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HomeMy WebLinkAbout020-1220-70-000 sti STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS .t k SUBDIVISION / CSM# LOT # ..A G SECTION/ 7 T Zf N-R ~o W, Town of ST. CROIX COUNTY, WISCONSIN ,vie PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM F/e'0'/ r Ze7 f~;A- t sr~ l~ • /o rr r e ,0 ?YX3° r 57 Ltr t 7 J - -f„ , r gee t'09 / 07 S~^ INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. i r BENCHMARK. ALTERNATE BM: SEPTIC TANK,/ PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: C% ie ~S Liquid Capacity: / ACC Setback from: Well ;;,,!;e House ~2 Other Pump: Manufacturer Model# Size r--- Float seperation Gallons/cycle: Alarm Location - SOIL ABSORPTION SYSTEM Width: Length 3v Number of trenches Distance & Direction to nearest prop. line: ,0 ,~r,4 Setback from: well: > 5-0 House 2> Other ELEVATIONS Building Sewer / ST Inlet. QT. 7 ST outlet 954. PC inlet PC bottom Pump Off Header/Manifolds •b'Z Bottom of system'., Existing Grade ® Final grade 1001-0 DATE OF INSTALLATION: ~p PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page _ of Labor aad Human Relations Divisian of Safety & Buildings in accord with ILHR 83.05, 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 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 PROPER OW ER: PROPERTY LOCATION S . GOVT. LOT S-4 1/4 1/4,S~ T '2 N,R,7 E (orNo PROPERTY OWNER':S MAIL NG DDRESS LOT # BLOCK # S D. NAME OR CSM # 1-2 A/ rf / ~ S ya CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE Q]fOWN NEAREST ROAD New Construction Use [ /J Residential / Number of bedrooms 3 [ ] Addition to existing building Replacement [ ] Public or commercial describe Code derived daily flow !YfO gpd Recommended design loading rate ed, gpd/ft2 trench, gpd/ft2 Absorption area required Z-)-o bed, ft2 s7d r trench, ft2 Maximum design loading rate __,_Zbed, gpd/ft2 _p trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE E GRADE SYSTEM IN FILL HOLDING TANK U=Unsuitable fors stem ❑S ❑U ❑S ❑U ❑S ❑U ❑S ❑U ❑S ❑U ❑S ❑U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tre & Ground z elev. , /o/Oft. 2 -3 5- Depth to , limiting factor J 3s - 3 a s . Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: CST Name:-Please Print Phone: -7 All Address: c~~~ Liu"rte & : tZ C ~~J u Signature: Date: CST Number: o iY 3~ PROPERTY OWNER SOIL DESCRIPTION REPORT Page of PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench k ?vv v......... Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # LMA Ground elev. ft. Depth to limiting factor Remarks: Boring # :v:.4 Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) Wiscorrsintepartmentof Industry, PRIVATE SEWAGE SYSTEM County: - aafetya and Human Relations INSPECTION REPORT ST. CROIX Safety and Division Sanitary Permit No.: GENERAL INFORMATION (ATTACH TO PERMIT) Pelt 1fWer6,RUCTION ❑ City ❑ Village 9 Town of: State Plan o.: Hudsqc)n CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 5 Benchmark Dosing / 3, 0/ / 103, ~,3 . Aeration Bldg. Sewer 1 'w Holding - St/A Inlet 5p 7 7 TANK SETBACK INFORMATION St/ Outlet g,(o~' SSA TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake ~ NA Dt Bottom Septic 35C g Dosing NA Headers 7 ~'3 9 s Aeration N Dist. Pipe Hol.di Bot. System' re~/~, ~/dam 10 PUMP / SIREM INFORMATION Final Grade Manufac u Demand d , Model Number PM TDH Lift Syste mead TDH Ft Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length33 r No. Of Trenches P No. Of Pits Inside Dia. Liquid Depth DIMENSIONS o2 DIMEN I SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACH a acturer: SETBACK CI INFORMATION Type O r/- Z R Moe Number: System: fSC a25 OR UNIT DISTRIBUTION SYSTEM Header Distribution Pipe(s), x Hole Size x e Spacing Vent To Air+otake Length ZE Dia- T Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Gr a System Depth Over 't Depth Over