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HomeMy WebLinkAbout020-1289-60-000 o ~ °o I I ~ N 4 0 o I ~ I ~a z I I h I F. ~ I z I 76 LL C O Q Cl) N z a)WE ~(1) i', = °o N C14 Z I'I a m o I c z a o z c d o 2 T5 fA FZ- m N z c E -a ~ `7 M N (D N O • AID d = L C c O O z w z ~ z o z C N - _ I n N ~i 3 I'' O R E V p w 'o t° h co a 'm o cp L C o d 0 N CI = M 3 ° N O ~i v • = M a a N N IL > 1 'a 7 O~ 0~ 0 N V1 J U 0) 0) p } N N N O - N co E O 0 Q = N m -0 m z o fD N .2' 2 I d Q } cJ? C6 Cl) 3 w U) U) O O O LU W C W N O a O O C 6 C C a o N 3 ~ Y a) N 0. G3 d pOj p ,o 0 N a CL CL y G N V L Q' O C E E a) co co O ao C N O O n} ? N (N O L L Lo 4 v7 M N F- F- N 'n N w E E U 'a L (D r]^~]Il ~ ° co N • 7T,i' O N 2 U N O ~ I O y i' _ EL L L 4) • m .2 a "~1 A 0 a. 0 U) 0 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ~CY/~SG4~UwS~ ~l ADDRESS L (c e v u U I''' SUBDIVISION / CSMf 81 LOT SECTION T N-RW, Town of f l r;n` y` ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM yb•'o, qe a . 13° Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: tU G+ T ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: ffle d( $v CSf.C APP Liquid Capacity: Setback from: Well_ dz ` House S--Z) Other Pump: Manufacturer ModelW Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length Number of trenches Distance & Direction to nearest prop. line: Setback from: well: House ~q D Other ELEVATIONS Building Sewer) ST Inlet. ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade f!~ Final grade DATE OF INSTALLATIO PLUMBER ON JOB: Ems,- LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor a'ndHumanRelations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village ❑ Town o : State PI CHESTOLOWSKI, ED & MARY X CST BM Elev.: Insp. BM Elev.: BM Description: t ¢ Parcel Tax No.: Off. /a), C~ r»Q cz5 /-acs TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark GS~~/7 /~C~ ~ ) 3 osi n & iZ a/, 3" Dosing,-- Aeration Bldg. Sewer 122-1 1~2. (03' Holding St/R( Inlet /e,96' TANK SETBACK INFORMATION St/ j#Outlet ,j ~j Vent TANKTO P/L WELL BLDG. AirIto ntake ROAD Dt Inlet Air NA Dt Bottom Septic > ~2 1 64 Dosing NA Header- .a /o8.sy' Aeration NA Dist. Pipe ,3 ioG.~G' Holding Bot. System 3' 6' t as• ~3' PUMP/ SIPHON INFORMATION Final Grade SEC o('s,T er Demand m er. /Bs d 5, r Model Number G ~.~7 6y TDH Lift Friction m T Loss ea For~effiai Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length .6 No. Of Trenches PITS-- No. Of Pits Inside Dia. th DIMENSIONS ~C 02 DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEAC anu adurer: SETBACK CH ER ` INFORMATION Typeo e-, r 2 ?I Moe Num er: System: et4 %r ti5bu? / Q A R UNIT DISTRIBUTION SYSTEM Header / Distribution Pipe(s) x Hole x Hole Spacin ent To Air frttaJCe Length Dia. Length 83 Dia. t Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade S ems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodde7x x Mulched fi5wtrench Center 1-1400-ITrench Edges Topsoil E] Yes E] No E] Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.), LOCATION: Hudsonn26.29.19W, NW, SE, Lot 33, Meadow D ive~ Plan revision required? ❑ Yes [~I~o Use other side for additional information. S 9 SBD-6710 (R 05/91) Date Inspector's Signatur Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ' SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code Co TY OhDILNA STATE SA AT9-- -Attach complete plans (to the county copy only)for the system, on paper not less than ~Q)1SU( 8% x 11 inches in size. ❑ ~ 3 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. PROPERTY OWNER PROPERTY LOCATION Ed & Mary Chestolowski NW % SE S 26 T 29, N, R 19 E (or) V~ PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # 2246 Nevada Ave. Apt. 12 33 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER qt- Louic; Park, J S94 612)SAA-AA71 Hi cTh adnws, 1 II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD ❑ State Owned ❑ FRI TOWN VILLAGE ;Hudson Meadow Drive ❑ Public ® 1 or 2 Fam. Dwelling-# of bedrooms J PARCEL TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) 1 1- 1 ❑ Apt/Condo r 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 80 Mobile Home Park 120 Service Station/Car Wash 50 Hotel/Motel 9 ❑ Off ice/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑X 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 # 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 El In-Ground 42❑Pit Privy El 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 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 450 825 830 .54 15 107.9 Feet 109.37 Feet VII. TANK CAPACITY Site in allons Total of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Se tic Tank or Holdin Tank 1 1000 1 Midwestern F] M Lift Pump Tank/Si hon 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): Plumb 's Signat a (o Stamps) MP/MPRSW No.: Business Phone Number: Joe Stang MP 6646 715 698-2266 Plumber's Address (Street, City, State, Zip Code) 506 Willow Drive Woodville, WI 54028 IX. COUNTY DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued Issuing A nt Signat (No S mps rdk Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-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) I N e vq ale, 1~v4r' Apz l ~ I I 1-lt+tdSh ~Gw Sti L~~ 33 I toe- i f3►I IG4.3? ~ 1 2 -13 83 JU~.G~{ ) o q, , S~~StGr,1 ~~t/ I& S O , 2• Q iy V °i e3 ' F IP 6? L t V e l... IPe ' 1 Y DEPAVTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY., , DIVISION LABOR AND' c P.O. BOX 7969 HUMAN RELATIONS PERCOLATION TESTS (115) MADISON, WI 53707 (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP~Y: TOT NO.:BLK. NO.: SUBDIVISI N NAME: PE /NG rVO1/ sE 1/ 2& J21 N/R 0 E lor) W t f u Pso,.j 33 H i I k4 E^.bowS_-M:- COUNTY: MAILING ADDRESS: 5+C'1, K &LE.v Cuf►Xo.v 7Z C e Cova'Ty `.o. Ij U D S'ca W I S Sya/ C- USE 9 -2-2.5DATES 013SERVATIONS MADE NO. BEDRMS : COM R IAL DESCRIPTION: PROFILE DESCRIPTIONS: TS: Residence 3QR MNew ❑Replace I Jv~E is Ig 9 J'U~Jt 1 S 3 16 9 I 5C5 ~ 1~4,~or~9- /ot-y ~ /,~u~PKh~4.PDT s/ RATING: S= Site suitable for system U= Site unsuitable for system • CONVENTIONAL: JIN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDINU TANK: RECOMMENDED SYSTEM •loptional) - ©s ou IMOUND: os ou os au [JS au EIS au b(STR(,R0rf, w-r0 E aw if lit VA ~o.~ s o~ S /of2~ If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.0915)(b), indicate: G `'4 S S Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEP, H NUMBER DEPTH IN, ELEVATION OBSERVED HET TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) /0AA-, /o YR 3/2- Iplo-ev y" 14 yR 31s 51, 1 5 b tt , ko > //0 r4" UFIC 36" /0 VA 4/¢ 5/, 1 P sbk, r,. it)e i 3&o -Coo' 75 ~5 B- / I/O 10q.37 _ 0-l1" -7, S YR 312- 5/, P/6tj&,; /2 "-2275 Vg P le, S~n.,Sb&, B- 2 yd lL2 Y3 ~Io > /yp &t I.F'o ; 2.2"-/Yb" /0 y~e fI6 f s 0_/2" -7♦ S Y,? 2_ !04A4 PIocve-a ~ /2- i,p " 7 S Ye Y/y 5-, B- (20 (20 1"M5 bk, m of I' j /P-Cooyx 4/f -4-0. S (0„_ afR 0-/2" 7,S YR 3/2 /OAH, Piow.o; 12."-/£'" 7.S YR 3/2 5/1) B- (5 l `~O "fJ 7 (l S /nom X fjQ ' 1?'f- qP" 7,S A 414 /S 0 c ,,e nnyf11 48"-Its " '7.S t/R 4"/y Soto 5,ocy2, s S 120 10z, -70' , > I 2.0 5(A- i L~ R tb P PO TM E f', R r3 y svQFgcE ~laEUh7ioNS 6F PERCOLATION TESTS y TEST DEPTH. WATER IN HOLE TEST TIME DR I WATER L V L-IN H S RATE MINUTES f NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD-1- PERIOD 2- PERIOD 3 PER INCH ' r s . 3 P_ y - IRV is P. 2 600 Is P_ I/ P 710 /047 - 30 l Z_ P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. 