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HomeMy WebLinkAbout032-2093-60-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT i OWNER S:&A ADDRESS. SUBDIVISION / CSM# LOT # SECTION s T- _T N-R_~W, Town of ST. CROIX COUNTY, ISCO N PLAN EW SHOW EV TH NG WITHIN 100 FEET OF SYSTEM ¢P w 1/ ~''-yo s~K s 0 INDICATE NORTH ARROW Provide setback and elevation information on reverse of t is form. S Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: , ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: We11House 1 Other Pump: Manufacturer Model#~ Size O Float seperation Gallons/cycle: Alarm Location Z SOIL ABSORPTION SYSTEM i Width: 42Length >~S_ Number of trenches Distance & Direction to nearest prop. line:, Setback from: well: House Other ELEVATIONS Building Sewer ST Inlet. 910 ST outlet 03,7/ PC inlet PC bottomq Pump Off Header/Manifold Bottom of system ~3,s 7 ,EaoS _ 9~/-f~C Existing Grade Q7 ~2 Final grade q'7~ C_ DATE OF INSTALLATION: PLUMBER ON JOB: J LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County' Labor and Human Relations INSPECTION REPORT ST. CROIX Safety aW'-Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Permit Holder's Name: ❑ City ❑ Village p Town of: State PIS WO EVERSON, DEAN X CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 1 f Benchmark 1of a~~- Dosing /00, Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet 01 7 q ItaTANK TO P/ L WELL BLDG. Ai nke ROAD Dt Inlet Septic NA Dt Bottom I~ Dosing NA Header / Man. 9 q q, S S Aeration NA Dist. Pipe 1,0 q41, q,5 Holding Bot. System 7 98 3, g7 PUMP/ SIPHON INFORMATION Final Grade C/7 Manufacturer C~.00 Demand _ 4-4,j, lip Model Number GPM TDH Lift t~ FrictiorV~ SystFier J TDH Ft o's ~ b Forcemain Length Dist. To Well 7 F SOIL ABSORPTION SYSTEM BED /TRENCH Width Length- - No. Of Trenches PIT No. Of Pits Inside Liquid Depth DIMENSIONS 5 DIMENSIONS SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of CHAMBER I I / Moe Number: System: qla / S OR UNIT / S a 9 /V DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVERq;">`P 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 E] Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Somerset.25.31.19W, NE, NE, Lot 13, 80th Street ,~,t-i3 G - - X41 y ~q Plan vision r i eti?' ❑ Yes ❑ No x~,^^11 Use other side for additional information. # VIVI Wdzk SBD-6710 (R 05/91) Date Inspector's Signature Cert No i ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: _ 'r!. SANITARY PERMIT APPLICATION ~R ' In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SAnTj Y R -Attach complete plans (to the county copy only) for the system, on paper not less than 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. PROP OWNER PROPERTY LOCATION N, R E/(or) J - ` '/4 '/4, PROPERTY OWNER'S MAILING AD RESS LOT # BLOCK # 'Cl TATE ZIP CODE PHONE NUMBER SUBDIVISION N E OR SM NUMBER II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD ) El State Owned D VILLAGE ❑ Public [Z 1 or 2 Fam. Dwelling-# of bedrooms_ PARCEL TAX NUMBER(S) / III. BUILDING USE: (If building type is public, check all that apply) Qsa .-~9.3 1 ❑ Apt/Condo 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. 54 New 2.E1 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 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.) (Min./i ch) ELEVATION Feet Feet VII. TANK CAPACITY Site in alIons 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 Holding Tank r Lift Pump Tank/Si hon Chamber AM El I - I gom vd El L1 1 0 Lf 0 Vlll. RESPONSIBILITY STATEMENT I, the and rsigned, assume responsibility for installatio of the onsite sewage syste shown on the attached plans. Plum r' a r Plumbe s Sig tur • (No MP/MPRSW No.: Business Phone Number: s r q Plum er's A res (Street; , State Zip C e): it / IX. COON /DEPARTMENT USE ONLY ❑ Disapproved Sani Permit Fes4lipcludes Groundwater Date Issued suing Agent Si n Ill Approved ❑ Owner Given Initial urcharge Fee) 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 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. 