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HomeMy WebLinkAbout040-1199-60-000 (D ° o a O br O I O _ C~ in ° r I o x ~ I y ~ ~ I O Y N C N E 0 T Q O ~ N N U N co C Z 0m 1L C 0 3 I =o m Y ~ cn o I 3 ~ I rn W Z C I Z W N co a m N F O C O co O Z d O d 2 d C O N H r (D E M 4) co N Z N ~ • ~ ~ O a L 6 O C Q U O 2 Q Z 1- Z O I Cc: 3 w M E Oo O O o G G a E iv N L_l~/V1 (n CO f' F~ N IL U) ? O O O ° LL m a) N O U) 6 m a) ~~yy cn .j U > rn rn } v o \i LO C 0 E N ~ o ` a) N IL N O N N N 7. N Q CIO a r- cl O O W N C i.+ O C ~ a0 Q) 00 © O M O N O N C (1 cm oo s. 3 a c E CL 7z Q LO o U O 67 O O N N ~ L A N u H V co O YT M N i~l • y"',~' O N 1- U) N O O ~ C¢ V1 0) m ~ E a S. L: a • C. d .V'. d! y C i a C 7 `~1 A c°a~I'o STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER rY ADDRESS SUBDIVISION / CSMJ C-->Lt"%CL .Jyx L C LOT _ SECTION T N-R NS/' - - Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM / 7 7 Y 1 i INDICATE' 140RTH hRROh' Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank ,narlhole c.-,ovet J r BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: ,,acs. Liquid Capacity: a. Setback from: Well-ALk- House Other PumA/t~ turer Model# Size Float//seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length 75' i Number of trenches T Distance & Direction to nearest prop. line: 1~ i Mi 4 Setback from: well:>_:5b House Other EL~TIONS Building Sewer4"S SST I t a70~ ST outlet nl. PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: PLUHBER ON JOB: LICENSE NUMBER: INSPECTOR: 9/93: )t wiseonsin 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-: Pe is N ❑ City ❑ Village Town of: State Plan o.: ATE R CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 00- 1 d-zi 4 1Q0. 1 / 12 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark D®. 77 Dosing Aeration Bldg. Sewer - Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet L .u b" gS. TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake 3 Septic >1? NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade S 9i, Manufacturer and Model Number GPM TDH Lift Fricti Syesteem TDH Ft Los Lengt Dia. HH Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS -6- DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM INFORMATION Type O lu,) CHAMBER Model Number: System: 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 30 Bed /Trench Edges x8-30 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Troy.28.28.19W, SE, NE, Lot 6, Sykora Lane ,C1_e,~. GX ,t~.,C,aF.,e.~J -f<-.. al~•2s_e_ ~Fl~-~-~~,<e~ °~j'~ . _ ~a 4--) :C 1 ~ ~,.~La! C~[,I'.l J "'rV~''t'~.6+r "~t.-.f-^{,i `Gi„c^1.2~Lf.'"a'T" k ~ '..1~..~ C Plan revision required? ❑ Yes ❑ No Use other side for additional information. /a 105-1 SBD-6710 (R 05/91) Date nspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: C 4 C 101.5 ~33~1~3- yy SANITARY PERMIT APPLICATION Safety and Buildings Division 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 8 112 x 11 inches in size. S* -i i~ • See reverse side for instructions for completing this application state sanitary Permit N mbb 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 Owner We Property Location S ktrq S f 1/4 MC, 1/4, S 2IA T z $ , N, R /9 E (or( @ Property Owner's Mailing Address Lot Number Block Number State t Zip Code Phone Number / Subdivision Name or CSM Numb r 1l ~ r 2'Z ( ) T52 ~Z$2 trw W t ~ ~ S y II. TYPE OF BUILDING: (check one) D State Owned L5 tit Nearest Road a9 e rv- 0 Public 1 or 2 Family Dwelling -No. of bedrooms c3 Vill Town of - s Owl III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) O 1o/ GO 1 E] 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. X New Replacement Re lacement of 4. E] Reconnection of 5- E] Repair of an System System 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 11E] Seepage Bed 21 ❑ Mound 30E] Specify Type 41 ❑ Holding Tank 12 )d Seepage Trench 22 ❑ In-Ground Pressure 42E] Pit Privy 13E] 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 GOO R ~Z~ (sOq ft.) Proposed ~q. ft.) .