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HomeMy WebLinkAbout012-1030-20-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER A06i) / ,7 TC[,CI ADDRESS aD SUBDIVISION / CSM# LOT # 0_N-RW, Town of Pip r SECTION--Z/ T3 ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM c t~ J~ i r Ad A Z25 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. I Provide 2 dimensions to center of septic tank manhole cover. P, 1 BENCHMARK• b lo ALTERNATE BM:. 117 rio SL'ca•cr c~r1►'7 N~ 3~ce %~/y"G?ur' SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: (,u e Liquid Capacity: Setback from: Well _ House Other Pump: Manufacturer Nj Model# Size_ fj~{ Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length Number of trenches Ie r~i r/5 Distance & Direction to nearest prop. line: JOcl 47, 2 23- Setback from: well:AIA House Other • ELEVATIONS Building Sewer ~ ST Inlet; 0 3 ST outlet PC inlet V Pr PC bottom AIA Pump Off AIAL Header/Manifold loltlm of system--2102 Existing Grade Final grade q DATE OF INSTALLATION: J Z ` o~ b 9~ PLUMBER ON JOB: R. T Cp,, z oh LICENSE NUMBER: ~p R So 3 199 INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor andMuman Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 209005 PerrmLitSs1~1Q_r s N n~N~D ❑ City ❑ Village ( Town of: State Plan ID No.: grin Prairie CST BM 'Elev.: 1J7 Insp. BM Elev.: BM Description: Parcel Tax No.: /lJv , ob /Gb A9400128 TANK INFORMATION ELEVATION DATA A/ TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. ;Y Septic PS G ~cr, e Benchmark 7a , /djj 'cam Dosi ng- rl 111.2 Aeration Bldg. Sewer cl Holding St/## Inlet (15 TANK SETBACK INFORMATION St/D~f Outlet 9 IN 3S TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic > Sp' ' NA Dt Bottom Dosin NA Header.010ii4;- Aeration NA Dist. Pipe H Bot. System _12- 7, PUMP/ SIPHON INFORMATION Final Grade 7,6'6 Manuf Demand m~ 5-7 / Model Number /04 7,'' TDH Lift F on Syesatem TDH Ft Fo n Length Dia. HH Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length r No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIM SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACH Man urer: SETBACK INFORMATION TypeO /(u-vC"'(` r CHABOK Model Number. System: ad "ve-0 ^ 2 &Z UNIT DISTRIBUTION SYSTEM Header / Manifold,. ~i Distribution Pipe(s) , x Hole Size x Hole S g Vent To Air In e Length Dia.' Length 3 Dia. Spacing I! I )i ste SOIL COVER x Pressure Systems Only xx Mound Or At-Gra Depth Over ~r Depth Over r3 „ r// , xDepth Of xx Seeded /Sodded xx Mulched El Yes E] No E] Yes El No Bed /Trench Edges ~J~ l0 Tx Bed /Trench Center 3_ _ 1 _T COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Eri Prairie.11.30.17W SE, SE, 160th Avenue 01 1/_x- ~6111) Plan revision required? ❑ Yes EI- -6 C, Use other side for additional information. r SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. =13-LF4R SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY mom _ST- Crv i STATE SA ITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than Uag60-5- 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 LOCATION Sgr %45 e- S T o, N, R E (or)(9 PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # d' S k 'L L^ 4 W `i-1144-1 ,20 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER pare (,,-Cte 'WA 1(6/A 37 ~`8 w L:I CITY NEAREST ROAD II. TYPE OF BUILDING: Check one ( ) State Owned ❑ VILLAGE : Aelt% h1J O T[v *a N ❑ Public 541-or 2 Fam. Dwelling- # of bedrooms - PARCEL AX NUMBER(S) 111. BUILDING USE: (If building type is public, check all that apply) / ©lo~ -f v~C~ -•~-a 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.'idew 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 ®-6eepage 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 00 1/a 9 Y a 1- °f a' Feet 96.3 Feet 07 CAPACITY VII. TANK Site in allons Total of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New lExisting Gallons Tanks Concrete glass App. Tanks Tanks structed I e- Septic Tank or Holdin Tank ~O L✓i S v f Lift Pump Tank/Si hon Chamber f- El Ej El LJ 1 0 1 F-1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): y b& .S r S C91 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit a (includes Groundwater Date Issued Issuing A nt SignaLurf No Sta s) Approved ❑ Owner Given Initial Surcharge Fee) ~ Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: zA4- LAP , 7 zr SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. s40itary permit is valid for two (2) years. 