HomeMy WebLinkAbout032-2063-90-100
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER z~,/jtiz ~i~~S~Y6rn.
ADDRESS /j ~7
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SUBDIVISION / CSM#. o~ Rc.rP s~ LOT #
SECTION___ZX T__.~o N-RZ2 W, Town of ~cs rhQrS-a
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:
ALTERNATE BM: cvm > '
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: (,J Liquid Capacity: /Oa6
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Setback from: Well ~ House DIY Other
Pump: Manufacturer /4 Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: .5 Length 113 Number of trenches
i
Distance & Direction to nearest prop. line: iao
Setback from: well: lam House 13 7 Other
,Y ELEVATIONS
Building Sewer ST Inlet; ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION: 4 Z Z - ~y
PLUMBER ON JOB:
LICENSE NUMBER:
i INSPECTOR:
3/93:jt
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JOB -
TIMM EXCAVATING SHEET NO. OF
Route 1 Box 192
WILSON, WISCONSIN 54027 CALCULATED BY k r f - DATE
(715) 772-3214 (715) 386-5443 f
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
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PRODUCT 205-1 Inc., Groton, Mess. 01471. To Order PHONE TOLL FREE 1800-225-6180
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I: s '~a i ertr'tS Xn~i#>t y • 30, I91l`RI#JtfREkV8E SYSTEM County:
Labor,~nd Human Relations INSPECTION REPORT
Safi6 and Buildings Division
' (ATTACH TO PERMIT) Sanitary ermit os
I GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village E Town of: State Plan D o.:
TRr%m isomey.-met
Parcel Tax No.:
Elev.: nsp. BM Elev.: BM Description: X
TANK INFORMATION ELEVATION DATA A9400104
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosi ng
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet 7 3 ' 98 a 7'
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic ' /Va NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe q5 qv
Holding Bot. System C~ gad
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand` k
Model Number GPM
TDH Lift LOL System TDH Ft
Fi
Forcemain Le th Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width 7 7 Length , No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSI N
LEACHING Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION Type O -a A , CHAMBER Model Number:
OR UNIT
System: 4-c `1
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.)
LOCATION: Somerset.18,30.19W, Heron Lane ,
Plan revision required? ❑ Yes ❑ No a{~ _
Use other side for additional information. i c,c 6
SBD-6710(R 05/91) Date I r'sSignature Cert No
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ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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I HR SANITARY PERMIT APPLICATION -
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 o(OTgg
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
J,d P L i'V % S T N, R (q .&W)o
PROPERTY OWNER'S MAILING ADDRESS ~ LOT # BLOCK #
99
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
_107ner5J4 lie A14
II. TYPE OF BUILDING: Check one) CITY NEAREST ROAD
( State Owned O
la TOWN OF: VILLAGE 0711 f r Ie
❑ Public 1 or 2 Fam. Dwelling- # of bedrooms -3- PARCEL AX NU BER() )d~1
III. BUILDING USE: (If building type is public, check all that apply) 032 - ~ (Q 3 - 90 - t 00
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.E1 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 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
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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 3 5(S" *l f I'7, Y Feet 1460' t(ce Feet
VII. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Se tic Tank or Holdin Tank " ee G
Lift Pump Tank/Si hon Chamber El E] 1:1 0 1 L]
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plum er's Name (Print): Plumber's Signature: (No Sta ps) MP/MPRSW No.: Business Phone Number:
`77; 3 ZZ- 715 77Z- 32/~t
Plum 's Address (Street, City, State, Zip Code:
17
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanita~rmit Fee (Includes Groundwater Date g ue Issuing Agent Signature (No Stamps)
` Surcharge Fee) Approved ❑ Owner Given Initial U Y
Adverse Determination
X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/68) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
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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 (SBF) 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 DIIHR.
Vlll. 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 B'h 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; close 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)
JOB TIMM EXCAVATING SHEET NO. OF
Route 1 Box 192
WILSON, WISCONSIN 54027 CALCULATED By ed" DATE
(715) 772-3214 (715) 386-5443
DATE
CHECKED BY
MPRS #3224 WI MPCA #696 MN
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PRODUCT 205-1 Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE I-BW-225-SUO
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JOB
TIMM EXCAVATING SHEET NO. Z OF Z
Route 1 Box 192
WILSON, WISCONSIN 54027 CALCULATED BY DATE 5 - z -f
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
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PRODUCT 205-1 Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE 1-800-225-6380
Wiycgnsip Clsfpartment of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
L.atx>r and Human Relations
Division rf Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
St. Croix
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 parts SE-SE-18 & NW-SW+SW-SW-17 &
Dave Lindstrom GOVT. LOT NE 1/4 SE 1/4,S 18 T 30 ,N,R 19 A" W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAIMAE OR CSM #
1527 Heron Lane
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE aOWN NEAREST ROAD
Heron Lane
New Construction Use [ X] Residential / Number of bedrooms 3 ( ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate • 7 bed, gpd/ft2 .8 trench, gpd/ft2
Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2 .8 trench, gpd/ft2
Recommended infiltration surface elevation(s) 97-4 ft (as referred to site plan benchmark)
Additional design/ site considerations install 5' x 112-51 trench on 100.4 contour as trench CL
Parent material sandy outwash Flood plain elevation, if applicable NA ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U=Unsuitable fors stem BS ❑U ®S ❑U ®S ❑U ®S ❑U ❑S U ❑S ®U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Bo ndcry Roots GPD/ft
Boring # Horizon in. Munsell GQu. Sz. Cont. Color Gr. Sz. Sh. Bed Trl'~1d1
1 0-24 10YR 2/1 - is 1 m sbk mvfr gs 1 f/m .7 .8
2 24-29 7.5YR 2.5/2 - ls. 1 m abk mvfr gw 1m .7 .8
3 29-36 IOYR 3/4 - .ls 0 sg ml cw if .7 .8
Ground
elev. 4 36-41 10YR 4/6 - s 0 sg ml cs - .7 :.8
100.4 ft.
