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HomeMy WebLinkAbout020-1291-20-000 • w STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER SA M M I L L E A- ADDRESS B8X 0' 2 S IL- HOG-so w~ Syo(~ SUBDIVISION / CSM# E{U M B 1 iZD 1-1 1 Ll- S LOT # / Z- SECTION_1-T 2-1 N-R ~ ~ Town of (-f O D So t4 ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 6,404E bRIvE ~A/' - - I N/ELL - v I 'sE-y o - At TAR &fArf V Q n ~ sqf 5E /oR1/E2 E/,=/00 INDICATE NOR H ARROW E s r c~7 i le Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: To A AT S E /oT el x ov- jE Z00, 00 ALTERNATE BM: 1"e a,5 - M Z boo.- E I _ 4/, Z/ SEPTIC TAN / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Q i S w/ Liquid Capacity: Setback from: Well 66 House / Other 7S Pump: Manufacturer - Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: i~Length qO' Number of trenches Distance & Direction to nearest prop. line: _20 ~ Setback from: well: '70 House Ye Other ELEVATIONS Building Sewer ST Inlet. S -l8 ST outlet PC inlet PC bottom Pump Off o Header/ManifoldF 4,•` 6 9Bo tom of system S S Existing Grade Final grade ~ I DATE OF INSTALLATION: PLUMBER ON JOB: JJ_, tea, LICENSE NUMBER:,I~~jj~/~ INSPECTOR: 3/93:jt Wisconsin Depaxtmentof Industry, PRIVATE SEWAGE SYSTEM County: Labor andHumanRelations INSPECTION REPORT ST. CROIX Safety and Buildings Division - ,a~~ (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State P MILLER, SAM X CST BM Elev.: Insp. BM Elev.: BM Description: Hadson Parcel Tax No.: D~ . 60 led-, 4~0- / &6 TANK INFORMATION ELEVATION DATA S TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ie<s_✓" &,,?C . Benchmark Dosi n Aeration Bldg. Sewer de ~ H St/!(f inlet s ' 0 " 7/ ` TANK SETBACK INFORMATION St/ ICE Outlet S /p 3yl TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic > Sb / ' r1,4 NA Dt Bottom Dosing NA Headed 103,7-2' Dist. Pipe Holdi Bot. System S1"' oa, 6a' PUMP/ SIPHON INFORMATION Final Grade Manufactur Demand fO c' S'T 3, a7~aG.93, Model Number :::::G)M TDH Lift Fri System TDH Ft Head For Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS d DIMEN 1 - 0141-SYSTEM TO P / L BLDG J:W SETBACK ±LL LAKE / STREAM LEACHIN INFORMATION Type O Mode Num er: System: &0'7CHA NIT DISTRIBUTION SYSTEM HeaderA#Aw tfultci Distribution Pipe(s) / x Hole Size x Hole Spacing Vent To Air Intake Length Dia- Length 3 Dia. S` Spacing ~D SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Sys s Depth Over , Depth Over xx Depth Of eeded/Sodded xx Bed /1sc #Center Q - SCl Bed/ Tope rEdges V6,- Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudso.27.29.19W, NW, NE, Lot 12, Badlands Road -1 i Plan revision required? ❑ Yes 0'Kob Use other side for additional information. SBD-6710 (R 5/91) 1~?Q Date Inspedor'sSignat re Cert. No. I ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: r ` j i SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code ':-J. • STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 0"1a'S+ 1/Q_',7(-7 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 '/4 '/4, S Z Tz , N, R E (orQ1l PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUM 3EER L) an wZ S d / - L./M 6 , --er l II. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) ❑ State Owned VILLAGE : 2 TOWN U~S apt L A A.0-5 eog ❑ Public )K~ 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUM ER(S) III. BUILDING USE: (If building type is public, check all that apply) 0 ZQ / 5P Z~ 1 ❑ Apt/Condo 6 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. [2 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) ELEVATION , _ ~ O Z-Q ZO .7 - 03 vO Feet 0~4k7 Feet VII. TANK CAPACITY Site in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks Concrete glass App. Tanks Tanks structed Septic Tank or Holdin Tank QD~ g i ci T 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 S ) MP/ RSW No.