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HomeMy WebLinkAbout020-1290-60-050 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER -S:A Al E k- ADDRESS BO)(-"' Z $ 2, 1-lJb 5o Al w 5 ~/t1/G SUBDIVISION csM# 14041 Q I k D Ff I LL S LOT # ~o SECTION 27 T Z? N-R_2?_o Town of falJDS 4/1/ ST. CROIX COUNTY, WISCONSIN sri s tc1 PLAN VIEW N~ SHOO EVERYTHING WITHIN 100 FEET OF SYSTEM V µous~ - w~L[. NME; 4S o~ 4 ZZ V~ 1 sb 1 ~ Jl1, y R.M. P "Pt PE ON 5ok`~ Z. 1.01+ ha-" 100.00 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. L i BENCHMARK: --r 1tep p ck Z/" :Pl'>r- ~1~ ~4y h cam, ALTERNATE BM : Top Sit) ON 3ac.t klnn r SEPTIC T / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: QQ Setback from: Well House Zb' Other ZS 7,~, S,w_ Cor„or {~a~ s~ Pump: Manufacturer Model# Size Float seperationGallons/cycle: Alarm Location - SOIL ABSORPTION SYSTEM Width: $ ! Length L(o Number of trenches Distance & Direction to nearest prop. line: 4 8' 4- Seu-~~, Setback from: well: (OD House 9G Other 13 -7 r o= ~aQs e._ 01, -7 ELEVATIONS Building Sewer - ST Inlet, C• 3 3-1 ST outlet _ g i PC--met 'PC-bottom Pump---O f f Header/Manifold Bottom of system ~~cS Q Existing Grade Final grade ~'TO 'O z_~ 5 DATE OF INSTALLATION: { PLUMBER ON JOB LICENSE NUMBER: INSPECTOR: 3/93:jt S S A-& d County: FL"A~E S WAGE Labor and F,iuman Relations alet ety and Buildings Division INSPECTION REPORT SrP - r_ Dix (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION 199996 Permit Holder's Name: ❑ City ❑ Village IR Town of: State Plan ID No.: v.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9400028 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Lye7V Benchmark 0o72, .72 /OO 72-1 Septic Z& 4-9- 4 Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet .3 91•3y TANK SETBACK INFORMATION St/ Ht Outlet 0/,4,9 TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic +~S b .20 NA Dt Bottom Dosing _ NA Header / Man. f f Aeration NA Dist. Pipe 33 Holding Bot. System Sy 22 PUMP/ SIPHON INFORMATION Final Grade ~ Manufacturer Demand 7-1 Model Number GPM TDH Lift Lric in yste TDH Ft Forcemain Length I Dia. H Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length, No. OfTrenches, PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS G DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Man turer SETBACK del um r: INFORMATION Type O CHAMBER System: ~2 D 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 ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson.27.29.19W, Lot 6, Hill Farm Road Plan revision required? ❑ Yes ❑ No Use other side for additional information. 'Z y SBD-6710 (R 05/91) Date Inspector's Signature Cert. No SANITARY PERMIT APPLICATION DiLHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY STAITARY RMI # -Attach complete plans (to the county copy only) for the system, on paper not less than ~1l7~,99~QQ77~~ 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. PROPERTY OWNER PROPERTY LOCATION SAM /0 /LL,E/Z L!/'/a C '/a, S Z TZ-7, N, R E (or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # o XZ~Z CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 114j4')_e115'A1 ~S SyO/~ 1(3 W4 z 7 41 O M 131 R D 141 1- L.S II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned VILLAGE #aM011 AIAL FARM ROi4 D ❑ Public M 1 or 2 Fam. Dwelling- # of bedrooms 3 PARCEL TAX NUMBER( S) III. BUILDING USE: (If building type is public, check all that apply) o zo - /Z7.0- (.0 ®s"o 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 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. © New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ 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 L/ REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION T s~ S 7Z 0 2, 7 g 91. ZO Feet 8 7. SO Feet VII. TANK CAPACITY in allons Total #of Prefab. CoSite n- Fiber- Plastic Exper. INFORMATION Manufacturer's Name - Steel New Existing