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HomeMy WebLinkAbout040-1217-50-000 Q ` ~o ° I 00 O n r ~ O I n 0 N !I ~ N I ~ I I a _0 I v, ~ I LO x N Y Z N C _ M . LL O m O -O O Q ~ 3 co Z H rn o z a v 00 F a m o I o z v c° y z o m F c CD J~ ' Cl) N O O co a) N H 7 ~ i • X11 ~ ~ ~ C ~ CL U) O N Q Q ro Z m z O 4.; z N O "O N C a N E E I Y _ m Y CL LO ~}yy m LL T) 0) C, C O a a o° In H H H O V O O O O z o •►v R oCL aa N T _ o CO uo Lo N v Mti~ Q N N O L ~ O N LL ° 7 E 7 N w m N a O) N N ~ 0 o m Q > cn co N IA ~m N c o E I O ° h O O O 00 r. Lo C) c Q) CL CL L E E ~ N O O O Co 06 N f- y rn O F- F_ rn rn ~ O N L L0 ON in E E U • y O O H O NI -7 ® CQ v v~+ 3t O. ' d a a CL (D P ~ STC - 104 ? } 1 AS BUILT SANITARY SYSTEM REPORT:' ..a OWNER ~:C~2 x tea. ADDRESS, SUBDIVISION / CSM# LOT # za SECTION ~7_T - _N-R W, Town of u ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WTTUTN 100 PEPT OP SVqTPM S; ocK~,t J?' 70 . 1, Go Gn~+cF ~~,JPt fi~ INDICATE NORTH ARROW Provide se ack a v tion information on reverse of this form. Prove 2 imensions to center of septic tank manhole cover. ,o BENCHMARK: ALTERNATE BM:, 117 s rnl ~?~/f/ J SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: 1t~ S Liquid Capacity: Setback from: Well House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length Number of trenches Distance & Direction to nearest prop. line: Setback from: well: -~Q House 7ja' Other ELEVATIONS Building Sewer'//J/_yg ST Inlet, ~ 7/ ST outlet PC inlet PC bottom Pump Off Header/Manifold,_5s- Bottom of system Existing Grade Final grade DATE OF INSTALLATION: - - PLUMBER ON JOB: / LICENSE NUMBER: INSPECTOR: l 3/93:jt Wiscoksin 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 JOHNSON, TROY X CST BM Elev.: Insp. BM Elev.: BM Description: 'rey Parcel Tax No.: I A9500294 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic S ~C4q C. 41 je~ Benchmark Dos g 314 C. . 6 wj. Aeration Bldg. Sewer Holding f.. St/ Inlet 1,091 TANK SETBACK INFORMATION StIt Outlet 3/' dog i Vent TANKTO P/L WELL BLDG. Airl to ntake ROAD Dt Inlet Ar I- Septic > SD ® r g' NA Dt Bottom Dosing NA Header / Man. i Aeration A Dist. Pipe 44-ol Bot. System d0 D.~ ~10' PUMP/ SIPHON INFORMATION Final Grade Manufart er Demand you-~~- 7 d /o S. 71 Model Number GPM riction System TDH Ft TDH Lift..- F Loss ead 7-7 Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No_ Of renches No. Of Pits Inside Dia. Liquid Depth DIMENSIONS D71 E SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEA Manufacturer: SETBACK INFORMATION Type Of y7,` - U; C M B E R Mode Num er. System: R UNIT DISTRIBUTION SYSTEM Header ~ ~ Distribution Pipe(s) x Hole Size x Ho -Veit To Air Intake Length Dia. Length Dia. Spacing 67 SOIL COVER x Pressure Systems Only xx Mound Or At- de Syst Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded Bed /Tienali.Center Bed l yEcl9es Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) A C c,,Jf LOCATION: Troy-7.28.19W, SE, SE, Lot 10, South Fork Plan revision required? ❑ Yes 2-'No d Use other side for additional information. 7~ da 9 d SBD-6710 (R 05/91) Date Inspector's Signatur Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION Safety and uilding WaterlSystem! 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 0 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. 5Z A- . • See reverse side for instructions for completing this application State sa~nitaarr Permit N~umner The information you provide may be used by other government agency programs ❑ Check if revision 1 to previous application [Privacy Law, s. 15.04 (1) (m)]. r te Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Propert wner Nam Property Location 1/4 1/4, S T , N,R (or& Prope. y ner's Mai Addr ss Lot Number Block Number Y=- ZZY! Ay City, t t X- If o Zip ode Phone Number Subdivisi Nam or CS Number 117- II. TYPE F B ING: (check one) ❑ State Owned ❑ Ity Nearest Road ❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms Town OF III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) C 1 ❑ Apartment/ Condo e7 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. jW New 2. E] 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 11,0 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./i ch) Elevation Feet Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex er. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel Plastic p New Existin strutted glass App. Tanks Tanks Septic Tank or Holding Tank ❑ ❑ ❑ 1:1 E] Lift Pump Tank /Siphon Chamber 1:1 El El 1:1 1:1 1:1 VIII. RESPONSIBILITY STATEMENT I, th undersigned, assume responsibility for ins ation onsite sewage system shown on the attached plans. Plu ~be Namn1P1 Plum er's Si e' tam ) MP/MPRSW No.: Business Phone Number: Plum er' Address (St irg, Cit Stat i Code)• r IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sani a y Permit Fee (Includes Groundwater ate Issued Issuing Ag t Sig ur No amps Approved ❑ Owner Given Initial Iff "I, Surcharge Fee) Adverse Determination ~ X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SHD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Ruildings 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 onsirte 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. 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(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 contamination investigations and establishment of standards. %74'0 ~o~,c, _s,~'/ Sir* ,~e 7 ;e, 8117 Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3 Labor and Human Relations Division of Safety & Buildings in accord with I 9 s. Adm. Code 1t COUNTY Attach complete site plan on paper not less than 8 1/2 x 1 in size. Plan ude, but not limited to vertical and horizontal reference point (BM ion aF Y lope, e r PARCEL I.D. # dimensioned, north arrow, and location and distance to st r ; APPLICANT INFORMATION-PLEASE PRINT A FORM ~Tt~ REVIEWED BY DATE L PROPERTYbWNER. - ,9004 ,ES OPER TION -rpoY T~Nai DER To t4k3 S' ~"'O'S , . ~L 1/4 SE 1/4,S 7 T28 N,R E( PROPERTY OWNERS MAILING ADDRESS ? LOT1k , OCK # SUBD. NAME OR CS CITY, STATE ZIP CODE PHONE NUMBER* f TY []VILLAGE OWN NEAREST ROAD -}vDSoAD WI . 5L/0/& (-1s)3J71-iLsZ 1-Ro 1--iv. YQ,,Pe .Ple [ New Construction Use J r esidential / Number of b6drooms 7 [ J Addition to existing building Replacement [ j Public or commercial describe Code derived dairy flow Cv oU gpd Recommended design loading rate bed, gpd/ft2 trench, gpol112 Absorption area required bed, 112 74-0 trench, ft2 Maximum design loading rate bed, gpd/ft2 ' trench, gpdV Recommended infiltration surface elevation(s) -lze- M . 3 ft (as referred to site plan benchmark) Additional design / site considerations uSE 7e8A1C-&5 OVGy 01) S4114--e- 4'1 12e I& OXZL-- S Parent material Se5 73 " 9VW4'A4"7- Flood plain elevation, if applicable iVfi9t- ft S =Suitable for system CONVENTIONAL MOUND 7IN-GROYND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING U = Unsuitable fors stem CC'S [I U ❑ S C~ 's- 11 U ❑ S b o Ch's' 0 U 0 S 9-1:11-'" SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourxlary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Twich S Ground Z /_2"12 D 7 D S ~~Q CS " -s G elev. 0 ft. -3 0 ^ylo 7 ~ Depth to limiting factor Remarks: Boring # /0 %P3/i Si/ •Q ~-e 4s /af N z y~ s yX y s. D S T Ground elev. 3 C'S O 19,&o ft. - Al Depth to limiting factor,., ~i Remarks: CST Name:-Please Print Ro BE R-,- 24 LB P Cc k7- Phone: Address: Ulbricht & Associates 7- z (Q - C'S7iy 2 S~ L private sewane consultants Signature: 655 O'Nell Rd. Date: CST Number: Hudson, Wis. 54016 3 PROPERTY OWNER SOIL DESCRIPTION REPORT Page of PARCEL I.D. aY LOt / d - S 0 U1tt- FORK Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Barrlary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed 5-rich :3. 0 -17 10 311 s./ .2-f sbk sti / , s / D 9 rP Ground elev. /D p.SO ft. Depth to limiting factor 7 Remarks: Boring # L,2 - 10 7,4--y P yl~ - ~s o s ~.e cs - 7 ; Ground M~ elev. 5 S S . ft. ,3 - /0 Y, e ,r 71,60 Depth to limiting factor Remarks: Boring # 9 /0 y 3/i Si! .C GQ e S /0f Q N , 2 s o CS 7 Ground elev. 1,7 • P ~0 3. ?0 ft. Depth to limiting factor 1 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: OWN ooonio nr/AnN A ta I o~ LO fj m ~ O ow ti p p / o Z ' N0. Co T . 35~'~ '/G - ~ N 1 _ w 0 lm 0 0 Vi ~ `mot o y ~ ~ 1 b ~ ' m Ri ` rl\ i` so. ~0T . 3s1 " N ;r or I ; I o 13. 'C ~m 1a I or ( ,z on m .O i0 I g i or 1rn .v or" 3'~ i~ itn to J ~3. IS 10 mole ( a a N ito in o ? r...