HomeMy WebLinkAbout012-2001-40-000
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
F J
OWNER ,yp ~~liQ
ADDRESS
i ryo~ 7
SUBDIVISION / CSM G, rn LOT ~S•.2
SECTION_ + T Q N-R_?? W, Town of 90"1 A
~ 41 < <O
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
L-L
I(
Now
I14DICATE NORTH ARROW
}>r.-ovide setback and elevation inform Lion on reverse of this form.
Provide dimensio,~; to center 01 ~,ept?c Lair: manhOl.e cover
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' LQgA%j rt9AMI,B IE 04.30 ATVAfPjEQaGf S+?f?A & CTY ty:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary it
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village a Town of: State Plan o.:
ev.: Insp. BM Elev.: BM Description: AA Parcel Tax No.:
03 2-2003 -40-000
TANK INFORMATION ELEVATION DATA A9400001
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet X150
TANK SETBACK INFORMATION St/ Ht Outlet qrs.- i? 13
Vent
TANK TO P / L WELL BLDG. A
ir Ito ntake ROAD Dt Inlet
Septic .>,54) NA Dt Bottom
Dosing NA Header / Man. d'
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction Syesatem TDH Ft
Forcemain Length EDii a. FFfi Dist. To Well
SOIL ABSORPTION SYSTEM
BED / TRENCH Width I Length , { No. Of eriches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION J'/ DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type Of I CHAMBER Model Number:
System: V t OR UNIT
DISTRIBUTION SYSTEM
Header/ Manifold I Distribution Pi e(s) y~ , I x Hole Size I x Hole Spacing I Vent To Air Intake
Length Dia. Length Dia. ~ 1 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 Bed /Trench Edges A ? Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCA'T'ION: ERN PRA IE 04.30. 7.566C,NW,NE,176TH & CTY RD.K
y
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. u 4l, ..l I .a U c
SBD-6710 (R 05/91) Date I pte (*,'sSignature Cert. No.
1
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
I~
DIL~HR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
~
aa..,,KUa~ awiwiaawres 51, r STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ /Q►~
8% x 11 inches in size. neck if revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
1/-co A A .-k 1J'/4 S T D, N, R r) W
PROPERTY OWNER'S MAILING AD RESS LOT # JS . Z 2 BLOCK #
176 7Y
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
Y~7 s- . GSl3
II. TYPE OF BUILDING: (Check one) El State Owned ❑ VILLAGE NEAREST ROAD
loin.&104 /76 9FG Rcl
❑ Public 1 or 2 Fam. Dwelling-## of bedrooms L MB
Ill. BUILDING USE: (If building type is public, check all that apply) D/a 60 / - 0
1 ❑ Apt/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 in line A. Check line B if applicable)
A) 1.~g New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit # - 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 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 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
1~e2.5.151 N1712 9 3i 9 Feet 6 13 Feet
VII. TANK CAPACITY Site
in alIons Total # of Prefab. Fiber- Exper.
INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank M Pq F1 F] F1
Lift Pump Tank/Si hon Chamber
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Nam11~ int): Plum is Signatur Stamps) MP/MPRSW No.: Business Phone Number:
Ceti 01 yNvi"ACV-s ~ /56 3 7/s- Pl(z
Plumber's Address (Street, City, S te, Zip Code):
l p4 9 ~ - Sfal 7
IX. COUNTY/DEPARTMENT USE ONLY
Disapproved Sanitary Permit,Fee (Includes Groundwater Date Issued Issui g Agent Signature (No Stamps)
Surcharge Fee)
VApproved ❑ Owner Given initial
Adverse Determination !S CJ
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: 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 the 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 & 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.
If. 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 in 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 in ##1-7.
VII. Tank information. Fill in the capacity of every new and/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 systE:m. 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% 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, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
/ w NF /,7
~'riit ~Na1r~`Q
No,
A &rA MA r k. 91 A*V&4 bh"t'r@-Q-
4~izel
gpra,cn- yew • /a x 9 'X193,
- ao - 9.3
Calu~! law~~s~"w
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X32
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rr,SS ; S~C~IV1, o~ zeci Sy
t NW ware 1 ~4 30 ~ 17
> 67 h Pry r~,
Fresh Alt Inlete And ODeerrallon PIps
1 ~
Approrid Venl Cop
MIA'--m I2'Aeoee
final arede
20. 42• Aber, Popp -4* Cad Iron
To final Brach Vent PIPe
wren Of Or SrnlnMrk Ce.aring
• lrra 2' Aggregate
Oee1 PIPe
DIarrlCrllOe
PIPe 0 0 0 -Tae e
Aggratooa
Beneath PIPe ° Perloruad Pipe barer
o -'C opting T.rmoneting At
90ttam 01 Sfelem
P~p~o~rp ~jf1e., c~rf.e~< ~6~
on /
SOIL FILL
DISTRIBUT1W.1 PIPE
Y e APPROVED S4)jpCTIC COVER
2"oFAGGREGA1E -►_ARISN Hp, V OF STRAW
OR M
r- LEV. OF Y^. OPlA-2r/~ AGGREGATE
FUT. - '.a•~` i`t.
