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HomeMy WebLinkAbout020-1290-80-000 1 i 1 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 1UF4 ADDRESS ~d L r i SUBDIVISION / CSM# CJ I LL ,-05 LOT # SECTION__?~TN-R W, Town of r• /y ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 10 FEET OF SYSTEM D Sc4LF - 1 Tit, Jul l~ - `To.~ t,✓ -70 T-W(# `A Ix s t A T~ s 5 IN ICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: $4~ l kf- / N 6.4 K T~ EL = /ect ~ ~ . 3. / ALTERNATE BM: T P ojr Na,r. so. -:96u . Seed :a ►.SEPTIC TANK / UMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: W Z i St 2 Liquid Capacity: /000 Setback from: Well G S House 'S r Other Pump: Manufacturer Model# Size Float seperation'- Gallons/cycle: _ Alarm Location ''SOIL ABSORPTION SYSTEM Width: -S Length 40' Number of trenches 2 Distance & Direction to nearest prop. line: / Sd '7'v FXsT /.7- Setback from: well: House `11-9 Other ELEVATIONS 7S Building Sewer ST Inlet; Z.. ST outlet y5~ PC inlet PC bottom Pump Off Header/Manifold %(0 Bottom of system Existing Grade Final grade L a DATE OF INSTALLATION: PLUMBER ON JOB: oV~swl<.o i LICENSE NUMBER: ' r 3 Z_ INSPECTOR: 3/93:jt Lt rt st 29.19W, P'RIVATIESEifk% SY lol dram RQ -County: Labor and Human Relations ations INSPECTION REPORT Safety 8nd Buildings Division GENERAL INFORMATION ATTACH TO PERMIT) Sanitary Permit No.: Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.: SAN lHudson Ele : i Insp. BM Elev. BM Description: Parcel Tax No.: 1GO, a~ c5~,,~e aS p6-L . TANK INFORMATION ELEVATION DATA A9400110 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosin Aeration Bldg. Sewer 1-1 Holding- St / yf Inlet 95~ TANK SETBACK INFORMATION St/ Outlet TANK TO P / L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic > 56r _3 NA Dt Bottom Dosing NA Header / Man. 3~r Aeration NA Dist. Pipe g °'3 9j 1Z'7 i Holding Bot. System 4 PUMP/ SIPHON INFORMATION Final Grade -r- S, M ac u Demand _:a3l Model Number GPM TDH Lift F Syste Ft mead n Length I Dia. f Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width I Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS J5 a DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type 0 yic. j 0i, l).. r CHAMBER Mode Number: OR UNIT System: ALT ` '>IC) 7-5 DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) , x Size x Hole Spacing V take Length Dia Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Depth Over Depth Over xx Depth Of xxx Mulched Bed /Trench Center Bed /Trench Edges Topsoil eNo ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson.27.29.I9W, SW, NE, Lot 8, Hill Fra Road O L n lief P>.?CX lY/d c ~~d ^ a U!~ o, Plan revision required? ❑ Yes No f Use other side for additional information. 191 SBD-6710 (R 05/91) Date Inspector's Signature Cert . No. SANITARY PERMIT APPLICATION co '~ILlllr~ln In accord with ILHR 83.05, Wis. Adm. Code . l.fLO /y STATE SANIT Y PERM T # -Attach complete plans (to the county copy only) for the system, on paper not less than 9OFgg 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 /L L E,2 U1 t/a G '/4, S 2 7 T ?-I, N, R E (or)S) PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER d SON IS'fOAo 1141A4,? • O A/ L Ls 11. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLLLAGE : NEAREST ROAD 10 4OWN OF: 50.E ///LL FARM IZo~D ❑ Public X 1 or 2 Fam. Dwelling-## of bedrooms PARCEL TAX NUMBER( ) III. BUILDING USE: (If building type is public, check all that apply) 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 40 Church/School 80 Mobile Home Park 120 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. 0 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 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 90. 