HomeMy WebLinkAbout020-1159-67-000
19
STC - 104
AS BUILT SANITARY SYSTEM REPORT 'w
`tea
OWNER v to ~i 4 \1,
ADDRESS NUd IINt ~n t
SUBDIVISION / CSM# LOT
SECTION ~G TAN-)q
Town of ~RV4U 0tJ
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
3 & VR VwV)
fi~4r~
y`. i3' 14'
O
sep IC a
D s~, s c~
yy, 3!'
V
e
I ~,,b b Bep
N
T
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form-
Provide 2 dimensions to center of septic tank manhole cover.
I
BENCHMARK: 'lop A F AC) At Uqc I~O-~C uz 160,0
ALTERNATE BM:
PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: W~ 2 s Liquid Capacity: 1000
~
•
Setback from: WellOVR(Z 75'House 13 Other 14
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: D Length Number of *',-...SAN
Il NQs
Distance & Direction to nearest prop, line: yap
S`
Setback from: well • 0V@K House Other
`I~i' {~'y~`bl~ 11•V~I 1 U`► ELEVATIONS Co~eR (l~.loo~
Building Sewer ST Inlet. 10, .35 ST outlet 08, ! y
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system 98-03 K" '15t s0o~
Existing Grade NO-?j Final grade DU•
DATE OF INSTALLATION:
PLUMBER ON JOB: f ~ )tjfo
LICENSE NUMBER: 7 by
INSPECTOR:
3/93:jt
Wisconsift pepartmentof Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION
Permit Holder's Name: City ❑ Village Town of: State Plan o.:
TREPTOW, THEODORE H & JOSEPHI E
CST BM Elev-: Insp- BM Elev.: BM Description: / Parcel Tax o.
/ /D~• 3L ~~c QS (~z. flirt A9400284
TANK INFORMATION ELEVATION DATA 17-113 9
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark 2 Qdv~
Dosin 22,4L1 o2, G
Aeration - Bldg. Sewer- 0 -e.C~
Hol ' St/ Winlet y' oS,aG
TANK SETBACK INFORMATION St/FO Outlet Zoe 6,9'4ps
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic ~5-6 >Z NA Dt Bottom '
i
Dosing NA HeaderfPa:-- ~3 9~ SS
O/
Aeration Dist. Pipe 17S-
17, 96,01
Holding Bot. System y'SL ~o
PUMP/ SIPHON INFORMATION Final Grade
Manu r Dem d CP C? oc SZ 07,
Model Number GPM
I Loss_ Friction TgH Fi
TDH Lift
For ain Length Did. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length / No. Of Trenches PIT No. Of Pits Inside Dia. Li uid Depth
DIMENSIONS /c;2 d DIMEN
r~ .
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEAC Manufacture
SETBACK CH ER
INFORMATION Type O 4z4-' /f Model Number:
System: S~ °Y ~Shc' UNIT
DISTRIBUTION SYSTEM
Header/manifold rr Distribution Pipe(s) x Hole Spacing Vent To Air Intake
Length Dia. Length $7 Dia. ~f Spacing CO
~
SOIL COVER x Pressure Systems Only xx Mound Or At- a Systems On
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Iched
Bed /J;re1tch Center Bed / Treacia•Edges 1 J Topso ❑ Yes ❑ No ❑ Yes -134
COMMENTS: (Include code discrepancies, persons present, etc.) * A Y-
LOCATION: HUDSON 16.29.19.910,SE,NE,LOT 19, MINNIE ROAD
C,4 sziw e-,(
~yz`se"' ~
Plan revision require . ❑ Yes B-19o-0 q
Use other side for additional information. /
SBD-6710 (R 05/91) Date Inspector's Signatur Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY,_~, C K~
STATE SAN TTY~PE~F ~ #
-Attach complete plans (to the county copy only) for the system, on paper riot less than GG~1
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
:Tgo 091 .5 '/",s 1 T-~J,N,R J I)- E(or W
PROI %OWNER'S MAILING A DRE Q LOT # BLOCK #A
ZIP99DE PHO BER SUBDIVISION NA OR CSM NUMBER
I t~"
CITY, STATE
11. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ,
❑ State Owned O
ED TOWN VILLAGE : uD ON I)C)
❑ Public N1 or 2 Fam. Dwelling--# of bedrooms ARCELT X NUMBER(S)
111. 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
30 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. Flew 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 6 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.) (Gal da /sq. ft.) (Min./inch) _ ELEV TION
. S Feet O Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION I New istin Gallons Tanks Manufacturer's Name oncre a structed Con- Steel glass Plastic App
Tanks Tanks
Septic Tank or Holdin Tank _ Jut)() Q F1 1 7 F1
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: (No Sta s) MP/MPR W No.: Business Phone Number:
M eQ U 7/5 386 -~aa v
Plumber's Address (Streeti CityJS late, Zip Code a
U b M' Fhb 6 ~UD! aN G-
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanjtary Permit Fee (includes Surcharge Fee) Groundwater ate Issue Issuing Ag m Si I a)
~
Approved El Owner Given initial f) 7/ /
Adverse Determination Cs'
X. CONDI IONS APPROVAL/REASONS FOR DISAPPROV L:
ZIV
SBD-6398(8.08/93) DISTRIBUTION: Original to County, One Copy To: Safety 8 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 & Bui►dings'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.
