HomeMy WebLinkAbout020-1052-90-100
S TC - 10 4
AS BUILT SANITARY SYSTEM REPOR r( ~
1 3
OWNER Hudson Con
g. of Jehovah's Witnesses, c d? toward;.lli
ADDRESS 696 McCutcheon Rd. OO`41`
;
6, ~
Hudson, Wi 54016
SUBDIVISION / CSMI LOT 6 & 7
SECTION- 2n T 29 N-R 19 W, Town of Hudson
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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Provide setback and elevation information on reverse of this form.
Provide 2'dimensions to center of septic tank manhole cover.
13ENC11MARK• Survey Stake S.E. Corner of Lot
ALTERNATE DM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Henry Huffcutt Liquid Capacity: 1400 Gal.
Setback from: Well 2•House Other
Pump: Manufacturer NA Model# NA Size NA
Float seperation NA Gallons/cycle: NA
Alarm Location NA
:SOIL ABSORPTION SYSTEM
Width: 5 ft. Length 75 ft. Number of trenches 2
Distance & Direction to nearest prop. line: 5 ft.
Setback from: well:7 2_tnouse_ Other
• ELEVATIONS
To P -Building Sewer 98.3 ST Inlet. 89.3 ST outlet 98.1
. PC inlet NA PC bottom NA Pump Off NA
Header/Manifold NA Bottom of system 97.2
Existing Grade 101.0 Final grade 101.0
DATE OF INSTALLATION: 6/9/94
PLUMBER ON JOB: Albert H. Krueger
LICENSE NUMBER: MP0004398
INSPECTOR: Mary
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Laboran~d Human Relations INSPECTION REPORT ST. CROIX
Safety and Build.Igs Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 218857
Pe bq6fl[ s ftd . JEHOVAH'S WITNES Lcity ❑ Village ER Town of: State Plan ID No.:
Hudson
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
U 160, L O & A9400141
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet g8,
TANK TO P/ L WELL BLDG. Airl to ntake ROAD Dt Inlet
Air l
Septic 251 . NA Dt Bottom
~,lo~ 4fs~is
Dosing NA Header/ Man.
7 Y 98, 6
Aeration NA Dist. Pipe
~.sa 9-7, y~
Holding Bot. System --71(14 47'
7,4,(-
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand -5~~ 7
Model Number GPM
TDH Lift Friction System TDH Ft
oss Forcemain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length No. Of Trenches PIT N0.Of Pits Inside Dia. Liquid Depth
DIMENSIONS -5-1 75 2~ DIMEN I N
SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O 7e.u CHAMBER Model Number.
System: X11)0 OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold Distribution 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 ❑ Yew ❑
COMMENTS: (Include code discrepancies, persons present, etc.)'-4
LOCATION: Hudson.20.29.19W, SWI, SE, Lot 71
se
A
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Plan revision required? ❑ Yes U/No nU
Use other side for additional information. wl~
SBD-6710 (R 05/91) Date Ins ector' Signature Cert. No
SANITARY PERMIT APPLICATION
'ILUR In accord with ILHR 83.05, Wis. Adm. Code COUNTY ST CROIX
STATE SANITi !§%n
-Attach complete plans (to the county copy only) for the system, on paper not less than //911~~
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. 240
PROPERTY OWNER Hudson Cong. of Jehovah's PROPERTY LOCATION
Witnesses c/o Howard Phillips qje '/a SE S 20 T 29 , N, R 19 MXK) W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
696 McCutcheon Rd.
CITY, STATE ZIP CODE PHONE NUMBER SIMI 9! R CSM NUMBER
Hudson, WI 154016 1(715 38 - 96
II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD
❑ State Owned 13 VILLAGE : Hudson CTH UU
12 TOWN 0 *
PARCEL TAXNUMBER(s)
X Public ❑ 1 or 2 Fam. Dwelling-#of bedrooms -
III. BUILDING USE: (If building type is public, check all that apply) 020-1652-90-100
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 R] 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. V1 New 2. ❑ Replacement 3. ❑ Replacement of 4.E] 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
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
576 720 750 0.8 97.3 Feet 101.5 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 Holding Tank
Lift Pump Tank/Si hon Chamber El I E] I F-1
VIII. RESPONSIBILITY STATEMENT C1 q 0
'R 2, 4 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 Stamps) MP/MPRSW No.: Business Phone Number:
Albert H. Krueger MP0004398 1(715 754-5574
Plumber's Address (Street, City, State, Zip Code):
RR 2, Box 197 A, Marion, WI 54950
IX. 'CO NTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date ssue Issuing Ag t Sign ture (No raimps)
,~,r Surcharge Fee)
Approved ❑ Owner Given initial _~c/ ~,~~j C~
Adverse Determination 7y v
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 sp.w~lge 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 systern. 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)
t
w
Rame. Sanitary r
-0 F
Show detailed plot plan, drawn to scale showing the lot size; location o~tall septic tan s;
holding or other tanks; building sewers: wells;%,water mains or water service; streams, or lake!