Depth to 5 41-86 10YR 5/4 - s 0 sg ml - - .7 i.8
limiting
factor
> 86"
Remarks:
Boring # 1 0-10 10YR 2/1 - is 1 m sbk mvfr cs 2f/m .7 .8
`t` 2.._. 2 10-32 10YR 2/2 - is 1 c-m sbk mvfr gs 2m .7 .8
3 32-49 10YR 3/4 - is 0 sg ml gs lm .7 .8
Ground
elev. 4 49-60 7.5YR 4/4 - is 0 sg ml gs lm .7 .8
96.7 ft.
Depth to 5 60-76 10YR 3/4 - scl 1 c sbk mfr - 1m .2 .3
limiting
factor
> 7611
Remarks:
CST Name:-Please Print Henry F. Grote Phone: 715-665-2681
Address: PO Box 57, Knapp, WI 54749-0057
Signature: Date: CST Number:
3/21/94 3065
PROPERTYOWNER Dave Lindstrom SOIL DESCRIPTION REPORT Pagey_.2.. of 3
PARCEL I.D. #
Depth Dominant Color Mottles Structure PD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Bouncky Roots Bed Trench
1 0-7 10YR 2/1 - is 2 m sbk mvfr cs 1m/c 7 1.8
2 7-27 10YR 2/2 - is 1 m-c sbk mvfr gs 2f/m .7 .8
Ground 3 27-35 10YR 3/4 - is 1 m sbk mvfr gw 1m/c .7 .8
elev. 4 35-53 10YR 4/4 - is 0 sg ml cs 1m .7 :.8
100.8ft.
Depth to 5 53-68 7.5YR 4/4 - fs 0 sg ml cs 1m .7 .8
limiting
factor 6 68-74 7.5YR 4/4 - fs 0 sg ml - - .7 .8
s 74"
w/ irregular, discontinuous 7.5YR 3/4 sl bands about 1" thick
i
Remarks:
Boring #
1 0-3 10YR 2/1 - is 2 m sbk mvfr cs if .7 .8
>4 4 2 3-27 10YR 2/2 - is 1 m sbk mvfr cs 1f/m 7 .8
3 27-52 10YR 4/4 - is 0 sg ml cs 1m .7 .8
Ground
elev. 4 52-82 7.5YR 4/4 - s 0 sg ml 7 g
98.2 ft. w/ irr gular 1/4"-1" .5YR 3/4 sl bands 53, 57, 62, & 75
Depth to
limiting
factor
> 82"
Remarks:
Boring #
1 0-9 10YR 2/1 - is 2 m sbk mvfr cs 1f/m .7 ;.8
5 2 9-26 10YR 2/2 - is 1 m sbk mvfr gs if .7 .8
3 26-32 10YR 3/4 - is 1 m sbk mvfr cs 1m .7 »8
Ground
elev. 4 32-38 7.5YR 3/4 - is 0 sg ml as - .7 .8
96.8 ft
5 38-46 7.5YR 4/4 - cs 0 sg ml cs - .7 8
Depth to 6 46-86 7.5YR 4/4
limiting sg ml - 1 f 7 8
factor 17
86"
Remarks: f or in horizon 4
Boring #
exploratory pi on higher ground: about 24" is over clean s to about ' below gr de; out ide sy tem area
Ground
elev.
wins ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
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STC-105 ,
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
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OWNER/BUYER _ 77)
,a v ra L o s f~ a
MAILING ADDRESS / Cer „N r : ua L S 7,( L
PROPERTY ADD
RESS eke (location of septic system) Please obtain from the Planning Dept.
CITY/STATE 5 0 r s r I~ 5 C.
X- sE v~sC,~,p,~~✓
PROPERTY LOCATION /V 6 1/4, 5 E 1/4, Section T N-R W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION _ LOT NUMBER
CERTIFIEDSURVEYMAP VOLUME ,PAGE _ LOTNUMBER -
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: 1, 4 e2
DATE: H - 7- -7 -
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
a
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STC-100
This application form is to be-completed in full and signed b
`the owndr(s), of the property being: developed. .Any inadequacies
Will duly. result An delays of the permit issuance. , Should this
development'be intended for resale by owner/c6htractor
house), them- second form should'*be retained and completed (when
the property' is sbld and submitted to this office with the
appeoptiate deed recording.
- ----------------------------------------------------------------------L
Owner of property D A~ o w►
Location ofpropert 1 4 SF.. sEC A~'`~cti4j~.
y~ / ,1/4, Section 'LB T N-R___ w
Township y. e
Mailing address pia
u w1 bvi i~ f r l/-1 L S
ell
Address of site
subdivision name
Lot no.
other homes on property? yes No
Previous owner of property - A9 ,e is /2
Total size of parcel S~/.7S 14c-.i-e -e s
Date parcel-was created
I'Are all corners and lot lines identifiable? Yes .No
Is this property ¢eing developed for (spec house)? Yes `No
volume rand • Page Number `J 7
of Deeds. --L---- as recorded with the Register.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER & 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 'thi's information form, by virtue of. a
warranty deed recorded _ e f ice f the county Register'~'of
Deeds as Document No.
own the proposed site for the sewage ~disposal t system) presently I e (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 o`ffiee of county Register of deeds as Document
Signature applicant Co-ap licant
2L- -7 - 9q
Date of Signature Da of Sign- ure.