DISTRIBrUTIOW PIPE TO BE AT LEAST IMCHES BELOW ORIGIIJAL GRADE
AQU AT LEAST LO IIJCHCS BUT 1.10 MORC THAI) tit INCNES BELOW FILIAL GRAD[
MAXIMUM DaPtH OF F-XCAVAT1,00 ROM ORIGWAL 6AVR WILL BE IQC.HCS
1'UKtMVI~ 0Ef n1 of EACA%/AT10" rAO^ 0~I4I4AL CRnOF- WILL INC. 30 _ INCHES
SIGIJCO: ~i
LICEIJSC IJUMBER:
OATS
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page I of
Labor and Human Reations
Division of Safety tt< 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 S7`, C N- u ~X
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. Oda - Z CJ o/ - YD
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
GOVT. LOT 1116rJ 14lVe 1/4,S T 3 Q N,R / 7 4!~or) W
PROP RTY OWNER':S MAILI GAD RESS LOT # BLOCK # SUBD. NAME OR CS #
776 7 T , /s-Ia 7
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE (MOWN NEAREST RO fl.
( New Construction Use [ ] Residential / Number of bedrooms [ ] Addition to existing building
[ ] Replacement [ ] Public or commercial describe
Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2 , S trench, gpd/ft2
Absorption area required / aS bed, ft2 9'4Z trench, ft2 Maximum design loading rate bed, gpd/ft2 5 trench, gpd/ft2
Recommended infiltration surface elevation(s) q3, $ ft (as referred to site plan benchm~15-iltrc Additional desigp / site considerations 5,A /oa, 5 Z'A
Parent material' i ~ Flood plain elevation, if applicable -N v ft
~
S =Suitable for system c VENTIONAL UND IN-GROUND PRESSURE AT GRAD SYSTEM IN FILL HOLDING TANK
S U S O U S❑ U ❑ S U ❑ S U ❑ S U
U= Unsuitable fors stem M
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
51/
/ sal<. a s ,3
a g-3o o y6 s, / shK rn~f~ W ZM 3
Ground 364) /D 4 /.5
G 56k ~h C n~ •
elev.
9 ft. lG S 51 C)- F CvJ a ~y ~5~
Depth to ,5 56' ~p C s GL,) (a 7
limiting
factor,
Remarks:
Boring #
5 / f sSk a 5 s►~ 13 ~ y
16 9 31J
f Sbk htu~'r+ Cw a rn 3 r
Ground
elev.
o /S o e s l~1t1fr e'.~ - y 'S
Depth to
limiting
factor ,
Remarks:
a Pr'nt Phone:
CST Name:-73
1 4
Address:
Signature: Date: CST Number:
PROPERTYOWNER~ SOIL DESCRIPTION REPORT Page of .3
PARCEL I.D. # j
Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
-31 4~:y4`:vv.:'ta:' - v -D 5/ l 3 sb~ ~ ~ C w o7+^ ,3
Ground 35:-7) /64 / D C S C 1r, !S
elev.
Pepth to
limiting
fa ti~
d
Remarks:
Boring # rk J-5
O.V t? S r O C s dw 1 h., k
Ground
elev. - lQ S p C s m C
Depth to S S O G s 1h ~ e.w G i b
limiting
~
factor
Remarks:
Boring #
:h 6
Ground ~o -7 Is O C S C L.-3 On . y Is fty.
ft.
Depth to
limiting
fac
O
F--T
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
IL-
Pte,, -.3
Nw .,we
rth ►rA)r►~. an
5`f' c G h p 1 X'
r1,3Dv-) ch Ma ri , 91
yon
Cal ulin-~~w~rs
d or¢, ~to~~..s
v
~ cs. ~ e -t- .l i rL.o
taOt/- bit Wjj.
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
rr St. Croix County
OWNER/BUYER W~ Lasz_
MAILING ADDRESS 17 6 7 5 L9 52`61-7
I7~-~ l)
PROPERTY ADDRESS 79'7
(location of septic system) Please tain from the Planning ept.
