HomeMy WebLinkAbout032-2012-20-100
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS
z-)s
SUBDIVISION / CSM# LOT #
SECTION T _ ?,&7 N-R W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW Wf~
SHOW EVERYTHING WITHIN 100 FEE OF SYSTEM
i
_ ~ ; y4Srir/ ~9
sy~
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
1
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BENCHMARK:
ALTERNATE BM: s,~;.a s.~ cure 274
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: ~e Liquid Capacity: /
Setback from: Well House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length Number of trenches IfZ i
Distance & Direction to nearest prop. line:
Setback from: well: House s Other
ELEVATIONS
i
Building Sewer ST Inlet, ST outlet
PC inlet PC bottom Pump Off
Header/Man fold Bottom of system
r,r~os ~ 9'C ~
Existing Grade 21~7 Final grade 7 7
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER: INSPECTOR: A
F 3/93:jt
WisconVn D,.Wartment of Industry, PRIVATE SEWAGE SYSTEM County:
Labora_ndHuman Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
.
Pe mit H lgL'' Na m `UZETTE C] City E] village f7_Town of: State Plan ID No.:
I pt- n: `X Parcel Tax No.:
BELT CST BM Elev.: Insp. BM Elev.: 7BM Descriptio
/doe /00t I~,,astt
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark oU~yS /Do,
Dosi ng
Aeration Bldg. Sewer q.7y (S , 7
Holding St/Ht Inlet y3 QS Oa
TANK SETBACK INFORMATION St/ Ht Outlet
Ventto
TANK TO P/ L WELL BLDG. Air Intake ROAD Dt Inlet
Septic D a U NA Dt Bottom
Dosing NA Header / Man.
,7a' ~ 4~ l 3
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade 15 G~7
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
oss Forcemain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. ?!,Trenches PIT No. Of Pits Inside Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK _
INFORMATION ypem CHAMBER
n , /O rt model Number.
System: stem: q
(nor-J y/ ( l 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 93 .q x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over 1' 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.)
LOCATION: S merset.3 30.19W, NE, SE, 170th A enue
07
~o_0 'T
Plan revision required? ❑ Yes ❑ No `
Use other side for additional information. ~c,, (t [6 4 _4 I
SBD-6710 (R 05/91) Date ! Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
i
. SANITARY PERMIT APPLICATION COUNTY
~'■~■'■■i In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than A 1100 12-
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 OWN PROPERTY LOCATION
t/4 t/4, S TSO , N, R JI? (or
PRO ~ ~OWNE~S Ms41LING~~DDRES LOT # BLOCK #
CITY, STATE ~JLt~ZZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
If. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD_
{ ❑ State Owned ~s VILLAGE : f~~
WMAIKI
❑ Public [9 J 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMBER( S)
III. BUILDING USE: (If building type is public, check all that apply) C -?C;120 1,~~ Cleo
1 ❑ Apt/Condo
20 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 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. N New 2. ❑ Replacement 3. ❑ Replacement of 4.E1 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 N 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.) (Minds h) ELEVATION
Feet 7 7 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 structed
Septic Tank or Holdin Tank
Lift Pump Tank/Si hon Chamber El I El El 1:1 1 0
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installati of the onsitV se A a system shown on the attached plans.
Plumb 's N me (Pjin Plumb SS- atur . ( ) MP/MPRSW No.: Business Phone Number:
lumber's Address tree ity, State, Zip C e):
A ~
t
i
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sary ary Permit Fee (includes Groundwater Date ssue Issuing Ag t Sig re (No mps
Approved ❑ owner Given initial Surcharge Fee)
Adverse Determination
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 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.
-
j 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)
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-copsin-rfepartment of Industry, SOIL AND SITE EVALUATION REPORT Page / of
r and Human Relations
'Division of Safety & Buildings in acco R 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less 2 xx 1 inches Ian must include, but S5 , J
not limited to vertical and horizontal refere nt (Bld]rtion an slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location a anroad.