V xx Depth Of xx Seeded/ Sodded xx Mulched Bed / h Center (D Bed/ Tcgmh Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson.17.29.20W, SY NE, Lot 120, Je sen Lane East 94, 4- , Q 'r"t Plan revision required? ❑ Yes 9_N_0 Use other side for additional information. Ile Q ja~-- SBD-6710 (R 05/91) Date Inspector's Signatur Cert. No. ADDITIONAL COMMENTS AND SKETCH ' SANITARY PERMIT NUMBER: I I II SANITARY PERMIT APPLICATION =i.riR co In accord with ILHR 83.05, Wis. Adm. Code FC3 ITA ER M-Attach complete plans (to the county copy only) for the system, on paper not less than 5 8% x 11 inches in size. t revision1to pralo application -See reverse side for instructions for completing this application. S TE PLAN I.D: NUM 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OW ER PROPERTY LOCATION S S / T ,N,R ale E(o PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # 1-20 1 CITY, STATE ZIP CODE PHONE NUMBER SUBD SIO NAME OR CSM NUMBER / 3'S l I R r C IL TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned VILLAGE : r- I OF: Z~iz AX NUMBERO , ❑ Public 1 or 2 Fam. Dwelling of bedrooms 3 PAR ELT Ill. BUILDING USE: (If building type is public, check all that apply) 020- 2-Z e9- O 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 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1.0 New 2. ❑ Replacement 3. ❑ Replacement of 4.0 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 Q 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 140 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) 9 ELEVATION `ISO d 6 ~ I D 9~%# Feet /oo.S~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 Holdin Tank 4 a'fa F-1 [:1 11 i [I Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. P er's Name (Print): Plumber's Signature: (No Stamps) ARIMPRSW No.: Business Phone Number: lu: 12 Ala 7 .7.4 C/ MiGmber's Address (Street, City, State, Zip de): r -2 IX. COUNTYIDEPARTMENT USE ONLY I -A ❑ Disapproved Sanita Permit Fee (includes Groundwater a e Issued I suing Agent Signature ( o Sumps) Approved ❑ Owner Given Initial 7/ j\ Surcharge Fee) Adverse Determination (J ///A 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. 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) X~ X ~2 X X- 1! ~l N ~1 3 X fllT n 1c s0~ w~/(1 -7 re' S•T- iii /Hiri~'ye.wk jtrdac,~J ffCmar~ DAME FOOMY PLUMBINtk d Pork Testa & Plumber Road RO Phone VMMI SNG 3 , i 1 k~1 I n LJ, ~ 1 C p I mm --1, a I~ .f `.t ~ ~ ~ A ~ w7~ r _ o+Zc a~' C I~ r IIS N I ~I I I ~ b I~ I WiscorMh Department of Industry, SOIL AND SITE EVALUATION REPORT Page __L_ of Laboi; and Human Relations Divisidn of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must include, but PARCEL I.D. # not limited to vertical and horizontal reference point (BM), direction and /o of slope, scale or dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROP TY 0 NER: PROPERTY LOCATION G GOVT. LOT SSG 1/4 1/4,S 7 T Z ,N,R2~ E (ot9V PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SU . NAME OR CSM # CITY, TATE ZIP CODE PHONE NUMBER JZCITY ILLAGE OWN NEAREST ROAD /ti w / ( - L C ax ~2re New Construction Use [,A Residential / Number of bedrooms [ ]Addition to existing building [ ] Replacement [ ] Public or commercial describe Code derived daily flow ~/SU gpd Recommended design loading rate 7 bed, gpd/ft2 . 9 trench, gpd/ft2 Absorption area required 7,2o bed, ft2 513" trench, ft2 Maximum design loading rate _,_7 bed, gpd/ft2. k trench, gpd/ft2 Recommended infiltration surface elevation(s) 7S. 9 ' ft (as referred to site plan benchmark) Additional design / site considerations 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 D S El U E] S m U [ZS ❑ U ❑ S T1J U ❑ S U ❑ S [7J U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. rBe Trench Z ~ -3 r ?C_ 341C Ay w v . 3 Ground -3 A111 5, dAf f elev. /k/. 