14 ('01 H IQ E N Ctt. r /0 7 9'0 7 ,1 u 74 105- Yd SYSTEM ELEVATION. <aw 7"REUerk - /oa-?o I i _ ~ I 1 I I I , s'-pc-oT. PLAN i i 1 I 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print : TESTS WERE COMPLETED ON: HOMESITE SEPTtC pLUMi~IN a CO. J c1 tiE /7 1 I ADDRESS: 6550'NEIL RD♦, HUDSON, WIS. 54016 CERTIFICATION NUMBER: PHONE NUMBERIo tional): ROBERT ULBRIGHT 24 S 2 3 g~ - ~ ( PLUMBER LIC. N0.3307 M.P.R.S. CST SIGNATUR r;i!NN. INSTALLER b DESIGNER LIC. NO. 00663 f ~5 Z ^ f C ~-~4 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. PLOT \ 33 • = /3,~c~iy~ p,•ls X a to RC /9 C47-eo,v$ ~ W w w z V3 4 9 ~ siop 0 q 2 V N ~y W / 3 `I y~~ r I Fc~~o, Su~utyoRS n [2 oz p lP-t oL~- 5. C . I-or co,2aER ~'l~ v~Tio~ = goo, O i ,WESITE SEPTIC PLUMBING CO. o5 O'NEIL RD., HUDSON, WIS. 54016 ROBERT ULBRIGHT C s Z y8Z PLASTER PLUMBER LIC. NO. 3307 M.P.R.S. ';TALLER & DESIGNER LIC. N0.00663 L~ 3 b STC-105 SEPTIC TANK MAINTENANCE AGREEMENT nSt. Croix County OWNER/BUYER 15 17W1ARD l Fl E~ToLc L~ S,fc l MAILING ADDRESS `r ~ 191u y r ol e fi 6/~ f PROPERTY ADDRESS 7-3f (location of septic system) Please obtain from the Planning Dept. CITY/STATE 3 N e4~"` S __~Z W PROPERTY LOCATION 1/4, ~L 1/4, Section 2 T `C N-R. TOWN OF -w sc' , ST. CROIX COUNTY, WI SUBDIVISION C' IL LOT NUMBER CERTIFIED SURVEY MAP , VOLUME/ 6,PAGE 6 01 , LOT 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 iration date. J SIGNED: DATE: St. Croix County Zoning Office Government Center 1 101 Carmichael Road Hudson, WI 54016 11/93 STC-100 This application form is to be completed in full and signed by the o~,11er (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 !I. the property is sold and submitted to this office with the appropriate deed recording. Owner of property C ~~ZDSio(.c6tJ5K i Location of property,/ 1/4 SC 1/4, Section' ~ L , T'N-R/~ W .Township Mailing address de St L S 'C A4 ~,lc Mty s- s-y,2 Address of 'site -13~ no , I;V(feo~ 4,. Subdivision name Lot Ito. 33 other homes on property? Yes ` No Previous owner of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No la this property being developed for (spec house)? Yes Volume !G_~_hnd Page )lumber c~G as recorded. with the Register of Deeds. 114CLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRA1ITY ULED which includes a DOCUMENT NUIWER, VOLUME AND PAGE NUIIUI It F. THE SEAL OF THE REGISTLR 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 referencos to a certified survey Map, the Certified survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(wc) 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. 5 / `l,3 oU , 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 county Register of deeds as Document No.sl93va Sign ture of 'ap~licatit Co-ap cant Date of Signature Date of gnature This SPACE RESERVED FOR RECORDING DATA DOCUMENT No. WARRANTY DEED STATE BAR OF WISCONSIN FORM 2-1982 519300 y L1088m;not REGISTER'S OFFICE ST. CROIX CO., Wf Glenn Waxon and Vycella M. Waxon,. husband and wife,-- - Reed1~orRecof . - 4 - - JUL' 2 0 199 _ i:o P. M conveys and we rants to EdWard.M.. Chestolowsk Reuter of Daft R, ',hes.tolowski,-husband and wife, i - I _ St. Croix County.-- . the following described real estate in - Tax Parcel No: State of Wisconsin: i • II Lot 33, High Meadows III in the Town of Hudson, St. Croix County, Wisconsin. r` I l ~~R I'I'I I This .-_..._ls._not._-.._ homestead property. II p (is not) Exception to warranties: Easements, restrictions and rights-of-way of record, if any. I a II 94 ` I)ated this day of _ : I F ✓ - _ _ A SEAL) (SEAL) Glenn Waxon ` i S s I (SEAL) ycella M. axon . AUTHENTICATION ACKNOWLEDGMENT; 1S STATE OF WISCONSIN St. Croix ss. County. ~ F xrson:'.y a thi, ' II authenticated this day of-•-------•--•------------ + 19.._... I n ----b--c---- fo.c + 19-.94- the above named 4 GI Waxon.-and--Vycella.M.-_Waxon, husband._and_wife_,..__. TITLE: !MEMBER STATE BAR OF WISCONSIN Y r. (If not,.-.-. { to me known to be the person S - . . who executed the authorized by § 706.06, Wis. Stats.) J.. i ment and nowledga the going ms name. Y THIS INSTRUMENT WAS DRAFTED BY _ II I Kris tina _0 My CoPublic S.t,...Croix.- County, Wis. " r` Att_o_rn___ e__y at Law mmission is ertnanent.([f not, state expAa •1 i (Signatures ~I Comay be authenticated or acknowledged. Both date: - - - - 1 ) are not necessary.) •Names of persons signing in any capacity should be typed or printed below tht{r eignae.ras- ~I Wisconsin Legal Blank Co.. Inc FORM No. 2 - IvS2 Milwaukee. Wisconsin WARRANTY DEED STATE BAR OF WISCONSIN , • y