2. -Youf'sanitary permit may be renewed before the expiration date, and at the time of renew .l any new criteria in the Wisconsin Administrative Code will be applicablle. 1 All revisions to !"Fit permit must be approved by the permit issuing authori-, 4. Changes in ow?u-ship or plumber requires a Sanitary Pero it Transfer'Q ,~-,vt Fc:rrF 'SBi.' 6399) to be submitted to 're county pear to installation. 5, Ons;tN 4eva~ige systems n ,Jfit bEe propei;y inaltitair'ed. Th« tangy(z) „ r r? r stn . _ ? 1ici~n5ed pumr whenever necE Esitry, usually every 2 to 3 year;,. 6. If you have questions concerning your onsite sewage sy~->e4rt, contact y out :a.i *.x de adrr =r strator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitAr permit application must include: 1. Property owner's name and mailing address. Provide the legal description aid parcel tax rinuiber(s) of where the system is to be installed. 11. Type of building being served. Check only one and complete # of bedrooms l 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, econnection, or repair. V. Type of system. Check appropriate box depending cn 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 tarok, is. the total ga[lofie:, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank --naterial. Corr,!:Oete for all septic, pump/siphon and holding tanks for this system. Check experimer°.tal approvai 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 B'h x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimeisions, 'ocation of holding tank(s), septic tank(s) or other treatment tanks; building sewers, well;;; water mains;,eater service; streams and lakes; pump or siphon tanks; distribution boxes; soli :absorption systems: repia',ement system areas; and the location of the building served; B) horizontal and v.itica; elevation reference; points; C) complete specifications for pumps and controls; dose volurne; elevation d'ferences; frict :r: 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. - - - - - - - - - - GROUNDWATEIR SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a num .,er w regulated practices which can effect grqundwaler. The rnonies collected through hyr :e srcharges are t.seii nion to,sn ,rc i,. .tJ water contamination n«Ystigafions and establishtrwrO of standards. SBD-6398 (R.11/88) ` 0.78 S~ f!/~.~w ~ve SE:~ SC ~ sac 7'31; ~ 7.~J.... _ ; QS~ti7i .r~~ X oCOG~f,O.J Ot •S.1l.E I~ i X , iol W i i~• u ' co ;~.i 4As WiGSG~'S ~i~ IOC~C a o y ~~6 Lizz, 7.200 ecl,-oo+•~•- TO WL3T (D~' )`p Ay~s7 l.oT r 0 Pia ~ 6C•. ..f i rG: ~ ~ l .C' le yb ~ I w• P G 3 'Pp Wipconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page j of 2 Labor and Human Relations f)ivision of Safety & Buildings in accord with ILHPAB3.05, 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 i 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 OWNE PROPERTY LOCATION GOVT. LOT 114 1/4,S/ T ,N,R 406 PROPERTY OWNER':S MAI ING ADDRESS LOT BLO K # SUBD. AME OR CSM # CI TATE ZIP CODE PHONE NUMBER CITY ❑VILLAGE OWN NEAREST ROAD New Construction Use Residential / Number of bedrooms [ J Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow ?00 _ gpd Recommended design loading rate +:bed, gpd1ft2 , S trench, gpd/ft2 Absorption area required bed, ft2 ~3-; ' trench, ft2 Maximum design loading rate , I bed, gpd/ft2_,,g _trench, gpd/ft2 Recommended infiltration surface elevation(s) WS ft (as referred to site plan benchmark) Additional design / site considerati ns Parent material ? Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem 0S ❑ U ® S ❑ U N1 S ❑ U OS ❑ U ❑ S DO ❑ S O U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. nt. Color Gr. Sz. Sh. Bed Trench Ground _ ? S- e ev. 62 X ft. ~ [,3;7 Depth to limiting factor Remarks: Boring # - r S `Ground ..v. - elev. 46~ o ft. Depth to limiting factor , I I i Remarks: CST Name:-Please Print Phone: ZZ2 Address: Signature: Date: CST Number: PROPERTY OWNER SOIL DESCRIPTION REPORT Page,-2 6f PARCEL I.D. # 4 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Ground 44 elev. ft. s -ZLS Depth to limiting factor > 91,1 Remarks: Boring # JV/,- h) Ground / elev. 1 ' )10 7/Z AJ ft. Depth to limiting factor Remarks: Boring # Ow ~e Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) 3,oF 4-1) ,5 • O7~4 /S v G9.1 S % ~ s.S el 71J ~p.SBr7;/l ~ S.