3 ft. y 41 r ~S IN Depth to r ( /oy o s o f k+ limiting factor Remarks: Goy w 30 ~O /-Y Ite c/c, Boring # 2 A$4 5-164 A% 3 Ground elev. r /90•D ft. Depth to 3 L7-F7 3 s - 7 limiting factor Remarks: CST Name:-Plea se Print v t~ Phone: _ 3656 Address: ~j Yo 1 c~ .L 33 a Signature: te: CST Number: r PROPERTYOWNER ~~~~(Z_zrS SOIL DESCRIPTION REPORT Page-mot PARCEL I.D. # ,r Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourxiary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trends hr 3 r' 2 <.< Ground 2- V/91 c • 4Z ~r w ! t . 2 elev. 100.0 'ft. Depth to 3 - ?S- 1 S m f / - p limiting factor Remarks: Boring # 31 4-11 Ipp e- S Ground 2. A- s K f Y ~ , .L . elev. Depth to 3 _ S w► - y 1.7 limiting factor Remarks: Boring # :.t 4v Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) r i /20 X X x"#.3 x X ~ IN x 390 Too x k * 1/ fc~c ~ a c rp / ~ d = /~Mr / tt~wwfi /yfP J~u~/ All~r..r+r /p0 0 i e%= 9s.9 DAVE FOOMY PLUMBING Licensed Perk Tester & PkmWr F N32 HeiRs►td ROBE~~M~SCN 34023 Phone 749- ^ ' e- ~f y S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 0't- ADDRESS 7-rq FIRE NUMBER CITY/STATE 4114,14" ZIPy b PROPERTY LOCATION:-h-61/4,161/4, SECTION, T-..24N-RJ2_W TOWN OF 14-411- St. Croix County, SUBDIVISION 62A-A ~ - LOT NUMBER Z fJ Improper use and maintenance of your septic system could VV 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 a 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. Croi Co. Z ni officer within 30 days of the three year expiration ate. r ~ SIGNED: i DATE : - ' 9 St. Croix co. Zoning Office, 911 4th St. 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), thenta 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 W a~ Location of, property f~1/4 &,a- 1/4, Section T N-RZo Township Mailing address Address of site Ito Subdivision name Lot no. I Z y other homes on property? yes No Previous owner of property L!tL& Total size of parcel Z ZS Date parcel-was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes V 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 & 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. I 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 County Register of deeds as Document No. Signa r of applicant Co-applicant Date of Signature Date of Signature r GWIN & WERTHEIMER, S.C. HUdH H• aWIN The Gwin Building 715.3W9510 1Nr MR WERTHEIMER 430 SECOND STREET FAX: 7163884458 "LM F. AYWN P.O. BOX 108 OR cotodk HUDSON, WISCONSIN 54018 May 6, 1994 Mr. Virgil Fedorinko HAND DELIVERED Delta Construction Co. 206 Second St. Hudson, WI 54016 Re: Lots 115 and 129, Parkview Estates Fifth Addition Dear Virgil: As you are aware, I represent Darrel and Beverly Wert, owners of the above entitled lots. Pursuant to the terms of a Vacant Land Offer to Purchase dated March 30, 1994 for the above mentioned lots and other lots, I have been authorized by my clients to convey the following agreement. The Werts hereby consent and give you permission to build homes on Lots 115 and 129 even though title has not yet changed from their name. By copy of this letter to Tom Nelson, St. Croix County Zoning Administrator, I am informing him of this agreement, the terms of which were discussed with him last week. It is my understanding that based on the strength of this letter of permission by the Werts, Mr. Nelson will allow you to pull septic permits on both of those lots and to proceed with building of homes thereon. Title to the property will be transferred from the Werts to either you or your company or the eventual buyers at the final closing on the property. I have assumed the responsibility of notifying Mr. Nelson of the names and particulars of the eventual buyers so that the information can be put on the septic permits and they can be correctly filed under the names of the eventual owners of the property. You have my permission, subject to the approval of your attorney, Barry Lundeen, to contact me directly to request any additional documentation or information you may need. If you have any questions, please contact me or Barry Lundeen. Very truly yours, GWIN & ER EI R, S.C. Hugh Gwin HHG/en cc: Darrel and Beverly Wert Tom Nelson, Zoning Administrator Attorney Barry Lundeen Jim Henry, Edina Realty GWZN & WERTHEIMER, S.C. HUGH H. am The Gwin Building ftft" A. WElITHEIMER 430 SECOND MEET FAX x: 71115 4~.0444M M11C3H. ANIIN P.O. BOX 100 OP MUN K HUDSON, WISCONSIN 54010 May 10, 1994 Mr. Virgil Fedorinko HAND DELIVERED Delta Construction Co. 206 Second St. Hudson, WI 54016 Re! Lots 120 and 125, Parkview Estates Fifth Addition bear Virgil: I previously had written you a letter on May 6, 1994 Indicating that the Werts were giving you permission to build on lots 115 and 129. It appears that I had the wrong lot numbers in that letter. The lot numbers that you want to build on, I have been informed, are lots 120 and 125. Accordingly, I am amending the lots listed in my letter of May 6, 1994 to read lots 120 and 125. 1 am copying all of the same parties on this letter to whom 1 had previously sent copies of the previous letter. If any of the people receiving this have any questions, please contact me. Very truly yours, GWIN & ER HEI R S.C. i HHG/en Hug YHGn cct Darrel and Beverly Wert Tom Nelson, Zoning Administrator Attorney Barry Lundeen Jim Henry, Edina Realty ST. CROIX COUNTY WISCONSIN - ZONING OFFICE p Y g q q q r n• .~.,,b ST. CROIX COUNTY GOVERNMENT CENTER rF.. , 1101 Carmichael Road Hudson, WI 54016-7710 " (715) 386-4680 October 17, 1994 Delta Construction 206 Second Street Hudson, Wisconsin 54016 ATTN: Virgil Fedorenko RE: Septic Inspection for Delta Construction Lot 120, Park View Estates, Town of Hudson Dear Mr. Fedorenko: An inspection of the septic system for Delta Construction, Lot 120, Park View Estates, was conducted on October 12, 1994. This property is located in the SE, of the NE, of Section 17, T29N-R20W, Town of Hudson, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a three (3) bedroom home. If you have any questions with regard to the ove, please do not hesitate in contacting our office. incerely, mes K. Thompson Assistant Zoning Administrator St. Croix County, Wisconsin mz D'-") [Ply WisconsintSepartmentofIndustry, PRIVATE SEWAGE SYSTEM County: La%c:~and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Permit HTA rCName:'RUCTION El City El village [ Town of: state Plan o.: DEL I Hudson- CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS H FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/Ht Ou t Vent TANK TO P/ L WELL BLDG. AirIto ntake ROAD Dt Inl Septic NA D ottom Dosing NA eader / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer 4emand Model Number GPM TDH Lift Lriction System TDH Ft Forcemai n Length Dia. HH It. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Lengt No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION TypeO Model Number: System: OR UNIT DISTRIBUTION SYSTE Header/Manifold stribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson.17.29.20W, SE, NE, Lot 120, Jensen Lane East Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No SANITARY PERMIT APPLICATION v'■■-~■~■ In accord with ILHR 83.05, Wis. Adm. Code cL.:U .TY ci~~ STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than a O 2- 8'fz 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. PROP TY NER PROPERTY LOCATION '/a, S l T.Z , N, R 2a E (of ~O PROPERTY OWNER'S DAAILING ADDRE LOT # ZD BLOCK # "2,94 1Z Iy.IC CITY, STATE ZIP CODE PHONE NUMBER SU DIVISION NAME ORrSNFhft "BER 00, 7yv_ LVLA CITY (REST ROAD Irl II. TYPE OF BUILDING: (Check one) ILLAGE : f ❑ State Owned 2 V ~QWN OF: ❑ Public 1Z 1 or 2 Fam. Dwelling-# of bedrooms-3 AR EL TAX NUMBS (S) III. BUILDING USE: (If building type is public, check all that apply) O 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 120 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. 