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HomeMy WebLinkAbout020-1290-40-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER SP /l9 RJJcLf2 ADDRESS g'OX ' zg Z Nyasa P ~Z Sys SUBDIVISION / CSM#~{uM 6l R, p H ILL S LOT I SECTION -.2- - T 2J N-R /7 (0 Town of HL-) L~sO yl/ ST. CROIX COUNTY, WISCONSIN PLAN VIEW '&-lA,T-0 P OFTE SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM:pED • E1= /W> ~4L~`E12 - s ~ ~ 0 0 x~ /VATS ~i TOEN C4# /E/. TRr/VCR 02 E/. _ /:7, z o 45 a ' . r i loA2~GG DRIVE W kY i 7 7 j G Q g tn'EL L yy o' /15 OF s8"I/ YoT A*-- T T4HEE~u = KS7ALL F -D ~ N INDICATE NORTH ARROW I So T k 107- Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole coves- r BENCHMARK: 'TD OG /0' ALTERNATE BM: 7o P n C rQ4064 716 rl SEPTIC TANK / PUMP CHAMBER / HOLDING-TANK INFORMATION Manufacturer: WE/$~le Liquid Capacity: 1406 Gp L Setback from: Well 0" House Other S S4 l~r~iQ/ 07 /r.rc Pump: Manufacturer Model# Size Float seperation Gallons/.cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: -S Length 4,0 Number of trenches - 2-Distance & Direction to nearest prop. line: Setback from: well: House other ELEVATIONS MANN°GE ZR! N6 s (6J01 75-0 ~ ~ 12,3- Iz,ss' $a-Ctam = 3 SO_ Building Sewer - ST Inlet: /4 SOST outlet - 90.36 PC inlet PC bottom Pump Off ~ o IJ 2-0,:. 2 Header/Manifold Bottom of system /S. Z 0 Existing Grade 0r$~,- Final grade /0, Tti j~ 3' 'no DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor'and Hurnan 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 PRAW2 MILLER, SAM CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark r p/= C r Aeration Bldg. Sewer Holding St/ F Inlet ~ 5_' TANK SETBACK INFORMATION St/~ Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic ? 5~ L-2) ' NA Dt Bottom XZA Dosing NA Header /tAan;;, lZ'32 3.9z Aeration NA Dist. Pipe 99,43 H g Bot. System PUMP/ SIPHON INFORMATION Final Grade ~2' Z92.o ' Ma acturer Demand Tmjo 0~ ' t Y,03 ?,5-, 7, Model Number GPM ,~1_ a ST S~ 9C TDH Lift Friction em TDH Los Forcemai ngth Dia. Dist. To we SOIL ABSORPTION SYSTEM BED/TRENCH Width Lengt i No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEA M u rer: SETBACK S er: / CH Mo INFORMATION ype O law ~r -7? UNIT System: -Er" DISTRIBUTION SYSTEM Header/Manifold „ Distribution Pipe(s) / x Hole Size x Hole Spacing Vent To Air Intake ~r Length _4 Dia. Length SZ Dia. Spacing C/ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Sys h~ t Depth Over Depth Over xx Depth Of Seeded / Sodded xx Mulched gigL -rench Center / - ~ wench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson 27.29.19W NW, NE, Lot 4 Hill Farm Road Plan revision required? ❑ Yes [~'N0 C~ Use other side for additional information. SBD-6710(R 05/91) Date Inspedor'sSignatu a Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: _ _ a rn. SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code Couy~Y~ f STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8'h 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 54M /V(ICL,-i2 //td'/4IVE'/a,S Z7 TZT, N,R E(or)V PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # z3ox # z 8Z CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 1100soiY (,✓I s/o% 386 2769 y(JN flCR /.//LL.7 11. TYPE OF BUILDING: (Check one CITY NEAREST ROAD ❑ State Owned VILLAGE : y(J,OSO/Y ~~c~ Icq~! .eogD 1 OF. ❑ Public M 1 or 2 Fam. Dwelling- # of bedrooms-3 PAR ELTAX NUMB R( ) 111. BUILDING USE: (If building type is public, check all that apply) O ZO - I Z5'0 _4y0 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 ❑ Church/School 80 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. 