11. 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 arid/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.
Vill. 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)
0 S S
A 1-11)
67 P L OT
R' 'E 1\
P '
M f 1 n ~1 ~E
NAME -
4 -w I C E N 5!
i LO C A
Qar~ ~e c. 6 opt € L' 16 0, 0 _
13@or oor"1
Soil QdK1N~ S ~a~
-g k,- te-jh
5R I:>
° ~~r~~~~ ~I,pN lao ~fi • ~ ~ Dd
/ A
Lot SQ'J" -oy
A1tec"I'le Q
3
'ro ~Np u~x w~ bi A AND
y
IJgw c~ Mkf.
`rot 04 T'AD
BoX
FRESH A'!1: It1Ltl:i AND ODSE0krlON PI.pE
CROSS SECTION _
Approved Vent Cap
Minimum 12" Above I ]d~
A" Cast Iron
Above Pipe Vend Pipe
he"-
To Final Gradr
Marsh I* Or Synthetic Covcri.ng_
Min. 2" Aygrcg';tl
Over Pipe I N
- Tee I
Dis lribu tio~ } _........_•I
Pipe
I\ggre9ate to rerf.orated Pipe l,eIow
_-CoUp).ing '.'er.minatinq T
Rc~ I)e~icath Pipe ` nottom. of System.
191~~ N
d of
ay# 40P.1
1 f
fYLocal Affairs b Development
Nas _ ON - •
Gv S 90 54 O
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.
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SovlNERLY
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"2p0.0+a
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. 0 4 29o ACRES
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~ 2,011 ACRES
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D T Y, OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
MNDUS DUSTRY DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 53969
HUMAN RELATIONS , 707
(H63.090) & Chapter 145.045)
LOCATION: SECTION. (o UT0VWVNS1H IP/M44?dtCTPAM4TY: LOT NO.: BLIK : SU DIVISION NA E:
fAi
4/y C
COUNTY: OWNER'S/BUYER'S NAME: IVIAI ADDRESS:
USE DAT S OBSERVATIONS MADE
NO.BEDRMS.: ICOMMERCIAFtESCRIPTION: IPROFIL DESCRIPTIONS: 'PERCOLATION TESTS:
QResidence ENNew ❑ Replace
RATING: S= Site suitable for system U= Site unsuitable for system
ONVENTIONAL MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTE (optional)
LIN S ❑U: S ❑U S ❑U ❑ S U ❑ S Zul
If Percolation Tests are NOT require DESIGN RATE) I If any portion of the tested area is in the /
under s.H63.09(5)(b), indicate: r Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS - 7
P.-rd Ar
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH T ICKN SS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTHtM. ELEVATION OBSERVED EST. HIGHEST- TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B-
B-3 -
- > - / l
B- Sz)as
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTE
NUMBER i;vGH-ES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PER PER INCH
-3
P- , 3
P--
P-
TF7
P
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are th hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at al borings and the direction and percent
of land slope.
SYSTEM ELEVATION
I
E 3
A I
I tttt3
~I
-10
y ~JT'c'i 4
ti -w
{ E
.
I ; I I , I , I I
,
a
o'
,
,
I ,
v~1 ,NI J
I.
I, the undersigned,4-rereby"certify that the soil tests reported on this form were made me in accord with the procedures and methods specified in the hii consin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. \
NAME (print)i TESTS WERE COMPLETED ON:
n
ADORE CERTIFICATI UMBER: PHONE NUMBER (optional):
CST IG ATU
DISTRIBUTION: Original and one copy to Local Authority, Prope"y Ownar and Soil Tester.
DILHn-SBD-6395 W. 32/82) - OVE
1
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 5395
To be a complete and accurate soil test, your report must include:
1. Complete Irgal description;
2. - use secti(-n must clearly indicate why this is a residence or commercial project;
1 IN"'JM ~~r of bedrooms or use planned;
4. a new . ment system;
5. -itplete the r:g boxes. A SUITABL- OR A MOLDING TANK ONLY IF ALL
OTHER SYSTEM XSED ON SOIL _ IONS;
6. SASE use the . 'abi here for writing profi' descriptions and comp "r.: the plot plan;
7. .'E A LEG IE' iy locating your test ations. Drawing ' is preferred. A
sheep
yo, r ~I alevation referen{ _ re clearly shop I e permanent;
d. 6 iate as o dates, names address food plain st exernp-
10 ;cti lot, sIace N.A. ~ the apl,,upriate (pox;
11, a; ' Dtrn ice Wt rtific n nut i' ,
12= M; e I( thle copi and di '_L SOIL TESTS SE FILED WITH THE
Lt WTHORITY V'VITHl`J E TION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Textures a, 31s
BR Eck
cob C 1011) Ss -
.fit C ( I e r 3'si !
s H
rrtr.ei s
I .
