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HomeMy WebLinkAbout030-2034-60-200 STC - 104 AS BUILT SANITARY SYSTEM REPO OWNER ,a ~CA44 s J p - 1S J e ADDRESS L4c~? ~~~pz~~ tr SUBDIVISION / CSM# S ~G~ LOT # SECTION_,T;~j_N-R,--V~W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHIN THI 100 FEET OF SYSTEM 6s ' ss v INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. . BENCHMARK: ~ O ,~ye ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Z ,0,/ Setback from: Well House_,L- 25L Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: ? Length Number of trenches Distance & Direction to nearest prop. line: /D( Setback from: well:__,,~4 House Other ELEVATIONS Building Sewer /fig ST Inlet; Js ST outlet 7 7 7 PC inlet PC bottom Pump Off Header/Ma nifold~Za,7,~27 Bottom of system ,jAx,! S^ Existing Grade Final grade DATE OF INSTALLATION: 'z2 PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt lpT"Partq►~ritopsHg?H. a.a _ 3n. aIQ~G:Sy#>M AVF:. County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar rmR Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI . X lisp. BM Elev.: BM Descriptio" • , Parcel Tax No.: TANK INFORMATION G ELEVATION DATA A9400124 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic J Benchmark 115, S Sao, Dosing Aeration Bldg. Sewer Holding St/Ht Inlet 3 s ;_3 TANK SETBACK INFORMATION St/ Ht Outlet Vent TANK TO P / L WELL BLDG. Air Ito ntake ROAD Dt Inlet Air Septic >5b' a NA Dt Bottom Dosing NA Header / Man. 7 Aeration NA Dist. Pipe 13.E /J ' Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade y5' U y. Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft oss Head Forcemain ength Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH width Length , No. Of Tr ches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS joZ 11-5 DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER Moe Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pip (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, etch) T.OC'.ATTOX. ST. .70SFP A4 30. n=NF NW=TbT 3= 73TH AVF, Ilk- Plan revision required? ❑ Yes ❑ No Use other side for additional information. ~ SBD-6710 (R 05/91) Date ✓ Inspector's Signature Cert. No. SANITARY PERMIT APPLICATION t~~~.lnn In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than El /~00 8% x 11 inches in size. c ec ~ 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. PROPE TY OWNER PROPERTY LOCATION % '/a, T , N, R ~(or PROPERTY R'S MAILING DDRESS LOT # BLOCK # 1 CITY ST TE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM M E El CITY NEA ST ROA II. TYPE OF BUILDING: Check one) ( State Owned E3 VILLAGE : - l _ ~ia s ro ;OWN OF: ❑ Public [0 1 or 2 Fam. Dwelling- # of bedrooms P ARCEL TAX NUMBER(S) 111. BUILDING USE: (If building type is public, check all that apply) U~j - 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 ® 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 ./i ch) ELEVATION REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min Feet -1 z Feet VII. TANK CAPACITY 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 Holdin Tank ° Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installa 'on of the onsite s wage system shown on the attached plans. Plumber s Name (Print):, Plumbe 's Si nat ps MP/MPRSW No.: Business Phone Number: i S 9 P u be ' Address (Street, City, State, Zip C de): IX. C TY/DE ARTMENT USE ONLY Disapproved Sa 'tary Permit Fee (Includes Groundwater ate Issued Issuing A nt Signature (No Sta s) Approved ❑ Owner Given Initial Surcharge Fee) , Q Adverse Determination 3 T 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) tmbe 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 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. i GROUNDWATER SURCHARGE i 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) ~uG /~~`G.UASd/✓ J d' ~ S9' 1,2m,~~w,ll yo ~ o s'p 1 - 7e ' a~ I 3 ' 1.9bor d Department bons Industry, SOIL AND SITE EVALUATION REPORT of Libor and Human Relations Page • 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 N,R(o~ PROPERTY WNER':S MAILING DDRESS (G Skt LOT # BLOC # SUBD. NAME OR CSM # v CITY T E ZIP CODE PHONE NUMBER ❑CITY ❑VI LAG GOWN NEAREST ROAD &1) tj p(J New Construction Use M Residential/ Number of bedrooms [ ] Addition to existing building J Replacement [ ] Public or commercial describe Code derived daily flow) Q gpd Recommended design loading rate 7 bed, gpd/0trench, gpd/ft2 Absorption area required bed, ft2.S trench, ft2 Maximum design loading rate 77 bed, gpd/ft2_,_.