dosing or pumping chanbers: distribution boxes: effluent disposal systems; replacement system
areas; location of buildinq served and other buildings.
vertical elevation reference point:- 1n
Horizontal reference T T) ~ F ('[~rnar of rnf-
point: South Lot Line survey stakes- Paralell CTH " 1 "
System elevation:-g7-'2-
S94- 30 240 Scale: a'-" 5
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If system Is a e sh lines, headerpipe (3 dimensional drawin)
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RELATIONS
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DEpARTi~~E T AND 'aulL01JIGS s
Q`s`vtSiOd~i OF SWETY
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Plumbers Signature: &L•
Date:
MP/MPRSW tlo: ~l LC) a ~-3 ~T PI
KINGDOM HALL ---HUDSON, WI 4/18/94
Septic Tank Size
Base 750 gal.
p r ra ' ~t : ~~~SD~Ja ..jf-T" c ensa
192 persons @ 3 576 gal
(church no kitchen) 1376 gal. needed
Seepage trench size
576 gal. @ o.8 gal per sq. ft. = 720 sq. ft. needed
(Church no kitchen)
2 trenches 5' x 75' = 750 sq. ft.
MP0004398
ONSITE SEWAGE SYSTE
DEPARTME'T O 1"MID .ESTRY: L "E'04 HU;.'M RELATIONS
DlviSiG J OF SAFETY AND EU{LDU43S
SEE CORRESPONDENCE:
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JACOBS LANE---I
TM]TS/Nej
9S' SPACES
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w I. I KINGDOM HALL
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JEHOVAH'S WITNESS]
HUDSON, WISCONSIN
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- OFFICE OF DIVISION
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tViswn§ir.Department of Industry, SOIL AND SITE EVALUATION REPORT Page of --3
uiror arks Human Relations
Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY ff
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, butT Goo tFr
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. 02 D 10 SL a~0 /OU
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
A, o e? ti.s W; fr~ss GOVT. LOT,~~L~r}/4 ,s 1/4,SZvT ?I N.R f Vqb&
PROPERTY OWNER':S MAILING ADDRESS / LOT.# BLQ # SUED. N CIE OR CSM #
CITY STATE IP CODE PHONE NUMBER ❑CITY LA E VO N NEAREST RQAD
New Construction Use (J Residential / Number of bedrooms Addition to existing building /V
(j Replacement (j Public or commeraal desaibe Lh u
Code derived daily flow Z~ gpd Recommended design loading rate ~7 ed, gpd/ft2 , I trench, gpd/ft2
_bed, gpd/ft2 • g trench, gpd1ft2
Absorption area required bed, ft2 72 o trench, ft2 Maximum design loading rate 7
Recommended infiltration surface elevation(s) yG• 3.3 ft ,(as referred to site plan benchmark)
Additional design / site considerations
Parent material 4m nc,4 Sa.,c~ PG S 3V °x s- Flood plain elevation, if applicable ft
S = Suitable for system QQNVENTIONAL MOUND IN ROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem PJ S ❑ U pas ❑ U gS ❑ U ® S ❑ U S ❑ U ❑ S BVU
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture , Structure Consistence Bouf*day Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trent
y
36
Ground 3 So "/Ot /d y/Z f~ S r s` •g
elev. ~ :
/U , v ft.
Depth to I
limiting t
factor „
Remarks: ; S r rl .15br':414 0? Od.AA,111 S
Boring # 0=1o, IN _T/ Owe / S 6' 611 le / S -S Aw. "7 i 4.1
1 Z 20°31 • ..s G ~S r 5~~ Vtr f~~ / f~
Ground 3 l/L ~
elev.
/t~ ft.
