Loading...
HomeMy WebLinkAbout032-2092-60-000 r "r r STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS SUBDIVISION / CSM# LOT # SECTION T N-R_W, Town of 0 ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM G~~n J/ o?y' INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: ,e ALTERNATE BM: SEPTIC TANK,/ PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: hJ~iS~S Liquid Capacity: f Setback from: Well House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length 7S Number of trenches Distance & Direction to nearest prop. line: f,,f 18 Setback from: well:_ House Other ELEVATIONS Building Sewer ST Inlet. _99,g3 ST outlet ?9e) PC inlet PC bottom Pump Off Header/Manifold C Bottom of system Existing Grade 9Z Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 7Z:~ 3 / 9 3 : j t Wisconsin,pepartmentof Industry, PRIVATE SEWAGE SYSTEM County: L`db.or ai4&Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 11 Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State Plan o.: VANASSE, MICHELLE 1X CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Head Forcemain Length Dia. Dist. To Well 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 CHAMBER INFORMATION Type Of Mode Number: System: 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.) LOCATION: SOMERSET.24.31.19W,NE,SE,LOT 3,205TH AVE. Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH • 4 SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION COUNTY t~'~Lf7■7 In accord with ILHR 83.05, Wis. Adm. Code STATE SANITA Y R WT # -Attach complete plans (to the county copy only) for the system, on paper not less than El A a 66 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 S '/a N, R(or)&W PROPERTY OWNER'S MAILING RESS LOT # BLOCK # CI STATE ZIP CODE PHONE NUMBER SUBDIVISIO AME OR CSM NUMBE II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned 0 VILLAGE : ~s is N OF: ❑ Public 54 1 or 2 Fam. Dwelling-#of bedrooms PARCELTAXNUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 120 Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ® New. 2.E1 Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.E] 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 _91M 911-6 VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin 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 Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installs ion of the onsite sewage system shown on the attached plans. Plumber' Na a (P " Plumb is gn ure: o s) MP/MPRSW No.: Business Phone Number: PI tubers ddr (Street, City, tate, Zip e): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitalu Permit Fee (Includes Groundwater ate Issued Issuing Agent Si SIM- s) ~T Owner Given Initial 9=harge Fee) Approved ❑ U f- S_~cl IK Adverse Determination 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 _p 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. 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) . ' /~,~'i/~ ~/~A~.t..iS.~ J J.S,f l'y1 S.tCc~-i✓/ ~~/J' J ~T /T Ise ~i.+~,Er~SFT NI ~7~5 A)AW a ~ Y ~s A 01:.`:1 PAC. C o r Cris w • lull '•lL/~f!'--~~` ,i • r#444, A4 wets AAI 06601vollae Pipe . i. MN••14 veal cop • MM,ww' la4 ~p•0 i ' Ile w 4* Coss 11r~.y . ZO• ate Ab•v 11~ w is, ("'o/•d• Vsm 0,y M-14 IN• 0. AelMlk C•..rler 0.01 ►4e Ol.l/le.►1~ • . 7 - he • Ctrs CL= o• Ala•1.1. ' i•..Ha 11~• , • 0,411010,411 I'll's Y•1e,• • C•.