(Gals/day/sq. ft-) (Min./inch) f t Ele ~ iri 'T~ -7 (o //feet VII. TANK Ca acit in gallons Total # Of r Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin strutted Tanks Tanks Septic Tank r Holding Tank La" 1 ZOd ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sew tem shown on the attached plans. Plumber's Name: (Print) Plu ber's Signat : (No amps) M PRSW No Business Phone Number: Plumber's Address (Stre , City, State, Zi Code D3. If `72.. IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Saip}tary Permit Fee (Includes Groundwater ate Issued Issuing Ag nt Signature ( Stamasf AA/pproved ❑ RJ Surcharge Fee) Owner Given Initial r / ( `1 Adverse Determination 1- X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: .BD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Dive ion, Owner, Plumber INSTRUCTIONS yz 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe 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: I. 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'. through 7. VII. Tank information. Fil 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 tD fill in name, license number wi h 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 sui-- ;itt:ed tc the Coo nty. The plans must include the following: A) plot plan, drawn to scale or with complete dimension,, location of nolding tank(s), septic tank(s) or otker treatment tanks; building sewers, well vrter mains/wate. ce; stre<:- is _-n:i lakes; pump or siphon to+lks; distric union t:;~ - sail absorption systems; re?al<cemerasystem art,,,,, t,ic ,ol-->>_ o fthe building served; B; +,O. I o 1~ <<1 1 v r='Cal 8 evaLOn rt'fererlCe p~) r C_; } con- P ete SpcC.i . for PUr p5 Grl(')nttoic; dose volume; elevn±ion difif~r~•nc:'s; friction loss; pump pQ-formance curve; pump r~ a ; ! _t- ump n,a -j~ _er, D) cross section of the soil absorption system if required by Lhe c,Dunty, soil test data on a 1 15 orm; &,,1 } il sizing information_ - GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practic:e> which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater ,_ontarrination investigations and establishment of standards. S, -ca, 14 f9eAnom S , N1 r 5 Z$ ~`~"z43 N, R 19 LJ of L GJ`Ct i ~l MPf~s*L 3zrZ ~ '(a , /o' Z-3' 4 5 t ~go/ ti pops s~ w~ A =gnu .s °fa~ a~- -S 4 ~ uo 'SPEC A& ss- ja 96 4-", -4 -75' A-it 0*4Ar des 0 -c-c+&XkA -A Wisconsiri Department of Industry, SOIL AND SITE EVALUATION REPORT Page / 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 c5 -k' K 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 OW R: PROPERTY LOCATION GOVT. LOT W 114 AIF 1/4,ST Z S N,R 19 E (o W PROPERTY OWNER':S MAILING AD MESS LOT BLOCK # SUBD. NAME OR CSM # Co 11 60 au.12.. S LANI ' O UJ i 1( S CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE OWN NEAREST ROAD eac, 1OZZ (713) ISZ-6282-5 Cosa ~.0~.2., New Construction Use Residential / Number of bedrooms ( ] Addition to existing building Replacement ( ] Public or commercial describe Code derived daily flow. GO gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2 Absorption area required /5d0 bed, ft2 AM trench, ft2 Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) JL(as referred to site plan benchmark) Additional design / site considerations Parent material" Flood plain elevation, if applicable ft S = Suitable for system 0 VENTIONAL MOUND I-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING T NK U= Unsuitable fors stem jKr! U S❑ U As ❑ U rbr S❑ U ❑ S U ❑ S 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 Tmr& 0-3 ME Z/1 5;1 _2m.SLk k4:fq- CC 3&02, 5' Z 47 10 R -9/?- - 5'l l► 6k 1%4 c s 2w, ►Z .3 Ground 3 I - B lave 4A6 Sc l 0111 S1 *145-%r- CS. /IV, 14 15' ft. Depth to 6 W S z/~ yvt C S. limiting factor q-7Q Nip: IV P Remarks: Boring # Z 3- /~~'oC' 3,/z s~ f sb(~ w~~~-~r c s z Z Ground A _q6 16 q14 elev. it. 44 4'. ajf ~ S Depth to limiting factors Remarks: CST Name:-Please Print Phone: -71S 46 Address: 1C F6 S' S Signature: ate: ZX- N7ber: PROPERTYOWNER T"-~j -C~s,r~ c 0. SOIL DESCRIPTION REPORT Page Z of Z' PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Botxxl3y Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench "Is C--s Z -I J 3/z - sit [,u sb6 N vim- c s 2,,,. Ground 3- 117-A 1b YK 41j Sc el.ev., ft. -32 lD 1 y 1(o >m / G Depth to 'J 32- /b p ' 1k -31(0 Zf r -&,A C limiting / p p L nip facto H 1C) wv 94 (Q.- ! 