HomeMy WebLinkAbout020-1294-50-000
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AS BUILT SANITARY SYSTEM REPORT RUE71Vf0 N
FEB 2 9 1996
OWNER '12 ur LQ S7 CROIX
C-Ot.I;~Ty
ADDRESS 7c (~iG r~ 6s~c/t° Z1h'C;OFFIC~
SUBDIVISION / CSM# LOT
SECTION- 2y T Zyi N-R If W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i
Y~
oar c~~ ~ ~ ~
D
7
i y
-'j
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INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: Tm+ Ok / m6r) 0
/ U +
ALTERNATE BM:
~~ns s r~z.
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: 6)4 Lk r C, P. Liquid Capacity: /000
Setback from: Well Z House a y other
Pump: Manufacturer /yA Model# Size
Float seperation Gallons/cycle:
Alarm Location
-:SOIL ABSORPTION SYSTEM
Width: -5 Length 75 ' Number of trenches 3
Distance & Direction to nearest prop. line: '70' fa Ah,
Setback from: well: 75" Housed 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: - _,0
PLUMBER ON JOB:
LICENSE NUMBER: A1111-W5 INSPECTOR: ~,•h'IrJy1
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor--and Human Relations ST. CROIX
Safety and Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI
JOHNSON, DON X Hudsen CST BM Elev.: , nsp. BM Elev.: BM Description: Parcel Tax No.:
I led. 4~~
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ~n Benchmark
e"
Dosi n aw - / 3%i OGR ~ ~
Aeration Bldg. Sewer
Holding St/ Inlet
TANK'_SETBACK INFORMATION St/ t outlet `p" , '
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet G
Air Intake
Septic a5! NA Dt Bottom
Dosing NA Header / Man.
Aeration Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer
Demand' °s 7- 03.
I
Model Number
TDH Lift Friction TDH
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION 7
5 I DIMENRM5 L Manufacturer:
SETBACK SYSTEM TO P/ L BLDG WELL LAKE / STREAM
INFORMATION Type O Ru,r CHA ER Moe Number:
System: 37, ~4 O NIT
DISTRIBUTION SYSTEM
Header-EA4arriiv+d Distribution Pipe(s) HoleSize x HoleSpacing Vent To Airlntake
Length 7 Dia. 7 Length Dia. Spacing _,L-L,
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Syste my
Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched
Bed /Trench Center Bed / Trench Edges Topsoil ❑ Yes ❑ No E] Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Hudson.24.29.19W, SE, NW, Lot 32
r ,.e+, IYct, C?.,... ~T , to
~ r~
J
Plan revision required? ❑ Yes ❑ No c n
Use other side for additional information. - j~
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
Av"
/ 7' -7 X0 2-„ yam ,
SANITARY PERMIT APPLICATION' Bureasafetyu of Bui Buiildii nWater Systems
gWater 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 Sanitary Permit Number
The information you provide may be used b other government agency
y y by programs ❑ if 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-7- Property Location
D&A ::R) KSOK 5 " 1 /4 ~ ) 4 1/4, S v 2 T e , N, R I (oQ
Property wner's Mailing Addre s _ Lot Number Block Nu ~a
7 2- /-IC ( 3;1-
City, St to , J Zip Code Phone Number Subdivisio ame or CSM u
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road
❑ Village
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF
Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo 4;1 sry
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. jX 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;R 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.) (Galsld y/sq. ft.) (Min./inch) 7"1 Eleyaation
05 iiay !A- Tz Feet Feet
VII. TANK Caa
in glloacctns Total # of Prefab. Site Fiber- Exper-
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Exist in strutted
Tanks Tanks
Septic Tank or Holding Tank /GYaf3 (J.ec,Es 1e ❑ ❑ ❑ ❑ 11
Lift Pump Tank /Siphon Chamber El El El El 1:1 El
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's me: (Print) Plumber' Signature: (No St mps) MP//MPR W N Business Phone Number:
~~x~ 3a~ 7177aZ 3a
Plumber's Ad ress (Street, City, State Zip ode):
IX. OUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing Ag t Si nature (N amps
'r Approve
X d ❑ Owner Given Initial ~~1 Surcharge fee)
p
Adverse Determination d)
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SRD-6398 (R. 05/94) DISTRIBUTION: original to Couniy, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS `
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
1 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
ll. 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, reconnec`ion, or repair.
V. Type of systern. Check appropriate box depending on system type.
VI_ Absorption system information. Provide all information requested for numbers ' thro(J0
VII. Tar-.k information Fill it the ca, ,city of every new/or existing tank, list the toy : ,:a.ions, of tanks and
7uf„c1..er's Warn d.c:te , efab or site constructe.1 and tank material C,--: .l; e Jc, ;)amp/siphon and
i nc, I inks r `,,is sy_ am. C')eck experimental approval only if tanks rec- L sjp ~i fl, i odu _t approval from
VII;_ Responsibility stat.ement_ Installing plumber isto fill in name, license number will? Approprial~ prefi> ;e.g. MP, etc.),
addlres_ and Phone number- Plumber must sign application form.
