HomeMy WebLinkAbout020-1292-90-000
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER SAM I L L F-k-
ADDRESS $oK V- z $ Z-
_KUPsoN wz ~YofI-
SUBDIVISION / CSM# (-I 0 M -13 l 12 D H (L L LOT # 20
SECTION 27 T 2-'7 N-R_IL_W, Town of H U D S O N
ST. CROIX COUNTY, WISCONSIN
i
PLAN VIEW LOT # P7
SHOW EVERYTHING WITHIN 100 FEET OF, STEM
12,LuF- s~RVe-E LANs
CAL - DE- SRC77B M
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100.
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NS p~ ~~S( INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
r
1 ;~IICI=III 1~1= 5,qz
BENCHMARK: I KI l u 12 Uj -H 17~ /co, 00
ALTERNATE BM: r-7 0
SEPTIC / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Wa j' z ~ Liquid capacity: l coco EAL,
Setback from: Well -~5 House Other
Pump: Manufacturer Model# _ Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: S' Length `f o Number of trenches
Distance--&-Direc~t on-to--nearest prop.-14-ne 56;V--Fn's-l:tic-
Setback from: well: IZ s House q6 Other
ELEVATIONS 141/4Nf%CE 0, $ 5
Building Sewer ST Inlet: N,0 z- ST outlet >7
PC inlet PC bottom Pump Off
16,f Ll
Header/Manifold Bottom of system
Existing Grade-,0 Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER: e ^
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor'bnd Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION .
Permit HoLdi4j' ❑ City ❑ Village Town of: State Plan o.:
~i
SAM ml LL 1 1292-90-000
02
/ ax o.
CST BM/,~Elev.: Insp. BM/~Elev.: BM Description: 1 Parcel T
t/✓t//l.L- ?c-ci 4
00" /D 0 11 J%Q4 003 22 1
TANK INFORMATION ELEV TION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic / Benchmark /00
Dosing r /l)~•33 /l7 '
Aeration Bldg. Sewer
Holding SONt~ Inlet ur y /l7/ R3
TANK SETBACK INFORMATION St/ t Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header/Man. g qd, -7
Aeration NA Dist. Pipe ~(S
Holding Bot. System
PUMP / SIPHON INFORMATION Final Grade
Manufacturer Demand _ jA!
Model Number GPM
TDH Lift Friction System TDH Ft
Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length ,'JJ No. Of T,~enches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS /X I!~ / DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O CHAMBER 3 a / /U / , / t1/14 OR UNIT Model Number:
System: /l/
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 ~cP Depth Overb ~tAl' 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.) tit•~ 3.
LOCATION:. Hu SON.27.29.19W,SE,NE,LOT 20,H~LL FARM ROAD Cwi
Plan revision required? ❑ Yes ❑ No Q
Use other side for additional information. y Fid , "
SBD-6710 (R 05/91) Date ns~ctor's Signature Cert No.
I
SANITARY PERMIT APPLICATION
■
'I;~'el`r■■~ In accord with ILHR 83.05; Wis. Adm. Code COUNT9.
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 go
8% X 11 inches In SIZ@. 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
F3 /L/' .5, 5-11, 4%,SZ? TZ7,N,R E(o
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CITY, STATE ZIP COD PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one) CITY 1 NEAREST ROAD
❑ State Owned O
VILLAGE T~J/~s ~IqX
K2' TOWN OF:
❑ Public 1 or 2 Fam. Dwelling- # of bedrooms PARCEL TAX NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply) 0 Z ' Z 9 Z
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. N New 2. ❑ Replacement 3. ❑ Replacement of 4.0 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 -
t~l Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 410 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 (s q. ft.) (Gals/day/sq. ft.) (Min./inch) C3' EL NATION
5 a (P ys 7 Z o (9,7 - / -oo Feet 47 C 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 000 15
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 Stam s) MP//MMfPRSW No.: Business Phone Number:
p 01.,6 &g rL J / - 1rVZ' 01I' Z
Plumbp s Address (Street, City, State, Zip Code): .Oe
/-77 i o n W-L - a
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sa i ryPermit Fee (Includes Groundwater Date Issued issuing A nt Sig No mps)
Surcharge Fee)
Approved ❑ Owner Given Initial
Adverse Determination / l4
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, 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.
