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HomeMy WebLinkAbout020-1267-80-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT.., 1 OWNER P'S'c R J c) e ✓ p ADDRESS SUN 1~1~C{ Sl~~ SUBDIVISION CSM# LOT SECTION dl T N-RW, Town of K'-A ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW E ERYTHING WITHIN 100 FEET OF SYSTEM 3 -TRet"C~p a' - ~s Sx70 35 ' Cle~ut ~ WPS~ lob ,y• ' /Zoo '1<< y 3 k 50 , o f N INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. I I r BENCHMARK: (~I V L I P= ~eV loo ,o ALTERNATE BM• SEPTIC TANK / P 'SON Manufacturer: Liquid Capacity: Setback from: Well 7 House-3 IOther Pump: Manufacturer Model# Size ` Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: S Length 70 Number of trenches Distance & Direction to nearest prop. line: ~S GVle r, tp Setback from: well: QQW House i U Other ry1, TKe+~ c M b 1~ e o..." Low -kc Pj< . NcavnR 9(0.0$ NeAOr(~ 9y.58 HCAMIZ 911,0 Ewa 95 ij ~ti~ 9v 3Y 'CNo g1.33 BQ,.,G~ i~1 :tZk I ~ ur S, o, ELEVATIONS skjt yo Building Sewer ST Inlet 93• yU ST outlet 93.aS PC inlet PC bottom Pump Off k -0 Header/Manifold Bottom of system h\jr) 13.s() Low 40•S~ Existing Grade Final grade W,3k U.00 Q 1, Low DATE OF INSTALLATION: l C7 9`I PLUMBER ON JOB: LICENSE NUMBER: 7J 1 INSPECTOR: 3/93: jt LGb pert ,st - 29. 19, %1VXf f SJOAdi SYlytWn Hi 11 l.Human Relations aE d ~ ~ Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) sanitary ermit Permit Holder's Name: ❑ City ❑ Village R Town of: State Plan D o.: ev:: Insp. BM Elev.: BM Description: R Parcel Tax No.: A /D TANK INFORMATION ELEVATION DATA A9400090 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Benchmark Septic /0 ~a /00, Dosi ng (U 1, d Aeration Bldg. Sewer Holding St/ Ht Inlet 23, V TANK SETBACK INFORMATION St/ Ht Outlet 1 ~ TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic >a 5' 7~ ` / " NA Dt Bottom Dosing NA Header/Man. ~o•i 9usy a 9 '7 8.85 ors S Aeration NA Dist. Pipe io•s / Div-35~ 9.7 9,,q9 Holding Bot. System /'8! 93- 5 7 PUMP/ SIPHON INFORMATION Final Grade 4-~q 9s,o Manufacturer Demand o~- Model Number GPM TDH Lift Fri ion System TDH Ft Fie Forcemai n Lengt Dia. Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width 5 Length / No. Of Tr nches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS JC -10 DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM INFORMATION Type O CHAMBER Model Number: System. 'Au /ts- / /1 )a Q~' A)[ OR UNIT "ej 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 Overe }J xx Depth Of F-x Seeded/Sodded xx Mulched Bed /Trench Center Bed /Trench Edges 0 %XX Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson.24.29.19, SW, NW, Lot 21, Hutton Hill Circle 171 ` 13% lY Plan revision required? ❑ Yes No 1 Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 1 ` SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code J 77PILHR COUNTS C MEMOS 0)X aaaaaas• v rauraM~s,awnna~w.ss STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ o qqb l 8% X 11 inches in size. Check if revision to revious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNE~v -p PROPERTY LOCATION ~7 e OP. S. %a NU'/a, S o~ y T 4, N, R E (or) W PRO b WNE 'S I A r LOT # BLOCK # t '1 ~ C 1 KJ-e D I I CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR M UMBER Hu N GJ )se- 6 al S 1)1 -c 11. TYPE OF BUILDING: (Check one ' I - ) State Owned ~J VILLAGE ~ ~U p NE A 00 )~C ❑ Public 1 or 2 Fam. Dwelling-# of bedrooms. EL M III. BUILDING USE: (If building type is public, check all that apply) oac)/ D f01 0 0 0 0 1 El Apt/Condo 1 7Q U 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 El Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. 