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HomeMy WebLinkAbout030-2091-40-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ~iJ `Llr/~r ADDRESS^,f-/ HGJ ¢it ~ht, SUBDIVISION / CSM# 1s(' 2~4~ -Si LOT # SECTION_T,-3t-_-)_N-RAW, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM aJ c~8 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK:p ~~o,b~ - /CJD O ALTERNATE BM:. SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Well House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length y~ Number of trenches Distance & Direction to nearest prop. line: Setback from: well:- House Other ELEVATIONS Building Sewer ST Inlet. 94,S ST outlet PC inlet PC bottom Pump Off Header/Manifold K2 Bottom of system Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: ' LICENSE NUMBER: LL~~~ INSPECTOR:- ~ //'//~d'10 e-A 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Lafet and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State P i2ja j5 03t 3 VANASSE, MICHELLE X CST BM/Elle}v.: Insp. BM Elev.: BM Description: Parcel Cc A9400269 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic `,C} J Benchmark,/ Dosing > r' 56.'x.'1 Aeration Bldg. Sewer Holding St/ Ht Inlet 4/ 4y TANK SETBACK INFORMATION St/Ht Outlet Vent TANK TO P / L WELL BLDG. Air Ito ntake ROAD Dt Inle Air Septic NA Dt ottom Dosing NA Header / Man. ?,oZ [ Je Cj 1 Aeration NA Dist. Pipe / Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand -5- 52 //fi fC 0 , Model Number GPM TDH Lift Lriction System TDH Ft Forcemain Length Dia. Dist. To Well Head SOIL ABSORPTION SYSTEM BED/TRENCH Width, Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type o c? / F+ ; CHAMBER Mode Number: System: t10 aZ 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.) r j7` w' / LOCATION: ST. JOSEPH.26.30.19W,NW,SW,LOT 4,AWAUTUKEE TRAIL Plan revision required? ❑ Yes ❑ No 3_ Use other side for additional information. a YClitii SBD-6710 (R 05191) Date Inspector's Signature Cert I ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: =:7-jffff1 SANITA RY PERMIT APPLICATION LHA In accord with ILHR 83.05, Wis. Adm. Code couNTY ...~.,_..a. QMIT -Attach complete plans (to the county copy only) for the system, on paper not less than STATE SANITARY 4 b T 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 '/a T , N, R (Oro' P P RTY OWNER'S MAILI G ADDRESS LOT # BLOCK # / CITY, TATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER r 7r 1 II. TYPE OF BUILDING: Check one CITY NEAR T ROAD ( ) ❑ State Owned VILLAGE ❑ Public 141 or 2 Fam. Dwelling of bedrooms ~ PARCEL B III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo /CJ 2 ❑ Assembly Hall 60 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. 0 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 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 420 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 Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank AW-[=- Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installati n of the gnsit wage system shown on the attached plans. Plumber' Name (Pri Plumbe 's Sin re o m MP/MPRSW No.: Business Phone Number: Piu tier's ddress Stree , City, Stat , Zip Code : J 1JP IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sa a Permit Fee (includes Groundwater Date ssue Issuing A nt Signatu s Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Ybu( sanitary permit may be renewed before the expiration date, and at the time of renew1-cl 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 1'ransfer/Renewal Form ,SR + 6399) to be submitted to the :aunty prior to installation. 5. Onsite sewage systems must-be properly maintained. The tani((s) must be -pur ~ ! t=.; a licensed pumper wherever necessary, usually every 2 to 3 years. 