HomeMy WebLinkAbout040-1214-70-000
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AS BUILT SANITARY SYSTEM REP,.
OWNER X--VERS4A.)
ADDRESS 3 S 7 SO . PA c I c
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SUBDIVISION / CSM# Arlo v4--.P LOT # `3
SECTION T 2'9 N-R W, Town of _T
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
4)C11 VO T" IW S 7`,9 7'~O O ~
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
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,'T' 5 4J /07' 4!PAx &W <.V . . 77,
BENCH24ARK:'r Z .3 Xe-7- 13y 00
ALTERNATE BM: Tb Pr.,1etl 4601AO& y7 O~O~ - Ad 3. 5-,0
SEPTIC TANK / PUMP CHAMBER / HOLDING.TANK INFORMATION
Manufacturer: ~&Ees (p
47 Liquid Capacity: 1200
Setback from: Well ~,A10 r f Other
House 12
fo D+74---
Model#~ Size /v 141A, Float- --Gpe*at4re+r
Gallons/cycle;
Alarm Location
-:SOIL ABSORPTION SYSTEM
Width: 5 Length Z
Number of trenches
Distance & Direction to nearest prop, line: 93 ' 'fo E' S L ,
Setback from: well: House 24 I
Other
ELEVATIONS
Building Sewer 161• ✓r ST Inlet : ~ 2.4
ST outlet ~D f • S~
PC inlet _pC bottom -
Pump Off
Header/Manifold
Bottom of system ~
Existing Grade .4 - 0
Final grade
/0 0. SO
DATE OF INSTALLATION: op-3-
PLUMBER ON JOB: R0.g,C r
LICENSE NUMBER: /0AWS 330 7
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Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: ST. CROIX
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 8873
PejVZX eOrN,amE~ fSAND~ ❑ City ❑ Village R Town of: State Plan ID No.:
CST BBMEEEElevv.: ,i Insp. BM Elev..: TBM escription: l i Parcel Tax No.:
'P AgAnnll 9;7
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark AX), /00,
Dosing c
Aeration Bldg. Sewer (pb S
Holding St/ Ht inlet (Q~ lot TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
NA Dt Bottom
Septic >/0 /J.
7/7
6 /
Dosing NA Header/ Man.
Aeration NA Dist. Pipe ~`6 g ,o~ `i
g~ S'
v ~
Holding Bot. System ~j`so / o
PUMP/ SIPHON INFORMATION Final Grade `s
U
Manufacturer Demand j `'.1 y l l bar
Model Number GPM
TDH Lift Friction System TDH Ft
Loss Head
Forcemai n Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Liquid Depth
DIMENSIONS -7y DIMENSI N
LEACHING Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION TypeO ¢c. CHAMBER Model Number:
System: /j'n , g~J 2b 1 F~~1A' 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 r , xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center l! Bed /Trench Edge Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
-COMMENTS: (Include code discre ancies, persons present, etc)
ION: Troy. 1b.28.19W, SW, Lot 38, souphern Pacific Road
EL~'; I to y. A - IJ''~ X •/'(y
k ' _ v I
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yy. 1 L}g
Plan rkisionvrquired? ❑ Yes ❑ No 04
a /
Use other side for additional information.
SBD-6710 (R 05/91) Date 4stor's Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: s
,
T W-
T
y t`..
R S~ SANITARY PERMIT APPLICATION
In accord with 1LHR 83.05, Wis. Adm. Code COUNTY
S; T, C-A bt X
STATE SANIT Y PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than /1(Q~ 3
8% x 11 inches in size. om U
❑ 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
JAK£S d
% 5,4NDRq- VE R,so,v Qv Y. NC-- Y., S !~o TN, R E (or W
PROPERTY
SL5 OWNERS MAILIINNADDRESS LOT # 310
BLOCK #
10-41-, CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
'1'! - voSo~✓ 10,/- 5 yal to 1(-715 pro •4.3 G/ovEre 6T, 7-1 o,v
Li TY
II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VI LL GE : TR O NEAREST ROAD v
❑ Public L...I 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply) C 7 d r l a-l zl_ 7 (9 0 Q d
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 120 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 4.0 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-ln-Fill ?CS E,g G(,, •Jr 7,~
VI. ABSORPTION SYSTEM INFORMATION: 9(r, 70 to d.
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 16. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
750 -7,50 -9 ~S•o
VII. TANK CAP CITY Feet f ~ Feet
in al Total Site
INFORMATION #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
New xistin Gallons Tanks Concrete glass App
Tanks Tanks tructed
Septic Tank or Holding Tank O /1-0 - S
Lift Pump Tank/Si hon Chamber 40AJ
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) 4AU/MPRSW No.: Business Phone Number:
RoEQT 2t cl.T' 3309 115 3F& 818
Plumber's Address (Street, City, State, Zip dC e
• -VPTO GJ /SrSS j' Nor • S of
IX. C UNTY/DEPARTMENT USE ONLY
❑ Disapproved Sa ry Permit Fee (Includes Groundwater Date Issued Issuing Ag nt Sig ature (No $ffmps
[Fle Surchar9a Fee
49 1 Approved El Owner Given initial 0 i % 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, 608-266-8815.
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)
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CL So• pAcrfrc F2aQ .
Fresh Air Inlets And Observation Pipe
Q~ Approved Vent Cap
Minimum 12' Above
Final Grade 1c
/00. 7 0
3 CD ' Above Pipe _ 40 Cost Iron
1o Final Grade Vent f0t
Synthetic Covering
Min. 24 Aggregate
Oistributioo - Teo
OtAggregate
Pipe 0 0 11 0 Perforated Pip
e aglow
Bo -Coupling Tocminotlnp At
Bottom 01 System
Fresh Air Inlets And Observation Pipe
Q+- Approved Vent Cop
Minimum 12' Above
Final Grade
7
10.
'
_ 4' Cost Iron
• 3 (o ' Above Pipe Vent Pipi
"to Final Grade
Synthetic Covering
Min. 2' Aggregate
Over Pipe
Distribution Teo
Pipo 0 0 0 0 0
L ' Aggregate 0 Perforated Pipe Below
Beneath Pipe
0 I-Calloling Terminating At
S.ySTEM Bottom Of System
55^ D
~SCS 13 0/eAy.4 AD T S/ l
Wi:zonsin Department of Industry, P.O. DESLKIPTION REPORT safet10 s Buiiurngs Division
Labor and Human Relations .O. x 7969
(Attach Soil Profile Location Map - To Scale - On A Separate, Signed Sheet) Madison, WI 53707
3 Page of
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+04 Z-ap,y _ 5*i2 E D Sys
Customer Name Sois Evaluation Date i Current Lan Use o^Ve9ttatrvt over Parent Materials
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ax arcs o. G/O /jam System Los m9 Rate m a ons Per q. Ft. Per ay
County ,s-~, c,Borx <o r ` 3d' sT Teo > , F fo 12 -f s le o v
Slope an Aspect
-System Geometry ♦n Dept
got legs Descnptron A,) 7-4&jV '01: 7,00/
Horizon Depth Dominant Color Mottles StructurM2_ Remarks: clayskins Loading
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656 O'NER013ERT ~BRIGHTIS. 54016
1 ORIGINAL ~1
+1S. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. S -
t,!N. IPISTALLEZ & DESIGNER LIC. NO.008Ef3
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Other Site Features:
Limiting Factors/Depth: CST Signature Date Signed Telephone No. CST Y
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655 0'NE!!_ RD., HUDSON, WIS. 54016
I ROBERT ULBRIGHT ~srtLYBZ
Gh, TOP 04 N e l WIS. MI'' TER PLUMBER LIC. NO. 3307 M.P.R.S.
cavc,eie 540 vvP" rANN. tN;ralLER & 01--.SIGNER LIC N0.00663
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wisconsrnEjepartmentofIndustry. P.O. B SOIL DESLrtIPTIONREPORT P.O.1y 6ox 7 7969
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F►an Rel~tl~rss (P . 9 Madison, WI $3707
Labor and1141
Attach Soil Profile Location Ma To Scale -On A Separate, Si ned Sheet)
Page ~ of
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w wuon Date Matsna s
ustomtI Nams , urrent lan Use or Veyetauve cover Paten
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HOMESITE SEPTIC PLUMBING CO.