_c._: ._<<.~,~-, :meat Us- Only
Cc _~n,, + D . ar`ment only
t:s not sma ! er Lh 8 1%2 x 1 1 Aches +mis, ` T The Ulans must
o, ~;r drawn: t~ wale or vvith con p!ei_E_ _ nd septic
n1.) or siphon
_ uii&,ig served;
Cipsevolume;
r _ .,ss se;:tion
r; info ,mation.
GROUNDWATER SURCHARGE
laded the creation of surcharges (fee,,) for a number c.' reg!_'a~cd E I vhK ca-,
se __•rch-,..rges are used for r7 ..,ut~r y grou cJ. ate I t 1.Y esi uc;t;ons
' JOB ~I,U ago
TIMM EXCAVATING SHEET NO. l OF Z
Route 1 Box 192
WILSON, WISCONSIN 54027 CALCULATED BY id~ ✓ DATE Z2
~
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
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PRODUCT 2051 Inc., Groton, Mas . 01471. To Order PHONE TOLL FREE 1,800.2256380
JOB
TIMM EXCAVATING SHEET NO. OF 2
Route 1 Box 192
WILSON, WISCONSIN 54027 CALCULATED BY ✓ 1--' DATE
(715) 772-3214 (715) 386.5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
SCALE
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PRODUCT 205-1 ~•Inc., Groton, Mass.01471, To Order PHONE TOLL FREE 1-8OP225-00
VEX T01 134Nh~ER CG.vST i762. 250 tk ST.
EA-t ER,0~. L_ L-;) W I S . .510(1- ~c$ 2-cps- 7 Y515 .
Wisconsin Department of Industry,
Labor and Human Relations SOIL AND SITE EVALUATION REPORT Page [ of 3
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
~2Ofx
A1 . ''0' 57'.
Attach complete site plan on paper not less than 8 1/2 x 1 i c s in site:- include, but
not limited to vertical and horizontal reference point (B ~hf on atlid of sl' le or PARCEL I.D. #
dimensioned, north arrow, and location and distance t, nest fa?,;i I
APPLICANT INFORMATION-PLEASE PRINT INFORM -T-1`ON REVIEWED BY DATE
PROPERTY OWNER: PROPE CATION e/
c~t•f'l a,,.~ N A R y ~ U $ ~ >Y U5 v~; ' GOVT. ~ 1/4 0 U) 1/4,S T 2f' N,R E (ce
PROPERTY OWNER':S MAILING ADDRESS OCK # SUBD. NAME OR CSM #
f~ 3 ti T r• sU-i R 1,Dc c-
CITY, STATE ZIP CODE PHONE N I VILLAGE OWN NEAREST ROAD
t4UDSOAD W1. $y01lo ('703P UpS.0 Mc'~(AAKi'P
[;]"New Construction Use [ Ai- Residential I Number of bedrooms -3 [ ] Addition to existing building
( ] Replacement [ ] Public or commercial describe
Code derived dairy flow y.5-0 gpd Recommended design loading rate bed, gpd/ft2 ,trench, gpd/ft2
Absorption area required /Vk bed, ft2 1115 trench, 112 Maximum design loading rate Abed, gpd/ft2 ' S trench, gpd/ft2
Recommended infiltration surface elevation(s) Ste- p9 • 3 ft (as referred to site plan benchmark)
Additional design / site considerations Zf S E~- 4-0 - -Ne Eti 4A5 w/ O ROp AOX d f S7-ke 13 U11 OA-)
Parent material SO 5 9 ;MeC- - s%r Sao%~sF.vTS Flood plain elevation, if applicable Al ti 71-- It
ev A, v w
rSu== Suitable br system CO IONAL MOt1flID INPUND PRESSURE AT GRADE SYYST IN Fl~L HO S NG T~
Unsuitable fors stem S❑ U 0S LrJ u [7S 11 U G 0`0 0'0_
'0
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Barclay Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tiench
1 '9 -137 / 3 51/. -611- 4o2P 4721-,P I-r-S
« . h. L /o YR y!l s/ /7cSAe Cs 17c . Y ..S
s - 2
Ground 3 2" /p el C S D S G~.Z 4- S • 7
elev.
7/ Qv
f"e
Depth to
limiting
factor v
Remarks: D~SiG.v 2lsi:~ /or~0ivs /PATE` foil 3 dt low sysT'E'--i ^ . S 6-PP
Boring # /D yje 3l3 22',f ,¢GTED 'r r lie- A, A3
< -3 W50 7,50 51,9 s ws c s _
Ground /
elev. 570 - /O iQ
p' f , l ft.
Depth to
limiting
factor , ,y
Remarks:
CST Name _Please Print b 6 ~2 T LQ C.Lt f Phone: l l S- 3 Q G_ S& It 8 S
Address: sS olmEfI ~D• ~U0.S0•J w t5. Sg06CO S- l b-q S CST," 24o02-_
Signature: Date: CST Number:
~4~- S x 7 S RlfSED
o,v "4 01A1 -4/f 74=- of
PROPERTY OWNER V 5 s SOIL DESCRIPTION REPORT Page Z of 3
PARCEL I.D. # 1-0-t ` .3 Z S O AJ R f D ie
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tmnch
o-S 10 3 she ~7Fe CS /UP Y •S
3
s_ 7 0 YR 314{ 2f shw n►,f i2 CS ! v f . s • G
Ground -3 / -1 7•5- yp `/loo - SI S~~ `fit? qS f- .s
elev.
