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HomeMy WebLinkAbout020-1288-60-000 STC - 10 4 AS BUILT SANITARY SYSTEM REPORT OWNER SAM AA I L L Eie- ADDRESS 00 X * Z $ 2- 1420 SoM wZ -5s/o SUBDIVISION CSM# LL Q(oO ST TION LOT # SECTION Z 1 T 2_T N-R .t Town of 14 u-b So Al ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~T pQ WE Wq.~ i sY, ` 4 WELL =s/ IF as - Ifo- zr µo~sE a9~KS'or i~ i AT- mF L oTcoeNQ- F-), loo.O'n * 11C II, INDICATE ORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. 1 BENCHMARK: Ta- of 1-",D1 PE aT S~ lvl~y,~,c~~~ =l"'na01 ALTERNATE BM: 7vQ OF S~L~ aF g~~~E apy,~ -7 PTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Lo e_i S q.✓' Liquid Capacity: ( Qpp Setback from: Well SS House Z Other_ z el Uv Nl~Ca,~ iv~fbrAl~ Pump: Manufacturer Model# Size Float seperation - Gallons/cycle: Alarm Location - SOIL ABSORPTION SYSTEM Width: t% Length ~lo Number of trenches - --Distance--&.-Dixect on-to- nea-re_st-prop 13-ne. 3 - Z otd 'N Setback from: well:I to'_ House yS Other u'* To ST Apy ELEVATIONS Building Sewer - ST Inlet; ST outlet `I.OrJ PC inlet PC bottom Pump Off _ " Header/Manifold9-14/ Bottom of system Existing Grade 5--66 Final grade 6-. n0 DATE OF INSTALLATION: I PLUMBER ON JOB: ~-o LICENSE NUMBER: _Z__ INSPECTOR: 3/93:7't Wisconsin Department ofIndustry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: - PLUNDELL Na MIC & MILLER , SAM ❑ City ❑ village Town of: state Plan o.: CST BM Elev.: Insp. BM Elev.: BM Description: 7 Parcel Tax No.: A-9 410 0 4. 0 -0 TANK INFORMATION ELEVATION DATA /I oA9 V TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic SQL, Benchmark 50A.2" Dosi ng lY d 0-2 Aeration Bldg. Sewer Holding"" St/ Inlet 8sy' 96, SY' TANK SETBACK INFORMATION St/Outlet 61 d5zr TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic 26 / -4 NA Dt Bottom Dosing NA Header a~ 9`5 9'g r Aeration A Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade S S/' Manufa Demand ~Q '7- M del Number GP TDH Lift Fric System H Ft Fo rn Head Length Dia. f Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width ~y Length , NO.O Trenches PIT No. Of Pits In ia. Liquid D th DIMENSIONS d ~d DIMtj5jQN5 ___*1 SYSTEM TO P/L BLDG WELL LAKE/STREAM NG Manufacturer: SETBACK INFORMATION Type O ✓7z - CcmiT; AMBER i Moe Number: System: LLA Yf 5_5D A OR UNIT DISTRIBUTION SYSTEM x Hole Size x Hole s ng Vent To Air Intak0,\,j Header / Manifold - Distribution Pipe(s) 6 r Length ~ Dia. Length Dia. ~Z Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade stems On Depth Over Depth Over /7 xx Depth Of xx Seeded/ Sodded xx Mulche Bed /Trench Center Bed /Trench Edges 3 Y~ Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson.21.29.19W, SE, NW, Lot 16, Za Grey Cir e Plan revision required? ❑ Yes R-9-0 Use other side for additional information. k'7-) SBD-6710 (R 05/91) Date Inspector's Signatu a Cert. No. ADDITIONAL COMMENTS AND SKETCH ' SANITARY PERMIT NUMBER: I I SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COT (h'~ STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 0-00 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 L, APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION ,DE 41 S E '/a /,(/'/a, S Z T Z9, N, R E (or 19 PROPERTY OWNER'S MAILING A RESS LOT # BLOCK # IF Z x CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 175 0/ s o/ 3 -77& y 6CL G S > S rfi 7 V CITY NEAREST ROAD II. TYPE OF BUILDING: (Check one) State Owned VILLAGE: R TTOWN OF: Uj) SO ZA 4 E to AE tf C/ Q~/E ❑ Public J91 or 2 Fam. Dwelling- # of bedrooms PARCEL TAX NUMB R(s) Ill. BUILDING USE: (If building type is public, check all that apply) Q Z d - l Z O 1 ❑ Apt/Condo 2 ❑ Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 50 Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ~ New 2. El Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 220 In-Ground 42 ❑ Pit Privy 130 Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. A13SORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE ~sO REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION J!n el'? "7 