Gallons Tanks Concrete glass App. Tanks Tanks strutted Septic Tank or Holdin Tank x 000 L✓6/SF~ 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 Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: 3 3 o~ 6 5-rr~o HB I~ ><3 2. z 7 32- Plumber's Address (Street, City, State, Zip Code): 130X `F zz NF t* No jj / 5-y'61 7 IX. CO TY/DEPARTMENT USE ONLY Disapproved Sa ' ry permit Fee (Includes Groundwater Date Issued I ge Signatu Stamps) )k3/Approved ❑ Owner Given Initial Su harge Fee) < X0 Adverse Determination oo~l X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: r SBD-6398 (formerly Plb-67) (R. 11/88) 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, 6138-266-3815. 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. Vlll. 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) l L- FA t R a _ C -7A c oT/pE /6O. S'S ~I I ON' ty~ ~I \ N o~ Ate- I Ln coo I W ~ _ \ Cam- ~ ~Q a LLI ~°s y~~ ro d N ~ v 0,00 3: rx V, _71YI7 _1117 35~" -v I----------r--------- -f- m m O i ~ I I z Y~ ~ I I I ~ °i < i~ i I t I ~ z i i i ~ I < C3 I I I e~ j G O I I ° I m m j m I I I I CA I rn I rn I w O^ 1 < I I I ~t I o I I I -o N I ~ O z ; ; m I I ° I ~o v I I I y m I N m p _ C 1 ~ Z C70 L4 I -p o~ f` x O -PY O _ o ° 0 -I °o C yy ---I I ° x < 7C G7 -I --i v = m N .D A o m o. z - _ -D m o X O -o . 4'. m 4' O 6Zj m pi 0 z I~ 4 i i Wisgorrsin,Department of Industry, SOIL AND SITE EVALUATION REPORT D 2 Page/ of La~s:~r and Human Relations Divisicn of fafety & Buildings in accord with ILHR 83.05, Wis. Adm. Code • COUNTY X 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 Q -:!),q I / / ' / GOVT. LOT t4W 1/4 N J 1/4,s2-7 T 29 AR E (or) W PROPERTY OWNER' MAILING AD99ESS LOT # BLOCK # SLOP. NAME OR CSM rRwr c-1n'4 K04 A Nv,Mtg; t2fl /LLS CITY, TATE IP CO E ONEN UMBER ❑CITY ❑VILLA E OWN AREST ROAD I A10 Lsaj W / 5 0)6 (//S-) 3 - L s0 ~ &LAnAs New Construction Use 14 Residential / Number of bedrooms Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow S;b gpd Recommended design loading rate 0.7 bed, gpd/ft2 0.19 trench, gpd/ft2 j_trench, gpd/ft2 Absorption area required A4<' bed, ft2 S&S trench, ft2 Maximum design loading rate 0s bed, gpd/ft2_0, Recommended infiltration surface elevation(s) C~IJK&r PLAtj ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable ft for system CO VENTIONAL UND IN-GROUND PRESSURE AT-GRADE 7W7TEM IN FILL HOLDING ANK able S 7nis Uuitable fors stem s ❑U ES ❑U [QS ❑U INS ❑U S OU [IS 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 -it) Ic2 Z s rr, Cr m 1 Ground l-33 j 1) y P_9 rev. Depth to yP, 4 0 /h /h D limiting factor Remarks: Boring # V- I CA :6 Z 6.4 0.s g -40 &)Y4 L s~ )"C G Z 6. 0.5 Ground elev. -12 10Y9 4 s S fh r 9z2 ft. Depth to limiting factor > r'0, ob Remarks: CST Name:-Please Print 'UA KEY ~ !&o Phone: Address: X / U fe • ~l Signatur Date: ~,S Q3 CST Number:.+V PROPERTY OWNERRAM lLd.C SOIL DESCRIPTION REPORT Page Zof .PARCEI.I.D. # -ai d 4UM&o Mw Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Botx~ary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Ground 8, r /Z 15 Y m 7 ~ :7 lev... ~Ift. Depth to limiting factor > Id •2S Remarks: Boring # L ~)1 7.Sy~ her Q a.4a Q:. i I-24 >o s Z I m (o k n,-~, a z 0.3 4.375 jove 34 Ground sL m r /v> 1 e j O 7 Ground . I fi-1 Ilove- . ft. Depth r rn~ p,7 0 to limiting 7 • Remarks: Boring L rr r>7~r C b ~.5 160- l» 0 Ground 9-Z Ss /AyR 4- 12>. Ili. r elev. s Depth to limiting factor > `3,54 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) 7 1 0 A - v J DIO Uo a Q ~ ~ £ u 4 NZ 1 i o _ N eP ` r l ' { r M a q~ ~ ~ p4 S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER_ S,4M M/L L ADDRESS L'O y FIRE NUMBER ZZg CITY/STATE_~U/gSD/Y &y= ZIP_~~/O/r, PROPERTY LOCATION : W 1/4 , _ /(/E 1/41 SECTION, T zy N-R 9 W TOWN OF- f/UDS041 , St. Croix County, SUBDIVISION _/{UM8/,'D N/LL S , 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 