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HomeMy WebLinkAbout020-1169-70-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TG< ADDRESS 3 4(l J~'iyLi `/Cr.~ SUBDIVISION / CSM# x aLOT # 332•, SECTION ) T Zf N-R /F W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i o D I -----~,NDI_CATE NORTH ARROW Provide setback and elevation information on reverse of this -In Provide 2 dimensions to center of septic tank manhole cover. i BENCHMARK: /Dp d~ SGft~L!.~ k .SG<-~ ~rizcr~ ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: ~ r L,70, Liquid Capacity: 164::5 Setback from: Well House Other Pump: Manufacturer /v Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: 5 Length 4 S/ Number of trenches Distance & Direction to nearest prop. line: ~GJ S© La `rtP i Setback from: well: /bpi House ~P Other ELEVATIONS Building Sewer ST Inlet. ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: 2- PLUMBER ON JOB: e_ % ~.r...._ LICENSE NUMBER: /j/JQ~ 322y~ INSPECTOR: 3/93 : jt WiSeonsinDepartment ofIndustry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION P rmit agC Na~~AUL J & IRENE M ❑ City [I Village Town of: State Plan o.: CON "TTT-1czr)N 169-70-(110 CST BM Elev.: Insp. BM Elev.: BM Description: SQ,~ lC 2u-e t' Parcel Tax No , -to TANK INFORMATION ELEVATION DATA G_o`r TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. 2 Benchmark ~ ~dD vJ Septic 4 Dosing. (D~lVi.i7 Off,<~ Aeration Bldg. Sewer Holding St/)t Inlet 5~" i TANK SETBACK INFORMATION St/1010f Outlet 96 TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic >SLS >25 3 NA Dt Bottom Dosin NA Headers Aeration NA Dist. Pipe 2 Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade mar o S Mam"clurer and Model Number PM Friction System TDH Ft TDH K I Loss ead Forcemain Length Dia. Fi Dist. To wen SOIL ABSORPTION SYSTEM BED/TRENCH Width Lengt i; No. Of Tr nches No. Of Pits Inside Dia. Liquid Depth DIMENSION S I/~ DIME SYSTEM TO P/ L BLDG WELL LAKE / STREAM RING Manufacturer: SETBACK CHA INFORMATION Type O r, p 3 System: 4 te,--4,"; OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s), Z „ x Hole Size x Hole Spacing Vent To Air Intake Length 33 Dia. Length T?,,. Dia. Spacing 1L 77 SOIL COVER x Pressure Systems Only xx Mound Or At-Grade S ms Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched BedlTrenchCenter Bed/Trench Edges Topsoil E] Yes ❑ No ❑ Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 07.29.19.1054,SE,NW,LOT 31-3.2,HIGH VIEW RD. / i Plan revision required? ❑ Yes ❑-No Use other side for additional information. SB -67 0 (R 05/91) Date Inspector's Signat re Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION COON In accord with ILHR 83.05, Wis. Adm. Code cE J STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ? 8% x 11 Inches in size. ❑ cne~ck 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. PROI ~TY OWNER PROPERTY LOCATION /I_f/ 5761/4 hj (•tJt/4, S T7-P, N, R ~ (or) PROPERTY OWNER'S M ING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION AME OR CSM NUMBER II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD ❑ State Owned 0 VILLAGE Gcf _4~_ Em. TOWN OF /6Z ❑ Public ❑ 1 or 2 Fam. Dwelling-#of bedrooms PARCEL TAX NUIVIESER(S) Ill. BUILDING USE: (If building type is public, check all that apply) - / b 9 70 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 40 Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 50 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. N New 2.E] 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 430 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) T/ l~ 'Alnc ELEVATION 7556 f300 ,9 Z -9 , v Feet /O Feet VII. TANK CAPACITY Site in allons Total of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank C,6, 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. Plumb 's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No : Business Phone Number: 3.2-7 Z/ 7/~ 77zz1f~ Plumber' Address (Street, City, State, Zip Code): .3 a~ 0;7614 A001e e-JIl ups IX. COUNTY/DEPARTMENT USE ONLY - Groundwater a e Issued Is 'ng Agent Signatu a No Stamps) ❑ Disapproved San' ary Permit Fee (includes Surcharge Fee) Approved F-1 Owner Given Initial l`Y lo- Adverse Determination - X. CONDITIONS OF APPROVAL/REASO S 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. 