ZO 7 Feet 9 7~ 5' Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed _EL~ Septic Tank or Holdin Tank /000 wv-, is a-*,- F] 7X~ 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. Plumber's Name (Print): Plumber's Signatu e: (No psi LO P/MPRSW No.: Business Phone Number: cov TQo r~ /°~/3z- Lys 3L 3 Plumber's Address (Street, City, State, Zip Code): IX. C TY/DEPARTMENT USE ONLY ❑ Disapproved S2-tary Permit Fee (Includes Groundwater Date ssue Issuing Age i Approved ❑ Owner Given Initial M~ ~SSe~ Surcharge Fee) 1~1 11 Ilk 07 Adverse Determination d X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: 41 SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety s 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, 60B-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. 111. 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) R IL L UAl0 LL/S/4 /YI/CGL p2 C~QcLE gSy z~}/VE / Cr~trcL i ,1~ i S G/lL-~ //tf ee _ /v - V ! Sao' i S ~ ~TEti1 E/ WELk o~ r 16 g- ~ fi'r'° //-7,6k 5 z 319") X M1 l v 6 ~ -G F h/T ° s~ / i I t i 44,,CS7- ~cT 41AI ' lL2•oo I-o T Y~ eCo S7w-r1tV 5 sTEiI~I a y~ oo ,le* J ~ I t UzW z ~ Fo= Fo= rr_ W a = v U9 d W 4 a ~ ~Y LLI _ ^ ~Y > X O p 'H O F-z O 0 I CL o M PO z F- O W ~ I LL =d. ~ I W a r: ~ I I I I in Ma I o U I I I U- Z to n. I I nW. I =d, U I I 1 a I 110 1 I I I i I I w I I I > • i,' O I I I I ' i+) I io I ip I i~ 1 I 1 ~ I a IL o z . ; I I I tan 3 I I I z I I I ~ ed, I ----------I j 41! ---~I y Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page I of tabor and Human Relations Doision of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUN C~P.o1~t Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but riot 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 1 E (or) W ~14~YI ILL GOVT. LOT SE 1141`4 W1/4,SZ I T V N,R /p PROPERTYyOW MAILING ADDRESS LQ~# BLOCK # SUED. NAMI&" 1 ~4 O CITY, TATE ZIP ``COD PHONE NUMBER ❑ CITY EIVI LAGE OWN((~/JJ NEAR ST ROAD n v~C1 1 S'tU) ( ) N TN U LA- (d New Construction Use Residential /Number of bedrooms [ J Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow So gpd Recommended design loading rate 0,-7 bed, gpd/ft2 O-%trench, gpd/ft2 Absorption area required 64< bed, ft2 S 6S trench, ft2 Maxilpum design loading rate 02 bed, gpd/ft2 ©g trench, gpd/ft2 Recommended infiltration surface elevation(s) 0'J 4K 3 ot2 ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable it ROUND PRESSURE AT GRADE SYSTEM IN FILL HOLDING T K S =Suitable for system co vENTIONAL ~gJND IN. U= Unsuitable fors stem XS ❑ U N~ S❑ U S❑ U 9S ❑ U WS ❑ U ❑ S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BOlYcby Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed mach 0-/6 ioyp23 l' sbK ► C 5 2 ..5 0.6 8 , 0-39 ~ 5; 1 sb~ r~~'r c s a .Z o .3 Ground iB 31-70 OY ¢ S Q 1 W ' 0.7 elev. 7 :0'g 92 ,61t g 0-ll O f2 4 4 S Q 9t- O• Depth to limiting Remarks: Boring# 4 D-tS / t23 L 3 ab n,~r C' S 7- 6< bY~4 4 3 - s n q.- /h I w 1 0,7 16,E Ground elev. I Z y 4 s 09 h, 6,7 9B eft Depth to limiting factor >16, 1 -7 Ll Remarks: CST Name:-Please Print / % Sad NS~~ Phone: ~6_ 4o To Address: Q /Y Signature: u , . Date: 1 0 Q A CST Number:. 94 PROPERTY OWNER'S4,(h M) LL SOIL DESCRIPTION REPORT Page Z of 3 PAR~'EL. I.D. l ~ (n) tft,t-~ ~~-D Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed rends ©-13 /oye, 3 1 L r►, a Th c 1,5 Z. r►l 0.S 0.6 g, 3- i ~ >o ,2 4 3 S ~ L Z a ~K r►., ~r S 1 m 0 6 . ~ Ground $i ~J-!5g, /0 p,~ S' r rh , I ' .7 6 elev $3 -llg /6 YR4 s O r m 1 l 5,? Depth to limiting factor 7 BZ Remarks: Boring # o-/4 3 M sb mii~- C S 2 p s 0.6 Q' 4-3z by 4 3 S, 1 r.r C 5 O 'd.6 Ground D /Dyr24 s - S 6 r Yh~ w ©,7 0 elev. It. Depth to limiting factor g y/ ~0 Remarks: Boring # f by 3/ Z-, 3 SLY, /h -Fr C' S 2M as o-6 13 S,L sLK ~r C S 1 O.S '0.6 13 4 PS- Ground 7' S ~vyoe 4 S' - S o 01 r 1h / W 1 C),7: a z $3 2 /by _ S r n~ 6.7 0. 