~"//3 ,~i~irJ Tif°.}ht'i~" ,/1 1444 , 611 c J j 7p r?ve \02 471! 3 S f X33 ~o, / / _ ~ l . STC-105 ' I SEPTIC TANK MAINTENANCE AGREEMENT St. Croix Count} owlvElvsUYER S' ~c~`J E G MAILING ADDRESS 20T K Il tS70-6E t, ty ~r-S r 19~a rbv~N~J~F PROPERTY ADDRESS SE% of SE OF SECTiOA) 30-/7 C (location of septic system) Please obtain from the Planning Dept. CITY/STATE IVFGJ PIC 14 PROPERTY LOCATION `vE 1/4, SE 1/4, Section T 30 N-R 17 W TOWN OF E2l,J P AIRI ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTEPUDSURVEY 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 duly 1, 1978. St. Croix County accepted this program in August of 1980, with the requiremnt 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: /A 1 G~ I St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 . i APPLICATION FOR SANITARY PERMIT STC-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 j_i1V t4Lj-r1gD Location of Property Section T 30 N-R~ W Township QLAJ P.& /,E Mailing Address 070 -SkA ( In a,.q Ave 1J r Address of Site Corje., O~ ((oG*" /}sc_ cL,,► r Subdivision Name 'Lot Number Previous Owner of Property Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes V' No Volume _ 12`~ and Page Number 33 1 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 refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTV OWNER CERTIFICATION I (We) eetti6y that a t statement/s on this 6otm ate tAue to the best o6 my (out) knowledge; that I (we) am (ate) the owner (,s) o6 the ptopetty de,6 c i,bed in this in6otmat on botm, by viAtue o6 a waivcanty deed recorded in the 066i.ce ob the County Register o6 Deeds a6 Document No. L(7,,z LY 6 and that I (We) ptesentty own the proposed bite Got the sewage di6pos (ot I (we) have obtained an easement, to nun with the above deicAibed ptopehty, Got the con6tAucti,on o6 .6aid system, and the same has been duty %ecotded in the 046ice o6 the County Regiztet o6 Deeds, ab Document No. y~~ G y G ) SIGNATURE OE? OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) sby DATE SIGNED DATE SIGNED DOCUMENT NO. STATE BAR OF WISCONSIN FORM 3-1982 THIS SPACE RESERVED FOR RECORDING DATA QUITCLAIM DEED 47 2. 64- 6 _ VOL 4PI1,~ ren e~ hay ser- c~~a REGISTER'S OFFICE ren ~C Iz~ h c~ y s~-r - f} t s~ia _ ST. CROIX CO., WI Rec'd for Record quit-claims to _ V_o re,n 0Lwr ki--k k ,,e r' CZ-i_c h t L-11 1 `a 1991 r? eial d N A IStcxd hvsbanck card of 8:30 A. /fM W~ o►S /-Nor'j aA Survl%rorSK,p PropU F* ~Cx " Register of Deeds the following described real estate in <'i '"U. X County, fl State of Wisconsin: 'j - - RETURNTC SE '/'j of S E '/~t , CX.-I{ t-he of SE- 'N o f Ala /Okt:-«( of sc c ham I I 3U I -7 4150 CL Tax Parcel No: 1_70 l u r, ct a-► e; t rcl r,, w; , CL ti S w C c n~ f -tti.Q /~;E 'Iv o{ S!= Y~ a~ Src tic., . i 3fi --(7J CAJ _jY d~sGT~ ~~~:c~ fC~r-t-) e 1 ~SCC{ irG~- fC.GClw`c~,{ ~~'~C-SGS~ .+--Cr'~ v~ l f ,i 4 ha ti' k C' _c z- re f'c t (cep a { ~r ~y , tom,, n~ rL, 1 t r~ r~ y c{ 1-t bcj..,,n 1-,9 co uni S' - li I, t S ncl- I This homestead property. I (is) (is not) G- r r. Dated this 1 1 day of L; '-j FSEALI (SEALI I ~arc~ S Oberhai ser I (SEAL) (SEAL) i AUTHENTICATION ACKNOWLEDGMENT j I Signature(s) STATE OF WISCONSIN SS. -fit r- CrDJ-x County t authenticated this day of 19__- Personally came before me thist9th _day of i _August , 19.91_ __the above named I Karen SA Oberhauser TITLE: MEMBER STATE BAR OF WISCONSIN not. _ to m know^Jb t lf~ (If authorized by § 706.06. Wis. Stats i for ng in$1ruA sh a the Same executed the O. fHl$INS'RU MENT VV AS DRAF IF) B• ~ Jam6xo_~ _ Notary Put,$•,`C~ r.*Qj2L__„ounty. W s (Signatures may be authenticated or acknowledged Bot^ My Comm ssror frsS,begmenAc~t~ (I-f not state exr ratior are not necessary I 1<+te Ap -1 1, 2~1 1993 r , S83 i STATE BAR Of':viSCONSiN OUIT CLAIM DEED TOW No 3- 1982 Ne!r:, Tax Forms P 0 Box 10208 Green Bay. At 5430' 0?08