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HomeMy WebLinkAbout020-1019-90-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER IS A /j'1 /ff / LLf /Z, ADDRESS,RO - SUBDIVISION CSM# 5/!i/ALL~,q. ~/a~k SECTION. T N-R Town of #0,4so q/ ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM pR l✓ E w A y GA 2A 6E SCR LE i~y= t o ~yXz~ TA, K Toe 61 N.D 0SE S y stF,ti. F-1, = 8 9. ~~wE ~ ~FouSf 14 14 M 9s - a y1 " - - Nc.TE2 NOTE g.M S PIKE I ti Towe L FeLf - - - - ARE A 160,60 y7 _ INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK:Splka /N T60)EIZ'40LFm 04(WES7 407 41NE E/•=100,Od ALTERNATE BM: Top of tjoiS g; FdV,IDA-ioAu E 1 = 101, S = / 3 Z SEPTIC TANK PUMP CHAMBER / HOLDING-TANK INFORMATION Manufacturer: (A) I S E g Liquid Capacity: DOv , Setback from: Well 5 House / 41 Other IS To S~ leiwcr aF Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length y, Number of trenches Distance & Direction to nearest prop. line: ~/7 fn WwT DoT I;He Setback from: well: 9 z House '1-7 Other I /D fo F,4 ST LaT t; ,,e ELEVATIONS Building Sewer ST Inlet; -7• s ' ST outlet PC inlet - PC bottom Pump Off 'Td. 1.0 S 3 Header/Manifold 1 Z. b Z--- Bottom of system 3• sus Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: ra LICENSE NUMBER: INSPECTOR: 3/93:jt • Wisconsin Department of Industry, Labor`.and Human Relations PRIVATE SEWAGE SYSTEM CountyST. CROIX Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit 218996 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: BAER MILLER Hucl-gon CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: A9400385 TANK INFORMATION ELEVATION DATA 9 ~S TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 0,-e e,.' Benchmark Gam, Dosi n w ~ f /71, , Aeration Bldg. Sewer Hold St/~11 Inlet TANK SETBACK INFORMATION St/ Outlet fP,5/ S3~ Vent TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet Septic NA Dt Bottom Dosing A Headerfi9f9t. Aeration A Dist. Pipe o ding Bot. System PUMP/ SIPHON INFORMATION Final Grade ' 93, (,;7/ Manufacturer- Demand Model Number GPM TDH Lift I Fri n m TDH Ft Forcemain ength Dia. Dist. TO e SOIL ABSORPTION SYSTEM BED/TRENCH Width a Length No.Of Trenches PIT No. Of Pits Insi uid Depth DIMENSIONS DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEAC Manufacturer: SETBACK INFORMATION Type O il- L rl CHA I ::M:. e Num System: c(7 X* UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) / Hole Size x Hole Spaci ent To take Length Dia. Length 7 Dia. Spacing X SOIL COVER x Pressure Systems Only xx Mound Or At-Gra ystems Depth Over ,r Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed / enter 7- Bed /T dges Topsoil E] Yes I-] No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) )CATION : Hudson.14.2 9.19 , SW, NFL, 1, L barq~~, 031- revision required? ❑ Yes do ther side for additional information. 9 10 (R 05/91) Date Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code Co TY STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ t $ 8% X 11 inches in size. Check if revision to revious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - P PR ORMATION. PROPERTY OWNER ~i PROPERTY LOCATION % E S4ilni~//LL~C S(jY, E%4,S TZ9 ,N,R /F E(or PROPERTY OWNER'S MAILI RESS LOT # BLOCK # Z CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER v sot o 38' Z / 4A~ T/Z STS II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD ❑ State Owned ❑ VILLAGE UDSD L~ ❑ Public Dq 1 or 2 Fam. Dwelling-# of bedrooms 3 'PARCEL TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) r4 0 1 ❑ Apt/Condo C/ 7 20 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. ~ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ 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 REQUIRE'D/ (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 7 -7 Z-6) 0-7 Feet 9Z-,- 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 structed Septic Tank or Holding Tank /000 (~Ja i S a- r Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (N M MP/MPRSW No.: Business Phone Number: ova s T 2.o H BEAK 7"~ 1; 2.