6. It you have questions concerning your onsite sewage system, contact your local-code adn-nistrator 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 nornber(s) of where the system is to be installed. il. Typeof 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 perrnit. Check only one in line A. Complete line B if permit is for tank replacement, --!connection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorn'ion system information. Provide all information requested in 141-7. VII. Tank ;nt? ranation. Fill in the capak:ity of every new and/or exisr r,..J k, !ist the ful-! r of tark:; ant manufacturer's name. Pidica e prefab or site consrru;-')~,,i and tank rrate+i.d. i tF :::r all sel)t p' inp/siphon and holding tanks fc,, this system. Check exf:r irnt ,tai a.ppnova: c J +r.> s received , xperin..?n"w product approval from DILHR. VIII, espons.ibiiity statement. Installing plumber is to fill in name, iic;E r e ) mbet with a;7! r >r+ri< pr9fix (e.g. MP, etc.), address and phone number. Plumber must sign application fc;rm. IX. County/ Department Use Only. X. County/Department Use Only. C'?n :;~e^Iflcatir of :+rJt Smaller than 81z a 11 Inches r~[; ~r be SUbmlt'r'(? to fhf Su i ntV. The 1- on, rnt! tale fc~;owing: A) plos Dian, drawn tb SCME or wi'~`° :P. Utr .w 'I } , r;}ion of hc-A og) ,a f nlic iank(s) or other treatment tanks; building `vate5 *yr service; s?reair, af)6 idkes; JUMP or' slphcon Clinks; distribution boxes ,c),i taw<:'4imi systewn rii rr-r.?nt system area , ,n c li- locat.on of the bui!d;ng served; B) horizontal and vc7r€i( Jevation ra.'ff rr..'rE p- 1r3; C) complete specifications for pumps and controls; (Jose volume; elevat )r differences, fric'.i_r, loss; pump performance curve; pump model and pump manufacturer; D) cross sect-on of the soil ab3or)tion 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 inciuded the creation of 3urcharqus f07 ; nurn,) r Of regulated practices which can effect groundwater. Trip- -+,on es collected through hese st~rc,haige;o ;1;t:. ;sei' 'or water contamination mvesiigatlons and establish: e,, i (st vz fit': ariia _ . SBD-6398 (R.11/88) , b 3 vz~ 42 G y8' PAC, c or y • G •1\ . .E Ak • U1e01 41►1 I/ 96601V41194 • PI veal Cot MWww /dt"@go i Coto If *4 Y•w1 1• /1.•1 ►V • 01,14• ' •1vM INI 01 hw~1•.Ik CaaM~ ' Pop 0 p•111••11~~ • • - T•• • F011440104 Piro 6,19w, • ~"C•,•11w~ irwlw•11•t Al " i•11•w 01 il•1•• . COIL rILLl . ©1MIBUT101.1 PIrC APPRO"cC S'wi'11CTIC COW 2" of l1GGR1:6A1E OK I" OF STRA oR MAR N.tiy !14, OP It -tl/a A.GGRCGATC ELEV. of= FEET, OISTRIpUTIow PIPt,To BC AT lchi'f WCHC3 BCLOW OR}G•1►JN1• •L.SADC AUN AT LCASTLO WCNCL OUT 1.1o oi%c TNA1J `12 IuC►{CS CCLOW rl►JAL ~,I~AOC 'W'MUM DEPKVi OF E-ACAVAT100 FKom oK16Y4AL 6RNv~ WILt. 15E -Z2_ IWLHCS YVKIMVM OEPTIi OF EXCAVATION f OM, U,I4111AL. GRADf. WILL. 6c INO<5 SiGIJL~: ` ' ti LICC►JSC 1JUM5E11; •v OgTC: ~(99- n1a Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of Labor and 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 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 GOVT. LOT 1/4 1/4,S T AR E (or PROPERTY OWNER':S MAILING ADDRESS LOT B 0 K # SUB NAME OR CSM # ROAD C TATE ZIP CODE PHONE NUMBER ❑ ITY VI LAGE OWN NEAREST ID ~(J New Construction Use [u] Residential / Number of bedrooms [ ] Addition to existing building Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate ~7 ed, gpd/ft2__,_~trench, gpd/ft2 Absorption area required bed, ft2.G trends, ft2 Maximum design loading rate __,~bed, gpd/ft2_4.&__trench, gpd/ft2 Recommended infiltration surface elevation(s) , l ft (as referred to site plan benchmark) Additional design / site considerations Parent material 04,4-au/ W2,441 -s- Flood plain elevation, if applicable ft s = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem 5D S ❑ U ®S ❑ U WS ❑ U ® S ❑ U ❑ S ®U ❑ S U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Bowdary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Ground - , elev. - - C ft. ['o_ 5e:- le Depth to limiting factor Remarks: Boring # J Ground / elev. _ ft. Depth to limiting factor > 2C Remarks: CST Name:-Please Print Phone: Address: Signature: N Date: CST Number: PROPERTYOWNERs~/,~ii~ SOIL DESCRIPTION REPORT Page~of 3 PARCEL I.D. # Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Bound3y Roots GPD/ft in. Munsell Qu. Sz. nt Color Gr. Sz. Sh. Bed Trench ^.i yv. AJZ V~ Z Ground 3 _ elev r ft. _ Depth to limiting factor CIO_ Remarks: Boring # Ground elev. ' ft. Depth to limiting factor Remarks: Boring # 4•'.iv:: 144 Ground - ' cr- el ft. a c~ Depth to limiting factor ?