Ill. 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)
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page -L of 3
Lat~v and 'Human Relations
®ivisign of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
C►x
-ST
Attach complete ship 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 t!55~ REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION a'
"SA kA ~ Lkat GOVT. LOT ~ 1/414F_ 1/4,S+~ G/T 2' N,R E (or) W
PROPERTY OWN t~S IKLLN DDRESS L7 ~ BLOCK # SUBQ.JV~ OW, Q# ,mss
STATE W) CODE PHONE NUMBER ❑CITY QV,ILLAGE OWN INEEESTROAD
CIjYj
NUISKbi <1111^
jK New Construction Use Residential ! Number of bedrooms [ ] Addition to existing building
j J Replacement [ ] Public or commercial describe
Code derived daily flow gpd Recommended design loading rate Q.7 bed, gpd/063 trench, gpd/ft2
Absorption area required 6445 bed, ft2 S6~ trench, ft2 Maximum design loading rate bed, gpd/11`1:2 d.T trench, gpd1ft2
Recommended infiltration surface elevation(s) 0.81 Am c 3e 3 ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable It
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE Y TEM IN FILL HOLDING-TANK
U= Unsuitable for system S❑ U ~S ❑ U as ❑ U S❑ U ~S ❑ U [I S W y
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 Trends
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Ground 93-01 Q
eW4 t- S +'%1 ? (S.? 4$
rev. ~
Depth to
limiting
Remarks:
Boring # A O-a i6vt 3 %&X ~r C ~
a-9 J`bY 3 S r /h a 'OL7 d"t
/D 4- S M 7 6.7 35
Ground
.elev.
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Depth to
limiting
factor
>J6.21
Remarks:
CST Name: Please Print N Phone: f Ova
Address: , d► d V~+ 1
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Signature: Date: 1 CST Number
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PROPERTY OWNER SOIL DESCRIPTION REPORT Page +Z of
PAR62LI.D. # 4+
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
BAAoring # Horizon in Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
C{ fr.•
p- 4 14[Y-1
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Ground 24-41 1
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Depth to
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Remarks:
Boring # t4 Jay
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Ground
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Depth to
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Remarks:
Boring # M-
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Boring #
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Depth to
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SBD-8330(8.05/92)
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER SAM M /I L.E2
MAILING ADDRESS t e, 2 9 L U A S O L,G>~ `r~` ~6
PROPERTY ADDRESS 7 S3 ) "A'r L- Se /I
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE / U S y /V (J Tj~U /6
PROPERTY LOCATION S 1/4, AIE 1/4, Section Z 7 , T Z `t? N-R -L- J
TOWN OF I-l y D S D ST. CROIX COUNTY, WI
SUBDIVISION H 0 M ]3 / 9 / /-L LOT NUMBER zO
CERTIFIED SURVEY MAP , VOLUMES~ PAGE a v , LOT NUMBER D
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: 5a491,
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 SA m ✓VI / L k- F t2
Location of property SF 1/4 Nf 1/4, Section :2 ,T_Zj N-R / j
Township ~40 p S ,,g aJ Mailing address itDX z8z
koD_T wT sVo/r-
Address of site
Subdivision name 14 u A/1 E? 4 2- ~/LL S Lot no. ZO
Other homes on property? Yes X" No
Previous owner of property IqV M R 4IVQ CDs
Total size of property Z, 3 o
Total size of parcel 2 , 30
Date parcel was created 'cl- 7 - 9.3
Are all corners and lot lines identifiable? A Yes No
Is this property being developed for (spec house)? r _Yes No
Volume S and Page Number / Do as recorded with the Register
of DeeddP Z/ Z$' Z
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. 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.
'y971 10-- 4nqo 'no z zn~
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S nature of Applicant Co-Applicant
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Date of Signatu e Date of Signature