- zYT 3L33 1 0 -D46~i~ Plumber's Address (Street, City, State, Zip Code): 10 Nj *k- Z Z, o.- W e I.C A(MOffD , O IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Saitary P rmit Fee (Includes Groundwater ate Issued I ing Agent Signature (No Stamps) X Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: 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 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) ` << e-,, 7-e fiolY RoAO \ 225/. 71 A1,Ve7'/; LOT /iNLC _ _.~,._...,r. ~,.M.. :5E ,1 ' ~ t o 3 0 W I- o o` h ~zA n u - C WA I w w -,JZ az 4v .2 1 W 43 lu 0 fd (I--- W p 1{ J I j O v (-AI-A 6C \ 1 tl E VV /9 Y 14/ ~(s 0' Q ~ Hoc S E ~ + v w WF[C V ~ 9o wi ~ J w v g.M, SPIKE /)V Q PoWE2 polE { i d RITE/2 N,4 TF_ /{~i - - A2F- A" 13 f 3S Q +E- yon - - 04- ss' T 'TEr PED J V z5o zzy, 7G' 5o&74 ZoT //N'= I~- z < t N I ~ I I I I Z I I I -S I n m t I I j < I I I 1~ ~ j ~ z I I ~ I il~ ~ j I I ~ I I I r,.i I ~ rn I t I I I ~ t I I ~ ~ I I I Z CA rn rn w I - _O j ~ I I I TI'S r I r I I I I cu I I j I' 7~ ~ I i -v i I I e t,, -u U) O I z I t rn I y z I I I C~ C I I I I °w I -o t I ► ~ I m i I I I N W m I 0 _ I O Z ou I -o e I b i m I x o AY O 0 _ CO O - c0 Cn -90 0 O O x I i -nom m V z~ o m -o W z b _ -o m m O rn c m L ' n Z \ R k, J r R F Wisconsin 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 io 1X Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but ;PT 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 ER: PROPERTY LOCATION SA A ) LLC_X GOVT. LOT SW 1/4 N Lr- 1/4,S 14 T Z 9 N,R / E (or) W PBME TY OWNE • MAILING AD _IESS LOT # BLOCK # SUP. NAME OR CSM # ©U~ ek b CITY, TATE ZIP COD PHONE NUMBER ❑CITY ❑VILLAGE OWN NE RESiO D l~ t ~ ( ) ~l c.J Lei Scs~J LSA New Construction Use [Or Residential / Number of bedrooms [ ] Addition to existing building Replacement _ [ ] Public or commercial describe Code derived daily flow SO gpd Recommended design loading rate Q 7 bed, gpd/ft2 6 1_6 - trench, gpd/ft2 Absorption area required 645 bed, ft2 trench, ft2 Maximum design loading rate Q 7 bed, gpd/1126 •l~ trench, gpd/ft2 Recommended infiltration surface elevation(s) ~ti1 Pi44 3 4F 3 ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system CqgNVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING T NK U= Unsuitable fors stem EN S ❑ U S❑ U WS ❑ U rys ❑ U S❑ U ❑ S KU 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 Ground 9Z D-o /0yP, 4"/ 4 r Al 7 D ~~6 elev. `~f ft. Depth to limiting tactor > -1 7Z Remarks: Boring # Z:< < F>1 10-2-K /ayk 3/,z Q 5 I~ W p 7 OX 4i:............. is Jz 3'-i2_1 ism 5 O rn I 1-~ o.'7 o `6 14- Ground elev Depth to limiting factor > 01 0"s Remarks: CST Name: Please Print Phone: d1ZYc~y t4 hi d)J ~I O 8~ Address: . C)` 14, v l Signature: DateiD 7 2 4 CST Number: PROPERTY OWNER-->AY1 ru f-,P- SOIL DESCRIPTION REPORT Page I of PARCEL I.D: # Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Ou. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench y$ \.:i: is A oA t o y,Z 3 z 5 L s, .4 < /O Y~ 3 3 S L. rh e: r ~J D ~ i'►~ Ground o'yw- 3 S 010 r n-► LJ T Q 7 O elev. 11L,6ft- $3 &O oYk4 4 S a r M 0.? O`6 Depth to limiting fac ? g qr Remarks: Boring # 0-g j Y 3 Z S L, 5b m~~ 2 04 llb.,~- Ground gZ 22--A-5 1,09 4 3~ _ s © r rh w t- b:7 0 elev. S rt!,, ft. $3 Q r O Depth to limiting >tS Remarks: Boring # o-14 iby~ 3 Z - S c, M cr C w t 0.4 O 4-12 dY d S © r rh 1 Q .7 1Wi i Ground elev. %.29 ft. Depth to limiting factor > J6 -UPS Remarks: Boring # w Ground elev. ft. Depth to limiting factor I Remarks: SBD-8330(8.05/92) ;V 1 s P44C oFL.S~ 7 c ~ M O c C cr- 5tw ~ ~ a 1 Q 1 ~ 1 C 4 W a a1 q Q ~ a ~ ~'~of? f 4 17. Z Xy/-7 ~Cocr~ CO ~Zi~~► ' JR 7(~ a7 VS ub Q~` X54 FG 88 87 2- W 53 cl- 83 ~fy oo i _ m NN i ~ I 2 -a I Mi QqI a zG4 i 2.. 