~trench, gpd/ft2 Recommended infiltration surface elevation(s) A~/, 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 SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem JZ S ❑ U _[ZS❑ U Cos ❑ U 0 S❑ U ❑ S 0 U ❑ S O U SOIL DESCRIPTION REPORT coring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. C nt. Color Gr. Sz. Sh. Bed Trer>cti VA _-2 Ground s - 7 elev. AS. /LLZ ft. Depth to limiting factor > 95' Remarks: Boring # 91-i~ i;' it l Yii Ground ` elev. le l ft. nt ~ Depth to limiting factor ,i.. Remarks:' CST Name:-Please Print J V J Phone: Address: ~ Signature: Date: CST Number: c~ _ PROPERTYOWNER lcts~ni SOIL DESCRIPTION REPORT Page~of' PARCEL I.D. # Depth Dominant Color Mottles Texture Structure Consistence Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Co t. Color Gr. Sz. Sh. Bound Bed Trench 4114 t~ 3 Ground - elev. Depth to limiting factor Remarks: Boring # All/ ?rh >.:.`4. Ground s elev ft. Depth to limifing factor Remarks: Boring # Ground s elev. /L ft. Depth to limiting factor >5 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) A6AIa/S 6/✓ /y~7 ~~'~°S~ N~~;~ N1J'~1, ski C? , T. 7 ~OOk" ~,~1cs//d~,~~P•f' ~q~a o.~F~~~~ /1~d~i~iv~~,ere~~-'s,~.o .~'l/D~o 3 al V I y I~t m 33 I G6 ` AW s~~o Via' 3' APAC, c 0 F ' ~rV ~ ~~CC~1V11 OT r7 ~ ` ' t o _1 9da ,S4O~/ floN Mf Moto 1 •I1 AIId 96641vo11M P1►/ • . vow got flael Good. so Uses top Coa 1104 le, tie" 4#0400 vem pipe Oar ►y• OLNI••II~ • ' h/• T.• ` ~•M•I• II~• ' Pvlw•l•d pipe 10 *few • ....Compl1.1 1.•wM9I1411 Al "tit sell.. 01 i1H•w • Prop us c o Ar%"l 9 rs%cl< . 501 Fill.' .013TKIBUTI0R) PIPC • APPRO`Ir p S'INriCTIC COvc 2~ OF nG0 GALE ,•..._MATCRI~~ OR 1' OF sTRA1. OR MARsti• ►'Ay T.L.EV. OF F IILY~ •0 t-L"/s I►GGRCGA.TC % OISTRIgUY101J PIPt,TO pC AT t=CA><T,' IWCNES 5CLOW ORiViWA1, •,.i~OC AUU AT LCAST&O IIJCHGL OUT 1.10 MOKC TH^N 4% 11jC1jC6 l1C1.OW /INAL CIll10G M~XUwM DIP01,0F EXCAVAT100 IfKoM ORIOWAL ,61 o WIL ~ 1. eC 1WCNes 1vK1MVM © ni OF EXCAVATloW F~LaJ~ IZ1►1gL. ORnvC Wll.l. ec ..c_.. INCHC s r tie LIGCuSC UUMSC11:. • 010 p 8 ~ 1994'' 2 ~ji ds X16121 o coN~~ s MES ec i gLGC CERTIFIED SURVEY MAP Located in part of the NE4 of the NW4 and in part of the SE14 of the NW4i all in Section 24, T30N, R20W, Town of St. Joseph, St. Croix County, Wisconsin; being Lot 1 of Certified Survey Map recorded in Volume 7, Page 2072 at the St. Croix County Register of Deeds office. NW Corner of Ni Corner of Section 24 North line of the NWj Section 24 S89°53'00"W S8905310011W 1300.85' I3 I ti~ ^ ^ I 1300.85' v IVIHLL N 4 o - ^ r.-r LOT AREAS ED C I r~Hli I c c c~-I o ° - - - - I Including R/W Excluding R/W N 1 889053' 0011W 289,091 Sq. Ft. 223,363 Sq. Ft. 200.00' Lot 2 6.64 Acres 5.13 Acres ° o L7 1 167:241 -0 LL I 32.76' Lot 3 146,806 Sq. Ft. 132,859 Sq. Ft. N 1 66, I ` \y x 3.37 Acres 3.05 Acres 0 0 loo' s M U i X92 c d Z a I o '06 d OWNER <`o s 0010 C" O 4-+ N c~ M Larry Gosselin c b 1497 23rd Street C .a Houlton, WI 54082 m J) I 31.90t: o 3 DSHEO 0~ CPS BARN .I - U Z o ~'Ooti~ \ ~r s N 26.161 Sy0 v~. cli ~I F-I ° V rsSO 1 (Sj i LLJ I W 3 aSHED N820461 10,,W -1 L~11 d o 258.061 / 0 ❑ GARAGE 2 I CL I i/7 0 00 o HOUSE SO / ~n- 'i 'tom. t, Nt CD _ I 2 F s 00 LO1 (SJI LY_( ' OTRAILER HOUSE. Or 4'4 CJ1 roI o (REMOVED) JIc\j I3 N F _ ~,9 0 I CJ LL C~I .C•)i o, ~ 01' W• OJ / ~ ~ :fir v~~d; ~r I I 21 o cr 0c0 rJX~j NE of the NW APPROVED J) I SEJ of the NW} LEGEND Aluminum County Section Monument Found MAY 2 '94 1" Iron Pipe Found S'i'. CROIX COUlWY 0 1" x 24" Iron Pipe Set weighing 1.68 lbs. P4?'!