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HomeMy WebLinkAbout038-1051-60-000 S a70 °o ) O M ~ ~ II, a I ~ m o o I 0o C, oa rn N Q o ~o~ o m ~ o co ON N L O A Y m y 2 N -0 3 N U :a 21 O I Q N N C L C a N o 3 m co a 'a c ai a~ ma~mti c d L 3 •L P a ~Qr c D o m o 0 Z > 0 O U y O N N a > o> c 0C14 ON - O E Q NE'OZ A N U M N o Z r d a N ~ ~ a m j 0 0 2 d c v ro 2 ~ c fA F- e- ai Z O M N N j y ~ N O U~~//l 3 m O N O ~ N O (D O p m O O N Q Z co z 0 N z m m E `V p is Y N 4 d _ d w o6 04 cn 4) Mr a G G a ~o c 0 o H ~ H U O O O •rv aaa N a ` a J U U) (M o°'i I F~V N N L O k E U m s to N M o m = Q c a c 0 0 O o E o E > O_ U) Q7 C C Q O 70 L N .p N Y Y ) N o O 3 M C )CD O\ 00 M m N t y m co L U • O r Cn (n N O y Cn O rte" a v a`, ~o li y a ds a a ~ w tt~~• am.~I a a c `~1 A u a 2 0 V) 0 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS ! e e1 1 N , SUBDIVISION / CSM# SECTIONT3?l N-RAW, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM e s~g C~.1K'<C~ !NDI-CATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. i s i 7 BENCHMARK: ~ ALTERNATE BM: 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 SOIL ABSORPTION SYSTEM Width: Length Number of trenches Distance & Direction to nearest prop. line: Setback from:.well: _-7,7 House,-;~? S-_ Other ELEVATIONS Building Sewer ST Inlet Zs ST outlet r!_ PC inlet PC bottom Pump Off Header/Manifold `s Bottom of system yj~ s Existing Graded Final grade y~ DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: LabwLnd I+oJman Relations INSPECTION REPORT ST. CROTX Safefy and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION PeSATTERLUN46, SAM El City El village Town of: State Plan o.: CST BM Elev.: Insp. BM Elev.: BM Description: l~ Parcel Tax No.: 100.0 Ave 0 (6h) 0 5 . TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark l(}d Dosing Aeration Bldg. Sewer (p,ff~ 97 /S Holding St/ Ht Inlet dS ?S TANK SETBACK INFORMATION St/ Ht Outlet 7,52 g TANK TO P/ L WELL BLDG. ventto ROAD Dt Inlet Air Intake Septic >jO' ~i ~a i Spa i NA Dt Bottom Dosi ng NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System g . 7 ~S i 3 PUMP/ SIPHON INFORMATION Final Grade Q~ . S Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Head Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM T( 5 3 3 5 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 INFORMATION Type O CHAMBER Model Number: System: ~f o~S ~5U 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.) ~_4 zr LOCA%P ON: Star Prairie.12.31.18W, SW, NW, 200th Avenue )x. o Plan revision required? ❑ 'y'es ❑ No Use other side for additional information. tyer (P Y-' SBD-6710 (R 05/91) Date Inspector's Signature Cert No. DR SANITARY PERMIT APPLICATION COUNTY 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 a 4 b 1 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 T , N, R E (or)O PROPERTY OWNER'S MAILING DDRESS LOT # BLOCK # zz2a --~Wdr 1 "~4 CI , STAT ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER n II. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) ❑ State Owned ❑ VILLAGE jelA D _ 0( ❑ Public 01 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX . UM Eli III. BUILDING USE: (if building type is public, check all that apply) O 3g U 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 9,0 Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2. [0 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 0 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./'rich) ELEVATION -t Feet Feet VII. TANK CAPACITY Site a allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks structed l znx 4 - I I Septic Tank or Holdin Tank llxd~ -'N- Fj El Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installa ' of the onsite sewage system shown on the attached plans. Plumber' ame Pri :I Plumber' Si a re: No` ps) MP/MPRSW No.: Business Phone Number: In Plu ber's Address (Street, City, State, Zip ode): IX. COON /DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued Issuing Agent Signature (No Stamps) Approved I El Owner Given Initial Surcharge Fee) '7 7- Adverse Determination o~ X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS t~ 1. A sanitary permit is valid for two (2) years. 2. YouF 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 ownertJhlp) or plumber requires a Sanitary Permit Transfer;Pe-,;-wal Fcrr SF-r- c 399) to be submW ad is the county prior to installation. 