HomeMy WebLinkAbout030-1045-80-000
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS
SUBDIVISION / CSM# LOT
SECTION _TN_R~/ y W, Town of
01 :7
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
I~
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:
ALTERNATE BM:
SE TIC TAN / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: e- Liquid Capacity: a~
Setback from: Well House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
:SOIL ABSORPTION SYSTEM
Width: /l Length Number of trenches
Distance & Direction to nearest prop. line:
i
Setback from: well :_771/~O House Other
ELEVATIONS
Building Sewer ST Inlet, l ST outlet
PC inlet PC bottom Pump Off
Header/Manifold / Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION: /Q 3®
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
l
WTSCo asin Department of Industry, PRIVATE SEWAGE SYSTEM j Ck~l County:
Labor and Human Relations ST. CROIX
INSPECTION REPORT ~q A
Safety and Buildings Division y'
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State Pla
HOULE, HELENE R. A
CST BM Elev.: Insp. BM Elev.: BM Description: St. jeseph Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic; Benchmark
Dosing
Aeration Bldg. Sewer r~ /7 Cl V,_
Holding St / Ht inlet 12 (,8
TANK SETBACK INFORMATION St/ Ht Outlet 4~ R3 n ,
TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet
rl
Septic > .J >1',16 ` a ro- NA Dt Bottom
Dosing NA Header / Man. Aeration NA Dist. Pipe yP , " t
Holding Bot. System g,y3 Qa7U '
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Deman
Model Number - - GPM
TDH Lift Fri on System TDH Ft
Forcemain Lengt6 I Dia. H Dist. TO Well_
SOIL ABSORPTION SYSTEM
BED/TRENCH width Length No. Of Tr ches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type >a~C) ~i _A OR UNIT Model Number:
System:
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
rB e Pth Over DePth Over xx DePth Of xx Seeded / Sodded xx Mulched
ed / Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: St. JosePh.21.30.19W SE NW, Rail Drive /i 1 .:l r
Plan revision required? ❑ Yes No
o Ps
may' k
. /v
Use other side for additional information G
SBD-6710(R 05/91) Date I pector`sSignature Cert No.
ADDITIONAL COMMENTS AND SKETCH - ,
SANITARY PERMIT NUMBER:
i
r,
AF =x.mr. 'IL and vi~~in SANITARY PERMIT APPLICATION Safety ofBuii gWater System!
Bureau of Buildiinn Water 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. n /
• See reverse side for instructions for completing this application state sa ar Permit Number
aZ719 7 7..-~-
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
Property Own r N 7 e Prop ert oc tion
L i4 , /i/4, S , T ON, R E (o
Property wner's Mailing Address of Number Block Number
Cit , Stat Zip Code Ph ne Number Subdivision Name or CSM Number
7
I. TYPE F BUILDING: check one State Owned ❑ it Near Road
( ) ❑ y / f
11 Public 1 or 2 Family Dwelling - No. of bedrooms j Town of 1 <cc r i^-
II1. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ 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 12E] 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. New 2. 'Replacement 3. ❑ Replacement of 4- ❑ Reconnection of 5. ❑ Repair of an
ystem ystem Tank OnlyExisting 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 E] Mound 30E] Specify Type 41 E] Holding Tank
12 ]Seepage Trench 22 ❑ In-Ground Pressure 42E] Pit Privy
13E] Seepage Pit 43 ❑ Vault Privy
14E] 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 (sift.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
Feet Feet
VII. TANK Capacity
gallonTotal # 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 L ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans-
Plumber' ame: (Print) Plumber's SigFr~prre: (No Stamps MP/MPRSW No.: Business Phone Number:
Plu be , Address (Street, City, State, Zip Code): /
IX. COUNTY / DEPA MENT USE O LY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
Surcharge Fee) o
Approved ❑ Owner Given Initial
Adverse Determination r 711V
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SBD-6398 (R. 0584) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
11- 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 mustinclude:
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.
r,
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.),- ,
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 followirrg: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic.
tank(sj 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 an
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.
I
rLV~l rLHIV J /Da
PFCbJECT lell.1- ADDRESS-
5';0- fl 7
1/4 1/4/
/T~e N/R W TOWN- 5 , s~ -COUNT` e>wl
MPRS Byron Bird Jr. 318 DATE
/~---mss
BEDROOM CLASS PERC 4V-- CONVENTIONAIX IN-GROUND PRESSURE
CONVENTIONAL LIFT MOUND- HOLDING TANK
SEPTIC TANK SIZE `LIFT TANK SIZE
DOSE TANK SIZE HOLDING TAN SIZE
A
1116 BSORPTION AREA PERC RATE - BED SIZE
Benchmark V.R.P. Assume Elevation 1 '
Location of Benchmark
* H.R.P.
