HomeMy WebLinkAbout012-1017-90-000
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ,S 7-~'X. 7T"' .~u
AD DRESS
G Air" Ott IrL7 ~
I
SUBDIVISION / CSMJ 4JA LOT I jl
SECTION (O T 30 N-R_Z_Z_W, Town of ZjelA)_ )P.<
ST. CROIX COUNTY, WISCONSIN
PLAN VIER L
SHOW EVERYTHING WITH N 100 FEET OF-SYST
~Z
i
/2~ IDS,
2
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this fot-ra.
Provide 2 dimensions to center of septic tank manhole cover-
k
ool
- BENCHMARK: AAC
ALTERNATE BM:
_ -SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: ~r/otLiquid Capacity: /
Setback from: Well House _fa , Other ,Z S, L
i
Pump:Manufacturer -Model# Size
Float,seperation` Gallons/cycle:
Alarm; Location - - - I
!!!!SOIL ABSORPTION SYSTEM
j i
Width: I 2 T nngth C" 1- Number cf trenchese 7
Distance & Direction to nearest prop. line:
S-
Y
?
Setback from: ►el l : House / Other
i
I
ELEVATIONS
Buildin Sewe'
q ST Inlet. ST outlet
I
PC iinjet PC bottom Pump Off
Header/Manifold _ Bottom of system
Existing Grade-,/ Final grade - 9&1 7
DATE OF INSTALLATION:
PLUMBER ON JOB: 4, f J f S
LICENSE NUMBER: p (4,7/
INSPECTOR:-
3/9 3 •-y, ~ 1
: jt
LalborancDmanRelationsdustry, PRIVATE SEWAGE SYSTEM County:
INSPECTION REPORT ST. CROIX
Safl'ty and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village Town of: State Pan o.:
BETTERLEY, ESTHER L. il
CST BM Elev.: Insp. BM Elev.: / BM Description: Parcel Tax No.:
,,a
TANK INFORMATION ELEVATION DATA d/
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark lv / ~
Dosi n
Aeration Bldg. Sewer
Holding- St/PW Inlet
T Ir
TANK SETBACK INFORMATION St/ Outlet 7i
Vent
TANKTO P/L WELL BLDG. Airs to ntake ROAD Dt Inlet
Septic 1,31 NA Dt Bottom
Dosin NA Headers
Aeration A Dist. Pipe S '
Hol Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manu cur Demand o'er
Model Number GPM
TDH Lift Frict' System TDH Ft
Forcema+ff Length Dia. Fi Dist. To Well
`.?J SOIL ABSORPTION SYSTEM
BED / Width Length / No. Of T enches DST No. Of Pits I e Dia. Ligaid Depth
61MEN-S-10141-
DIMENSIONS Z
fso
SYSTEM TO P / L BLDG WELL LAKE / STREAM actur
SETBACK CH BER
INFORMATION Type O s, r Moe Number:
System: C'v, be" ~ a S UNIT
DISTRIBUTION SYSTEM
Header/Manifold r Distribution Pipe(s) 4, x Hole Size x Hole Spacing ve Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade s Only
Depth Over Depth Over xx Depth Of x Seeded/Sodded -MMulched
Bed/ Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.), 1U 1 C1>K_
LOCATION: Erin Prairie.6.30.17W, SE, SW, County Road GC
Plan revision required? ❑ Yes No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
L
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION
e:•■~nn In accord with ILHR 83.05, Wis. Adm. Code C7
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than tom, 156 5-Z-
8% x 11 inches in size. ❑ Check 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 LO ATION
SC` t/4 SO) Y4, S T_~O, N, R 1 ` E (or V&
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOC
CITY STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one CITY NE EST ROAD
❑ State Owned VILLAGE ~ l/7=
❑ Public Rq1 or 2 Fam. Dwelling-#of bedrooms AR ELTAX NUMBER(5)
Ill. BUILDING USE: (If building type is public, check all that apply)
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.E1 New 2. Replacement 3. ❑ Replacement of 4.E1 Reconnection of 51-1 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 CK Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 El ` y
El VaultP
13 ❑ Seepage Pit Pressure 43
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/ q. ft.) (Min./inch) ELEVATION
~3 r~Jr 7 ?Feet Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. lFiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name oncrete Con- Steel s Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank antis tw d c-_,- ,Ow e.5
Lift Pump Tank/Si hon Chamber e-.
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's ame (Print): Plumber's Signature: (No Stamps) MP PRSW No.: Business Phone Number:
L - 4 /
Plum er's Address (Street, City, tate, Zip C
> d) C &L C
lX. C UNTY/DEPARTMENT USE ONLY
❑ Disapproved S ry Permit Fee (includes Groundwater ate Issued Issuing Age Si ure (N
Surcharge Fee)
Approved ❑ Owner Given Initial y~Q/}~
Adverse Determination D (l -
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(R.08/93) 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.
IL Typ cof building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling.
IIL 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 totaligallons, 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.
