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HomeMy WebLinkAbout020-1291-10-000 t t STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER S ~w7 001/L L ,452 ADDRESS 90X -At- as--Z- All.,, L>z6)y SUBDIVISION / CSM# N J l~ l3 1~ © L V 5 LOT # SECTION Z 7 T 2- 5 N-R /P Town of C,~ p S e1Sl ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~r"~" 1$~~ g~/t/I,ToP of /'PIPS - ° - Ili/A T c i 23, 4 r Iqf V ys ' b v W6 L ( i (,Oa 0 D ~ q5 ~sT Lo7 L/N INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. 1 r r BENCHMARK: ALTERNATE BM: 70lI o~ ~G~t21s.:J2~a ~.L A~JrO~ SEPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: 100C) Setback from: Well V House _?7 Other ~-I- Fi.•y, /V Pump: Manufacturer Model# Size'--- Float seperation- Gallons/cycle:- Alarm Location - `:SOIL ABSORPTION SYSTEM i Width: ~g Length go Number of trenches - -Distance--&-Direction-to-nea-rest prep: 3-i-ne: P_ Setback from: well: House Other 1 zb rt° F LoT /r'H° ELEVATIONS Building Sewer ST Inlet. t? - Z ST outlet I2, PC inlet - PC bottom Pump Off -~N_ 13 q~ Header/Manifold eH- i4os Bottom of system Existing Grade [('y Final grade l~,y DATE OF INSTALLATION: PLUMBER ON JOB: v ~ LICENSE NUMBER: INSPECTOR: 3/93:jt ,Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX < Saf2ty and Buildings Division - GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI MILLER, SAM X 9P 1291 10 000 .lkm.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel r j i 19, epT A~~e A9400250 TANK INFORMATION ELEVATION DATA 09 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing- / S Aeration Bldg. Sewer Holdin St/Yf Inlet 30 TANK SETBACK INFORMATION St/ Outlet 00 TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic 4-~ -'39' NA Dt Bottom Dosin NA Header / . /~1_?/ Aeration NA Dist. Pipe j 38 SZ Hol Bot. System 519 ' PUMP/ SIPHON INFORMATION Final Grade 9' 9S/d Manufacturer Demand o S T. S_ ~8 93, 6a2 Model Number GP TDH Lift Fricti Ft Force ength Dia. Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width G Length No. Of T enches PI No. Of Pits Inside Dia. Id Depth DIMENSIONS 0 </O DIMEN 1 N SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEA nufadurer: SETBACK INFORMATION Type O o.<,fx µ CH R Moe Num er: System: pa..cd R UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) s er x Hole Size x Hole Spacin Air Intake Length Dia. Length . Z Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade ems Only , Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Depth Over Q) r, I Sod rr Topsoil E] Yes ❑ No C] Yes E] No Bed / TfealMenter Bed / T Fdges ClId- COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: H dson.27.29.19W,I W,~E,L T 1r HILL FARM ROAD Plan revision required? ❑ Yes No Use other side for additional information. j~ f) g SBD-6710 (R 05/91) Date Inspect is Signatur Cert. No. ADDITIONAL COMMENTS AND SKETCH r SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION coin In accord with ILHR 83.05, Wis. Adm. Code STATE SANITA' Y PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 0 cZ3 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 -S-A /VI X Qj _)e . /a 0 S Z 7 T zCf , N, R / E (or)(0 PROPERTY WNER'S MAILING ADDRESS LOT # BLOCK # Boy( -FZgZ H CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER HU N\ 12D H LG S ~ 7 /o go ? s wL S G/ 3g' z 76 II. TYPE OF BUILDING: Check one CITY NEAREST ROAD FV_j :ja TOWN OF: ( ) ❑ State Owned ❑ VILLAGE : DSOG IMILLEAR-M ❑ Public 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) Z U 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 N 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) C~ ELEVATION V8 -72-0 0,7 { Q, 60 Feet / 3 S Feet CAPACITY VII. TANK 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 Septic Tank or Holding Tank 0040 tL S ✓ - F] F] I D_ F-1 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: MP/MPRSW No.: Business Phone Number: po C. sTeo Plumber's Address (Street, City, State, Zip Code): oop, iz~ ~w /cyitilD~d wL se IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sam ary Permit Fee (Includes Groundwater ate Issue Issuing Agent Signature (No Stamps) _9( , - g~; - - koy Surcharge Fee) Approved ❑ Owner Given Initial Q~ I'l (V I Adverse Determination o 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 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 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 6% 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) s M AA ILLE tZ ti UM$ i-D WLL- L.oT SV sTF-m SI 90,00 SCALD 1/y~_ • 13: M, Tc~ c F I LoT P I'P;t AT -SF- coiZK ~ oa a~ EA5-r l c7 LINE ~~7• sc ' ~ ~~NDIN6 EASEAAIFwT 8 M. I1 Ro N E AT jHE SE LoT Coll-MEA F1,= 100,00 i 84, / 1 i i LTEiZ- A RF A NAT L q0.00 G A -A i 90' 9Q.S0~ V e I ~ ~ ~ yo' l h 1 LOT l~p 7 rso ~ Lo? I o L ~T'/z - - LL1 z ~ 6kR~F6E dddy \ a( ~i'xa2' USE WELL I 1 R E w A y i WEST 101 LING Z18.13 ~ F A tZ M lEo,4 D_ _ ~ - z I I I pt I ~ i I I I j < R' I I I c7 j ~ Z 1 I I ~ 1 I I j G j < I I o I Gi C13 I z I , j 1 -a d I I I ~ I _ L4 c~ j I I I `I j D I I I 1 I I j co I 1 011 1 I I I n 1 I I I m I I -o cn o z I I H I n z -n 1 I I n C I O , I I r I -u rn o I I 1 o I C 1 I I ~w I .ti j I I .P I m I I -T o {as C/) I m 1 O LA I Z co I ~ ~ ~ s i m Z'Ps I~\ S~ X ~ -PY N` COo 2 --I CA O co cn Fn -n x J m y. =O Az b -o m -u m X ~~77 O C O `*1 P, Ps ~ I~ E 1 0 m I W"nsin Department of Industry, L4bor ai Hu man Relations SOIL AND SITE EVALUATION REPORT Page of x} Division of safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY S-r C£~ i ' Attach complete site plan on paper not less than 81/2 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 OWN R: PROPERTY LOCATION 11 I LL, t GOVT. LOT t4 W 1/4 N t 1/4,S 27 T Zc N,R 9 E (or) W PR PERTY OW ER':S MAILIN DDR SS LOT # BLOCK # SUBD. N OR CSM # ! j ~ kOuZ ~f ~A N CITY, STATE ZIP CODE PHONE NUMBER CITY V LLAGE OWN N WEST ROAD tSA t04 4 A-< New Construction Use KI Residential / Number of bedrooms Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 4<93 gpd Recommended design loading rate 6 bed, gpd$ 6, trench, gpolft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate 0, 7 bed, gpd/ft2 4 $ trench, gpd1ft2 Recommended infiltration surface elevation(s) Sc~ tr PAC'k 3 o C ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable It S =Suitable for system 0 VENTIONAL MOWJ D I ROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK -U = Unsuitable for system s O U ❑ S U S O U O S U O S U [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 ranch d-Ig 07 P, J L Z c~ r Z Q_ 06 E3 8) nyk~l~_ L 3 c PC- ill 'f~l C Ground {~i 33.5 -7,S-V 4 i-h 7 O elev. °7-S3 ft. / jpyPZ Depth to limiting factor >i0.1 7 Remarks: Boring # F lu 3t G /c_c - s 2 N~ NA 13 A 3f- ~9 nyoF ?Z/ 1_ I 5~ ri~r c S I a Ground 16VR 3l& 6.4 cos 7 a elev. SZ- /v~ ~I r rn S IT 97.Zsft. Depth to t~ lffwl~ /d yf' ? s rv I T O I limiting factor >9.9'Z Remarks: CST Name. Please Print 1 f2VL~Y J~ N ~St~n~ Phone: Address: U t.5_~6"j Signature: Date: , ~ , ~ ~ ~ CST Number. 3M4 aft I . LA PROPERTY OWNER SAA A)LLLIP, SOIL DESCRIPTION REPORT Page -Z of 3 ,PARCEL I.D. # Lo i 1I go 8 ~ Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench U.S 4.6 g-z 1 taYr~ 3 3 _ L, Z S, n,~, C Is Ground r, l D. z elev. g3 /aft Depth to limiting factor Remarks: Boring # A d-14 /t)vvV/ L, c r. r O's r1 QS p.6 Q- 14 -3~ I4`l 3 3 Z c Ski r~ C S 1 S a.