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HomeMy WebLinkAbout036-1050-60-000 4 3 o p 6~) 0. 0 v ~ 0 N N b L N r N O N O O ~ N o u7 p. O c C Z a) 3 Q I 7 t0 4 O N C LL i ~ O ~ 'Op L p X Co O m N > Q i Q ' 3 Cl) v ~ Z N W o Z p z y y C'4 FM- ~ a m 0 E C7 p 5 Q z ~t c U ~ ~ O N CD Z d c O fn F- O CD Z ~ C 'C`7 `N co a) ~ ~ I N N 0 !v p N o aa)i Q w Z co z O N z N ~ ~ m Y Z d N v a c LO LO r-I 47 A a) C 0 0 0 U C C CL E c N N co y to y c U O o ' Q Z 0 0 0 0 o 0 CL B Z.; g 0) It N m o cn 0) 0) uN J L) rn rn Z O Cl) C) cfl T E N N f4 O > > M N L m N Q, Lo a m N 0 al Q co In N O o n ° O N C ►+i c © o N 3 c a) c N a rn o m (D o l o > o p N N Er- L o~ Y N E w cp ao 4) 0 M 04 o ..M M _M ~9 (6 N eOn p E U yTn' O N (n CO N O N H S r ~ E N +Lp-'k C. N a CL 4) C E L c C 7 r~ 7 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS SUBDIVISION / CSM# 2)~ LOT # SECTION,----)_T._ZZ N-R W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~uS~ q3, 6Z Al A ; IND CATE NORTH ARROW r Provide setback and elevation informati n on rev rse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK r S'7ar'1557`~ ALTERNATE BM:q ~1 - SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Well House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location i SOIL ABSORPTION SYSTEM Width: / Length Z-;~ Number of trenches Distance & Direction to nearest prop. line: ~ _?g~ - Setback from: well: House ~s Other ELEVATIONS Building Sewer ST Inlet. ~~,gS'! ST outlet s s PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Cyr Final grade Q DATE OF INSTALLATION: - J PLUMBER ON JOB: / ✓ LICENSE NUMBER: -2d7 2 INSPECTOR: 116s 3/93:jt Wisc6nsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: ' Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI BLADER, KEVIN X CST BM Elev.: Insp. BM Elev.: BM Description: Parcel T : /l0-(0 e, TANK INFORMATION ELEVATION DATA 11 ~9 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 5 C.. O O . Benchmark 3 ~S Q~• GPI Dosing Aeration Bldg. Sewer Holding St/,l;9 Inlet 96. F7 TANK SETBACK INFORMATION St/A Outlet G' 9~•S~ vent TANK TO P / L WELL BLDG. Air Ito ntake ROAD Dt Inlet n Air Septic >56 NA Dt Bottom Dosing NA Header/ 30, r Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufa er Demand Tsl' V.?. /v , Model Number TDH Lift Friction Y TDH Ft Fo m4f<a Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM DIMENRENNH Width Length e No. Of Trenches PIT No. Of Pits Insid id Depth DI SYSTEM TO P/L BLDG WELL LAKE/STREAM ACHIN 'Manufacturer: SETBACK INFORMATION Type O fie".) CHA o e Number. System: OR NIT DISTRIBUTION SYSTEM Header/Manifold , Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length _ Z Dia. Length L2_/ Dia. Spacing (D 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 Zg - ~Q Bed / Trench EdgesTopsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.)4 LOCATION : ST ON 21.3 .17.309A,NEf~4E,170TH STREJT/,-).~, r J 6~/~ c ,~?C T :Uf dZ^ r4,J / i C+--C > 40 Q ~C ~t Gt ~-P~• rrlc/( C(. O 07r Plan revision required? ❑ Yes [a,-No / Use other side for additional information. [/Z [~g F4/- I 1,~ I SBD-6710 (R 05/91) Date Inspector's Signature Cert No 1 ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: " II I e e. SANITARY PERMIT APPLICATION couNTY v~~lAln 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 8% x 11 inches in size. ❑ Check if revi ion to re-vious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPE OWNER PROPERTY LOCATION Ard IA7 4"e % '/4, S T , N, R (Or~ PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # Cl , STAT ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NU