~l Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) 81 w.g~ ~'rr ~s z ~ AIA) VY SA) 730.i/j el>-VI) 1 / / /~C~ <3a ,ova ~j GIST/,r~ 6 3 ~l o}" 7 i8' I IL-30 f6 so' a?io' 3/0 ) _ _ j N w~ 00 N vii• 10 to , Z co I o O (c) 1 S89 29'57"E 370.57'- 8 <n \ \ y • • • • • • • • • • • z EAST-WEST 1/4 LINE OF SECTION 26 2NER OF 26 X15 8 ~ SMALL TRACT LOT 5 \ 3.09 ACRES VOL. 100.8 7 PG. 2 7 2 134,520 SQ.FT. \ 6 - - . 9 SAS o \ 1 /~O Op, ro S O N83 10 24„ s° E ~ 00" •oso~ 10 6> \ 438 Q4 1 \ 'E 44 ~ 29 \ N70 ~ Q \ M ~ 11 • M o LOT 4. o 0 3.09 ACRES J N 134,520 SQ. FT. 1 _ N Q i N89°51'27"W 520.00' I • I I M LOT 3 M I ~ N 3.00 ACRES N 130,722 SO. FT. N 1 0 ~ Q I W co I N89''3J'27 "W 3,Zp• pp' 1 I O O . ( 3 w I w W ti I O W 0 LOT 2 0) 0Y° I w 3.00 ACRES M z o i ' I J O N 130,722 SQ. FT.Q N_ O ( Q 0 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT 1 St. Croix County OWNER/BUYER ~odcA- MAILING ADDRESS .9-0._ 311 PROPERTY ADDRESS J'- 4em C w3vl' , (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION L~ 1/4,_. W 1/4, Section a , T 30 N-R Q tW TOWN OF ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP , VOLUME 110 "0, PAGE 01 c , LOT NUMBER Y 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 ye' pi tion date. SIGNED: DATE: ~~~gvr 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 '`cYL„gl Location of property M0_1/4 Std 1/4, Section `;)(o T,30 N-R I E.W Township Mailing address ~.C~ , 3'► k ~J cti D2S Address of site 1.351 ~~.~xwcu~~ASY+- L'A'N Subdivision name ,a~ Lot no. Other homes on property? Yes x No Previous owner of property Total size of property cue Total size of parcel 3 .p q Sao Date parcel was created l GCA"D- Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house)? --,I- Yes No Volume 01--1b and Page Number (D 19 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. 519 lj~ZaC? , 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. Signature o Applicant Co-Applicant fAlo Date of Signature natP of q;nnat11.-P • 1 DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 5IL9820 1 1,09 - r REGISTER'S OFFICE ST. CROIX CO., WI Reed for Record Richard O Stout and Janet P. Stout, - husband and wife survivorship marital AUG 3 1994 Qroperty_, at 10:00 /~A.M conveys and warrants to Michelle M. Vanasse 7llca Regteter of Deeds RETURN TO the following described real estate in St. Croix County, State of Wisconsin: Tax Parcel No: Lot 4, Plat of Bass Lake South, Town of St. Joseph. ~e+ rip y r~ This is nOt homestead property. (is) (is not) Exception to warranties: easements, restrictions and rights-of-way of record, if any. ad this 2 day of Au st 19 94 (SEAL) l~tX~ i~_(SEAQ • Richard O. Stout Janet P. Stout (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN Ss. St. Croix County. authenticated this day of 19 Personally came before me this day of August 11994 the above named Richard O Stout and Janet P Stout TITLE: MEMBER STATE BAR OF WISCONSIN (If not, me known to be the person s who executed the authorized by § 706.06, Wis. Stats.) PVL G oing instrument nd a knowledge the same. THIS INST13 MEN WAS DRAFTED BY Janet P. Stout 7253 watu ee rail co TART 2 Hudson, W1 54016 -a Not yc blic r County, Wis. (Signatures may be authenticated or acknowle as 008LI& mission is permanent. (If not, state expiration are not necessary.) 9 19 ) OF W IS 'Names of persons signing in any capacity should be typed or printed below their signatures. S132 NTF 0021 WARRANTY DEED STATE BAR OF WISCONSIN Nelco Tax Forms, P.O. Box 10208, Green Bay, WI 54307-0208