8s A~. \.9 I M ~ I Li.l I i O M n1 a' `y E- Z Z o m I 0 ~I I i~ 33 7~Y i , X 96 I; 1 99 ,37.76' 97 ~/A 18 l . oo' 98 ''~A C] t 100 " 101 N99- z4 -39E zzq, 3 I I I I I I ~11 101 1/ ° T P . STC 105 SEPTIC TANK MAINTENANCE AGREEMENT St.. Croix County rn . OWNER/BUY-ER /-_;cx_m S. MAILING ADDRESS ~~aC ?g,2 fl y p S O N W PROPERTY ADDRESS LA i5 A ICrO, (location of septic system) Please obtain from the Planning Dept. CITY/STATE can "`)'X_ PROPERTY LOCATION 5 LQ 1/4, NEE 1/4, Section VA T- '2- q N-R ~ 9 W TOWN OF XA j-&S ST. CROIX COUNTY, «'I SUBDIVISION Sl%j &t- L 7rA CT LOT NUMBER I CERTIFIED SURVEY MAP Al? , VOLUME ?20, PAGE 3$ S~LOT NUMBER lmoroper 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 ,,cars 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 Count), 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 fonn, 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 expiration date. SIGNED: DATE: l 4 ' 2 4_- q - - - St. Croix County Zoning Office Goveriuncnt Centel 1101 Carmichael I\'oad hiudson, AV'1 >4010 11/93 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 C ry s-k-ci \ O v. ~3 c~ec~ /fir/ 1011 4 L51r-, Location of property St,.s 1/4 '*(E 1/4, Section \4 T 2-9 N-R %9 W Township H~,, d r,►~ Mailing address rdX -u z~Z -lil- 5 9q" tt) = -7` G / Address of site e A6 Subdivision name 44 7tr/4e'T Lot no. Other homes on property? Yes-No Previous owner of property 4V& Rg_,a r- Total size of property e,, 04 C 4k) Total size of parcel A r . r LJ Date parcel was created /c) _ Z 3 _ 7 CJ Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house)? I Yes No Volume/ dD and Page Number as recorded witn 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. _57'Z_ -z -7 gam" , 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. SSig ature of Applicant Co-Applicant Date of Signature Date of Sianat-.iire . DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1982 522785 Vol Cr stal A Baer a/k/a Cr stal - Baer t f - - - - r I-Z ; ' OCT 2 5 1994 I' - - - - 10:00 and warrants to am-_E-.--_Mil.ler 10:00 A v RETURN TO the following described real estate in S_t...... Q Qr-odx county, State of Wisconsin: Tax Parcel No: A parcel of land located in part of the SW1/4 of the NE1/4 of Section 14, T29N, R19W, Town of Hudson, St. Croix County, Wisconsin, further described as follows: Commencing at the N1/4 corner of said Section 14; thence S0003613311E, along the west line of the NE1/4 of said section, 1311.11 feet to the point of beginning; thence continuing S00036'33"E, along said west line, 689.30 feet; thence N89024139"E, along the north line of a parcel recorded and described in Volume 835, page 47 at the St. Croix County Register of Deeds Office, 224.76 feet; thence N0003612411W, along the west line of a parcel recorded and described in Volume 609, page 264 at said office, 690.07 feet to the north line of the SW14 of the NEY4; thence S89012'52"W, along said north line, 224.79 feet to the point of beginning. 4SFr This 1S------Ot homestead property. MX(is not) Exception to warranties: Easements, restrictions and rights-of-way of record, if any. i -kb Dated this .2LA-------------- day of October----------- 19....94. ----(SEAL) - 'J6 a' (SEAL) * Crystal A. Baer,. a/k/a Crystal Bair (SEAL) ..----(SEAL) x AUTHENTICATION ACKNOWLEDGMENT Signatur (s) -~^~~5~ ~vY STATE OF WISCONSIN ~ ~ SS. ----------------------County. authenticated th' __.._day of____19~.__ Personally came before me this day of October------------------- 19.._.94 the above named Crystal A....Baer,_ ask/a Crystal T t_ IV/ 49. (,A~1~1 P Baer.. TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) to me known to be the person who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY .Kris_tina Ogland---------------------- Attorney at Law Notary Public -----------------------------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. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. FORM No. 2 - 1982 Milwaukee, Wisconsin p CA C ~ 0 d 0 o oz ~ s C F j Z G ~o O C~ 70 0 0 0 rJ I IE _ N