HomeMy WebLinkAbout032-1082-40-000
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STC - 104
AS BUILT SANITARY SYSTEM REPORT.
r.~
OWNER -
ADDRESS ~b t
Gill' SUBDIVISION / CSM# "Y~ LOT #
SECTION _T,__3/ N-R_q i Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTUiNG WITHIN 100 FEET OF SYSTEM
SS ,
p Sut K
I
INDICATE NORTH ARROW
Provide setb ck and elevation information on reverse of this form.
Provide dimensions to center of septic tank manhole cover.
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER
/ HOLDING TANK INFORMATION
Manufacturer:
Liquid Capacity:
Setback from: Well
House zl ~
Other
Pump: Manufacturer
Model#Size
Float seperation
Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width:--_,47,2 Length
Number of trenches
Distance & Direction to nearest prop. line:
r
Setback from: well:
House Other
ELEVATIONS
Building Sewer
ST Inlet: ST outlet
PC inlet Sv
PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade- 2Z 7 Final grade_
DATE OF INSTALLATION:
_ c S--
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
labor and Human Relations 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
HENNESSEY, ROGER X
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark _PL ~a~ oo
z
Dosing ya=
Aeration Bldg. Sewer 9. 9 '
Holding St/Ht Inlet 5 9l °a'
TANK SETBACK INFORMATION St/ Ht Outlet sf,7 7' Qg S~_ /
TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet
irl
Septic , S 3 40, , 5- NA Dt Bottom
Dosing NA Header / Man. q a 4~ s
Aeration NA Dist. Pipe G a~' qy b y '
Holding Bot. System gyp, S' 43,1? °
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand /oa. i9
Model Number GPM
TDH Lift Lrict' n System TDH Ft
Forcemain Len Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED / TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS /01 ~S DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING -manufacturer:
SETBACK
INFORMATION Type Of CHAMBER ~ Model Number:
System: --6-4 1.700&O, 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 3~ a Bed / Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: SOMERSET.28.31.19, NE, SE, 192ND AVENUE
V 4,
Plan revision required? ❑ Yes No
Use other side for additional information.
SBD-6710 (R 05/91) Date InWctor's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
t ,
Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building Water System
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 12 x 11 inches in size. Z~00Zy
• See reverse side for instructions for completing this application State Sanitary Permit Number
a11D7~~evwus The information you provide may be used by other government agency programs E] Check it revision to application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION IN ORMATION -PLEASE PRINT ALL INFORMATION
Prope wner Name Property Location
1/4 1/4, T , N, R / E (or
Propert w is Mail n AdV Lot Number Bloc Num er
Cit State Zip Code Phone Number Subdivision Name or CS Number
Ill. TYPE F BUILDING: (check one) ❑ State Owned o City Nearest Road
E] Public 1 or 2 Family Dwelling - No. of bedrooms Town OF
111. BUILDING USE: (If building type is public, check all that apply) Parcel Ta
x Number(s) ~~qt
0 E"?
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 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. 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 ❑ 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.) (Gals/day/sq. ft.) (Min,. Inch) Elevation
' Feet Feet TANK Capacity
VII. in gallons Total # of r Prefab. Site Fiber- Ex er_
NFORMATION Gallons Tanks Manufacturer s Name Concrete Con- steel glass Plastic App
New Exist in strutted
Tanks Tanks
Septic Tank or Holding Tank f ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for i tallation "e onsite sewage system shown on the attached plans.
rur' Na e: ( t Plumb is S n ur ~ to s) MP/MPRSW No.: Business Phone Number:
I tuber s Address Street, Y, Sta -Zip Co
r
IX. COUN Y / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Issuing A ent Si nature( tam s)
pproved El Owner Given Initial Surcharge Fee)
Adverse Determination /a
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Suety & 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.
Vl: 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 8 112 x 11 inches must be subrr itied tc the co inty. The plans must
include the following: A) plot flan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or otl,r. r i_reatrnent tank,; building sewers; wells, water mains`t,^r.,ter servi -e, stre:3rns and I~:kes; pump or siphon
tanks; distribution hoxe~, soi! absorption systems; replacement system areas; and the lo(a'_ior- o'the building served;
S) horizonta' .,n-i vert cal els va'ion reference points; C) complete spe-lfications or pumps a--d rontrois; dose volume;
elevation differences frlcuon loss; pump performance curve; pump model and p mp mw- { ci ir(-!r; D) crosssection
of the soil absorption sys~~ern if required by the (ounty; E_) soil test data on a 1 15 1:)rm; and F') _=11 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.
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page
Labor and Human Relations of
'Division 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 PARC .D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROP TY OWNER: PROPERTY LOCATION
GOVT. LOT 114,S T N,R p X(or)0
zL_ A/I
4PRPERTY OWNER':S MAILING AD RESS LOT # BLO # SUBD. NAM OR CSM #
1 -
TY, TAE ZIP CODE PHONE NUMBER ❑CITY ❑ I LAGE (MOWN NEAREST ROAD
(6//o)/ a
[~Q New Construction Use [A Residential / Number of bedrooms [ ] Addition to existing building
j J Replacement [ J Public or commercial describe
Code derived daily flow 9Pd Recommended design loading rate r bed, gpd/ft2-,trench, gpd/ft2
Absorption area required 4~~ bed, ft2,,:Z& trench, ft2 Maximum design loading rate - ; bed, gpd/ft2_,_~Ltrench, gpd/ft2
Recommended infiltration surface elevation(s)ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material _ Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem [OS ❑ U [D'S E] U S E3 U ®S ❑ U El S 19 U 1:1 S Iffu
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Botnday Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed TmrK:h
i., S
y..:,..