~i -
Cry
°
R
Of
- cx;
VI,. -
TIC' gym;
t
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
I
OWNER/BUYER Doke- P. ~ jo S E P l4 (A1 e ~ . T ke- f to V✓'
MAILING ADDRESS ~j cQ (Q rI (t /U /1 / R t),
PROPERTY ADDRESS dl~ Rf)
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE 1-W [).S(OAf to Vv 1 15TO 169
PROPERTY LOCATION S LV71/4, 1/4, Section 10 , TX g N-R_W
TOWN OF 14 L2 1) -9n A ST. CROIX COUNTY, WI
SUBDIVISION NO O (~Tk L ( All r LOT NUMBER
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 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 expiration date.
SIGNED: 6Y
DATE: 19 ej ~j 'a ~Z_
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
i
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- R-f0p0fL? R. ' J-Q5ErR(N A, T7~EP7^QV
Location of propertyS L,-~1/4 A) ,e!~ 1/4, Section , T_.EZIN-RP? W
Township U d-)Q AJ
Mailing address 15-(p (p ( W A I E
Address of site ~(Q(o Al j Al N 19 U
Subdivision name AA ppLL") kT l T" k ( ~j Lot no.
Other homes on property? yes ✓ No
Previous owner of property o QA)R L D Of- L6R / ,e`J
Total size of parcel aQn
Date parcel was created .~n L \ Are all corners and lot lines identifiable? ✓ Yes No
Is this property being developed for (spec house)? Yes ✓No
volume 7Q yand Page Number 1.3 ' 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 & 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 * (our) knowledge that 4e (we) kn (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. c and that (we) presently
own the proposed site for the sewage disposal system or ~e (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 County Register of deeds as Document
No -41fg~
Signature of applic Co appl cant
gate of Signatu Date of~gnature
TNIS STAGE RESERYEO 11011 RECORDING DATA
DOCUMENT NO. WAITmAiVY DEED
' STATE BAR OF WISCONSIN FORM 2 -19921
REGISTERS OFFICE
a9►' 7il9i% `134 ST. CROIX CO., WIS.
-
Recd. fCr R-cc--.l this. 20
Donald Stephens and Lori Stephens, husband and dray of Mw A.D. 19U
IM.
wife as survivors..1p property, of 11 ;.35 A.
.
• I t rnnnell -biovol
conveys and warrants to TheOdOre•- A-.- TreptOW_ _and ..,Ivaephi.ne_.A>---.Trep.tow.,..-hus.t aAd --and--wife as DepVutJCylJd
maxi a:~._prOPe-rty="---W?~th--rights--of surviy~rsh..
II RETURN TO
the following described real estate in ...S.t~..Cr012C ................."---County,
State of Wisconsin:
Tax Parcel No:
Lots Nineteen (19) and Twenty (20) of Northline Station II in the Town I~
of Hudson.
(I
I
I
111 11
1i ~I
This is--riot---------- homestead property.
I ~
I` (is) (is not)
I! Exception to warranties:
I~
Ma
ii 18th . , 1s_8..
.
Dated this day of _ y . . - -
(SEAL) . u' . . (SEAL)
.Donald"- ori_ Stephens-------------------
Ste "hens."
------.(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
STATE OF WISCONSIN
Signature (s)
ss.
St. Croix County.
- -
18th
authenticated this day of 19------ Personally came before me this - _ day of
May , 19-.87_. the above named
Donald.-Stephens._.and__ Lori"- Stephens
-
TITLE: MEMBER STATE BAR OF WISCONSIN
("no t. "
authorized by § 7130.06, is. StatsJ to me known to be the persons. wli4 exe` ited the
foregoi g instrument and ackn w edge* Lh,4.sanj~, ~
THIS INSTRUMENT WAS DRAFTED BY -
Reiastra, Van Dyk & Needham, S. C.
r _
. Attorneys " at Law TanL. Glaser 2
~ av}~.
Wisconsin 54017-0127 St Croix a
chmond Notary Public . 0 19
9
~ieW Rl - r
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, s te„ p atf 6.11.'
not necessary.) date- 3-3-1-91-----------_, J
aNamm of persona si;ninB in any capacity should be typed or printed below their siBnsb.~n's.
- - STATE BAR OF WISCONSIN Stock No. 13W2
ttGltid~r~~~pm,Y TT FORM No. 2- 1982