APPLICANT INFORMATION-PLEA RINT\\ALL 114f0'E4ATI REVIEwEDBY DATE
PROPERTY OWNER:' ROPERTY LOCATION
114 1/4,S T N,R ~(or&
OVT. LOT
Al, __gg
PROP TY OWNERS MAILING ADDRESS t' LOT B OC # SUBD. AME OR CSM #
Q /
CITY STATE ZIP CODE 11 E 464 B R CITY VILLAGE OWN NEAREST ROAD
14 Z
kj New Construction Use [j(f Residential / Number of bedrooms Addition to existing building
[ ] Replacement [ ] Public or commercial describe
Code derived daily flow 1/St~ gpd Recommended design loading rate ed, gpd/ft2_1S__trench, gpd/ft2
Absorption area required Z4 LZ bed, ft2, trench, ft2 Maximum design loading rate bed, gpd/ft2_.,_~trench, gpd/ft2
Recommended infiltration surface elevation(s) ,99R ft (as referred to site plan benchmark)
Additional design / site considerations
Are, 5 Flood plain elevation, if applicable ft
Parent material , -
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U=Unsuitable fors stem 0S ❑U ®S ❑U ZIS ❑U ®S ❑U ❑S JAIU ❑S 9IU
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 Trer&
Ground
elev. sJ- r~
ft. Depth to
limiting
fact
Remarks:
Boring #
Ground
elev.
7
Depth to 9V zs~ A 19
limiting
factor
Remarks:
CST Name:-Please Print Phone:
Address: ~
Signature: ) Date: CST Number:
ZL~Z / -5'
PROPERTY OWNER ~ L,- SOIL DESCRIPTION REPORT PAge42
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/f't
g in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trends
is
Ground
elev. s Jj,-
ft. _
- 7
Azzo
'OLZ Depth to
limiting
factor
Remarks:
Boring #
X-N •i:
/o 9 /25,
All
Ground
elev. s rw /
ft.
Depth to
limiting
factor ,
Remarks:
Boring #
Ground
elev. s
Depth to r ^
limiting
factor
Remarks:
Boring #
4?v'Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
SCpm ~.Pss✓~ T ~J
~ SCt ~~.,gl3lE ~i~EA
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3
l FILED
0 C T 2 1 1994►
5122722 0 JAMES O'CONNELL
Register of Deeds
St Croix Co,, WI
b'
CEP T I F I ED SUP V E Y MCI P
Located in the NE 1 /4 of the SE 1 /4 of Section 3, T 30N, R 19W, T own
of Somerset, St. Croix County, Wisconsin. E 1/4 COR.
Surveyed under the direction of Suzette Belisle SEC. 3
Owned by: Dale & Earl Belisle T 3oN, R 19W
1719 Cty Rd. "I", Somerset, Wi. 54025 (BERNTSEN CAP)
UNPLATTED LANDS
N 89'00'32"5 433.84'
In
W
N ~
N N o cnI U.
o~ o
z
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Cr)
W1 w LOT W
in ~ QI
ei J
QI 130, 805 SQUARE FEET n z~
zl N (3.003 ACRES) to nI
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z Cn
L SOUTH LINE OF THE NE 1/4 OF
N
THE SE I/4 POINT OF BEGINNING
66.16' 1
16' 9°00'32''
5- 9 00'32"W--433.84
3 6 500.00'....
6 _
z
ED LANDS
UNPLATT
u
I_ a l N
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W 0
1 _1
W
1 a o Bearings reference to the
w > N
East line of the SE 1 /4 of M
Section 3, assumed
N02° 5 7115 "E.
SE COR.
LEGEND SEC. 3
( I " IRON PIPE)
SECTION CORNER MONUMENT
TT (AS NOTED) ~~1~~N~~~NIy
GoNS
O I" X 24" IRON PIPE WEIGHING
1.68 LBS. / LIN. FT. SET
* HARVEY G.