70- ELEVATION y S 0 SCv 3 600 0.6 Feet 91 7O Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New ~Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank ~O~d C.t.I a S F-1 F] Lift Pump Tank/Si hon Chamber Vlll. 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: 'Dow STRO115r 0 t - j?~ - Z" Zyi 3z33 Plumber' Address (Street, City, State, Zip Code): t^' D J9 DX 'a 7, '1- )4 F W L 1VSoK w= p/ 7 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanita Permit Fee (Includes Groundwater Date sue i g Agent S' n re (No Stamps) Surcharge Fee) XApproved F-1 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 8 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, 603-266-3815. 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 arid/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) SAM M ILGE ~IvMl~/R~ /!/ll s l07` 8 „r~ %y :~O TRENCH ~A F/ P) 90.70) <tl ~q/• 7o) ~s) (92.70) I LOT / F-R sf ffi" LO - i ~ppD lNA I ! L oT s .S ~ i LOT Q I 1 I~ ~ I Y o~ I F w y y J i WELL, m o 54~ ~I ~ HpusE ~ ~fl ~N 6 E ~8'X Sd " i j4 XJ2 , s~~ nt z v s~ Ttly v d 1 d Q.M. s~~rE zN DOALF-, 6Ak TREE EL. 100A 8-5 Doff I g~i t e q1 J~ , 1 AITU ATE I-or 411E AREAi~b, Ise ± B-~ SAC soaY`/~ nor tiNe Z93•40 ',/,~vofc.vtE1 _ ~ s 3 < 39 01 70 m z l b o j 1 , m O m m i oo I .p I N ` ~ OQ m o" I ~ o ~ ~ j { J n1 ~ w I i d in D "0 I ~ W 'U I ~ r 2 i m i CA m ~ • x o ~y _ O O --q O tp cn 90 14- 0 o --4 0 Fn m t1 x < x0 ~ V 2 m z T 'v -D m .D -n X O o° N n' Wi$consin Department of Industry, SOIL AND SITE EVALUATION REPORT C3 R Page I of Labor and Human Relations ,Division C1 Safety Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but r ~Q X 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 SAM M r CLE4 GOVT. LOT S w 1/4 ►V F 1/4,S Z 7 T i.q N,R ~ y E (00 PROP RTY OWNJ~Ri':S MAILINPDDRESS LO # BLOCK # SUBD,.~ AME OR CSM k6o TS~ZO0< NoA& 1 N[~mel a N/LLS City, STATE ZIP ODE PHONE NUMBER ❑CITY OVIL]AGE OWN NAREST ROAD ~s~ ~,.J a s4o c ) / /U .A& c-bnr 4S New Construction Use [41 Residential / Number of bedrooms 3 Addition to existing building I VA j J Replacement [ J Public or commercial describe Code derived daily flow gpd Recommended design loading rate 6, 7 bed, gpd$ O.8 trench, gpd/ft2 Absorption area required W, bed, ft2 St, 3 trench, ft2 Maximum design loading rate 0 7 bed, gpd/ft2D 6 trench, gpd/ft2 Recommended infiltration surface elevation(s) Ishl PAt,C anN ft (as referred to site plan benchmark) Additional design / site considerations n/Q Parent material Flood plain elevation, if applicable NQ ft S = Suitable for system CONVENTIONAL IMgUND IN-GROUND PRESSURE A -GRADE RS IN FILL HOLDING ANK U = Unsuitable fors stem H1 S ❑ U ® S ❑ U 20S ❑ U S ❑ U ~(S El U El S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bogy Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench / v 3 z rtn ~r C S Ground S- /OY 3 4 S Q S 1,c o 0 7 % elev. D `?2.Sl ft. 8 7311? 4 M VC-C) 0.7 O, Depth to limiting i Remarks: Boring # Z r A 10-I TSy U - S I C r 41F S t -7 10.16 /4 C-S B 38 16"le, 41A &I - S co o Ground elev. R5, ' ft. Depth to limiting factor _T_ > //,S6 Remarks: CST Name.-Please Print R yLly JQ~ Phone: Address: p , / I ' Tb , +DU~C ~l U ~5d ~ W i Signature: _4& Date: _ S 94 CSTNumber: '2V\ PROPERTY OWNER 'SAM rL~'F SOIL DESCRIPTION REPORT Page? of PARCELI.D.