BER 1 LLAGE NEAREST ROA II. TYPE OF BUILDING: (Check One) El State Owned VICITY ja TOWN OF:: Xzln ARCEL TAX NUMBER(S) ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms P III. BUILDING USE: (If building type is public, check all that apply) O~~D ` ~DS~ 7d 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 El Hotel/Motel 9 El Office/Factory 13 El 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 4.0 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 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min. /inch) ELEVATION /-M 1 `8 , Feet Feet VII. TANK CAPACITY Site in allons Total Ali of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for install i n of the onsite sewage system shown on the attached plans. Plumber' Name (Pri Plumb 's n re: to ) MP/MPRSW No.: Business Phone Number: 1 11:: -9 umber's Address (Street, City, State, Zip Code YO .t2 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sani Permit Fee_bcludes Groundwater ate Issued Issuing Agent Signature Approved ❑ Owner Given Initial O U rcharge Fee) 9' 4 7 Adverse Determination , • X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety8 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. 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) /7j~lSe"CJ vuL'! I s1J G~~os yy- %o All I ~ - Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1-of Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than,8 tl 17~z7 i . Plan must include, but "I I not limited to vertical and horizontal referenp ,pojnf (B direction f slope, scale or PARCEL I.D. # dimensioned, north arrow, and location aro distance t p~ql t road. REVIEWED BY DATE APPLICANT INFORMATION-PLEA -F/RINfL INF ATI WRPER OWNER: ROPERTY LOCATION OVT. LOT 114AIZ 1/4,S T N,R i ory OWNER':S MA ING ADDRESS LOT 6 0 K# SUB .NAME OR CSM # CITY, STATE ZIPCODE ¢t gI8 ❑CITY ❑VI G OWN TNEAREST ROAD -S - New Construction Use [VI Residential /Number of bedrooms [ ] Addition to existing building ] Replacement [ ] Public or commercial describe Code derived daily flow fd° gpd Recommended design loading rate bed, gpd/ft2-,-2 _trench, gpd/ft2 Absorption area required 8TS bed, ft2 trench, ft2 Maximum design loading rate --Z-bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) -52 s- ft (as referred to site plan benchmark) Additional design / site considerations e, Parent material Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE T AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem [~1 S ❑ U (OS ❑ U 0S ❑ U ®S ❑ U ❑ S ®U ❑ S M 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 ?13 42Z :2 191, Ground J - elev. Depth to limiting factor Remarks: Boring # Ground elev. ft. j i - Depth to limiting factor Remarks: CST Name:-Please Print J Phone: Address: Signature: Date: CST Numb PROPERTYOWNER - SOIL DESCRIPTION REPORT Pag~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 Ground V7~ -9 elev. ft. - 14 Depth to limiting factor Remarks: Boring # 7 ~ Ground elev. _ 2U ft. C Depth to limiting factor Remarks: Boring # o- .I- A24 Ground - elev. Depth to limiting factor a~C Remarks: Boring # Liz Ground l elev. Depth to limiting factor Remarks: y SBD-8330(8.05/92) ~Jici l~r N/, i✓~"~9 see/, 3/,nl~ 7~ r 1° I 1 1 ~g I /8• - l- 8" I ( I s PAC, C or a t~t17' don • f//111. A11 Wets A&4 ObliolVg1jon pipe ' APNs911 Vest Cop • MMhwr YD4ao~e•o i , 10 so 4* Coal ties To 11441's/s•• Vs" Pits -Yvio 14P 01 101h91k C9..rlns ' r1• Z• A/M.•Nls '.r .c 0901 pits m1a11so1{l,I~ t4• Yoe / • ss•ssl• PIPS • ►9r1440U• Pipe Y.1•v • -C.y11e1 Y..absll•t AI v A•N•o 01 i/Ns•s oo 4 • toll rILL.