Compltte plans and specifications not smaller than 8% x 11 inches+mgst 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; buildingKsevlrers; 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.
. I
SBD-6398 (R.11/88)
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ixsinDepartmentoflndustry, SOIL AND SITE EVALUATION REPORT Page 1 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 2 ~'i si . Plan must include, but St. I.D. # Croix
PARCEL
not limited to vertical and horizontal reference direction dfw slope, scale or
dimensioned, north arrow, and location and st~nCe ton es&oad. 012-1017-90
REVIEWED BY DATE
APPLICANT INFORMATION-PLEAS w NT ALI i;Wdjfut'ATI
PROPERTY OWNER: f .-P OPERTY LOCATION
v
T S E S Mor) W
Esther BetterlY VT. LO 1/4 W v4,S6 T 30 N ,R 17
"t3 e
PROPERTY OWNER':S MAII-ING ADDRESS /OT # JBSUBD. NAME OR CSM #
1524 Ct Rd GG na na na
CITY, STATE ZIP CODE PJt1MBIJ ❑CITY ❑VILLAGEi OWN NEAREST ROAD
New Richmond, Wi. 5401` 1-325 Erin Prairie Co. Rd #GG
[ ew Construction Use [x* Residential / Number of bedrooms [ ] Addition to existing building
]Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate • 7 bed, gpd/ft2 .8 trench, gpd/ft2
Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate . 7 bed, gpd/ft2.3_trench, gpd/f<2
Recommended infiltrator, surface elevation(s) 93.99 ft (as referred to site plan benchmark)
Additional design / site considerations na
Parent material stream terrace Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U=Unsuitable for svstem ®S ❑ U I S O U ®S O U ®S 1:3 U ( ❑ S F ❑ S frJ U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundoy Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trertrf
1 0-9 10 r3 2 none 1 2msbk mfr cs 2f .5 .6
z;
2 9-21 7.5yr4/4 none is osg mfr gw if .7 .8
Ground 3 21-9 10 r4/4 none cos osg ml na na .7 .8
elev.
97.87t.
i
Depth to
limiting
factor
+90,
Remarks:
Boring #
1 0-9 10 r3 2 none 1 2msbk mfr cs 2f .5 .6
2 .1 2 - r 4 4 none s' 2
Ground 3 22-3 10 r4 6 none is os mfr w na . 7 . 8
elev. 4 39-9 10 r4/4 none cos os ml n na .7 .8
96.72 ft.
Depth to
limiting
factor
+90"
Remarks:
CST Name:-Please Print Phone:
Gary T_ Steel 715-246-62001
Address:
1554 200t Ave. New Richmond Wi. 54017
Signature: Date: CST Number:
7-25-94 2298
PROPERTY OWNER Esther RP+-+.ar1 3A SOIL DESCRIPTION REPORT Page 2:_~cf-i
PARCEL I.D.# 012-1017-90
Boring # Horizon) Depth I Dominant Color I Mottles I Texture Structure Consistence ~Bounclary I Roots B tl DTft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
M
3.. 1 0-720 10 r3 3 none 2msr mfr w 2
2 20:4 10yr4/4 none sil lfsr m gw na .2 j.3
Ground 3 40-4 7.5yr4/4 none is osg mfr na .7 1.8
elev.
96.72 ft. 4 45=9 7.5yr4/4 none s os mfr na na .7 ':.8
Depth to
limiting
factor
+90"
Remarks:
Boring #
A>....~^a:::>; 1 10-8 none 2m . 5 .6
.,K 4 2
8-24 ; 10 r4 4 none s' Ifsbk mfr Cjw if .2 .3
Ground 3 24-4 7.5yr4/6 none is os mfr Crw .7 .8
elev. 4 48-9 10 r4 4 none c os ml na n- .7 .8
9 8 * -2._ ft.
Depth to
limiting
factor
+941
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting j
factor
I
. I
Remarks:
Boring #
Ground
elev. I
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel Esther Betterley 1554 200th Ave.
CSTM2298 SE4SW4 S6-T30N-R17w New Richmond, WI 54017
MPRSW 3254 town of Erin Prarie (715) 246-6200
~N WMou)~1(7L=12
111=40 L_
BM=top ofNE cormer of cement patio at el. 100'
X_y
78
k ~~R ~2r
-A
g a-
2
~ 9 / 20
~r
(~A►1L ~I
_1Zs
Gary L. Steel
7-25-94.
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS C`) da
- -PROPERTY ADDRES
(location of septic system) Please obtain from the Planning Dept.
ITY/STATE
f
P OPERTY LOCATION ~Z= 1/4, S u.) 1/4, Section 6' T~N-R. I W
OWN OF LIZ/^) ,log /40- d IF- ST.' CROIX COUNTY, WI
S DIVISION . LOT NUMBER
RTIFIED SURVEY MAP VOLUME 7PAGE 172~, OT NUMBE C. ,-J,4
Improper use and maintenance of your septic system could,'result in its remature failure to handle
antes. Proper maintenance consists of pumping out the se t1 'tank every three years or sooner, if needed
y licensed septic tank pumper.' "iv flat you put into the syste i can affect the function of the septic tank
a treatment stage in the waste disposal system.