9 M- ft Depth to limiting factor /0,06 - Remarks: Boring # 13 Ground elev. ft. Depth to limiting factor F-t- Remarks: SBD-8330(R.05/92) Loll 6CALr 1'3d' ~S g-3 QEC.60,rxEnlh,EIL rsT cnmELEV4TIarJ3 N o&-m 4~ C - 4 • DDS 94.60 a 4 C9, ..r J 1 A61, (.bT Co+-JJL-C / V. STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County O WNERIBUYER iQ / ~-U/Il DELL / S~1 'l M I L.4157`e,_ MAILING ADDRESS ,gaX' z ~f Z. #W__54016 T '_f e) 1(0 PROPERTY ADDRESS Z A /tl E 6 /e E)V GLj~t (location of septic system) Please obtain from the Planning Dept. CITY/STATE KV D S 0 N (.,6j Z--- PROPERTY LOCATION S 1/4, N Gt) 1/4, Section Z T Z N-R_/f TOWN OF(/ D -501 ST. CROIX COUNTY, WI SUBDIVISION tVIE LL S ~7/1 tl 60 LOT NUMER 1~6 IV.4 TD .L ppu,,V&q-r-=6' y7JZ9 , VOLUME `Z PAGE 3"i9, LOTNUMBER 14, 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. 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 completed and returned to the St. Croix County Zoning Officer within 30 days of the three r expiratio te. SIGNED: DATE: I ( 3 ~c~- - _ St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, AVI 54016 103 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 EZ/G Z P p t Z L SX fI-1 A//Z,-~ Location of property S = 1/4~/ 4J 4, Section TAN-R l9 (OOW Township 11c.-IL) SO A/ Mailingaddress &oX Wz8' Z Address of site gS-/ Zff~C/ ~ieF f✓ C~ 2 L Subdivision name Wr--LL S `7r4,e60 S7-,4r70 S' Lot no. Other homes on property? Yes_, No Previous owner of property A,)VIT,4 1/V,4~ LL-S Total size of property S 3 6¢c Total size of parcel 2 , 6-3 ^C- Date parcel was created _ 12-- 3o - rj / Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? k Yes No Volume 9Lg and Page Number 3/1 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. `/77 z9/ , 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. / d Signatur gofplicant -Applicant el' L/ Date of Signature Date of Signature rn ~i ro h7 ro ro C ~ J-P 1 t DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORp:NO DATA STATE BAR OF WISCONSIN FORM 2-1982 477%91 vol _'S :319 REGISTER'S OFFICE ST. CROIX CO., WI Anita G. Wells, a single woman Reed for Record DEC 3 01991 °i.2:40 P. M conveys and warrants to John. A._ Elbert and- Eric J_ Lundell, as...Tenants.:in Common,. an undivided. one-half interest...... RegtsferofDeedi each . _ . . the following described real estate in St.... Croix County, . Mate of Wisconsin: All that part of the Northeast Quarter of the Northwest Tax Parcel No: Quarter (NE}NW}) lying Southerly (Sly) of the Railroad Right-of-way; The Southeast Quarter of the Northwest Quarter (.°E}NW}); The East Half of the Southwest Quarter (E}SW}), EXCEPT r•+p part to Alfred L. Ekblad , in Volume 498, page 484; part to Leslie L. Swenson in Volume 498, page 504; part to 7 Donald F. Johnsin, in Volume 500, page 525; and part to Donald L. Jordan, in Volume 580, page 354, all in Section Twenty-One (21), Township Twenty-Nine (29) North, Range Nineteen (19) West. I This Warranty Deed is given in full and final satisfaction of that original Land Contract between the parties, dated December 4, 1989, recorded December 13, 1989, at 11:30 A.M., in Vol. 858 of Records, on page 633-634 as Document No. 454203, Office of Register of Deeds for St. Croix Co., WI. This . is not . homestead property. (is) (is not) Exception t:: warranties: Easements, restrictions and rights-of-way of record. hated this 27.th day cf December 19 91 (SEAL) I~ (SEAL) • Anita G.. Wells . (SEAL) (SEALI AUTHENTICATION ACKNOWLEDGMENT Siena e(s) OF Anita . Wells, a STATE OF WISCONSIN ) si gl woman ss. qq 27t11la of..... December 1 aut a d t 19 I crsonady came before meS this _ day of - 19_.. the above named Leo A. Beskar TITLE: MEMBER STATE BAR OF WISCONSIN (I f not, authorized by $ 106.6, Wis. Stats.) to nre knmvn to he the ner:on who executed the fore nine in<trument :Ind acknowledge the <anrc. c.9 INSTRUMENT WAS DRAFTED BY Leo A. Beskar, Attorney Rodli; 8eskar 6 B61es;..S:C:. 219 North .Madu.S. Nnt;lh I'Ilt lie pp 71 1g ii n ('aunt}, Wis. (§k*RFirt+.A"kk~'he aLe tic.~ted or acknmclod:•ed. Roth )Ic C:uunli<-non is nernlancnt- if not. state exp ration are not necessary.) date: 19 'Names of per-- ?inning in nny arin-ty i,, bl h.. r WARRANTY DEED TTArr BAR OF IN 114 CONSIN Wis, ^.51n L,- :.I'ttidnk C- Inc;