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 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 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 13% 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) L JOB TIMM EXCAVATING SHEET NO. OF 2 Route 1 Box 192 ~i•',~ .q WILSON, WISCONSIN 54027 CALCULATED BY Ji DATE (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE r ,L .ia.~~,..... rr V i i / . ' ..................:}"re.rc 4 S r~'S/ Z1 .cam r _ .3.$. _ T y 1 1,.... ~s......i . ....0...... 1 c - - - r ~y vww f~ ~r ~a ~-4 . . PRODUCT 205-1 Inc, Grotm, Mass. 01471. To Order PHONE TOLL FREE I-800-2256380 JOB TCc~ TIMM EXCAVATING z Route 1 Box 192 SHEET NO. OF WILSON, WISCONSIN 54027 CALCULATED BY+ DATE (715) 772-3214 (715) 386-5443 / MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE `I' Q n _4 .'~~I~ -j EG g9'sy lit 2 } f m... 9. PRODUCT 205-1 Inc.,Groton, Mass. 01471. To Order PHONE TOLL FREE 1.800-225.6388 Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page / of 3 Labor anti Human Relations Division of Safety & Buildings in accord with II-HR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but I.D. # 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 P NPEQL R TY ER: PROPERTY LOCATION rJC p GOVT. LOT SE 1/4 AjLJ 1/4,S 7 T Z 9 N,R f' E (or) W PROPERTY 0 NER':S MAILING ADDRESS LOT # BLOCK # SUBS NAME OR CSM # 3j-3Z 1CAntcw toc&b CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE OWN NEAREST ROAD ( ) 1 91) ms of r,l: 6 u VI') E w 9,0 A & Q(f New Construction Use ¢ Residential / Number of bedrooms S [ ] Addition to existing building j J Replacement [ J Public or commercial describe Code derived daily flow 6 gpd Recommended design loading rate - bed, gpd/ft2 ©A trench, gpd1ft2 Absorption area required - bed, ft2 f trench, 9 Maximum design loading rate bed, gpd/ft2A_trench, gpolft2 Recommended infiltration surface elevation(s) _oU A40C 7 6T- 33 ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable ft S - Suitable for system NVENTIONAL M UND IN-GROUND PRESSURE T GRADE SY TEM IN FILL HOLDING T K U - Unsuitable for system S ❑ U (MS ❑ U Ii S ❑ U S ❑ U RS ❑ U ❑ S KU SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Botxx~ry Roots Bed Tmr& O- /b 3/ - L 2 c fil r X'j 7 D. 6 23 io S ; L f sbK M - La Z 0.3 17- P, A &Z Ground g 3-37 IbY 4 1 sbK M"~ , + _ D •3 4- elev. I !Aft. '9-9Z TS 5 -P Depth to limiting factor Remarks: Boring # A 0 -S /aYR l - L, 2 cr r w 7 d.b Z JA) M :6.31 13 Ground W9 S' a L Sb 1 w 7 rr, X1.3 elev. Q >r C's / b4 /o~l.l~t g 7.5 R Depth to -9? Y S A" -16-41 limiting factor Remarks: CST Name. Please Print Phone: ~rnIS4 ~ dress: P, o. -&x 9 I Signature: Date: //Z-7/ 9 CST Number: PROPERTY OWNER PAOL &NGbb~j SOIL DESCRIPTION REPORT Page z of PARCEL I.D. # L -31-3Z Af, c a LJ6(5t~ Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed re+xh ©-g /aYP, 3 / Z cr M r C w Z p. x-17 YR4 Z S4 / sbK A-, I w Z m 03 Ground 17- 3Z dY?- 3 elev. s 1 o 1 ft 3L-96 -TS Yk 4/3 Depth to limiting factor Remarks: Boring # A /AYO, 311 L > C w 6, 16 "1 .2 4 S, L 1 sk Li z M 'a.3 Ground $ A-4Z /aY 4/i. - S, L f gbK r-► w - p,3 IoZ~ft Z-~S 7 SY 46!