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/Ile, 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 Co. Zoning officer within 30 days of the three year expiration date. SIGNED: 0 4z DATE' Z 2 2- c/ St. Croix co. Zoning Office / 911 4th St. Hudson, WI 54016 STC-100 i 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 An delays of the pOrmit issuance. ,should this development be intended for resale by owner/contractor,(spec house), thenia 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 5AI.7.7 AI/LLAck Location of property NW1/4 N~F--1/4, Section -7-7 , T z'7 N-R Z Township ~~~soy Mailing address f-OX 4;e- Z S-- So GIJ.Z Syo~G Address of site _ 779 #11L rAR Ro.ab subdivision name_#OM 3IA>,Q fl/z4 5 Lot no. Other homes on property? yes No Previous owner of property H0M T? ( R D 4-4 A1,0 e- Total size of parcel z, 7i1 4c- Date parcel .was created -7-/z-93 !'Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house)? A' Yes No Volume-/02/and, Page Number Zg 2-_ 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. 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. s-oaz o' , 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. Sa zzaq attire of pplicant Co-applicant Date of Signature Date of Signature. DOCUMENT NO. STATE BAR OF WISCONSIN r ORM 1-1962 1 THIS SPA71 co,:0INO DATA WARRANTY DEED 502 VOL 1 1P1 REC. srt~~~s cry is ~ This Deed, made between .,Humbird Land Corporation, ST. C;101X CO., 4ti'i ft:;c d for Rccord A Minnesota Corporation authorized to do business i in Wisconsin JUL 1 2 1993 { i ........................................................................••----•...._•---•°•----•-I Grantor, and._$M_.E.. Miller.... at 42'C`~. P. X11 f Register of Deevs Grantee, J Witnesseth, That the said Grantor, for a valuable consideration...... i RETURN TO conveys to Grantee the following described real estate in ...$.X.e..G1O1X GNeef'+- i] County, State of Wisconsin: a2 0 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 Couaty on April 7, 1993 in Vol. 5 of Plats, Page y# 99, Document No. 497107. Lots 13, 14, 15, 16, 17, 18, 19, 20, 21, i2, 23, 24 and 25 t_ 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. , J~l I This xg_.nQt......... homestead property. (iaJ (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And...Huaibi zd__Land..Co.rPQra~.ion. warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements shown on the above mentioned plats. i and will warrant and defend the same. Dated this 12th day of ...Ally , 19_.93... ' Humbird Land Corporation, a Minnesota Corporation authorized to do business in Wisconsin .....................................................................(SEAL) By............................ (SEAL) a Austin J. Baillon, President - ....................•-'---•----•---_..._......._--...•---.......(SEAL) ---•--------------•---•........•----............-•--............----(SEAL) • • AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ~J~• . ss y County. authenticated this ........day of 19 Peraonall came before me this . ~~~`.day of -----------July 19._93.. the abbbW6 ter • • side*t :o'f-----~:'~.. y bgpted y . TITLE: MEMBER STATE BAR OF WISCONSIN ' -._Humbk~d..l,an¢-•~orporatiolZ_,-_•~-_~.j. (If not. a. authorized b e y $ 706.06, Wis. Stats.) I t to me known to be the person kvP ecuted tlu~ fore gohing* trument and acknowledgifll a san Q THIS INSTRUMENT WAS DRAFTED BV UJ IN N I . y._,. Q.. Kueppers,._Hackel..&.hueppeca 1350--Capital..Gent>_e, __St... Paul,._Mii-.5.~.1Q2- Notary lie __..5_T _...._...G county, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (if not, state expiration are not necessary.) date: 19.........) r c 'Names of persons slenin; in any capacity should be typed or printed below their Signatures--~=_- VARRANTT DEED STATE BAR OF WISCONSIN Wisconsin Leval Blank Co. Ina✓r FORM No. 1 - 1782 Milwaukee, Wis. 4 - 0,,e7 ,~t.C7 to ~ ~ D ~3~~ Gnn..~~'kf 0/-,l8 Ov q $S