- FENCE JOHNSON '10V
• S-1899
V HUDS 4ft
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SCALE IN FEET I" - 100' ,;w f,lap►nir
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNERBUYER
MAILING ADDRESS 71.J
PROPERTY ADDRESS (P! o"Z O , -
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION 1/4, 1/4, Section, TN-R_4_W
TOWN OF ,\PJ1 \ ST. CROIX COUNTY, WI
SUBDIVISION Al LOT NUMBER 1
CERTIFIED SURVEY MAP S 7a VOLUME/C) , 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 ear expiration date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
S T C - 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
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
Location of property 1/4 1/41 Section _IT N-R~W
ownship Mailing address
Address of site v
Subdivision name Lot no.
Other homes on property? Yes No
Previous owner of property
Total size of property
Total size of parcel
Date parcel was created c7 a
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec hous ) ? Yes No
Volume &6- and Page Number -l~=L as recorded with the R ister
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. 7a l 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.
r-
v-.,-4x-j gna ur f A icant Co-Applicant
Date of Signature Date of Signature
v0L11U0PaaF123
iI DOCUMENT NO. STATE BAR OF WISCONSIN FORM 3-1982 THIS SPACE RESERVED FOR RECORDING DATA
522 721 QUIT CLAIM DEED
Earl Belisle a/k/a Earl M. Belisle and
Dale Belisle a/k/a Dale E. Belisle-,.s ingle OCT 1994
men f
quit-claims to SuZ•ettE__J-._ _Belisle 4: 0
the following described real estate in S_t . Cr_ O_ iX___________ County,
State of Wisconsin: RETURN To
REMINGTON LAW OFFICES
126 S. Knowles Ave.
--New--Richmond, WI 54017_.
Tax Parcel No_
A portion of the Northeast Quarter of the Southeast Quarter
of Section 3, Township 30 North, Range 19 West further described
as follows:
AJ.N-
Lot 1 of Certified Survey Map recorded . October 21 1994
in volume 10 of Certified Survey maps at page 2832 as
Document No. 522722 ~I
i
I
FED
I
I
i
This - - - __-•1S
homestead ro ert
P P Y• I
i
(is) (is not)
Dated this 26th SePtember 94
- - day of 19------
~i
i
• (SEAL) / (SEAL)
'i - * Earl Bel-sle a//a Earl--r?-.--
Belisle~q
(SEAL) ~/.c~.r-„•I, . ......(SEAL) I
* * Dale__Belisle •a/k/a l
Dale E. Belisle
I
AUTHENTICATION ACKNOWLEDGMENT
Signature (s) STATE OF WISCONSIN
ss.
ST. CR__OIX County.
authenticated this day of............... 19 Personally came before me this 9
a3...... day of
se~?-?~e:!??? 19.4___ the above named
s3~1__.ft_J.i-ale_-_a _]c-a--Earl--M................
----&t_liale---
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by § 706.06, Wis. Stats.)
- to me known to be the person __S___-__-_ who executed the
foregoing instrument and acknowledge~Yhe same.
THIS INSTRUMENT WAS DRAFTED BY '
REMINGTON LAW OFFICES
--n o---- t------ n
ith A. Remi
Jud
R1chmond_,...W.j 54017
Notary Public ........St.
-
- bounty; his.
(Signatures may be authenticated or acknowledged. Both My Commission is permanents a expiration
are not necessary.) date:
QUIT CLAIM DEED
S'P:1TF: R.4R OF WISCONSIN wiscnntiin Leval Blank Co. Inc.
ACKNOWLEDGMENT VOL 1~o0pa~E124
-M 0i t% f~
STATE OF )
Lx~'-54; ) ss.
COUNTY OF PGEIf-
Personally came before me this day of September,
1994, the above named Dale Belisle a/k/a Dale E. Belisle to
me known to be the person who executed the foregoing
ins rument and acknowledge the same.
' d~ux
N tart' ublic
My Commission expires: JJM~RNMW~
00,
COUNTY
lie WAS ON
,a, ISM
'~'i.vt m
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10~
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WW 432 28X44 2BR-2B 1203 SQ. FT.
48'-0"
OPT.VAULT CEILING
° 8'_0
o
0
° 13' 4" E ° 10'- 8" 0 5'- 4" 10'-8"
OPT. O.H. O GLASS ® K
1AUNDR9 00 00
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52'-0"