0 New 2.E1 Replacement 3. ❑ Replacement of 4.0 Reconnection of 511 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 430 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) / X9.00'gi oAoT)ON ~Sd SAS (oOC~ ; $ ~'t g~,a0~ Feet Z 9,0,60 Feet VII TANK CAPACITY Site in gallons Total # of Prefab. Con- Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete str cted Steel glass Plastic App Tanks Tanks Se tic Tank or Holdin Tank DUU / G✓2i o 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 Stamps) MP,/~~M/PPRSW No.: Business Phone Number: c L" Sfir I. bt S ?Z Z 7 3 2 3 3 Plumber Address (Street, City, State, Zip Code): Rd X*' I Z-z E U/ ICHMON.14 S I -V41 IX. COUNTY DEPARTMENT USE ONLY Groundwater ate Issued Issuing Age Sig o S ps ❑ Disapproved Sani Permit F~Includes ~rcharge Fee) 5 Approved ❑ Owner Given Initial Adverse Determination 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 SanitaryPermit 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) SAM M I L L E 4 H u tit 3 i R A HILLS LOT # SY57EM CL cioo'UPPr=fl4I g~, oo~ LowFre Z cto SC14 L E Vy. /o , a, $Y M, To P of Ta.l, ~E ID, WIG fjT ~P ~~~Z ~ 4+; NE N,64' I1 ~0.~M Roa l V, OQ' -KWL T A RM RLP EAs-r 607 t/N£ zoc,oc• B.M. T-o? OF TEL. PED, AT NE (-OR NER E L = 100. Do R I it I j E IVN I ' I I I I I 6~IRh~E 1 I House 24~XSt~ 2.6'XSOP I V (oS 2~. v ~ h -27/ O I J 4-~ I ~ ALT C R AIA7 F- St v 0 E" ~ 1 S' _ vi 171' L OT 3 L. oT 4 TS I { W WEST [or L/yE zoo,oo' k z ~ t -v I m o I z I i I - I C) I ~ ~ o 0 o rri ;u r 3 m i ~ z I ~ ' 'o I I `t, m I a h1 I o ~ ~ 2 I~ b co I ~ N v O m j I! 0 ~ • I I ~ ~ Z ~ A, n _ J r --i z CA -u _ 4 Z .far b °°0 CA S~ X Cm-M .90 0 O 0 Fn Nz -o o -o q I . 0 z ~m~ m ~ +r , Wisconsin Darartrtt+t of ll'ndustry, SOIL AND SITE EVALUATION REPORT Page Labor and Kwan Iabons Divir:0,N"f#,ty r# Burl[iings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Aittdch complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but Sr Cto 1~1 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 PROPERTYPWNER: PROPERTY LOCATION p Q "::>41M KQ_T~ GOVT. LOT 9 W 1/4 t& 1/4,SZ7 T'7-9 N,R 19 E (w) W -rko &'KLM#, ILLS PROPERTY I~ ERj~ MAILING LOT BLOCK# SU(~D)NAME ,~j /~/tJII►S JtK /~I ATE IP CO E PHONE NUMBER ❑CITY ❑VI LAGE OWN N REST ROAD I T [l New Construction Use [ Residential / Number of bedrooms [ ] Addition to existing building j J Replacement [ J Public or comrrr ercial describe Code derived daily flow gpd Recommended design loading rate 11 bed, gpd/ft2o40 trench, gpolft2 Absorption area required bed, ft2 Sb~ trench ft2 Maximum design loading rate o ` 7 bed, gpd/ft2 $ trench, gpd/ft2 Recommended infiltration surface elevation(s)t ft (as rerred to site plan benchmark) Additional design/site considerations ` kc-iocNcs 12A,04Ly &COYh Mh^nk~.EA~ Parent material Flood plain elevation, if applicable It 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 Depth Dominant Color Mottles Texture Structure Consistence Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Y Bed Trends .k :Li ii: i'' *Z oA x<'1 o-/z idY+~~ I g 1 rnr° Y}t. C, xah4 \i Zo /6t/P, 413 5~- ` r r~, r C~ Q O, Ground g-z 6-3,`~ /dye- 4-A G Y11 r re) ~ c ~ Q.7 O g ~14V I~ft. 4Z Y 4 s r Depth to limiting factor > ~Q.33 Remarks: Boring# - SL 7 /bE cr, lY3 r C3`~ C),n, gr rh ~r Ground igg-3 t/ ' 4 S Y` rn C. Z .7 O elev. Z--1Z1 S or, r 9z~ft. Depth to limiting factor ~ 111ZLZ Remarks: CST Name:-Please Print \~~(SdN Phone: Address: , f:) p_ k l tj i 6 Signature: 1~U Date: , 7 q~ CST Number: PRQPERYYOWNER ~~I~I rt~L SOIL DESCRIPTION REPORT Page of3 •PARCECI.D.# 'Lsr4 14UAvAi Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3 0 -15 ioye TT, I cr m .r C. Z O. 0.5 r Z r7 -11 U> Ground 0yoe *A r t O.~ O elev. ft. Depth to limiting f'tsy._ Remarks: Boring # k<>:;:::<:{ A 0-1 I Idyl 3 Z -S L C 23-fZ+ 1611P- 0. M,!Ir Ground elev. Depth to limiting fact% s~ • Remarks: Boring # c)--7 lo ye, S C 1 n, C r I1'li- Z ~1© w#s:< ::::•Nx:< -3~Z $ 1-2, aye 4 6 ^ 6B Groundv 172-42/ /by e 4 S yvi 6; , elev. Depth to limiting factor Remarks: Boring # v\4 M:ti •::i4-.iv.:::i: Ground elev. 1 ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) ' R J w r l O ~ t J 7 7t7 i 1 ~ i M 1 G' w r Pv~ , do 07 o LA1\21 z m m P t75~ F s a o P~ r rr .1 p z ~ J is ~ 'FAD-M -PbA)s STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER S A