~ Ground PZ /oy 414 S r+r f Q7 b,i elev. q[:7o ft Depth to D limiting D 3 ~b Y~Q 4/6, S factor Remarks:3 Boring # p-~ /C~Y~3 / _ Z c r rvt~r C S Z O,S ~.6 El J7, c. s 1W 0, n, , I J7 Q, Ground _ elev. $ 1 10Y 4 r m, ft. Depth to limiting factor >_2.73 Remarks: Boring # 131 Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) r c r (N N 1 y: O W 1 • ` - r rb A i a ,o w T t/QI 1 Q~ ~ ~ ~"C7 1 ly - ~ 10 1 I im w STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER S_ A /y/ 1 1 4 / L Z F e MAILING ADDRESS ee9 V ' Z f (u L o PROPERTY ADDRESS 7 9 3 FA e O ~l D (location of septic system) Please obtain from the Planning Dept. CITY/STATE H U 0 S o A w z S V o PROPERTY LOCATION i~tJ 1/4, N F 1/4, Section 2 T 2 9 N-R. TOWN OF b S n ST. CROIX COUNTY, WI SUBDIVISION N y nn 12 A f~ l L L S LOT NUMBER I I CERTIFIED SURVEY MAP y 9 ~ p , VOLUME PAGE 9 , 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. t SIGNED: DATE: 7 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 B 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 S'f1/N M / LL.fc? Location of property1/4 N 1/4, SectionZ -7 ,T 2-9 N-R / W Township U D So Mailing address Bo x # zX 2--- N u ~Sov~ w r YO Address of site A11LL Fq P-A4 laces A D Subdivision name l7 to R 10-0 r} I LL- S Lot no. Other homes on property? Yes_No Previous owner of property Hu M (~l2 Q LAAIO Total size of property Z. ZY0 y¢~. Total size of parcel -2, 2 yo ` C, Date parcel was created - / Z -9 3 Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? _ k Yes No Volume 102-1 and Page Number Z 8 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 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. SD ZZ © ' , 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. S© -21 Of Signature of Applicant Co-Applicant Date of Signature Date of Signature DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1962 THIS [PAC[ RESERVED FOR RECORDING DATA WARRANTY DEED 502209 VOL LL__ 1021 PAGE 2R-2 REGISTER'S OFFICE ; S. coax co., 4vi This Deed, made between ..Humbird` Land Corporation,. - R c d for r:cord . Minnesota Corporation authorized t do busi ness .t . s .in..Wisconsin . JUL 12 1993 Grantor, at VRSistBr :20 P. and Sam E Miller i, of Deeds i , Grantee, Witnessett1, That the said Grantor, for a valuable consideration...... 1 RETURN TO conveys to Grantee the following described real estate in Crr9?x-----_ - County, State of Wisconsin Lots 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 nd 12 in the Plat of Humbird Hills, Town dson 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 lst 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. OV / i This ia..nRt......... homestead property. (W (is not) Together wi'h all and singular the hereditaments and appurtenances thereunto belonging; And...K1301k7. Si..ia$ASI.. ^.r Q~ t 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. 19..93... Dated this 12t,h............. day of ...July-........... _Humbird Land Corporation, a Minnesota Corporation authorized to do business in Wisconsin (SEAL) BY... (SEAL) a Austin J. Baillon, President (SEAL) ...(SEAL) r a • AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN SS. ; County. ° authenticated this day of 19...... Personally came before me this /-f.-.'((day of ..,Tiny , 19..93.. the abbt, `wined • :3 •---•--•----•-•--••-------------••----................w................... 47- • 'f C AU.5itjA__~a...B._.a.illQ_n.a Presidevqo 4 . r , TITLE: MEMBER STATE BAR OF WISCONSIN $r}1?j,d-_n¢. CQrporatiorr, ~.,___~.1_~.~.P.a•~ (If not, ...~.--...I~..: « authorized by § 706.06, Wis. Stats.) to me known to be the person `I IW4 ecuted' thA j foregoing . trument and acknowledgA, t7l4Le ,20 h ,t U THIS INSTRUMENT WAS DRAFTED BY Ll f HEN 0. 14 t YVrDw-p-.•••~•• f µ.:.O...,L. - .Kueppecs,_.Hackel..&.Kueppe.zs • • 1350__Capital_.Centze, ..St._. Pau1,..M1I..5c5.L02. Notary lic ..._.-r......r" .Q./.x........._County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: 19 ) •Names of persons si[ning In any capacity should be typed or printed below their sisnatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Ino- i FORM No. 1-1985 Milwaukee. Wu.