• DIZITKIBUY101.1 PIPE • APPRp`rcp S1j)JpiC'TiC COVC 2" OF hGrigK6A'(E "--MATF-RiA,. OR 9' OF STFAb OR MARsti• 0. &,j ELEV. OF2Es:: <1'_,_..._ °'`(-f0 s-F A,GGRCGATE 0I5T'R14UYIOIJ PIrC .'I'r, DC AT L,CAi7 IwCNCs BCLOW ORIGIIJAI, •~.;AOE AUU AT LCAi740IWC.NCL OUT 140 mope THAW 42 IuCIiC$ CIELOW IrIWxL. C1lAOE M~ctrwM DEPfvi OF EXCAVATIOP FKoM OR16WAL 6 WIC +~Ao ~ 1. BC _ IiJCNES 1vN,MUM pEFT11 OF EACAVAT1c" f~orti5 G~iOINgL. GRA94 WIL.L. ISC 11.lcNC5 s1G uV0 LIcCUSC uUMIDEII: •0 gTC 1 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER Zvi v~ U- MAILING ADDRESS Bo)( PROPERTY ADDRESS ( ocation f septic sys;IP le ase obtain from the Planning Dept. CITY/STATE Lj J__ PROPERTY LOCATION 1/4, 1/4, section,, T-,2LN-R_ lW TOWN OF ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP ,VOLUMEe PAGE/37LOTNUMBER 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 returne o the St. Croix County Zoning Officer within 30 days of the three year expirad date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 ~ r - - 5ve f 4a' ' i p ~ { 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 114 1/4, Sect ionc;:,~,T,ZLN-R_Z_W ~ Township rt~fi✓` Mailing address Address of site 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 t~ r ; ( ~2 Are all corners and lot lines identifiable? k-~Yes No Is this property being developed for (spec house)? Yes i/' No Volumel and Page Number 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. x,/60 ~1 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. ignature of Applicant Co-Applicant ~Y- ( ~ `1 hate of S i anntj!rr' Tlatp nf q i onat-iirP V " owl ~FQ .1 I a c qj G3MENT NO. I WARRANTY DEED ..HIS SPACE RESERVED FOR RECORDING DATA ~ •oo ~I b~ STATE BAR OF WISCONSIN FORM 2 -1982 X16012 _ • v6L sa isPAGE1.37 Dale E. Swenson and Neoma P. Swenson, husband and wife cc)'*"Vil as joint -tenants------- - . ! - MAY 1994 oo conveys and warrants to --Kevin K.--Blader, a single .man ~ s-: A. - - - ETtirst National Bank - - 109E Sewn t. _ - New. Richmond. W-_ - St Croix 54. - the following described real estate in .....................County, State of Wisconsin: Tax Parcel No: I The East Half of the Northeast Quarter, Section Twenty-One (21), Township Thirty-One North, Range Seventeen (17) West, EXCEPT Lot 1 of Certified Survey Map filed October 17, 1979, in Volume "3", Certified Survey Maps, page 877, as Document #360526. i i Vat,,., NSFE11 0S 0-0 FEB I I I This is-not homestead property. (is) (is not) Exception to warranties : Dated this Z6 April-- 19------94-- - day of - - - - - - - - - -------(SEAL) - - - - - - - - (SEAL) * Dale E. Swenson (SEAL)----- (SEAL) * * Neoma P. Swenson - - ~,~et,eaeFas;,~„ t' . .el Ilia . ?"f AUTHENTICATION ACKNOWLE NIT., s" STATE OF WISCONSIN ra aa Signature(s) N M ~ .ST. CROIX----------------- ~S« authenticated this ........day of 19 Personally came befor~^mett i' ~.~c.dayKdf A ril 'Z --------------P------------------ !f.1~fyy "s: the ea}~b~analned !f AI k Dale- E-'- Swenson _ and Nern . + d~t:yF FQ--- ssy~--•---------- 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 for inAistre t ackn we a same. THIS INSTRUMENT WAS DRAFTED BY - REINSTRA, VAN DYK & NEEDHAM, S.C. 20I Soufti 1~riowTes Ave : P--0 1; 0 x727--- * /n %~►~~%l ~ON1'Q f (Q New Richmond, WI 54017 _ - Notary Public County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: f- ---Z "`L-------------------------------------- •Names of persons signing in any capacity should be typed or printed below their signatures. ws>aueuTO nt t»n STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc.