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HomeMy WebLinkAbout032-1095-50-000 O I 4; 4q ' O ev 0. t U ~ a ©O N N 19 C. O) O I p N iy 3 (D ~ I io 0 v x C W N ~ I Z .N U. c aa) ~ I t To C I I Z w E rn Z p Z d m a m I M F- O I O Z d c v U N (D O 2 O (p li ?I (D Z c E a ~ ~ ch I N O) 7 N C d U) c O O m C ~ U O O O a Z 00 Z O N a z c N i m Y LO m (n Cj 4) R CL d N 0 0 ° `n G O a a o iv N LO E (0 `Y' > F H F 7 U = N tv d O ° p I •N a a a v d 4` o LO 0 VJ U ! rn rn co a o X O N_ T r r C O 2 N 7 0n ° O N N r `F d Q Q co !v co 7 C CO, c I - H c O O N° ° N 0 w 0 d O O LO CL CL a .0 r _r N O N E E trv N Lo L O O y C O O O Q) 0 L L O o. co M v° o 0) 0 N E E v it O co U) g N O Cn ~ w = E d M CL m xt n ` a T a m 2 m c E c c r~ CJ O 3 3 ya0 p Co1 A 0 a 2 O v) 0 STC - 10 4 " AS BUILT SANITARY SYSTEM REPORT y OWNER q ADDRESS SUBDIVISION / CSM# F LOT SECTION T, -?ZN-R W, Town of ' ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYST I ~a o441 .r / buses i le`' INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. v- BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer:— A I Liquid Capacity: 4~00 Setback from: Well J House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location .SOIL ABSORPTION SYSTEM Width: Length ~l*' Number of trenches Distance & Direction to nearest prop. line. r Setback from: well: House_ Other ELEVATIONS Building Sewer ST Inlet. 3 ST outlet G' PC inlet PC bottom Pump Off Header/Manifold Bottom of system 9 Existing Grade- Final grade :2-~ DATE OF INSTALLATION: G 1 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 GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI o.. MONTPETIT, JOHN 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 U SOS Dosing Aeration Bldg. Sewer Holding St/0 Inlet TANK SETBACK INFORMATION St/pt Outlet ~7' 9 TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic fdd - / NA Dt Bottom Dosing NA Headers ' ~.,Srj' 19- Aeration Dist. Pipe 91 ~1(0 Holding Bot. System yo, 90 PUMP/ SIPHON INFORMATION Final Grade r Demand ~P s T S, f fl~a2~ Q Model Number GP TDH Lift F' ss n ead Forcemain Length I I Dia. Dist. TO Well SOIL ABSORPTION SYSTEM DIMENSIONS BED/TRENCH Width/ i Length / / No. Of renches PIT No. Of Pits Inside Dia. th cP N SYSTEM TO P/L BLDG WELL LAKE/ STREAM acturer: SETBACK INFORMATION Type O CHAMMIC Moe Wu System: OZJ ,35/ 1-- NIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole ng Vent To take Length Dia Length 1f.3 / Dia. Sparing SOIL COVER x Pressure Systems Only xx Mound Or At-Gra ys Only Depth Over Depth Over xx Depth Of xx Seeded /Sodded Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes o COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: QSo/m~ers~ett. 334/. 3,1..1A9eW,, SW, NE,, county Road O~~% ~~~if/h Gi-Y-P )v - /GC.l~1 ~ ~ ~ , ~ •C~_ ~:Lt,ci',J, Plan revision required? ❑ Yes ~Uo Use other side for additional information. ~41 ~ A 9 SBD-6710 (R 05/91) Date Inspector's Signature Cert. No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water Systems 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 1/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Nu ber --2 c/?7,?O The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Prope y Owner Na Property Location T , N, R E (or 1/4 1/4,5 Proper Owner's Mailing A d ess Lot Number Block Num e Cit , State Zip Code Phone Number Subdivision Name or CSM N mber ( ) age Nearest Road II. TYPE O F B ILOING: (check one) ❑ State Owned ❑ C] VII it( of Public 14 l or 2 Family Dwelling - No. of bedrooms %T( III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 03 Z -/OQS 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. pQNew 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 [g 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/dayI q, ft.) (Min./' ch) Elevation Feet Feet VII. TANK capacity gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the ndersigned, ume responsibility for inst ion o e onsite sewage system shown on the attached plans. PluA~sS~ign a S) MP/MPRSW No.: Business Phone Number: Plu er' Nam 7 / I r J i Plumber's Addres treet, Sta , ip Co IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved San ary Permit Fee (Includes Groundwater Date Issued Issuing gent Si ature (No a s) A roved Surcharge Fee) pp ❑ Owner Given Initial /~~t /X~a _S__ Adverse Determination ` X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05194) DISTR18UTION: 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 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 sanitarK 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. 