Ground
elev. j
,9~7 ft. L - -
Depth to
limiting
factor
Remarks:
Boring # /
2A
Ground
elev.
g~ ft.
Depth to
limiting
factor
Remarks:
CST Name: Please Print Phone:
:Z 'IAL
91
Address: 2!L M
Signature: J j Date: CST Numb r:
PROPERTY OWNER = - SOIL DESCRIPTION REPORT Page~df
' PARCEL LD.#
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends
Ground /
elev.
lQf~ /
ft. l -
Depth to
limiting
factor
• Remarks:
Boring # /
Ground
elev.
X~- ft.
Depth to
limiting
factor
Remarks:
Boring. # l - J /
142
Ground e-j
elev. _ / - - .41 ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
38~~
'a 19
3L' K~b
~ .mod
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r
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS
PROPERTY ADDRESS
(location of septic system) Please obtain from the P ning Dept.
CITY/STATE
PROPERTY LOCATION1/4,_ 1/4, Section, T_,_N-R W
TOWN OF z ST. CROIX COUNTY, WI
SUBDIVISION 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 tZSt. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (I)
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 xpiration te.
SIGNED:
DATE: Cam- l 1 T L2 cj
611
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
S T L 100
• This application form is to be complet(-ICI i.rr full. and signed by the
owner(s) of the property being developed. Any inadequacic,.f: will
only result in delays of the permit issuance. Should thif:
development be intended for resale by owner/contractor., (spec
house), then a second ifoum should be i:etnined and completed when
the property is sold and submitted to this office with thc,
appropriate died recording.
Owner of propel.-t:y ..__._c
Location of property-~__I_/9_~5 -.1/4, .>ecLion
Townships Mail.illy addr.crs:~
- -
APT)
Address of site -----SS--_.__--------
uhdivi sion mime I_,ot: no.
Other homes on property"? Yc - No
I'rev i.ous owner of proper. t y
Total sire of property
Total size of parcel
Date parcel was created
Ar:c ill corner!-. and lot .1..i_nes i.dcnt:i_I i_;-rba.c Y(,!; No
Is this propert.,,• being developed for (:pec house)", No
Vo1-umlr arrd Page Number rc~cordcxl with t.11rr Register
of [)(-,(,CIS.
INCI,UU1; WITH THIS APPLICAT101i THE' FOLLOW1.14G:
A WARRAN'T'Y DEED which includes a DOCUilII IT iIUMBER, VOLUME AND PAGE
IIUt•ilEI' AMID THE SI, 01' 1.'IIh REU.TS'I'1l;R O1'' In Cldrlitn, a
pL'u7. so ~ to avoid
certi.f.i.ed survey, if available, worn]ci be lie]
del,lys of the reviewing process. if the c_iecrl drscr- i.ption
I: C, ferenccf; to ;r Corti ficd Survey p, the cor- t1 1i ed Survey Map
shall ,11so be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that Zr.ll statement.: oil thi. s form Ire true to the
be:-,t of illy (our:) knowledge that 1. (wc) !m (rrre) the owner. of the
property described in th.i.s information foram, by virtue of a
,tr r:anty dcaed r:ec:orded in the of f i.c-e of. tlrc County Reg i_ .ter. of
Deeds as Document No. and that I (we) presently
own tlrc proposed site for the sewl-lge disposal system or I (we)
obtained an casement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
th(_! office of the County Regi:-.;ter of Deed! il!; Document No.
n ure of A) pl ~t Co Applr.c"irnt
of Signature 1)at_c! 0 f_ Sign'l tur,,
49$ . ~ ~ "ir?_.01.~ ~ .~i# ...a-.. :.~l~a;,~t~~?a '•+lv~},..~ !'tit .`•t
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 3-1962 THIS SPACE RESERVED FOR RECORDING DATA
QUIT CLAIM DEED
43 c-a✓ ,
_ . =
52~~ vac m Pq^ osaw
REGISTER'S OFF CE
- L!nda L- dah ST. CROIX CO., W1
Recd W Record
quit-clait~alo e vine, 'DEC 15 1994
at ~A
c <-1-44
d Dads
the following described real estate in 6
State of Wlaconaln: C_ r- County,
RETURN TO
J T3 / Tax Parcel No: L) - ! 0
I e 9 ~4cre5 ~ p -
PCJ 3e,147
5e~ )S T31AI k i`i rv 1ilJE 5E
r.
:3
This_ (S Ys (is n4 homestead property.
hs) not) --1 00,
Dated thi W 1 _day of_y__/
'SEAL) '
(SEAL)
(SEAL) (SEAL)
THENTICATION ACKNOWLEDGMENT
Signalurs(s STATE OF WISCONSIN
ss.
X County.
authenticated this-..4,j--day of 19 Personally came before me this_ 3 +
day of
\ 19-4-the above named
r
TITLE: MEMBERSTATE BAR OF WISCONSIN
(If not, to me known to be the erson yr
authorized by § 71)8.06, Wis. Slats.) P whO executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Nomy Pt+Oi of Wfeontra t R
Notary Public nty.'.Vis.
(Signatures may be authenticated or acknowledged. Both My Commiss.on 's permanent. (It not, state expiration
are not necessary.)
date: 3 19~.) T
'Names of persons signing in any .:aoacrty should be typed or printed below their signatures
SB3 NTF ow
QUITCLAIM DEED STATE BAR OF W ISCONSIN
FORM No. 7-1982
Nelcu Tax Forms, P.O. Box 10208, Green Bay, M 51307-OM r
A.:;. tY y.,, -•}'tt'~ ~i'. t.F • '*qe. y.s. ,-;a*.. ;•^e,4• •.ta .,w,... a,-. y