4 Il. 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. i SBD-6398 (R.11/88) ' E ~~saJ ~tY,E fly s~~o7s, T3/lkll elAA) 7- 9kl 411,A'o ~`YOu 5~f /o / ~ ~ , .boo ~a r~~ cf b i 19'A I ell Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of Labor and.Human Relations Division of 5a ty & Buildings in a rtl ILHR 83.05, Wis. Adm. Code Ij I i sI COUNTY ) Attach complete site plan on paper not oePlan must include, but not limited to vertical and horizontal refint (B*, direction f slope, scale or L .dimensioned, north arrow, and location nArest road. APPLICANT INFORMATION-PLE NT AkL.1NF0JkMA REVIEWED BY DATE j PROPERTY OWNER: t PROPERTY LOCATION 'r. GOVT. LOT AIZ 114 1/4,S T N,R R/(or)9 PROP RTY OWNER':S MAILING ADDRESSLOT # BLOCK # SUB . NAME OR SM # CITY, STATE ZIP CODE E Mp R ❑CITY VILLAGE [MOWN NEAREST D J% New Construction Use [xJ Residential / Number of bedrooms 3 [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2-,-trench, gpd/ft2 Absorption area required 94o bed, ft2 75'h trench, ft2 Maximum design loading rate 15`~ bed, gpd/ft2 , ~ trench, gpd/ft2 Recommended infiltration surface elevation(s) 9? Z ft (as referred to site plan benchmark) Additional design / site nsidera ions - - - Parent material ' Iood plain elevation, if applicable _ ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK 7 ® S ❑ U ❑ S ~1 U ❑ S ® U U= Unsuitable for s stem ®S ❑ U ZI S❑ U WS ❑ U 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 Trench r cJ , A-Z Ground elev ~:21~ 44 el Depth to limiting A)11 -7 '9 I factor Remarks: Boring # i Ground elev Z 7 L9 ft. S-;~- ';r4 ~rie4k e2 MOO Depth to limiting 4L _7 factor Remarks: CST Name:-Please Print Phone: Address: - / S Signature: 7 T Date: CST Number: PROPERTY OWNER SOIL. DESCRIPTION REPORT Pag%--~2 of PARCEL I.D. # Depth Dominant Color Mottles Texture Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Consistence Bcunclay Roots Bed Tnch -2 1-_-21 JA 9e ,Z Ground Z1j elev. Q ft. f Depth to limiting factor Remarks: Boring # i -Ground-•• elev. ft. Depth to limiting factor Remarks: Boring # Z al Ground elev. - - -71 -51111 A1111 -j/ ft. Depth to limiting factor 7 sz/ Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) so 4) 0 3 77a d / o C °P7 ' PAGE OF PUMP CHAMBER CROSS SECTIO►J AND SPECIFICATIONS 'ter VENT CAP 4*C,I. VENT PIPE WEATHE R PROOF APPROVED LOCKING ~ JUWCTIOIJ BOX MANHOLE COVER ?_5' FR¢M DOOR, WIAIDOW OR FRESH I2"MIU. ( AIR IUTAKE GRADE I 40 MIN. `a - IB' MIAI. COQDUIT PROVIDE I AI RTIGHT SEAL APPROVED JOINAPPROVED JOIWTS IWLE T rjB W/C.I. PIPE W/ca. PIP£ EXTENDIW{s 3ALARM EXTENOIUG 3' OWTO SOLID SOIL I i ( ONTO SOLID SOIL I i oN c PUMP OFF D CONCRETE BLOCK r RISER EXIT PERMITTED ONLY IF TANK MAULWACTUR6R HAS SUCH APPROVAL SPECIFICAT IOKJS I:P•fiIC AND OSE TANKS MAWUFACTURER: IJUMBER OF DOSES: PER DAy TAWK C,IZ6: G LL0IJS DOSE VOLUME: GALLOIJS ALARM MAIJUFACTURER: CAPACITIES: Am INCHES OR ...