5. Ons;te st.vage systems must be properr rnaintairred. The t; ptio. tank(s) mt.st be pumper whenever necessary, usually every 2 to 3 years. 6. If you lave questions concerning your onsite sewage system, ccrrrtact your local code adrp'rrstr it or or the State o Wisconsin, Safety'& Buildings Division, 608-266-3815. To tie complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcol ta;< ri;, iber(s) of where th:, system is to be installed: 11. Type of building being served. Check only one and complete of bedrooms i' 1 or 2 FarniI, ?welIing. 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 replac me nt, rsconiection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VI1. Tank information. Fill in the capacity of every new aid/or existing 'rink, !ist the total gallons, .-;umber of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. t"c:,rrsF ate for all septic, pump/siphon and holding tanks for this system. Check experimental approval only it :.anks 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 3% 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, !)cation of - holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/v✓ater 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"refere~ice ioints; C) complete specifications for pumps and controls; close voiunme; elevation differences: fricti,jii 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 jng information. - - - - - - - - - - - - - - - - - - - - - GROUNDWATER- SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharces (fees) for a number of regulated practices which can effect groundwater. The monies collected througn these surcharges are used for roonitorino gro;indwater, g waler contamination ;nvesfigatir,rU and>establishr E ri f >tar3rtarc.s. SBD-6398 (R.11/88) / n/O/ /l (iTn CJZ~J <L7~~ VIN l.V7CN FIC /~~G ~~O T-~~VTJ 1314 (-2T11 J/ Olt ~s ~ weld G~ r N . ;1 PAC, c or n 1 {~D Ak 1111111 U4 0►1111eIIOA PIPS y1 ,Qr/ ~1K~ ( '"I •A►Nalf Y•N Cy 1. p YMhw' YII4QDevo i , to. 4:, At•.• rlp c..l a" X1,1 . 1. I" o/ed• Vom rife YM i•A •:.,r is .c• Ow ry;M•/us - OI H/ D •II~~ ~Ir• Too ' ~ o•AIIIeHI~ ~ ' bs»•It Ilpe a 1`411944101 Pips Y•t•. • ••"C•M11s1 /••~ellot AI • ieu••► 01 i111•A t' • Pro v~ c D ~in•.~ 9 c~< GOIL FILL ©MTKIBUTIOM PIPC • r APPP O'Ic G S'p•/'piCTIC COVC 2"0~ GG OTC 1' OF STRA1. R GAZE 0K MAKs6 N.~y ELEV. OF :i EC .L 'AA 00 ls•tl/s AGC.KCG-,TC ' • • ~ r ~ ,411 • C)IS'"14UT101.1 PIP[ YU pC AT 4CA>iT --70IWCHCS BELOW ORiGrIUA1, •,.,woj. AUU AT LChSTLO IWCNLL OUT 140 MORE THAW 42 ILICNCi DELOW FWAL. GIIAOC MAZVwr1 ()EPTH OF EXCAVAT100 FROM OR16Wg1. 6R)\DF. WiLt. 9E. 11JCNCs tvrr,MVM 0CF711 OF EACAVATIC" f R~~ a 01~14llJA.L G~AD~ wlt.i.. IBC _jZ&_ INCH[ 3 SiG/JC~: SIG Cu SC UUMBC 11: - ogr C • `7 ~ Wisconsin DVartment of Industry, SOIL AND SITE EVALUATION REPORT Page--,/ of Labor and Hum4n Relations Divisioraof Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code ' COUNTY 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 GOVT. LOT 114 1/0T ,N,R IIS tt (or)V 4,1 PROPERTY OWNER':S MAILING DRESS LOT # BLO # SUBD. NAME OR CSM # C TY, ATE;; ZIP CODE PHONE NUMBER ❑CITY ILLAGE MOWN NEAREST ROAD A ( ) [ ] New Construction Use b(f Residential / Number of bedrooms [ ] Addition to existing building ~j Replacement [ ] Public or commercial describe Code derived daily flow, gpd Recommended design loading rate ~Z ed, gpd/ft2_.,_,f_trench, gpd/ft2 Absorption area required , . G bed, ft2trench, ft2 Maximum design loading rate __~bed, gpd/ft2_trench, gpolft2 Recommended infiltration surface elevation(s), ft (as referred to site plan benchmark) Additional design / site considerations Parent material ,l Z'y' 'ecee a,&trf 'A,6a4 /,,k, Flood plain elevation, if applicable Z'J ~ ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem 10 S ❑ U 50 S❑ U 1~1 S❑ U ®S O U ❑ S 0 U ❑ S Jz~ 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 Tmr& k _S d-9,_ Ground _ elev. &7_ ft. Depth to limiting factor ~lcZ Remarks: Boring # r :Z LR Ground elev. ft. Depth to limiting factor Remarks: CST Name:-Please Print Phone: Address: Date: CST Number Signature: ZZ PROPERTY OWNER SOIL DESCRIPTION REPORT P of PARCEL I.D. # Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench IX S Ground S 9' le x'- elev. 2 ft. Depth to limiting factor ~/Q3 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # A ~t... Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) .C~,;,~'.r/ `~~e't'• ~t1s„ry o } s,p.iry • Sk1cv,Gu~x"- ,~!/Dc9.D c r;~ cs ~,9alb ! Well SdS--s i 3 _ 17 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ~yy\t \ S 6~A lu MAILING ADDRESS 13 -a 3 p~ ✓yl►-~ dV~.~} W ~e~l~ PROPERTY ADDRESS V'A~ I Lo 0-y SA,, \ ~.J Sly 1~ (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION Slt 1/4, N l~ 1/4, Section, T-3 j N-R__W TOWN OF S~ G Y ?y k ST. CROIX COUNTY, WI SUBDIVISION 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: 1 DATE: 2 S Cry St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 STC - 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 ' ) S4 lyld m Location of propert 5v,) 1/4 Nt 1/4, Section T,3)_N-R__L&_W Mailing address Township Sr~ r^~5t'r e l 3a~3 - pvP ~ecu ~ch~ Address of site K/7, Subdivision name Lot no. Other homes on property? Yes No Previous owner of property Z-(./j/Ze f Ll nd Total size of property ACy Total size of parcel Date parcel was created Are all corners and lot lines identifiable? X_Yes No Is this property being developed for (spec house)? Yes No rr ^^~~QQ ~ Volume J and Page Number 591 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. 519 7/ , 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. Signature of pplicant Co-Applicant ?-"96-9 Date of S i.anat>>rP Rata of q i onatiira DOCUMENT NO. STATE BAR OF WISCONSIN FORM 5-1982 THIS SPACE RESERVED FOR RECORDING DATA PERSONAL REPRESENTATIVE'S DEED 518'719 r .-------amue 1- ---------5atte--lund---------------------------------------------------------- I1ao1'Id ybr as Personal Representative of the estate of J U L 6 1994 Lucille W. Satterlund a/_ k_/a ------Lucille Satterlund_ 11:4 ("Decedent"),~.,.;. 36011 , c for a valuable consideration conveyn s, without warranty, to Samuel J. Satterlud -----f Grantee, RETURN To the following described real estate in ................................................County, Judith A. Remington State of Wisconsin (hereinafter called the "Property") : REMINGTON LAW OFFICES New Righm-nd. W! 54017 Tax Parcel No: An undivided one-third interest in the following described real estate: A parcel of land located in the Southwest Quarter of Northwest Quarter of Section 12, Township 31, Range 18 described as follows: That part of the Northeastern area of said Southwest Quarter of Northwest Quarter of Section 12, lying between the North line of CTH IIHII as now laid out and travelled as of the date of May 12, 1955, and the South bank of the Apple River. EMP..T This deed is given in partial distribution of the Estate of Lucille W. Satterlund and is exempt from transfer tax and transfer tax return. Personal Representative by this deed does convey to Grantee all of the estate and interest in the Property which the Decedent had immediately prior to Decedent's death, and all of the estate and interest in the Property which the Personal Representative hp s since acquired. Dated this -day of ______________________July 1994----- (SEAL) ~1_.. --------(SEAL) Samuel J. Satterlund . Personal Representative Personal Representative AUTHENTICATION ACKNOWLEDGEMENT Signature(s) STATE OF WISCONSIN SS. S . T CROIX s - X------------ County. r authenticated this day of___________________________ 19 Personalily came before me. th}s day of t.. 9._.. the above named -----------------------------•-----------------------------Samuel J. 8iif: erlund TITLE: MEMBER STATE BAR OF WISCONSIN (If not- authorized by § 706.06, Wis. Stats.) to me known to be the pe son wh exec d the foregoing instr a wled THIS INSTRUMENT WAS DRAFTED BY Judith A. Remington * ~ A i c t_S~rl~ REMINGTON LA 6~1_0 'R M 4 1 ~I~w_-Rcmond_,••.WI-______5-017________________ Notary Public St- Croix County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is peanent. (If not, state expiration are not necessary.) PAUf , 19fj:5...) ~ePAUCSON-JR:-l----d- - ~ •Names of persons signing in any capacity should be typed or printed below their signatures. STATE PAR OF WISCONSIN Wi-eonsin Legal Blank Co. Tne. PEIR°ONAL FREIPRE5ENTATIVE'3 DF.P]D le o f? + N+,. 5 1992 %!i', ,1 , ~1