/04 XO ft. y 2 . s R 31S/ / Mn`f r • Q S •S
Depth to S ~.-7 S yR (p /S /ih~ ~S G'S •1
limiting D
factor
Remarks: .
Boring #
1,4-A tip
10-6p 31.L
Y 3 Sr/, •w~ shit .w. ~ip C5 /uf . S . Co
Ground .
elev. /6 V4,
. S. 4 , S aQ5' GS
!0 3 . /o ft. S ~
Depth to
limiting
factor
Remarks: ` '1.$' k d,4A.P- S of S/ l.P 2~`i a-f' • ~y . S
Boring # D-~ /O YICD /Z. S11 yik 4m7g5e eS 2 S
i z Z 'k ! D I/jQ 31tir,r/7~it° c S . y S
i TIc' Spo.et~-
Ground 4 Td " o A r - 2 o 4
elev. 3 O-S~ 7 SY~'/~/ , {i' aS . y S
/o a .~o ft.
Depth to u S Vn yl4
limiting 5 (v
Y/P S~ S d S ~C •Co
r
facto
Remarks:
Boring #
Ground
i ~ l
elev. 1i~ i
ft.
Depth to
limiting
factor
Remarks:
con ooon10 nc,nn,
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER / - f JJ~ MAILING ADDRESS lQ o~ 5 i'~~-l
PROPERTY ADDRESS O 9 -7 M 4 w
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE 6 1,~)ajn
PROPERTY LOCATION 1/4, IV (A) 1/4, Section T__:~_N-R_jj_W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION " )rjg& 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 expiration date. 7
211; -1 SIGNED:
DATE: /a~ l~S
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, Wl 54016 11/93
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 of property Jk-73 414 44~
Location of property_1/4 X1/4, Section TN-R__Z~' W
Township,,,. Mailing address
a7 13jh 5
Address of site a~ wiC~l"0.4u
Subdivision name Lot no.
Other homes on property? Yes x, No
Previous owner of property ~ m ki,~ c11
Total size of property o 3 7 Ae-
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? N --Yes No
Is this property being developed for (spec house) ? Yes >c No
Volume and Page Number L,13 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. S~ 7 55_, 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.
gnature o Applicant Co-Applicant
Date of Signature Date of Signature
537555 STATE BAR OF WISCONSIN FORM 1 - 1982
a~ J J WARRANTY DEED
DOCUMENT NO. VOL 1.153 n 6 -
- - I t,• t 0iTI Ei
~ci
This Deed made between Greenwood Enterprises, Inc.
a Wisconsin corporation D EC 1 8 1995
`a, 10:00 A. M
Grantor, „
and Donald F. Johnson, a single person
::.t~;r of t7errcts ,
i
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration of one THIS SPACE RESERVED FOR RECORDING DATA
dollar and other good and valuable consideration NAME AND RETURN ADDRESS Nv/D
conveys to Grantee the following described real estate in St. Croix Donald F. Johnson
County, State of Wisconsin: 627 13th Street
Hudson, WI 54016
c 2a / Zs~/ -
(Parcel Identification Number)
Lot 32 of the Plat of SunRidge II, filed in the Office of the Register of Deeds
for St. Croix County, Wisconsin on August 1, 1994, in Volume 6 of Plats, at Page
17, as Document Number 519728.
T A o~F~'R
This is not homestead property.
CcW (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And Greenwood Enterprises, Inc.,
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements, restrictions and reservations, if any, of record
and will warrant and defend the same.
Dated this ~S day of .,Olt
, 19 95
GREE OD ENTERP ES, I GREENWOOD ENTERP S C.
By : (SEAL) By
(SEAL)
* James F Rusrh, its president
(SEAL) (SEAL)
* *
AUTHENTICATION ACKNOWLEDGMENT
Signature(V James E. Rusch, its president STATE OF WISCONSIN
ss.
ST. CROIX County.
u nticat th day of November 19 95 Personally came before me this day of
a ?
No-%rember 1945_ the above named
f
* 'Lois A. Mur Mare Rusrh, its speretarv
TITLE: MEMB STATE BAR OF WIS NSIN
(If not,
authorize 1s. tats.) .~PR~ PvB to me known to be the person who executed the
or ing instrument and ack owled he ame.
THIS INSTRUMENT WAS DRAFTED BY
Lois A. Murray. Zilz and Estre ER. /
621 Second Street i SCHMIDT * el?el A, ISC!"1 YY)
HtIdZ~ULI, W! 54016 Lary Public '-rv, 6r i" K County, Wis.
(Signatures may be authenticated or acknowledgre not y commission is permanent. (If not, state expiration, te:
/ p
necessary.) al IN ($GD ~ S 19
*Names of persons signing in any capacity should be typed or printed below their signatures.
i
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc.
FORM No. I - 1982 Milwaukee. Wis.