11~New 2.E] Replacement 3. ❑ Replacement of 4.E] Reconnection of 5.0 Repair of an ystem 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 REQ IRED sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min /inch) 4J.U LEV,e,T( N +.5 d 0 ~00 l~ - 0 S n Feet c) Fee VII. TANK CAPACITY Site INFORMATION in allons Total of Manufacturer's Prefab. Fiber- Exper. New istin Gallons Tanks Name oncr a Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank 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. Plumb 's Name (Print): Plumber's Signat re: (No Stamps) MP/MPRSW No.: Business Phone Number: S;~ m ~ mu 10 0~1 - l5 38 9 bd Piu Per's Address (Street, City, TDO ateZip Code). 11 ll ~ll f tiu N(k Sow 1l~IS~- IX. C /DEPARTMENT USE ONLY t5 V ❑ Disapproved San' ryPermitF a (Includes Groundwater Date sue Issuing ent S' re N tamps Approved El Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) 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 811 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) Q. L.. E~ PLOTA U "D Z) I ; N AM E ,i, C E N S DAT E::~_- 7- P L 0 tj& : Mir' tit 14S Wells Atnk F FA Rfih raaM. 34 d Sy~~t~ Aoz4 I~Q A~Q ~ P~ f Np e ~ SV~ 1~~►"'~ $(p~ B A Z T is%,s 3s 1 ?s w' 3 ftCN cle s I w PVC Pia . f-kv- (000 C 12001A) s4c_ 2 n r' y j3eL%ovrv Norvn e FRESH All' E 41Li•:'.CS AND OBSERVATIntj Pl.PE cnoSS SECTION Approved Vent Cap Minimum 12" Above I g .0 t) `Y S U A" Cast Iron Above Pipe Vend Pipe To Final Grade- Marsh llay or ~Synthetic Covcri.ng_ Min. 2 Aggrc(j"- _ Over Pipe J Distribution~ _I 1 ~ Tee Pipe f 9S>UU l~_ Aggregate rerf.oratied Pipe Delow o i) neath Pipe 1C. --Coup). ing '*er.minat:ing T Rot•tom. of System. 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Z' 7, 0 v oo) ` ~ I ~ STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 64E66or)/ s• 136VAl6/7 MAILING ADDRESS 3'1.1 ~U~U~n! LANF l1I~a~Scvv GcJr S 5~0/~/ PROPERTY ADDRESS g06 A{aiiw (location of septic system) Please obtain from the Planning Dept. CITY/STATE /~v~✓Sa~, A"JZ- PROPERTY LOCATION S (-J 1/4, /UW 1/4, Section y To?? N-R 9 W TOWN OF lfUCSON ST. CROIX COUNTY, WI SUBDIVISION SLJA) 1Q 06C LOT NUMBER CERTIFIED SURVEY MAP - , VOLUME , PAGE -71 , 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: DATE: ~ St. Croix County Zoning Office Government Center 1101 Cannichael Road Hudson, WI 54016 11/93 S T C - 100 `this application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,(spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. of property ~jrg pr S ` Location of /property-5W 1/4 AhJ 1/4, Section ,7Y , T ~9 N-R~W `I~ o w^ s h i p p~ f7Ul~So~J trailing address - D~tl lti;1vC 21144 J GA _41,1 Address of site O6/ -/'V// , Subdivision name So,., 1A2~QSE Lot no. .7 Other homes on property? Yes X No Previous owner of property Total size of parcel 2 SS Date parcel was-created Are all corners and lot lines identifiable? - • --_Z____Y e s No Is this property being developed for (spec house)? X Yes No volume and Page Number 7l as recorded with the Register of Deeds . INCLUDE WITH THIS APPLICATION THE FOLLOWING: - A WAJZRANTY 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 (we) certify that all statements on this form are true to the `.;e s t of my (our) knowledge that I (we) am the property described in this information f(are) the owner) orm, by virt e(sofoa '.arranty deed recorded in the office of the Count Re Feeds as Document No. Y gister of the proposed site for the sewage disd saat I (we) presently obtained an easement to r p 1 system or I (we un t ) he ab th~ ove de construe scribed ro of p f tion p ert said system, and t Y~ or recorded in the office of count Re he same has been duly No. Y gister of deeds as Document i re of app icant Co-applicant G ~ 9~ D e o Si nature Date of Signature NS- bocuMENT NO. WARRANTY DEED TNI] SPACL RLSLRYLD FOR RLCOR0IN6 DATA I 92339 STATE BAR OF WISCONSIN FORM 2-1982 VOL 983PAGE REGISI R' S OFFICE Greenwood Enterprises, Inc., a Wisconsin Corporation, ST. CROIX CO., W, • Rec'i for Record I ..................Grantor.--•- DECD 2 1:25 JM r S. Bennett a sin le erson I, conveys and warrants to .~r~~$$4__Y ......................:........._..8--•--_P.._..--•--.•. M `T ...............•-•...........••--•--•-•-•...------•••••Grantee_.._........-• $4-1t%'WW of a"& RLTURN TO Heywood S Cari P.O. Box 229 St. Croix Hudson, WI 54016 the following descalbed real estate in ................................................County, - State of Wisconsin: Tax Parcel No: Lot 21 of the Plat of SunRidge filed in the Office of the Register of Deeds for St. Croix County, Wisconsin, on September 22, 1989 in Volume 5 of Plats, at Page 71, as Document 0451750. O TOE :a Elm This 44__ARt.......... homestead property. (-Jc (is not) . Exception to warranties: Dated this ~i`.C.;E2f A---------------- day of November------------------- 19..42... ~f SEAL James..E.__Busah,--PrESideat ' Mary- h,•-Sacreta-ryjTreasuser °..-•-----(SEAL) (SEAL) ~ . 1 AUTHENTICATION ACKNOWLEDGMENT Signature (a) STATE OF WISCONSIN as. ...r.._........__--------- St. Croix ix St. Cro ----County. auth tics this 'y oflaQYLtA 19. 2 Personally came before me this . 3 bl` daq of ..._...---November 19--92-. the above named .__Maz~r._xa..Ruaeh.,_.Se~setazX/Tzaasuza---------- yas!~x----------------------------------------------------- TITLE: MEMBER STATE BAR OF WISCO p (If not. . authorized by 1708.08, Wis. State. •Y to me known to be the person who executed the e~gJO J ~'J y for ing instrnment and Howl the same. THIS INSTRUMENT WAS DRAFTED _ Reood S Cari,~ h)r Walter `r tr- ...../lG~..L.• ~ll~!-_. .r, : ° ` s Qr ~lile jjff..f t~.1rSOiv r fi~ C - L.................. --ox - ----•t Hudson. Box 229 t WI ~~cc'•• C Notary Public St..--Croix---------- County, Wis . (Signatures may be authenticated or 8t•~nowlel~fd.My Commission is permanent. (If not, state expiration are not necessary.) QQratLLion i, date 3/3 / ONsws of persons sifftine is any capacity should be typed or printed below their slsnaturs WARRANT! Da')® aTATR BAR O)• WISC r o l Z ii a - ~y (A MCI d A a 3 u o A N Alt Z 3 © c 0 z a d N d tA N M ?p 4, 4~1 Lim 0-0 w H f% LA H CA N~ 3m 3 kA c r% rz~ %A e% 0 N vl N A d IL 10 Y N Z 1 A N y d \ O Qp A ? lz~ vA .\OA 0 m a - y 02. 0 C %A -Vt co Ln CS 3 f* 13 0) OL rD er fob =Y: ; 110 Q C' r~ 1~~ O Col01 ZM o~,~~'. 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