- 'O. Depth to limiting factor Remarks: Boring # A o-11 !oY 3 I S~ d T A, 0.5 13 R, 2 f O`/ 3 S r w Z d Jgx 24 -104 161k 4 4 1 5 M Ground It6ft Depth to limiting factor Remarks: Boring # 13 Ground elev. it Depth to limiting factor Remarks: SBD-8330(R.05/92) ,a a ~ r rr oati _ f, i / i Lip I 2 rn n F i o 'O 7. ' 1O z i ~ r L ,j (N N cpl v LA o 'O v'O~ ~ UA w W J on p - o 0 o N C> ~ a F C> (ti P LA ri O rr, a Z STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER /CLCC C' / MAILING ADDRESS 3 e~Jf4 PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE c 4 GCJ~S ~~/a/,~ PROPERTY LOCATION 1/4, %4(1 1/4, Section 7 T Zh N-R /y' W TOWN OF ST. CROIX COUNTY, WI Z SUBDIVISION LET NUMBER 31- 3 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 th e function of the septic tank as a treatment stage in the waste dispo I system. ;rthCro' County residents may be eligible to receive a grant for a maximum of 60% of the cost of rep ment f a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted is 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 expir n date. j SIGNED: DATE: St_ Croix County Zoning Office Government Center 1101 Carmichael Road 11/93 Hudson, WI 54016 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 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 Location of property S 1/4, Section TAN-R_ W Township Mailing address Address of site /ea) Subdivision name Lot no. 3 - 2 other homes on property? Yes No Previous owner of property 11&Lez, /2-07,12 Total size of property Total size of parcel 7 o.c rP8 Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes A 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., 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. Z gnat re of pplicant Co-Applicant Date of ignature Date of Signature . i , DOCUMENT No. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA I STATE BAR OF WISCONSIN FORM 2-1982 - - UOSTERS c FFICL: Mary Ann Windolff, a widow not remarried, ST. CROIX CO., WIS. 'Ace'd. for Record this 31st y Of July A.EX 1?86 conveys and warrants to .Paul..J._Congdon__and___Irenn__M.•_.•-___ 2:15 P Congdon, ...husband..and-_wife...as... joint.. tenants....... o 11'au & Irene M. Cong n 705 Monroe St. N. the following described real estate in ...._.....,St.....C>~Q.I.X ................County, Hudson, WI 54016 State of Wisconsin: Tax Parcel NO:C.l,e56?.^.~Lq - 7D LOTS 31 and 32, the Plat of Ranchwood in the Town of Hudson, St. Croix County, Wisconsin.- SUBJECT TO the restriction that the aforesaid Lots are being conveyed as a combination containing at least 1.7 acres, and that the individual Lots or parts thereof may not be separately conveyed or mortgaged until all of the aforesaid Lots are connected to municipal sanitary sewer and water facilities. Until such connection, said combination of Lots shall be owned and used only as a single unified parcel for one single family home, and appurtenant buildings. TOGETHER WITH AND SUBJECT TO any and all easements, covenants, reservations and restrictions of record. 71 IANSF gpt11~. 1. This 1S not homestead property. EEE' (is) (is not) Of IeW G a Exception to warranties: .to~18~~~~• Dated this 1 St day of July.....................--...--.._.-, 19_8 0 •---•-•---•-----•-•......(SEAL) ...........(SEAL) indolff. * w Mary..Ann. .....(SEAL) ------------------------------------(SEAL) w AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN St. Croix County. ss. authenticated this day of 19...... Personally came before me this 31Ptday of P.1tY pjje !14y 19..86-- the above named Mary.Ann• W ndolff xyWaA, TITLE: MEMBER STATE BAR OF WISCO E. x} fR (If not , authorized by § 706.06, Wis. Stats.) M9FSCt~'; r, ' e known to be the pe on who executed the ryNtq " ' foregoin ent an ac owledge the same. THIS INSTRUMENT WAS DRAFTED BY . _ K}. _.e__Glber.. Gi. bert, Mudge, Porter' & Luridee2l ........^~i.on? s.._-_-•-.--__-.. :.a,10---Se-C-------------- WI.-54016 Notary Public S _ _-County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: 19.........) .Names of persons signing in any capacity should be typed or printed below their Signatures,A WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal lllank Cu. Inf. FORM No. 2- 3982 Milwaukec. Wis.