Box 106
Hudson, 54016
the following described real estate in ........................Count State of Wisconsin:
Tax Parcel No: 020-1301-70•..
Lot 146, Park View Estates Sixth Addition, Town of Hudson, St. Croix County,
Wisconsin. ~I
II
I
. EXE
This deed is given in full satisfaction of a land contract between the parties
dated October 12, 1994 and recorded October 13, 1994 in Volume 1099, at Page 125
as Document No. 522459 in the office of the Register of Deeds for St. Croix
County, Wisconsin.
This 1S- 110t--- - homestead property.
-
kgJ (is not)
Exception to warranties: TOOTER WITH AND SUBJECT TO anv other easements, covenants,
reservations or restrictions of record, if any, but this shall not be deemed to extend any
such other recorded encumbrances beyond the term established by law therefor.
19_94
Dated his I day of D-----ec---e-n--------------------------------------- 1994
6 -
AL) ------------------------.-(SEAL)
Darrel E. Wert
.
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C - -------(SEAL) - (SEAL)
W Beverly A. Wert
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AUTHENTICATION ACKNOWLEDGMENT
Signature(s) - °,j 1E._.jA~F t.-aXj d---------------------- STATE OF WISCONSIN
Bever A. j ss.
/ ------------------------County.
authenti ed t day f--_ P9C z'.....-, 19.94_ Personally came before me this ----------------day of
•
19-------- the above named
Hughn
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not-
authorized by § 706.06, Wis. Stats.)
to me known to be the person who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
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Atty'•-Hug•--H._ Cowin
4Q__$.-t_.HUC$OI7,__ 54016
Notary Public County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.) date- 19--------•)
-Names of persona signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Leaal Blank Co.. Inc.