~Lr GALLOWS MODEL NUMBER: 8=IUCHE5 OR GALLOWS SWITCH TYPE: - C=INCHES OR ~G GALLOWS PUMP MANUFACTURCR: D:~IUCHES OR Z9 GALLOWS MODEL NUMBER: WOTE: PUMP ANO ALARM ARE TO BE l bW11CH TYPE: I USTALLED OW SEPARATE CIRCUITS PUMP DIS(.FIAR(.E. RA'T'E /4,0 VERTICAL, DIFFERENCE bETWEEU PUMP OFF AND OISTRIBUTIOW PIPE...FEET + MINIMUM NETWORK SUPPLY PRESSURE / ....'D FEET + FEET OF FORCE MAIN G F/OO FLFRICTIOW FACTOR..FEET TOTAL Dy1JAMIC. HEAD J L_Lc~ FEET IUTERNAL DIME SIONS OF AN LEKIGTH ;WIDTH -;LIQUID DEPTH SIGIJED: LICENSE NUMBER: _s DATE:,1t-*f79~~ Performance Curves Pumps METERS FEET 90 MODEL 3885 25 SIZE 3/4' Solids WE1SH 7.0 = 20 WE1OH 60 -WE07H 15 50 40 WEOSH I 10 30 WE03 E03L 20 VY 5 10 0 0 0 10 20 30 40 50 60 70 80 90 100 110 120 GPM I i i 1 0 10 20 30 m3/h CAPACITY U GOU LDS PUMPS, INC. SEW-CA FALLS PEW YOPK 13148 METERS FEET 120 MODEL 3885 35 110 W SIZE 3/a" Solids E1 HHH 100 30 90 25 80 70 20 60 O WEO5HH - 50 H 15 40 10 30 20 5 10 0 0 0 10 20 30 40 50 60 70 80 90 100 110 120 GPM L i i 1 0 10 20 30 m'/h CAPACITY 01985 Goulds Pumps. Inc. Effective July, 1985 C3885 • STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER PhAnClo, 3, F_t~ 'T r d MAILING ADDRESS (#V3 9_00V" a(se i 3 l l ~CQ rn.er -i L0Z S VDa-5 PROPERTY ADDRESS lqqo RP-11 ~Y'U:P_ (location of septic system) Please obtain from the Planning Dept. CITY/STATE t.-of- 13, $1 otr- tea, I/OnSe4~ 'lurHt_ tOt~ tlr`dJ Ibt diJ PROPERTY LOCATION_ 1/49 1/4, Section T _ ? / N-R__Lq_W TOWN OF Sariler- ST. CROIX COUNTY, WI SUBDIVISION j LOT NUMBER CERTIFIED SURVEY MAP , VOLUME , 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: DATE: 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 Pa+y-t-ucL- ~)Pcw,) &)ersoO Location of property "_1/4 _1/4, Section,-2!1:~,T_,.?f N-R_& _W Township -SO Yn0-Y- C~ ' Mailing address ash Igo- Lek Address of site (af 13 141nek a~ aAJ T,et take klcll.s I ~ Aidb460 Subdivision name 00'Ren'S -Rkr4le., L,)LtQ W 9.% L 15f14& L t no. Other homes on property? Yes No Previous owner of property a ~Q NS P 1y ~cAr~~ Sen) Total size of property x'39 QCY2 S Wk~ch 0<<l c~l~ l SS`l s9. -~~~1~nut~ Total size of parcel Date parcel was created Are all corners and lot lines identifiable? V Yes No Is this property being developed for (spec (Es),? Yes No Volume 1099 and Page Number 423 d 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. -T-6,K PQrmi No" 032 ` d 0 q3_toO 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. a a So 9 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. so 9 5 AV /1 / I A S gnature o Applicant Co-Applicant l0 / )(--f 5/ Date of Sionattir(- nata nf ~irinatiira I .DOCUMENT NO. WARRANTY DEED III THIS SPACE RESERVED FOR RECORDING DATA i • STATE BAR OF WISCONSIN FORM 2 -1982 522509 not 1Q9gPa~F 30 I, Richard M. Hansen and Jane A. Hansen husband and wl.fe - - l OCT 14 1994 - iI conve Dean M. Everson and-Patricia A. ~I nd warrants to II jj ves arson husband. and-wife - - _ - 1:00 - ~ - RETURN TO . L II the following described real estate in St. Croix County, State of Wisconsin: Tax Parcel No:.032-2093-60....... I Lot 13, Block 2, Hansen's Turtle Lake Hills First Addition in the Town of Somerset, St. Croix County, Wisconsin. i 1 0ls s, . qq, • it r; I ~I This ...is- not homestead property. ~(is not) I Exception to warranties: Easements, restrictions and rights-of-way of record, if any. i Dated this October 19 94 day of - - - - - - - - (SEAL) ---(SEAL) d M. Hansen .-..(SEAL) - - (SEAL) * Jane A. Hansen - - AUTHENTICATION ACKNOWLEDGMENT Signature(s)`_vV`__r": STATE OF WISCONSIN Ja-,I~ A tss. - ~ S--t--. C-r--o--i--x County- authenticated this ay of__19gl' Personally came before me this ________________day of QC_4QbQx--------------- 19__94__ the above named Richard M. Hansen and- Jane- A.--Hansen nJ /k- ©~C'11 1 17 -1 - usband nd TITLE: MEMBER STATE BAR OF WISCONSIN (If not, - by § 706.06, Wis: Stats.) to me known to be the person S__________ who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY , Krlstina_ Ogland * - - - - 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: 19 _ . - - - - '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. FORM No. 2 - 1982 Milwaukee. `Nisconsin