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 following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(sjor other treatment tanks; buiCding 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 contamination investigations and establishment of standards- `ham / SJ~ ~ s~srcJV V o~ / q ~ a I~ D Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page -L of 3 Labor and 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 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 PROPE TY OWNER: PROPERTY LOCATION GOVT. LOT w' 1/4 _ 1/4,S T N,R i(or)rr PROPERTY OWNE ':S MAILI G AD ESS LOT if BLOCK # SUBD NAME OR CSM # CITY, STATE ZIP CODE PHONE NUMBER ❑CITY`❑VILLAGE LOTOWN NEAREST 0 D - 7 New Construction UseResidential / Number of bedrooms [ J Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow.. 9Pd Recommended design loading rate 1~bed, gpd/ft2_, ,f- trench, gpd/ft2 Absorption area required , 4,2-s- bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2 , trench, gpd/ft2 Recommended infiltration surface elevation(s) It (as referred to site plan benchmark) Additional design / site considerations Parent material J-2RI Flood plain elevation, if applicable It S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem (A S ❑ U J Z S ❑ U g s ❑ U Q S ❑ U ❑ S Cad U ❑ S O U 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 Trench 0- -7 115 Z2 ,2 z, Z1, Ground elev. 9,1- -till; L Depth to limiting factor } 9l Remarks: Boring # ice: in...:::tii~:L•: Ground elevv Depth to limiting factor Remarks: CST Name:-Please Print ' ✓ Phone: Address: Signature: Date: CST Number: r- PROPERTY OWNER r ~l~.;Qrlr SOIL DESCRIPTION REPORT Page of 621 PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BoundEvy Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 1 Ground elev. ft. Depth to limiting factor~ Remarks: Boring # F;vi•::•iti:i::iiii:L 4n Z ;2L,- 7 1 Ground elev. ft. 1 Depth to limiting factor > Remarks: Boring # ? ..tam: Ground elev. Depth to limiting factor yci Remarks: Boring # w Ground elev. ft. Depth to limiting factor i I Remarks: SBD-8330(8.05/92) A; 111C~10,1:~Cllr So~~s,~ sus Ilk eQ:,any ot~ ' ys' r STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 1064" MAILING ADDRESS (601 a e C_ PROPERTY ADDRESS (location of septi system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION 5 W 1/4, N 1/4, Section, T__-3/ N-R / IJ W 'SOWN OF ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP , VOLUMEPAGE 16 , 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 (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 re to e St. Croix County Zoning Officer within 30 days of the three year a on date. SIGNED: ` DATE: Q ' ate.' / St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - 100 • 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 t1le 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 3 ~ d- 1<"etly /no in X0 r- Location of property !S U/ 1/4 NF 1/4, Section 1 N-R-W Township ,Son d r5r7- Mailing address Aox 5onn e r SY 71 U,'5 Address of site Subdivision name Lot, no. Other homes on property? Yes _ _No Previous owner of property l_~e 4 e r 5o n Total size of property I_ cr e c, Total size of parcel Date parcel was created -7 - - O(s Are all corners and lot lines identifiable? Yes 41 No Is this property being developed for (spec house) ? Yes No Volume 1129 and Page Number 366 _ 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 TI11 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 decd 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. 