1 Y Remarks: Boring # -17 70I''C 3/Z - sr f sb~ r~ VSO Ground 3 17-Z I0e '-4/1- 'Zw,Is6k 1'~t r' ~S f`ti► rJ~ elev. Q S G' S l~• G S 4 ft -26 Depth to Q .t p limiting fac r t4-70 AD tvgj Nf (Y I Remarks: Boring # ~5: > 3-15 `v l~ 3/z S~ I s y r cs Z, Z::,3 J5 -Z5 ID4/4 _SCZUA SbE- h1 -_~tr CS IC,, Ground e S` ft. 3 ql(o S u : taw I C S , -7 . 57 C -Q Depth to p ' limiting ..I YID 5~~$ S ~w~i ~Pr 16 factor Remarks: Boring # Z (7 ~~~R 3~Z t /wt S d~r GS Ground:>:: ~ 7`~ le ~f~ . SG( ~C ►'K ~ r G S cu S C75 ft. C- 5 Depth to _ limiting factor Ab e. ~ .S f.( a J Remarks: SBD-8330(8.05/92) Sod j P>eprt 1~qe 3af 3 aP owt&ec.. Riv_. 5 01' / ►q- /45 ~e~c -~ac~ fat Co (Sc,., dawt& T ((s c: STM It 23 2'7 , N~► S a g z$ n1► R l9 Lj end ~3~ka~a ~_cVA e, CSI-de-sac p JS 14 E ~ ~ ~ z ~M ~S scream; i IA -taeer ~ v ~0 hna,,rl~a..l v,~/ r~66aw . ~s 166 (Oft QAtr"v-. AM r 54 Aso' STC-105 C TAN MAINTENANCE AGREEMENT S Croix County OWNER/BUYER r" MAILING ADDRESS PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE R; V roc- z-2, PROPERTY LOCATION SE- 1/4, NE- 1/4, Section, T N-R tj _W - ----V-C) ST. CROIX COUNTY/', WI TOWN OF / SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP IVI+, 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 expir tion date SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 sTC - 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. --------------------t.... - Owner of property Location of property 17<X1/4, Section 2 $ ,T2j_N-R 9 W Township -7-rpu Mailing address (011 SM60%r0% L V%. ZZ 54 0 Address of site B Subdivision name SC4L4 CACkW ~ 44~ ~S Lot no. 4 other homes on property?Yes _No Previous owner of property ( c gyp try-C~~TA cit.. Total size of property !~kn CLG~~C'. Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? X_Yes No Volume .5-// 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. 32 z p 2se') , 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 of,f.ce of the County Register of Deeds as Document No. 14 ee of Applicant Co-Applicant Dat o Sianature Date of Sianatiire DOCUMENT NO. , I STATE BAR OF WISCONSIN-FORM 1 (l WARRANTY DEED 3220.80 r IS SPACE RESERVED FOR RECORDING DATA THIS DEED, made between Earl Cernohous, Bernard Cerno bus, REGISTERS OFFICE Rosella Cernohous Hendrickson, Margaret Cernohous Ahrens, ST. CROIX CO.. WIS. Lilliam Cernohous Blake Recd for Record this- __2.$th an_ Sykora Land Company, Inc** a Wisconsin Grantor day of--Ikr A.D.19?L Corporation A: . M. Grantee, W i t n e s s e t h, That the said Grantor for a valuable cons ideratiortn?xenty- RGstof Dee s One Thousand and NO/lOO----($21,000.00)--- --Dollars FZ conveys to Grantee the following described real estate in St, (:rni3c County, RETURN TO State of Wisconsin: The Southeast Quarter of the Northeast Quarter (SFJNF,*) of Section 28, Towiship 28 North, Range Nineteen West. Tax Keyk This is not homestead property. i i_ a TRANSFER } FEE y` Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining, And said five grantors and each of them warrant that the title is good, indefeasible in fee simple and free and clear of encumbrances except eaubg=ntar of rat*nrd and will warrant and defend the some. Executed at giver Fal I s, Wisconsin and t s 2nd day of May '19-Z4 St. Paul, Minnesota SEAL) e,rno olts j SIGNED AND SEALED IN PRESENCE OF _k1%1 6 ern0 O ell C OTl (SEAL) „ e eernohvus Lillian Ce Ohous Blake ' LSFAL) earet Cernohous Ahrens \ c Signatures of Earl Cernohous, and Rosell.a Ciern0I1OUS Hendrickson authergiCifeii'thfo '2 /l/0 day of May yy ~ . G a116• -Banta t t 0- Title: MIROW Minnesota Other Party Authorized under Sec. 706.06 STATE OF viz. Notary Public , State of Wisconsin Ramsey County. as' My commission eucpires: 6/6/76 ~I Personally came before me, this th day of Ma 19Z4 the above named Berlgard Cernohous , Lillian Cernohous Blake and Marg-ir~ers1 oT us A1WWs to`me,kngwn to be the person S who executed the foregoing instrument and acknowledged the same. v :T6 "!npnt was drafted by Earl H. Plante i . MN • Bonn Notary Public Ream ey County, mss. Rive Falls, Wisconsin L H• PLAPI7E Th *use of witnesses is optional. My Commission (ExpireKK sr' as c~~ =6J t~ rAl•+r.. Nutan - w___._. - ._._flAY ri:unnusswr, t+<I,nas at„ 1.. . Names of persons signing in any capacity should be typed or printed below their Mt res. IlGM11NrCanpry ryt WARRANTY DEED-STATE BAR OF WISCONSIN, FORM NO. 1 - 1971 BOOK FV:1413