- Business Phone Number: S O k e 343 Plumber's Address (Street, City State, Zip ode : IX. NTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Ag nt Sign a (No S ps) YS%¢'` Approved El Owner Given Initial /~i~/0 Surcharge Fee) CQy~/ Adverse Determination y%%V%_0 Surcharge Fee) X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(8.08/93) 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, 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 EI% 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) ' ~iJST Lo7LiNE z/7 0~ ' ~iYo Sl.~~t' o~ ~i ~ y U ^ o 0 1~ 't 4 O o ti F Ab 73 r- m m n 4 A IroT ( -I } O R D rmO ono a~C ~ ' ~ Z Yn C7 C N Z k5y I m g~ A T N O LAJ Z l ~ iz) -1 v~ ~ :c o 't) I m C rn T" ,Q1 0 ~0 In / J L 7r- r lui o vi a ty 1\ _ r- ~ o lA ~ _ c Q m y N f1~ C \ ` (1 c° ~i~~112 ~Nr~ 0 1s~ Q b O ~N 2l J- TAT -Wisconsin D'epartmenf of Industry, SOIL AND SITE EVALUATION REPORT Page I of 3 Laborand Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code • COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but R 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 S4 M M 1 L.LOP- GOVT. LOT /e/ LA) 1/4 N E 1/4,Sn T Z9 N,R 9 E (or) W PROPERTY OWNERS MAILI ADDRESS OT BLOCK # SUD . AME OR C M # ,I k6oT koc umdjpA dacs CI ST T ZIP CODE PHONE NUMBER ❑CITY ❑VI GE OWN N R I EA ROAD one ( ) L )GE Lb"JisS New Construction Use Residential / Number of bedrooms [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate (~.7 bed, gpd/ft2 01 trench, gpd/ft2 Absorption area required bed, ft2 SAS trench, ft2 Maximum design loading rate 0.7 bed, gpd/ft2n.% trench, gpd/112 Recommended infiltration surface elevation(s) 64 PW40- ~cnb l- ~ it (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system 79S ENTIONAL OUND It~ROUND PRESSURE AT-GRADE 79S TEM IN FILL HOLDING T K U =Unsuitable for s stem ❑ U S E] U PIS ❑ U of S El U El U ❑ S IU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Botnxiay Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trendl >v, VILA _r% ILL L Os 2 N N uruund L~ 31-4? Wle 3/4 -Z n, SbK r C Li / 0S O,6 elev. icl` -ot. $ 0I2-/COY ~ 414- Q r►~ l 02 Depth to limiting factor 7 /x.17 Remarks: Boring # 2 S D, L Z A b rats r C w l.•:<::: r, Z ~3~•30 Y 3 ~ S, L Z rh s1o1; rn r C ~ ~ O .S' p .6 hr:}. •hiiC~ Ground yQ S r r~ 0:7 :dg elev. /0$ 1,16 ft. Depth to limiting f t Remarks: CST Name:-Please Print Phone: Address: A o So 1") Signature: Date: C L CST Number: A &A -PROPERTY 0WNER 441 M,LCCO SOIL DESCRIPTION REPORT Page? of PAHCELI.D.#,L/Z 9UM810-4 Boring # FHo~rizzonn Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench -1 /4 3 ~ L ~ ~b 1h r+- C w 2 O's d, ME le 01 Q'LAJ :.;.v Ground e az pyp, 414- S 0.7 O el v. 161.0t. Depth to limiting factor >~D•G16 Remarks: Boring # 247 10-S b-& 16M L C) 0 L 02 31 3 14- 6 Yk \tiih~:ti•:•.sv\ r3 -~~7 oY S r P1 O • o is Ground elev. /o7,96ft. Depth to limiting factor ~ Remarks: Boring # 2 , ' /d ©9 ids! 3 / m c t- C w Ground Oy►2 © vh rM 0,7 el v. /6 <ft. Depth to limiting f to ~z Remarks: Boring # 0:•: v4tiL3i4:•:ti •4 Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) N i LL ~-'b,Q ik ~d►~~ ~ b Qe . . z"a 1. f n. !I r) Ak~ , N w' ~r ¢ D Z 71 lp. p 4 ~ 1 rb ~ I C Z u: N _s W ,b 0 c ~ L W I c 1 W Ilk- STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER "S Affi /yI /Z 4 eP_ MAILING ADDRESS Zg6 X Z Q /so t" Lt-)-Z PROPERTY ADDRESS G 7/ ?,419L A AID s Aa A Q (location of septic system) Please obtain from the Planning Dept. CITY/STATE U .D SO Al Ly Z /fv PROPERTY LOCATION 1YA1114, WAE 1/4, Section -2-"' 7 T zI N-R TOWN OF 9 4,U SC. A, ST. CROIX COUNTY, WI r SUBDIVISION /~fW 68't r d' / LOT NUMBER Z- CERTIFIED SURVEY MAPyq 7) D7, VOLUMES , PAGE, LOT NUMBER 1 Z 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: DD DATE: y 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 5,410f /I//LL~•e Location of propertyAL&o~_1/4 N,--- 1/4, Section Z,T2_? N-R /Y Township Ny DN Mailing address .?d(-W Z8 2-- D .5 w St/o14 Address of site 7 1 B AD LA N D g A -0 Subdivision name ~~t 3 vv L, rX V r 5 Lot no. ( Z_ Other homes on property? Yes~_No Previous owner of property H w.b;rQ ~a Q G . Total size of property . z yo /4c Total size of parcel 2. L y o Date parcel was created I Z - '7 - U Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? C Yes No Volume /02-1 and Page Number 2cF- 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 y office of the County Register of Deeds as Document No. ~p ZZ d 2 , 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. SCE 2 Z o 9 Signature o Applicant Co-Applicant Date of Signature Date of Signature `gyp z CR 'I aW Z ~t a W FO ~d N LLI :3 n. o w a 4 Z -j M .d 0 > I- ~ O Y N O O ~fi O F- m r O O X ~ w I 1 v w ~I N i~ z I - w I a I I j 1 4. 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P THE SW 114 OF THE NE 114• ALL IN SECT/ON 27, T29Na R/. Of HUDSON, ST CRO/X COUNTY, WISCONSIN. • 1" iron pipe found O 2"X30" iron pipe weighing 3.65 lbs. / !in. ft. set all other-lot corners are marked with 1"X24" iron JOHNSON S~ a pipe weighing 1.68 lbs. / lin, ft. e $ ~oo Drainage and ponding easements to elevation shown SURVEYIN( Section corner monument - Aluminum cap found HUDSON. (356.67')Previously recorded information • ZI ~ 1••1N~.N -Sn t No CURVE DATA TABLE LCCATION SKETCH Curve Lot Central Radius Arc Cb~r, Number No. Angle Length I Bndry 46.00'00'• 167.00' 134.08' Si3'S5 NE CORNER seIs N R 27 2 - 46.00'00" 233.00' 187.07' S22'S~ T 29, 19W \ 2 6 20'31'02" 233.00' 83.44' 510.1! / 2 Road 1617'08" 233.00' 66.23' S28'3' o'\ 2 7 9'11150 233.00' 37.40' S412: UNPLA7TED LANDS at - - _ I w1 ourLOT z z; ~ 8.300 SO. FT.~ J) 14.14' 0.144-AC. 0' 00' 14' M 898.38' S 217.56' 217.06' ~~''y~ • 217.5 _2171.51V ,.y o I I A•~' 884.2-' I 1 14-00' . 1 -I i -::r- /4 I I ~E6\S~*oxco-a 001 4jAU i 12\1 1 t 97.98 SO. FT. ~ 97. 54 SO. FT. v 97.56 SO. FT. I _,,97,560 a•... FT. ~ 2.i40 AC. ly 2.240 AC. M 2.240 AC, j W Q .s•J'o- -..,try ID I sl •~iJJPR"'- L7~ 0 2.2x0 4C. d I a'o~ I ^ S F OI ~1 ° ~1 V z I 0 01 I _ z CD 1 I O~ 1 z z Z Q W I I OI I cr BENCHMARK- TOP OF C NCRETE OF SOUTH POST C H MBIRQ ' I HILLJS° SIGN, ELEV. • 5.02 14 ...881.54'' 6 f' ( I'- .00,/ I or 216.13' 216.13' 216.13' 216.15 $ 00.710' 14'M 302.86 I N 00 00' 2057 ' 11 E 1201.91 , 6 r14 RO D I,, ro ~A3 S 00'00•f1•M 122.27' 160.~, ,206,91• 200.00• 200.00200.00• i I 1193.7938.00 0 p. 1 40'X 40' JOINT \ ~',Ei -M DRAINAGE EASEMENT RDRI "E UNNING EASEMEN \ I I RUNNNG 40' ALONG ~L]I 1 I COMMON LOT LINE - "4-BUILOING ~10• AND 20' ON EACH II SETBACK I I p LOT. I I 50•-.~ LINE O P al O O I P ' (5 I 01 O + • I • • 05 ' o II O y O W BB.39 50. FT. 88.39 O. FT. v 80,39 SO. FT. Y1 88.3 S0. FT. W 118.105 50 FT. d 01 O O : 85,791 S0. FT. 2 1 w 2.029 AC. » I 2.029 AC. w 2.029 AC 2.029 AC. .71 AI:. "'00 N n ♦ 2.061 A4 I co 7 O 3t Z 0 ml I p0 p O m I 1A ° ~ ~ ~ cu II ~ ° ~I m I i II to I I ° 27.82' Z 200.00 200.00' 200.00' 200.00' 200.00' 267.3•-' I I nn'nn' 4d"F 4' n0 •R'