CITY/STATE 3-1do 7
PROPERTY LOCATION 1/4, 1/4, Sections T 34 N-R l 7 W
TOWN OF f' .T 1 1 r-a 1 r' `e , ST. CROIX COUNTY, WI
SUBDIVISION Te W -P--q YYl s LOT NUMBER /5
CERTIFIED SURVEY MAP , VOLUME ?W PAGE ITO , 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 expiratiion/ date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
APPLICATION FOR SANITARY PERMIT
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 the permit
issuapce. 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 _ ~9Q 1 C31A'e-
Location of Property 14, Section T N R W
f8wnship SKr may./ r u 1 r1 'P
Mailing Address'
Subdivision Name
Lot Number
Previous Owner of Property e rl r3
Total Size of Parcel .2 /q 4G e,--,
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Yes No
Is this property being developed for resale (spec house) ?
i
Volume and Page Number /ya._ as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed
2. Land Contract
3. Other recordings filed with the Register of Deeds Office
Surveydelays
In addition, a certified survey, if available, would
tosa Certifiedavoid
referenceshelpful
of the reviewing process. If the deed description
Map, the the Certified Survey-Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTV OWNER CERTIFICATION
I (We) centi"6y that aU 6tatement6 on this 4onm ane t,%ueto the o6.cnyth.,b (oLvL)
knowledge; that I (we) am (are) the owner (d) o S the pt p~y deAcAibed
.in6onmati"on ~onm, by vi tue o6 a waAAanty deed neeonded in the 066iee 06 the
County Reg.i,6teA o4 Deeds as Document No. and that I (we)
pned entt y own the pnopob ed .6 to bon the a eiu~ oa az d y4tem (on I (we) have
obtained an ea6ement, to nun with the above deb ehibed pnopelcty, bon the.
eonatAr.ction o6 aai"d system, and the Game had been du.Cy neeonded in the 066iee
o6 the County Re ten o66 D ed6, as Document No.
SIGNATURE F OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE'SIGNED DATE SIGNED
3
DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
1-
STATE BAR OF WISCONSIN FORM 2 - 1982
i. 482981
949PAGE12
VOL
REGISTER'S OFFICE
S X
li Carl . .........Peters and..E.
A, Peters_z_.husband and Rec'dfor R ecorBI d t
!I w1-fe- - .
~I MAYO G 1992
of 8:45 A. M
I I
-
it conveys and warrants to ._H41.1-e.-Rqi_1_ders,-__inc.
.
_ 0
J"t~ister of Deeds
- _ -
16
7E T U R N'
Halle Builders
- - . . ii , Inc.
i 1767 115th t.
the following described real estate in St.. C_rai.X ................County, i NeW_ Richmond,. WI.._ 54017 -
i State of Wisconsin: f
I', I Tax Parcel No: .
Lots 15, 16, 17, 18, 19, 20, 21, 22, 27, 28, 29, 30, 31, 32, 33 and 34,
Block II74II Plat of Jewett Mills in the Town of Erin Prarie.
ii
i
i'
,I
ii
~I
i
I
I
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This 5._ nit_____________ homestead property.
(is) (is not)
Ii
ij Exception to warranties:
Easements and restrictions of record if any.
Dated this 24th . day of Av - - , 19. 92....
(SEAL) (SEAL)
- * Car.l-.-F_--Peters--- -
n 9 ,...G,.-.~s , (SEAL)
it ,Elizabeth A. Peters
AUTHENTICATION ACKNOWLEDGMENT
Signature (s) STATE OF WISCONSIN
SS.
St. Croix County.
authenticated this ........day of........................... 19...... Personally came before me this L4 h __day of
__-8r?ri.~----------•_______________ 19 92 the above named
nd Elizabeth A. Peters,-
Carl F. Peters and-
* husband and wife
- -
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, - - -
authorized by § 706.06, Wis. Stats.) S to me kn wn to be the perso . cr•exee o,
8bs 4%
foregoi g instr ent a,+rid nowl ge
THIS INSTRUMENT WAS DRAFTED BY
William J. Radosevich, Attorney at Law
Karen M. VanSomeren ~s
502 Second St., Hudson, WI 54016 -
Notary Public s,
" . .
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If ndly~~ (R e-xl~+"
are not necessary.) date: ___-December- 17_.___---- ------IAN....`._..> i•
*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.
FORM No. 2- 1982 Mllwe.nkec. wis.