~,le•1 IM•.le•,b! AI 61119+ 01 ilN•,a • Pru 01 c D ~in..l 9 601L ►ILL' © IrC APPRO`/c G S'h/Ptunc COVc 2" of AGGR>rGA1E J ~ `''i'~A7 R1^l OR 10 OF STKA OK MAKs►• N,Ay F • "d4 d1L'° 00 Ys - a AG G K C G AT C ELEV, of Er,' OISYRIauylow PIrt,YO bC AT 4E"TCZ~a_ IWCHC3 BCLOW ORWIWAI. •,rAOc AkJU AT. LCAiT401A9G14CL OUY WO MOKC THAN 42. I►Jcl{CL 10CLOW /Ih1AL. 6,l^OC l1NLMUM DEPTH OF F-)(CAVATIpu FKOM OWWg1, 6R1% WIu4. BC IQr-HES tVHIr1VM 0EFT11 OF EXCAVATIoPU 0~I4INAL GRAPE WILL 5C INCHCs SIGIJCO: II LICCUSC Uur\oE It. oqr c : - . • Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page _L of Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY - , fi,;~7/X, 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 PROPE TY OWNER: PROPERTY LOCATION GOVT. LOT 11~5 1/4,ST N,R 44 PROPERTY OWNER':S AILIjVG DDRESS LOT # BLQQK# SU NAM OR CSM # CI STATE ZIP CODE PHONE NUMBER ❑CITY gVILLAGE OWN NEAR ST PICA ~,(J New Construction Use b(] Residential / Number of bedrooms [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate gibed, gpd/ft2_,~_trench, gpd/ft2 Absorption area required bed, ft2 /,oa trench, ft2 Maximum design loading rate ,bed, gpd/ft2,trench, gpd/ft2 Recommended infiltration surface elevation(s) Sd ft (as referred to site plan benchmark) Additional design / sit considerations Parent material 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 R1 S1 U 011 El U ® S El U MS ❑ U ❑ S O U ❑ S ® U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Clu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Baartdary Roots Bed Trench lek -0/6 AJ,11 -4-L Ground 3 / 7 elev. '2W ft. - - Z~s Depth to limiting fact Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: CST Name:-Please Print Phone: Address: Signature: t Date: CST Numbe PROPERTY OWNER ✓~d SOIL DESCRIPTION REPORT Page9, . of PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench J~ b Ground _ / 1 elev. It - Depth to limiting factor a fiR Remarks: Boring # Za2s Ground elev. 2~L ft. F Depth to limiting factor Remarks: Boring # 4;Kvi 9 -7 .•Ground.... elev _ ft. h, Depth to limiting factor >~l Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) ~ •r ~ ~7r'~ ~ -s:~~y~, 5.~~~~~ ~-..~'i~✓ x°/qty 7 4- ~oc~r o,.J o~ S> Ts~i.ne~x /S • ~ a J ass E 1 rviE IN OF SE[rlON 2.,r JI N.x:9w~ P CG SECTION 24,T lI N,R 19w LIN 9El/I NE CORNER OF SE Ne>•3 )'OS"W .1]29.63.. I ~4 ai.:,. ,U. 14t Vr °2'Tte. ! J]00 Ne>•s>'os ..]z9m- PUBLIC 6~LOOS y >•mos•w~ ~w STREET _ 6 Ioo IR].61 •00 246 00 YeS.OI N'2B3. YBa00 YBS00 , 5p a ¢ .3°°° 8°N y~~: °O rv f ROfS)JI 2 di i 8 el'' ase so,l~ $g ry8 ~b I u`W ryI 175,300 sq. If 141,000 sq. Ir. E •f yt 2 3 4 ° w \:bti wr .Y ° -1.00'0'. ° M a; ~ t °8 130, 331sq. ft. 133,951 sq.ir. 131,599 .4 ft 133,951 sq, ft. Q: 2 5Y. eso !z. ry°' Y h ~...~A ~ 137,9231 _ ~ ~V d3.~`Gk ddl'" r ~e•C. o• ,4~ ryi 'a , ?s, ~ ! 0 ~ t ryy 0 C _ S~ P63.00 PW.00 9° 9.,. .,is P/ R .N e. ti~.(82,750 sG rt IY xs)•STww 42).61 xe)5)os .oo 1 2 E 1y6. 60 8I~ 1' ° w _ 171,001 sq. lt. of gPPROX)MATE HIGH WATER ELEV. 86Q0 \ E' s>noo , APPROXIMATE LOW WATER ELEV.-855-3 5^ yO p~ i ApPROXIMATE WATER ELEV.P860Q1,^~ k (w h o• p (APRIL, 1981) 'ro A t 4 234,850 I o U ALL ELEV ON U.S.G.S.. MEAN 6EA \\i p - LEVEL DATUM ~J $ JI 4 I k t I59.600w.n. cal sr~ Nz oz i1 ,1.20.0 rt r 18 lys ~L. 8 °o 8 .!IW R•~e•TR R 159,600 Q. ft. - ~ I ~11 .104, W h 4o p0 ° 9 w o\ i 171.001 94 ft Cl- • Y :OERTIF IED SURVEY MAP UI No-fJ0 lose.... 8 j QQE r4, 759600 qft . 