M M I L L F Q MAILING ADDRESS o X¢ Z 8 L H U p s o h w / ' PROPERTY ADDRESS 8 1411-L. F ,4 2 M P- o A D (location of septic system) Please obtain from the Planning Dept. CITY/STATE N J D ,5 0 K I,W T__ 5 1-/ -0/G i PROPERTY LOCATION iV4-1 1/4, A/e 1/4, Section 2 7 , T N-R i9 TOWN OF N y D Soy , ST. CROIX COUNTY, WI ~Lg b'/~ D L L S LOT NUMBER SUBDIVISION g CERTIFIED SURVEY MAP s17 7/ o7 , VOLUME S , PAGE LOT NUMBER y 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: g- q y St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 • S T C - loo 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 SA M M I LLB rZ Location of property _!NW 1/4 A/ "-E 1/4, Section -Z 7 ,T z 9 N-R / 9 W Township N L) D 5 o)y Mailing address (3 0 X= z (f Z NL) psoA/ WX syot(. Address of site- 776 HILI- FARnn koAD Subdivision name A u rv1 Q i R p RILL-3 Lot no. Other homes on property? Yes X No Previous owner of property _ A u M B i~ D '_A ~V Q -O- Total size of property z, 2,7 Xe_ Total size of parcel 2. z f 14 4f, Date parcel was created y- 7-F 3 Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house)? X Yes No Volume /oi) and Page Number z F Z 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. 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. Sp z z o9 , 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. SOz 2.01 ffcu".c~ .62 Signature of Applicant Co-Applicant (0 Date of Signature Date of Signature r! , ' DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE REaeRVaD FOR RECORDING DATA WARRANTY DEED 502209 col 1 REGISTER'S OFFICE Sl. C~OIX CO., 1Vj This Deed, made between __Humbird Land Corporation, R:c'd for record - .A Minnesota Corporation authorized to do business JA. wieconsin__ _ JUL 1 2 1993 Grantor, at Pftg.3tor :20 P. R and Sam E,, Miller... _ • of Deeds Grantee, ` Witnesseth, That the said Grantor, for a valuable consideration...... - conveys to Grantee the following descrihed real estate in .$t. Croix RETURN To County, State of Wisconsin. %~i Gtinl~ G - 9 o y ~~~.~.C.eta/l• Lots 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12 in the Plat of Humbird Hills, Town of Hudson as filed Tax Parcel No: and recorded in the office of the Register of Deeds for St. Croix County on April 7, 1993 in Vol. 5 of Plats, Page 99, Document No. 497107. Lots 13, 14, 15, 16, 17,-18, 19, 20, 21, 22, 23, 24 and 25 in the Plat of Humbird Hills 1st Addition as filed and recorded in the Office of the register of Deeds for St. Croix County on .April 7, 1993, in Vol. 5, Page 100, Document No. 497,108. ',~00 0,• S This ig..nQt...... homestead property. (W (is not) Together wi'h all and singular the hereditaments and appurtenances thereunto belonging; And_ warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements shown on the above mentioned plats. and will warrant and defend the same. Dated this 12th day of ...July.......................................................... 19..93... _Humbird Land Corporation, a Minnesota Corporation authorized to do bushiness in Wisconsin .......(SEAL) By-- (SEAL) Austin J. Baillon, President (SEAL) (SEAL) i a AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ~jJ~ ss. t L_ .County,. authenticated this day of_____________ 19 Personally came before me this ..day of -Jul y , 1931. the abbbe" nWed 1 . - Baillon Presidewt . o'f• ~~c TITLE: MEMBER STATE BAR OF WISCONSIN Hum!ird.L;Lnd-Corporatioq•~: (If not- ' authorized by § 708.08, Wis. Stats.) n.,•.j to me known to be the person O kvh~ ed the •U - forego4ing trument and acknowledgl}e .171 THIS INSTRUMENT. WAS DRAFTED BY 1I ~ rT N h . 1 D-Q•k• f _Kueppezsr-•Hackel--&--KunpRe~--------••------•..._.... . 1350_.Capital._Centre,.St.._Pau1,..MN.S5L02_ Notarie.. ..S.T.._...G L..........County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (if not, state expiration are not necessary.) date: 19.........) ONames of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Leal Blank Co. Inc. FORM No. I-1982 Milwaukee, Wis.