655 O'NEIL RD., HUDSON, WIS. 5016
ROBERT ULBRIGHT
C(OPY ty~Z
41S. MASTER PLUMBER LIC. NO. 3307 M.P.f~.>'>.
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Additional Remarks: `
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SOD-0330(N 000)
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655 O'NEIL RD., HUDSON, WIS. 5406
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAKING ADDRESS t 7 kC_; (C,) -CIA` C'° I F_~ f w 1"
PROPERTY ADDRESS 3 J f SD PA c l l r c- 14
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE S O~ yam/
PROPERTY LOCATION SW 1/4, /V 6:-114, Section /Co , T 2- k N-R
TOWN OF 1 / ST. CROIX COUNTY, WI
SUBDIVISION 64'10 V 6 2~ 5 LOT NUMBER 3
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.
i.i SIGNED: ,w, I✓'j. ,{,a~ -
DATE: G-
I
St. Croix County Zoning Office
~r~ cA Government, Center.,
1101 Carmichael Road
Hudson, WI 54016 11/93
STC-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), thenla 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 ~ 1/4 NE 1/4, Section T Z# N-R /r W
Township 0J
Mailing address °y`_ 41/. S$Xa/~
Address of site
Subdivision name ~~U STitT7O~J Lot no.
Other homes on property? yes No
Previous owner of property
Total size of parcel 2 b /7 Ae 5
Date parcel-was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes o
volume 6-6fand Page Number a,5'1 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 & 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 i the office of the County Register o'.
Deeds as Document No. 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 County Register of deeds as Document
No.
4 1--
sign tore of applicant C pplicant
Date of Signature Data of S re
WARRANTY DEED Nis SPA E o-bERVED FOR REGORtiiNG DATA
DOCUMENT NO.
STATE BAR OF WISCON31N FORM 2-1982
r.. 513938 1~$PAGt 251 REGISTER'S OFFICE
ST. CRO1K M Mn
Robe rt_G...Hansun-and.Christine M.- Hanson,..husband RadGlbrRscoM
-
- r
and. -wlfe MAR 9 1994
_
-
_ ~ 8..30 M a
conveys and warrants to - Jalrles"B. Iverson and Sandra-.K--
Iverson,- husband and-wife,..." " neupi~ee►dDeed~
-t
RETURN Tq James & Sandra Iverson
Hudson t t540-
- - - WI 016
. ...County,
the following described real estate in -$Z...CrOlY
State of Wisconsin:
Tax Parcel No:
Wt 38, Glovet Station Second Addition to the Town of Troy,
A St. Croix County, Wisconsin.
J~
1
xA
This is not homestead property.
- -
(is not)
Exception to warranties: Easements, restrictions and rights-of-way of
;x record, if any.
March , 1x.94 '
Dated this day of
` (SEAL)
(SEAL)
Robert C. Hanson
- -
- _(SEAL) 1-~I I Qi (SEAL(
- .
I
Christine M. Hanson
- -
"
AUTHENTICATION ACKNOWLEDGMENT
.y . 1'. I • r •Yr,
t5tnr~'oj P(lbert_C•_-_Hanson---------------------- STATE OF WISCONSIN
sa.
1S~tLi M•~_-onsoIl
F : - County.
t -
______~rCh---- 19_94 Personally came before me this day of
aphpltic6te& day of
4 - , 19 the above named
.
- - -
•r - -
Vlf-
x . -
•
l~rtit~•_Og_and----- -
rr : TIT.LT: 14 19MEkER STATE BAR OF WISCONSIN - - - -
I~ ~Yt'nat.
~i 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
II
Eris-tlna-Qgland_--"•--------"------
Notary Public - CO ty W"'
Attarney_at_Law,
On
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. If not, state es (ration
are not necessary.) date: . l .
~I 'Names of persons signing in any capacity should be typed or printed below their signatures.
Wisconsin Legal Blank Co.. Inc.
I~ WARRANTY DEED STATE BAR OF WISCONSIN Milwaukee. Wisconsm
FORM No. 2 - 1,02 va2
P