Depth to
limiting o
`fat
Remarks:
CST Name: P Pri I / Q Phone: T 3 /
26 'ffl
Address: 0,70 t!~/ _ N S(Y1 IJ r I ~5~0~
Si nature: /7~✓ Date: CST Number
PROPEL: .OWNER Ty l'1 Vrvlr0, L0 4 ►W5~-- SOIL DESCRIPTION REPORT PageXol
PARCELI.D.# )'2-C - 10SL - ~Q -
Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft
9 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed Trent
r ,
3s S l?33 /1 6K i~rd~ lA''J y~ , s
Ground ar/1
Depth to
limiting
factor
"
Remarks:
Boring #
. A D ,r" z / /bore % ~ sdk ~ ~ v~ , ~ . L
y s
F-t
Ground '3 20"-5Y /oye y S /
Depth to
limiting
f ca for
8
Remarks:
Boring #
2- 2Y~,3
Ground MAO v
Depth to
limiting
factor
Remarks:
Boring # ,
Z l~ oZ3 ~ .Sy'I? ~ z f S~g'' w► sa'~ r~ J , 7 = , F'
Ground '3 31 87 0
11ev. 5N
Depth to
limiting
factor
Remarks:
.SB D-8330(8.05/92)
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N N
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00 I line of the SE} of Section 20, assumed
_ N 1L to bear S8901512211W.
N m ID
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UNPLATTED LANDS iaao
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER Hudson Congregation Of Jehovah's Witnesses
MAILING ADDRESS c/o Howard Phillips 696 McCutcheon Road HUdson, WI. 54016
PROPERTY ADDRESS 485 Jacobs Lane Hudson, WI.
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE Hudson W'I'
PROPERTY LOCATION SW 1/4, SE 1/4, Section 20 T 29 N-R 19 W
TOWN OF Hudson ST. CROIX COUNTY, WI
SUBDIVISION n/a LOT NUMBER n/a' "
ocumen
CERTIFIED SURVEY MAP 504961 VOLUME , PAGE , LOT NUMBER Lot 7
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 iration dat .
SIGNED:
i
DATE: (/sue
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
S T C - 100
L 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 Hudson Congregation Of Jehovah's Witnesses. Inc.
Location of property SW 1/4 SE 1/4, Section 20 T 29 N-R 19 W
Township Hudson Mailing address 696 McCutcheon Road
- Hudson, WI. 54016
Address of site 485 Jacobs Lane Hudson, WI. 54016
Subdivision name n/a Lot no. Cert Surv Lot 7
Other homes on property? Yes X No
Previous owner of property John Wi ndol ff
Total size of property 2.41
Total size of parcel 2.41
Date parcel was created 6-21-93
Are all corners and lot lines identifiable? X Yes No
Is this property being developed for (spec house) ? Yes X No
volume 1035 and Page Number 372 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. ringRpq 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.
n/a
Jnature'6f Applica t Co-Applicant
Date of Signature Date of Signature
uu1,. ttr'1. rh crytlra~'!
i, tY.rrrrer~'rt :r+ or a/xo c•r< u,t,t 1r ur an ipcinrntcrU cvJ
.krKr!nc rct dcncipg (he
• • DOCUMENT NO. WARRANTY DEf=D uxr,.lv~r.,rw., 1:,,,d
STATE BAR OF WISCONSIN FORM 2-1982
..............John..Wi ndol ff i18C'd for hecoru
S EP 2 1: 1993
Ut 8.30 A.~
FlUdsoh"Cbrl- -g- regatibn-.of.....-....---.'.'....".'..'- , j
conveys and warrants to ~r1
........................................Jehovali.........I tresses,: f ncorporated......
Rr:C!< :eu ro! oz:r::: e J j
RETURN TO
.
Cr0Y:6i.-X
the following described real estate in $t • County,
State of Wisconsin:
Tax Parcel No:
I~
That part of the Southeast 1/4 of the Southeast 1/4 (SE1/4 of SE1/4) and
the Southwest 1/4 of the Southeast 1/4 (SW1/4 of SE1/4) of Section 20,
Township 29 North, Range 19 West described as follows:
l
Lot 6 of Certified Survey Map filed September 2, 1993 as Document No.
504961, EXCEPT the West 38 feet thereof;
I
ALSO the West 38 feet of Lot 7 of Certified Survey Map filed September ii
2, 1993 as Document No. 504961.
I
I.
II
~i
This ryS no-t . homestead property.
(is) (is not) n 2 L1 O 1
Exception to warranties:
i
. II
Dated this 16th mber 1993
............6th day of S....ept....e......................................,
.....................................................................(SEAL) . ...........(SEAL)
John Wi ff
w •
(SEAL) (SEAL)
"
u
AUTHENTICATION ACKNOWLEDGMENT II
Signature (s) STATE OF WISCONSIN j
ss.
ST....CRDIX.................. County.