St. Croix Coun residents may be eligible to receive .g grant for a ma Cimum of 60% of the cost
bf replacement of a failing system, which was in operation prior to July 1;Ii "1978. St. Croix County
accepted this program i~ August of 1980, with the requirement that owners ob all new systems agree to
keep their system properly maintained. I 1'
I The property o er agrees to submit to St. Croix Zoning a'certificationform, signed by the owner
d by a mater plumber, journeyman plumber, restricted plu 'ber for a licens pumper veri mg that (1)
he on-site wastewater disposal system is in proper operati g ndition an (2) after inspection and
pumping (if necessary); the septic tank is less than 1/3 full o sl ge and scu
i
I/We, the undersigned have read the above requirements and agree to maintain the pivate 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 mast be completed and returned tolhe St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
8 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 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 Ti-fret
Location of property 1/4 ScAJ 1/4, Section T.-30N-R_Z.,27_W
Township L~2~r+S E2,tftae- Mailing address /.:s~ -rv e<0
ij
Address of site S
Subdivision name -Lot no.
Other homes on property? Yes c/ No
A
T
Previous owner of property c
Total size of property a ,c-
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? i Yes No
k Is this property being developed for (spec house)? Yes No
F Volume 7_ and Page Number ~2 Z as recorded' with the Regi~ter
of Deeds. i
-
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND AGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In additio , 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 Ce tified 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 y
described in this information form, by virtue warranty deed recorded a the office of the Co nt Register f of
Deeds as Document No. 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.
Signature of Applicant Co-Applicant
/E /41
Date of Signatu a Date of Signature
i I
I
QOCUMENT No. TATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA
WARRANTY DEED
457228 _ OV /_PA~. )
- - - -
REGISTER'S OFFICE
This Deed, made between .K >4e-Sl--D,•--. e_ teX -~y-,--.d . ~IX CO., w1
for Record
............,...••G rantor•-=-. APR C G 1590
di : 0/ 0 ~ A. M /n~nn
and.---. Esther._L_..Be-tterley................... 9
* ~~t M
- -
90 tb~ptper of Deed
. . _
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration
Sixty..Thousand...0-6.0-,.0.00..00.). Do-l,l,ars_-------.-------,---
conveys to Grantee the following described real estate in S.t. - _Cr-Q~X_. RET(,; i IRI `ITS
County, State of Wisconsin: '
River F.:.., r .h, ..1~~$
Part of the Southeast Quarter (SE34) of the Tax Parcel No:
Southwest Quarter (SWk), Section 6-30-17,
described as: Commencing at the Southwest corner thereof; thence
East on the South line of the SEk of the SWk, 15 rods; thence
North to the Southerly line of the Willow River; thence Westerly
on said Southerly line to the West tine of said SE34 of SWk; thence
South on said line to place of beginning.
Grantor is the surviving spouse of Alan H. Betterley, deceased.
TRAiv~o~k
SI 8._._a
This ..___..15........._- homestead property.
XXN@iX4W10=
Together with all and :angular the hereditaments and appurtenances thereunto belonging;
-
And...... Karen..D..- B_etterley_,._.a__single woman,,
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except municipal
and zoning ordinances, easements, reservations and restrictions of
record;
and will warrant and defend the same.
Dated this - .5th - day of April.-------- - 199.0-
.(SEAL) .CJ (SEAL)
aren D. Bet erley
- - -
_(SEAL) _.......-.(SEAL)
i f
- - -
AUTHENTICATION ACKNOWLEDGMENT
Signature (s) STATE OF WISCONSIN )
} SS.
f
. leY'Ce County.
authenticated this .-day of------------ 19_..__. Personally came before me this ...5th
_.a.&$y of
~ j~lloye n3tye.fl~
_ _ - A pri1----- 199
Karen.-D...-_Betterley-,-_-. g g._wo 1
H
TITLE: MEMBER STATE BAR OF WISCONSIN
t
(If not,
authorized by 5 706.06, Wis. Stats.) '
to me known to he the person executed the
foregoin;; instrument and acknowledge tkn same.
THIS INSTRUMENT WAS CR4FTEO BY Charles --.E-.---Whi-te Attorney a-t. Law
- ,Nary E.' Cahalan
River Falls, WI 54022 P?_erce
. Notn 1,lic Count- Wi .
(Signature; may he authenticated or acknoaled ed. loth NIA- I' 'ntssinnXXAXt-X;}(;jJL"XxtXXXiX]tX~7A
are not r.ccessar}.l XM: expires 09/29/91 XXXXR4XXCXXXXX
•N'ames of P-- si4ninR in -y i-y ,H.. I -0 I ' 1,. 't- i -
WARRANTY DEED STATE {S.%R OF WIS(ONSIN
FOR %I No. I - I9yY ~t i;an Aker, Wis.