530C~gU 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' 30 rjq p Y-i f plicant .Co App icant: [tote. of. Signatui:c Dade of. S1i9naturo I' ~ I s State Bar of Wisconsin Form 2 - 32 • 530990 WARRANTY DEED DOCUMENT NO. VOi_ 112 V PAGE 360 ^ i` W. L. PETERSON AND ASSOCIATES, INC., A v`L 7 1995 MINNESOTA CORPORATION 1:00 P. conveys and warrants to John L. Montpetit and Kelly M. Montpetit, husband and wife holding as w. survivorshipmarital property I - THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS ~2 c9 r2/aoo the following described real estate in St. Croix Fr &r+Ges St . SOrn~~{ sU~_ K' d County, State of Wisconsin: (Parcel Identification Number) See attached Exhibit "A" attached hereto and made a part hereof as if set forth in full herein. `SFIZZ S-1V506 FEE This is not homestead property. ,X§f (is not) Exception to warranties: Easements, restrictions and rights-of-way of record, if any. Dated this 29th day of June '19 95. W. L./ PETERSON AND ASSOCIATES, INC (SEAL) By: (SEAL) * W. L. Peterson, President (SEAL) (SEAL) * * AUTHENTICATION ACKNOWLEDGMENT L• PtiS~ STATE OF WISCONSIN It V. Si gnat SS. St. Croix I A, • - County. day of Personallv cam: before me this _ 2 9th _ day of W. _ _ June _ 1995 ' the above named Ij W. L. Peterson j % TE BAR OF WISCONSIN _ ~i authorized by §706.06, Wis. Stats.) to me known to be the person who executed the I~ foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Leo-- A. _Beskar. Attorne~_ * - - ~TVLI B SKA~2 BOLES & KRUEGER, S.C. Nort Main Street Notary Public County, Wis. ~i-ver ~'a Ts ~ (Signatures may autben tcated or ac cnow7eiiged. Both are not My commission is permanent. (If not, state expiration date: I necessary.) 19._.) *Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. ~I FORM No. 2 -'982 Milwaukee. Wis. 1 EXHIBIT "A" Vol_ 1129PAGE 3191 Legal Description: No. 1 The Southwest Quarter of the Northeast Quarter (SW1/4 NE1/4) of Section 34, Township 31 North, Range 19 West, St. Croix County, Wisconsin, EXCEPT a strip 1 rod wide off the West side thereof and EXCEPT commencing at the E1/4 corner of said Sect ftn 34; thence N89037103"W, along the south line of the NEl/4 of said section, 1320.69 feet to the SW corner of Lot 2 of Certified Survey Map recorded in Volume 10, page 2903 at the St. Croix County Register of Deeds office, being the point of beginning; thence continuing N89037103"W, along said south line, 179.83 feet; thence N0301015111E, 347.73 feet; thence N82055'44"E, 128.27 feet to the point of curvature of a 566.00 foot radius curve, concave northerly, whose central angle measures 0203215011, whose chord bears N81039'19"E and measures 25.16 feet; thence easterly, along the arc of said curve, 25.16 feet to the east line of the SWl/4 of the NE1/4 of said section; thence S01017'59"E, along said east line and the west line of said Lot 2, 367.93 feet to the point of beginning. Parcel contains 1.36 acres (594,261 Sq. Ft.) AND No. 2 Part of the SE1/4 of NE1/4 of Section 34, Township 31 North, Range 19 West, St. Croix County, Wisconsin, described as follows: The Northwesterly 66 feet of Lot 2 of Certified Survey Map recorded in vol. 10, page 2903. NOTE: The 1.36 acre parcel excepted from the above described property (No. 1) is being retained by the Grantor herein and shall attach and adjoin Lot 2 of Certified Survey Map recorded in Vol. 10, page 2903, to create one parcel as prescribed by Sec. 18.05(A) (3) of the St. Croix County Zoning Ordinance. The property above described as No. 2 shall attach and adjoin the property above described as No. 1 to create one parcel as prescribed by Sec. 18.05(A) (3) of the St. Croix County Zoning Ordinances. The Grantor herein reserves a perpetual easement over and across the property above described as No. 2 for vehicular ingress and egress.