4W,1 16°•28 21 ~ 4)'30.00 ,~cf /O l \ \L \ ' \'v 140,031 sq. ft. APPROXIMATE HIGH WATER ELEV.•8GQO wog APPROXIMATE LOW WATER ELEV, x855.3 APPROXIMATE WATER ELEV.•B6O.O ~o fib. (APRIL, 1981) I 8m ,ALL ELEV. ON U.S.G.S., MEAN SEA LEVEL DATUM. IIYr ,yu 131,830 sq. It Q- w I - Ne)•S)'OS W 485.79 TURTLE NBT•Pd°,= N E (DEEDY0 LAKE ' t... - .INE °F THE NI/Y, NE IN,9EGPE,LII M.,R.HW. N' S - -4186.00-. S 1 ry~ry w W w ° nx ~m oq 8 PRIVATE POND prH ~ ° (APPROXIMATE WATER ELEV 860.0 e.z6, ossaw (APRIL,1981) R•4'3. Apo LY OUTLOT 4,234,850 sv. /t. 152,021 sfft A n ~u ~ 13!.69.• I.b-N6M06'le•W- 160.6- biJ NORTH LIME OF ;HE E16669G) i Qom. ' 1w4 lL/ 't. °a _ • WEST 100.0.01,!. 4.49 x-W a lti w STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER C MAILING ADDRESS -1Y, 0, l ¢ JTY\~ f.~ ~~J p PROPERTY ADDRESS '7 W aa~ a (location of septic system) Please obtain from the Planning Dept. CITY/STATE w / PROPERTY LOCATION ~4r 1/4, _541~ 1/4, Section 4 T - 1 N-R~W 9- TOWN OF ST. CROIX COUNTY, WI SUBDIVISION CJ 1 LOT NUMBED a CERTIFIED SURVEY MAP O, VOLUMFIb9a, PAGE I_6, 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 mu t be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year ira ' ate. SIGNED: aa 4 riwa DATE: x O 2 "7 L1 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 F JV . -7 9 S T C - 100 03a - a0c)2 - ~b 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. I V of property 4La Location o property_1/4_1/4, Section,,T~N-R / W Township t4 Mailing address #00• ins f1~~ U Son 2, Address of site $S ' CUB--c. Subdivision name Lot no. Other homes on property? Yes !t< No Previous owner of property A-~ Total size of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes X No Volume /01_2 and Page Number Ao~ 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. oy 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. i Signature of Applicant Co-Applicant F77777 WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2 -19821 520496 REGISTER'S OFFICE Rlchard.--M.,.._Hane-en---and...Jane--A.-..Hansen , ST. CROIX CO., WI hu-shand---and..wi.f-a...... Ree'dliorRewrd - - j AUG 2 2 1994 conveys and warrants to __Mi.che-ll-e.M.--.Vanasse____________________________ 11:30 . - at ~.,~AM Re~ateroroeeds RETURN TO , the following described real estate in St-.---Cx.o1-x....... -------------County State of Wisconsin: Tax Parcel No: Lot 3, Block 2, Hansen's Turtle Lake Hills First Addition in the Town of Somerset, St. Croix County, Wisconsin. Ls o This ....1_S__I1ot--------- homestead property. (is) (is not) Exception to warranties: easements, restrictions and rights-of-way of record, if any. Dated this day of .r!- - 19..94.. -----(SEAL) -:(SEAL) J _ ne-. A-' Hans-en --------(SEAL) (SEAL) * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) _--Richard M. Hansen, STATE OF WISCONSIN - -----------------------------n, Jane A. Hansen ss. .County. authenticated thisM.day of..- yr 19__-9.4 Personally came before :ne this. _dsy of - , 19-----... the above named * Kristina Ogland TITLE: MEMBER STATE BAR OF WISCONSIN (If not- authorized by § 706.06, Wis. Stats.) to me known to be the person who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Kristina 0-land Attorney at Law Notary Public ------------------------------------------County, Wis. (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. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. . ~d ~.~u~ ~ ~1 I , ~ \ ~.r J , 2, ~ ~ 3 ~ - ~ 7 ~ , r 2 Z-- r