}li3rfs99~ Piaur / x Masonry Nail Set in Concrete Surface Zoning and -0:'% / PaT%S Committip Roadway Setback Line w m It not recorde(~ within 30 days 4f approval date: approval Shan tASCALE IN FEET & vim! N 0 100 200 400 VOLUME 10 PAGE 2753 s STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER AQU f L-'f ,/~Ct fi t!?SC7r'I IS /Y74 MAILING ADDRESS A/91 13".j . PROPERTY ADDRESS' (location of septic system) Please obtain from the Planning Dept. CITY/STATE 0/1 S / y I PROPERTY LOCATION 1/4, ) 11/4, Section L/ T-30 N-R d W TOWN OF Sl. Jofwh - ) 51- de z)_1-4 lt4' ST. CROIX COUNTY, WI SUBDIVISION- - 42~g LOT NUMBER 3 er/ 0?7~~ CERTIFIED SURVEY MAPVOLUME i PAGE , 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. SIGNED: ~z h~ lc6s DATE: /-,7//) M3 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 STC -loo . 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 )souse), 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 u 4, Lei 01)n A 1 0 - i t 'ii- <L "S~ Ili j Location of property l/4 11,,)1/4, section, T 30 N-Ro20 w .Township S / • Jv ST rL / ` U01S C.mSjv) Hailing address (,mot is a&l-l S a~'Z Address of site 3 rC/<- Subdivision name Lot no... other homes on property? yes L~ No Previous owner of property ?,Total size of parcel Cir-,--e S Date parcel was created ~ Are all corners and lot lines identifiable? =_iss No Is thin property being developed for (spec house)? Yes I/No Volume and page Number 3 as recorded. with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE rOLLOWING: A t41 RIU1 ITY DEED which includes a DOCUMENT NU2u3ER, VOLUME AND PAGE, 2 umi3I R & THE SEAL OF THE 11CGISTI i 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 referencas to a cartified survey map, the certified survey Hap shall also be required. PROPIIiTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best of ny (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. 6:/(.,"1 , and that I (we) own the proposed site for the sewage. disposal system orreI (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 county Register of deeds as Document No._ ~i of 1 f n ure of 'ap 1 cant C -a ppl c i Date of S gnature Date of s gnature DOCUMENT No. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA 516589 STATE BAR OF WISCONSIN FORM 2-1982 YOL 10 7 8 PAGE Laurence P. Gosselin and Sheila J. Gosselin, husband .....and wife MAY 12 1994 - - Z.30 conveys and warrants to DOll laS Ghristo her Ma rluson and p g -p s ~Ir . or/ 066aa __arie. Ann_•Magnuson,~ husband anI wi e, . - RETURN TO the following described real estate in .........St.....Croix .....................County, State of Wisconsin: Tax Parcel No: Part of the NE1/4 of the NW1/4 and part of the SE1/4 of the NW1/4, Section 24, T30N, R20W, Town of St. Joseph, St. Croix County, Wisconsin, described as follows: Lot 3, Certified Survey Map recorded in Vol. 10, Page 2753, as Doc. No. 516121. Reserving unto the Grantors hereto an easement for access to and from the "barn" and the shed" located on the above described property and depicted on the above described Certified Survey Map. This is. -110t---- homestead property. (is not) Exception to warranties: Easements, restrictions and rights-of-way of record, if any. Dated this - day of May - - 19- -94.. (SEAL) ..-o~iw (SEAL) Laurence P. Gosselin (SEAL) A. ,AGG's Z ~AAO_---------- (SEAL) * * Shei.la--J....GoaseIin AUTHENTICATION ACKNOWLEDGMENT Signature(s) ...Laurence P..-Gosselin and STATE OF WISCONSIN Sheiia_ J, _ Gosselin-------------------------------------- ss. Wf .............................County. authenticated this __._Uay i,f......... May........... 19..94 Personally care before me this ................day of 19-------. the above named Kristina 0 land TITLE: MEMBER STATE BAR OF WISCONSIN (If not, person who executed the authorized ed by § 706 706. .066, , Wis. St Stats.) to me known to be the who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY xstna_ 0gland------•---------------------------------- A tQr[leY at w Notary Public --..CountWis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date *Names of persons signing in any capacity should be typed or printed below their signatures. o... yen«--- .n_