# LA 8 N )X1iBr1R& Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed mrK:h t 0-19 7. D - L 1 c,- C S 2g.37 p., 4 S t", C r m Ic's Ground C w CO :7 S elev. •br ft. lg -/r5 O it 4-14- 0,7 0,t Depth to limiting fa for > Remarks: Boring # A 0-j6 7.SY 6 rn cr- ,~,-Gr - 5 O I c s / c o o. 7 /6- -7 /O)LR -3/4 ~Z 7-/r`i ioy 3 _ S U j Ica 6.7 d.S Ground elev. 9Z.71 ft. Depth to limiting ~ f~ctry~ Remarks: Boring # -i~ 2 d - S 1 I r, cr y C J 4 El 16-26 ioy,e 4 - S c s z 0.7 056 - S 1 c~ ~,7 o g 26 Ground elev. ft. Depth to limiting factor Remarks: Boring # 13 Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) -I l n Tv 75, a-:Nt 179 a.: (°L'Z b7C~c'~ ~ Q[.ob d ~ ~ Z 1 rLV ~ t d- Q$ oo'oo/ . nrollb~~l~ ~ ~Y STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER SAM /Vt / c 4 E Z Z /,6 MALivG ADDRESS ~.t c. PROPERTY ADDRESS Z N , ✓ V" 7 (location of septic system) Please obtain from the Planning Dept. CITY/STATE tJ D.5 D /1/ W- It S /DI6 PROPERTY LOCATION S G{/ 1/4, 61,E 1/4, Section Z 7 T Z% N-R 9 TOWN OF 14 U.D SO A/ ST. CROIX COUNTY, WI SUBDIVISION J-1 y N\, 3 1 R~ N I LL s LOT NUMBER F CERTIFIED SURVEY MAP V71 O 7 , VOLUME 1©Z( PAGE Zg Z, LOT NUMBER S 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 Carmichael 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. Owner of property S14 In ~ll~L L E ,2 Location of property 54✓ 1/4 1/4, Section Z-7, T Z 1 N-R / i Township 110OS0N Mailing address 130X 4f Z f - A0 I> 50 7 WY S s/D/ Address of site 777 1 7qQr Yr-, ~O /4 p Subdivision name t-( 0 M 1~ I R D N I BLS Lot no. 8 Other homes on property? Yes X No Previous owner of property f/UM ~/,P D 4 4ND c,n. Total size of property b • toZ~ AL Total size of parcel 56 A C, Date parcel was created Z'17/S Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house)? X Yes No Volume L/ and Page Number Z$ 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. 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. SO z 2o , 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. SOZz.oq §-~6natui~e o pplicant Co-Applicant Date of Signature Date of Signature • • DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1988 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 502209 VOL REGISTER'S OFFICE 1021 pirr 9;Q9 This Deed, made between Humb"ird Land Corporation, ST: fi ; CCROiX RO:x icc CO.., , W1 A Minnesota Corporation authorized to do business n_.Wisconsin JUL 1 2 1993 Grantor, at :20 and 54M E. Miller 4 . Register of Deeds 3 , Grantee, S WitnesSettl, That the said Grantor, for a valuable consideration...... ) RETURN TO conveys to Grantee the following described real estate in $X: Croix County, State of Wisconsin. :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 Tae: 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 1 April 7, 1993, in Vol. 5, Page 100, Document No. 497,108. IN .5 L ..^8"r'µ This ig..nQt......... homestead property. (k1 (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And...H13R1b7 ~Q..kASi..~^.1 PQ>.81 }on 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 business in Wisconsin r~ fI (SEAL) (SEAL) BY... !Gt......... • Austin J. Baillon, President (SEAL) ................(SEAL) I • • AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN as. . County. authenticated this day of 19 Personally came before me this /'2..'`-(day of --July 19.13.. the abbtZ'1m led .1. 1 % , ) .._Al};31i1.[t._~, Ba 19n,...President .o'E".. .sot. TITLE: MEMBER STATE BAR OF WISCONSIN $gg11)j,~ ~,nd--~prporatiolY• ~•;':.~_j_l.~-• •t•~ (If not P authorized by § 708.06 Wis. Stats.) to me (mown to be the person a Wvl~ ~cecuted tki f foregoing ' trument and acknowleedg Sli4,e wind 0 H O THIS INSTRUMENT. WAS DRAFTED BY - (,J~H N b. d t Y ✓Ni d'Q,~.,,•••••~' f _Kueppers,...Hackel..&.ICuepAers----.............. • rpta .L350-.Capital..Centre,-.-St._.Paul,..BR..55.102. Notarc ....5.7'......C .Q./...........County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (Tf not, state expiration are not necessary.) date: 'Names of persons sicnina is any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc. i FORM No. 1-1982 Milwaukee, Wis. J. A,