- o a 10 0;A I I or 1< ' ID 10 irnc Irn 1'0 40' 40) f I UNPLATTEO LANDS OWNED By r2488_".7*,7' I.04' 40` W ~O 10 ~Ir n ~Int ~ m Iv ~-szo 00, c c tc~ ~o I \ o ti N ~D :i (JI , s ° • s v`r~` i ~ O► 0 10 1C 7p i S s y 'o ' O 1< r ~ N w N a Q 40' 40' 0 O 'OD p m W • N i ' o So. N 11 m i~o P ` fy6' LA u -4.00 V O N D kA 0 • Y1 ~'3 O I 2 tj1 t w t • Zr T E 1 no CL 0, - ' 1•Ja' O" ' A ~ ` 265.09' DRAINAGE EASEMENT 1 - 775.37' ~ i v 527.00 w ~ - N01'00'SI'W PUBLIC STREET ~ 1ue•57' / w ~ a~ 1 CD • o m ' W JL •r N o N 0 'iN t. N N N O v OO_ J a ~O O a" V p V ' a • N 7 N W'~ !11 in 0 ~s t4 t O A S A N o N Mx a 1A y s~0 1 = 46.6 ' a..FY. O 1322.t2' SOI.00'5i"E M[451 L1NE Of t11E 5E 1•4 Of tnE SE 914 SEC tsoh 7 ^ i 00 = i UNPLATTEO LANDS OWNED BY OTHERS j - - - - - - - - O w STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWN ERBUYER -Y'p l/ a n 4( TPn n `-4 r ~TDA r)6 &-Yl MAILING ADDRESS S- l< C,U /j D~C~ PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE~liL~ ~-C PROPERTY LOCATION 5;0E_: 1/4,'F 1/4, Section ---7_, T c7`, N-R l~ TOWN OF ray y ST. CROIX COUNTY, WI SUBDIVISION F l f LFb_ rk LOT NUMBER O 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 year expiration date. SIGNED: DATE:/ y ~9 S St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 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 -Froci V f -eam ~&v- Jd d1 n 5 Location of property 1/4 5%_1/4, Section 7 ,T(~Le N-R l~ Q Township_F~-oMailingaddress /1~/ S, - d/ r-) 1s - 9'I Address of site ~1 G Subdivision name ~~Qte,M JamLot no. /U other homes on property? -Yes x No Previous owner of property Total size of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes N!o Is this property being developed for (spec house) ? Yes yt No Volume and Page Number 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_ LZ-22~/. , 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. ign ur of Applicant J-Appl'i ant l~ a5 ~ Date of S ature Date of Signature ign FROM :EDINA REALTY HUDSON 19%,08-31 16:45 #259 P.01/01 S S 329 VOL 0PAC- 1pi State bar of Wisconsin Form 2 -1981 WARRANTY DEED FEGISTa'S OFFICE DOCUMENT NO. ST. Mix C}MM - RoOd fof Reooro Brian K. Smith and Carol I Smith, f/k/a Carol 199 Nicholson, husband and wife, Troy C. Johnson and Jennifer J. ~ PA~Dow' Conveys an(1 warrants to Johnson husband and wife, THIS SPACE RESERVED FOR RECORCING DATA NAME AND RETURN ADDRESS the following described real Cstate in St. C nj x County, State of Wisconsin; I (Farce( Identification Number) Lot 10, South Fork* Addition in the Town of Troy, St. Croix County., Wisconsin. g I This is homestead property. Exception to warranties: Easements, restrictions and rights-of-way of record, if any. ~r Dated this 3 day of August }g 9~ (SEAL) C (SE LW w Brian K. Smith - I (SEAL) O--1-1 W <2 (SEAL) • Carol. T. Smith, a/Va Carol I. _ Nicholson AUTHENTICATION ACKNOWLEDGMENT SlgnatlirC(S) Brian K. Smith, Carol STATE OF WISCONSIN SS. 1. Smith, a/k/a Carol 1. Nicholson County. authenticated this day of August 19 95 Personally came before me this day of 19 the above named M Kristina Ogland TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706,06, Wis. Stats,) to me known to be the prrson who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Kristina Ogland $ttCrn"V A AW Notary Public County, Wis. (Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration date: necessary.) •Nmms or persons sixning in nny enpz6Iy should be typed or primed bcloay their signnwres. WARRANTY DEED VATS BAR OF WISCONSIN W;SCOnSirl Legal Blank Co., Inc. ponh4Nn, -t9bt Mitwaukoe.pNis. ST. CROIX COUNTY WISCONSIN ZONING OFFICE ■ N a ■ r ■ ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 December 8, 1995 Hartman Homes P.O. Box 326 Somerset, Wisconsin 54025 ATTN: Becky RE: Septic Inspection for Property Located at 423 South Fork Drive, Hudson, Wisconsin Dear Becky: An inspection of the septic system for the above address was conducted on November 2, 1995. This property is located in the SE; of the SE; of Section 7, T28N-R19W, Lot 10, South Fork Addition, Town of Troy, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a three (3) bedroom home. Should you have any questions, please do not hesitate in contacting our office. in rely, e. 7 ames K. Thomps n Assistant Zoning Administrator St. Croix County, Wisconsin mz