C7 Borehole Q Well Scale = Feet
0 Perc Hole System Elevation 9 o
Uent
12"
TYPAR COVERING
J
12' 3' a 6' 3' 3' 40 3'
" Sewer Rock
6 12' 18' "
l
r
o
1 sf
win Department of Industry, SOIL AND SITE EVALUATION REPORT Page of
L' EV Human Relations
Divisio of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 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 OWNER: PROPERTY LOCATION
GOVT. LOT 1/4 ly4Y.1114, T3v AR l E W
PROPERTY OWNER':S MAILING ADDRESS LOT # LOCK SUBD. NAME OR CSM #
syw t , ~~z r'
CITY STA ZIP ODE PHONE NUMBER ❑CITY ❑VILLAGE OWN JN [ ] New Construction Use [ Residential / Number of bedrooms [ ] Addition to existing
building
Replacement [ ] Public or commercial describe
Code derived daily flow 4`.50 gpd Recommended design loading rate 1 bed, gpd/ft2 .>'-trench, gpd1ft2
Absorption area required //A)~`bed, ft2 ~ trench, ft2 Maximum design loading rate gibed, gpd/ft2 Sr trench, gpd/ft2
Recommended infiltration surface elevation(s) 02 ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material G% er / Flood plain elevation, if applicable It
S = Suitable for system CONVENTIONAL MOUND IN ROUND PRESSURE AT-GRADE SYSTEM IN ILL HOLDING TANK
U = Unsuitable fors stem jffs ❑ U as ❑ U S El U J'S El U ❑ S ❑ S Ag~U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Bancla►y Roots Bed Tmnch 400
10~1 41-
Ground 1A* "ev
elev.
'5~ft.
Depth to A op
limiting
factor a
Remarks:
Boring #
;
Ground
elev.
Depth to
limiting
factor
Remarks:
CST Name:-Please Print Phone:
Address:
/01
Signature: , Date: CST Numbe :
PROPERTYOWNER11e%rr-e' SOIL DESCRIPTION REPORT Page _
PARCEL LD.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourxiary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color. Gr. Sz. Sh. Bed Trench
Ground
elev
ft.
Depth to
limiting
fact&,.
Remarks:
Boring #
w -02
Ground
Depth to
limiting
fact
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
uF
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
Soil Test Plot Plan
Project Name Helene A. Houle Byro Bird Jr.
Address 59 W. 4th St. Apt 24B
St. Paul, MN 55102 TM #3479
Lot Subdivision Date 10/2/95
SE 1/4 NW 1/4S21 T 30 N/1319 W Township E. St. Joseph
Boring ()Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft.Base of Siding
System Elevation 92.0 * H R P Same as Benchmark
2tv~wR
W11
80'
f~ o
o
M
15' 45'
` o
2
tar
M
8'
00
3
1
1
0
N
5
4
Scale 1/4 = 10 Ft. When Dimensions aren't stated
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER e o
MAILING ADDRESS ~~'yG>/f d 5f ,7_.i
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE 4~f~ I 44~- r
./4, "6/4, Section TN-RW
PROPERTY LOCATION /44
TOWN OF _,,X' J7~ ~S ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIEDSURVEY 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.
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.
SIGNED:
~i
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
~e - jG U
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 "e sc ~Y
Location of property,5~~ 1/4 Gr 1/4, Section o~/ T ZELN-R~W
Township ~Mailing address
Address of site
Subdivision name Lot no.
Other homes on property? Yes No
Previous owner of property
Total size of property
Total size of parcel
Date parcel was created CC k u s~ o?
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes _,Z No
Volume and Page Number /~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. 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.
Signature of Applicant Co-Applicant
/o -2-
Date of Signature Date of Signature
OOCUINENT NO. STATE BAR OF ''WISCONSIN-FORM 3
QUIT CLAIM DEED
351210 t/ i1_ dJ THIS SP.~CE RESERVED EOa QEC:ORUI.G DATA
- REGISTER'S OFF;CE
Raymond W. Houle, a single man ST. CROIX CO., V11S.
r
- Recd. for n._coro
Helene Houle day of A A. D. 19-16
quit-claims to
- - - R.yidM of D~~d~
I -
q' the following described real estate in - St - Cro lX _ - County,
} State of Wisconsin: RETURN TO
1
The Southeast Quarter (SE4), of the
Northwest Quarter (NW 4) of Section
Twenty One (21) Township Thirty North
DON), Range Nineteen West (19W) Tax Y-ey No.
i
.1
1
TRi £R
i
1
This 18 homestead property.
(is) (is not) March- _ 19_76.
r Dated this 18th day of
L J
(SEAL) t___(SEAL)
Raymond W. Houle
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signatures authenticated this. -_-_.--day of STATE OF R18f MINNESOTI
19- SS.
_-Washington Countyl
Personally came before me, this - 18th day of
March the above named Raymond W.
TITLE: MEMBER STATE BAR OF WISCONSIN Houle
(If not,
authorized by 5 706.06, Wis. Stats.)
This instrument was drafted by
to me known to be the person,- who executed the fore-
John E. Walsh going instrument and acknowled^,d the same.
Attorney at Law Stillwater, MN 55082
Steven K. Ulrich _
Washington
County,
(Signatures may be authenticated or acknowledged. Both Notary PubIic-
are not necessary.) XA,"+aul~AdllL+l►AhtA~I~~1L+~k`a.►~auA~ My Commission is permanent. (If not, state expiration
3TE'VEII K. ULR!(',M date: March 5 19 _82.)
° Motary Public, Wa3h, Co. Minn. i.-
My C,--;S rA EA; hN
T~gTt7';~t'Y7't>'r'Y7'1 /'Pi f`i'~f;l'P'l7 it'37f
ne Iv1cr0N5;V: FORM NO. 3-1977