0 New 2. ❑ Replacement 3. ❑ Replacement of 4.0 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 0 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 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION /,f0 3 3 , i rFeet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank J Lift Pump Tank/Si l Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage stem shown on the attached plans. PI ber's Name (Print): Plumber's Signature: (No S% y14PFM7 PRSW No.. Business Phone Number: c 36 ~ Cuis Address (Street, Ci fate, Zi ode): ~3ci r u 3 IX. COUNTY/D A TMENT USE O LY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Agent Si s) „ V;" S Approved ❑ Owner Given initial urcharge Fee) ~~FfL fX,/1 G Adverse Determination M U✓ 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 z . 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 alicensed 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. tTo 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 ar11:5 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 uaed for monitoring groundwater, ground- water contamination investigations and establishment of standards: SBD-6398 (R.11188) r~N Lit \ _ a DAVE FOGWY PLUMB" y~ ' Lftnsed Perk 'fester 6 Plumber i ` #3233 OM ROBE W1 54023 ~a" X~ y3" ~y f`J ~y > lo/ --.C / ys !.7Z izv X 2I ~ X 37 " -X I I 3° s« /~Se • as /oJ'e ~~ia~r~~/~ "'"'S'ri ~ /o/.yd ~ afsu~e ~ooo 'I X ~T CO!'Nt/rS 'l- i I NSP #S6o2 u DAVE FOOFATY PLUMBIris. UCOM i FWk Te mbar ROSENTS,"W S MIN4023 Phone 749.3656 ~a N y~o, /t'CT" ~ " t 1 o r Sc~~r /V Q~ - c1r a 7 o r GS~~ S . % . r /off ~ #j 1a /fly ~riri ~1+~* 1'.r~ ~a c ~s ° Sri ° f I i Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page-of 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 8 1/2 x 11 inches in size. Plan must include, but 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 OWNER: PROPERTY LOCATION GOVT. LOT _5 F 1/4 NE 1/4,S f 7 T 9 AR ~O E (o~ PROPERTY OWNER':S MALI G ADDRESS LOT # BLOCK # BD. NAME OR CSM # /o?O 4r'' Uvu/ i74 0_ CI SATE ZIP CODE PHONE NUMBER [CITY []VILLAGE []TOWN NEAREST ROA New Construction Use [ ] Residential / Number of bedrooms 3 [ ] Addition to existing building Replacement [ ] Public or commercial describe Code derived daily flow ysz) gpd Recommended design loading rate ,Z bed, gpd/ft2 , Y trench, gpd/ft2 Absorption area required 7.zo bed, ft2 rjs trench, ft2 Maximum design loading rate ___7 bed, gpd/ft2 , 8 trench, gpd/ft2 Recommended infiltration surface elevation(s) 9s, ft (as referred to site plan benchmark) Additional design / site considerations 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 ®S ❑U ❑S ®U ❑S ®U ❑S ®U ❑S ®U ❑S ®U 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 4.44 7Vf Ground elev. eft. z -35 7 S S~~ .2 m 4)e ytl ✓ r s Vf . ~l •S Depth to limiting factor 3- ~G s 3 S p a2~t Remarks: Boring # Z 33 O 9 J SG rr 56 k /h v -~r s l V Ground elev. S2 ft. Depth to 3 3-56 ~.S ` S e M l s - . P limiting factor /V of ;7 Remarks: CST Name:-Please Print Phone: ° s 'e r f- 3GS/O Address: •3a /7©~r S' 013 Signature: Date: CST Number: vt 9~ 3 -z 3 3 74, PROPERTY OWNER SOIL DESCRIPTION REPORT Page of PARCELI.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench •x.••.•.4'•'...v.4 / p -/6 cS 6/k, Cdr c S V-; Ground /o 3,)3 c 1 s6K v ~r 3 ) v s- elev. 11 ft - 3 3~ S9 s r r~ i S Depth to f5 d S s / ,P limiting factor Remarks: Boring # E•`• l o-17 0 Ground elev. 2- o 3 3 / nr a6k /PE- ft. rH v~r S a , 5~ Depth to limiting 3 y_9 5 S rrr _ - factor Remarks: Boring # : s -/y 2 SIX Ground elev.-37 y 5 s no ( c s 11V-22- ft. 17 F Depth to SZ S D S k~ l - ,8 limiting i_~~ 0 6 S d ty, .d factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) . • t DAVE FOGERTY PLLgM G Licensed Perk Tester & Plumber #3233 #3289 Fogerty Heights Road ROBERTS, WISCONSIN 54023 Phone 749-3656 AND V Trey.