HomeMy WebLinkAbout040-1199-80-000
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STC - 104
AS BUILT SANITARY SYSTEM REPORT""'
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OWNER ,2.t41` S~j\t`OL
ADDRESS
SUBDIVISION / CSM#Tit, b~ S. LOT #
SECTION T Zia N-R I W. Town of a
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
g Izzo got
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CV1,
Ito
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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S~;ce weal `-S7
.t QQ xr n _ CC p
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BENCHMARK: xy 0i CtkQ_ 60 6.
Xu G~
ALTERNATE BM: 6 f 04-544~ CAI~JA OL* lfaj c5u'- ~
It, Ste"cftr L/t Q rr
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: (A Liquid Capacity:
Setback from: Well lea Ho'usOct Other
Pump: Manufacturer Model# Size
Float seperation_ Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length Number of trenches- ~j
Distance & Direction to nearest prop. line:
Setback from: well: No "J~House~ s~ Other
ELEVATIONS !g.e e
Building Sewer ST Inlet. ST outlet
PC inlet PC bottom 4)1k _ Pump Of f AF/P+
Header/Manifold Bottom of system
Existing Grade Final grpOe
DATE OF INSTALLATION: //,//,S-/ V
PLUMBER ON JOB:
LICENSE NUMBER: S3ZI 2-
INSPECTOR:-
3 / 9 3 j t
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Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety anti Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
Permit Holder's Name: ❑ City ❑ Village aTown of: State Plan o.:
SYKORA, PETER X
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax o.
D d`
1091 A9400292
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Q?7 Benchmark UU X00,
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet 9 ~a 3
Vent
TANK TO P/ L WELL BLDG. A
ir Ito ntake ROAD Dt Inlet
Air
Septic X025 / 5 j ° NA Dt Bottom
Dosing NA Header / Man. a;; ;s ~s
Aeration NA Dist. Pipe 6 9'y qs rq
Holding Bot. System a a 3 9k, 9
4'Y- L
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift F tion System TDH Ft
Forcemain ength Dia. Dist. To Well
mead
SOIL ABSORPTION SYSTEM
BED /TRENCH Width I Length 9 No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ~i DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O -Va.o CHAMBER OR UNIT Model Number:
System: f~ rC.G~
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 1 v1 Depth Over Q xx Depth Of xx Seeded / Sodded xx Mulched
Bed /Trench Center a.-` Bed /Trench Edges) u J Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.), T
LOCATION: TROY 28.28.19.915,SE,NE,LOT 8, SYKORA LANE
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yco ' ~Azg, ICJ' ~1 1)yat, "1 /0 T g®~
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. ko f
SBD-6710(R 05/91) Date Inspector's Signature Cert No.
I
1
I
ADDITIONAL COMMENTS AND SKETCH
T
SANITARY PERMIT NUMBER:
i
II
M.~...
R SANITARY PERMIT APPLICATION
v'~iL■~f1 In accord with ILHR 83.05, Wis. Adm. Code COUNTY
Coo
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ /,Jn 69
8% x 11 inches in size. neck if evtslon 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
ft_-f4_,r S ~=cC 0. 515: % A112 a, S ze TZG, N, R 19 E (or W
PROPERTY OWNEER'S.MAILING ADDRESS LOT # g BLOCK #
QTY, STATE -Krf~ ZIP CODE PHONE NUMBER/ SUBDIVISION NAME OR CSMN'UMBER
i Y tY LKJ i . ,5'~O 2Z / - tp282 S c AA,~ O,D uJ v, +T i l l S
II. TYPE OF BUILDING: Check one) CITY NEAREST ROAD
( ❑ State Owned ❑ VILLAGE ; -T-U-0 i. S ~OJ`a,►~e-
52- TOWN OF ❑ Public X 1 or 2 Fam. Dwelling-## of bedrooms -4- PARCEL TAX NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply) o ` Q g Q
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 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. N New 2.E] Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 51:1 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: L Oa
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5.,&RG. RAffE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) p ` , , it ELEVATION
Q~ / 2 CEO /ZOO , s / ! -7 ~~feet• 9'7 Feet
CAPACITY
VII. TANK Site
in al Ions. Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
G .
Se tic Tan rHoldin Tank o IWO WFIG7" F1 El F]
I um Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumb is Signatu (No am s) M M RSW No Business Phone Number:
S +6m ~ ~ ~ 3z t z '~s 56 3 ~9~8
Plumber's Address (Street, City, State, Zip Code):
9010 oK -75 ~5 -1-7 L/
IX. CO TY/DEPARTMENT USE ONLY
❑ Disapproved SanitWj Per it _Ff (Includes Groundwater Date Issued Issuing A ent Sig No mps)
Approved ❑ Owner Given Initial ~%:CJY rcharge Fee)
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety s 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 F
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) fora 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)
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page I of 3
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 1/2 x 11 inches in size. Plan must include, but St G v- O t ~
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 0 NER: I PROPERTY LOCATION
e-~ e-v, 6m, GOVT. LOT .S E 1/4 NF_ 1/4,S ,?8T 28 N,R f 9 E (o W
PROPER OWNER':S MAILING ADD S LOT BLOCK # SUBD. NAME OR CSM #
_ S"kAA0_j V.. 1 S
CI STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE ®fOWN NEAREST ROAD
-~Z 8z- v.o koaro,, 1-awz.-
u°e 0Z7 l57 2 -5 ::2 Lit
New Construction Use U(] Residential / Number of bedrooms [ ] Addition to existing building
[ ] Replacement [ ] Public or commercial describe
Code derived daily flow OD gpd Recommended design loading rate 4~ bed, gpd/ft2 .S trench, gpd/ft2
Absorption area required 15'00 bed, ft2 /ZD C) trench, ft2 Maximum design loading rate , 4 bed, gpd/ft2 5 trench, gpd/ft2
Recommended infiltration surface elevation(s) It (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable /V/A- -ft
LS = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable forsystem S O U S❑ U S❑ U 0S ❑ U El S ®U El S
L,[~] U
SOIL DESCRIPTION REPORT
G P D/ft
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 0 - 4/ /0 ve CL 10
s' P
Ground 6 Cla1 I rs
elev.
25 ft. 8-6Z 7, SYe S14 SG s bl~ (.+A G cc) lV f 5
Depth to 62 70 757YK 5 p S S 1~
limiting
factor
Remarks: ~A + 5
Boring # cf12 - S r
I ht S- r GS 11~P ,
:Ground 3 f7_ /vY'~ S~ ut GL4,)
elev. c-Lo /Vf
ft.
/ 7VN,
Depth to S 68-70 .SYR / ss '4:
~
limiting
fact
Remarks:
CST Name _Please Print s l s~ Phone: -7/5-
Address:
2 -.9d X ~O 2.
Signature: Date: CST Number:
PROPERTY OWNER TG0j I I Q~ &A-brQ SOIL DESCRIPTION REPORT Page? of 3
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
l 1 w, r a s .334/c NP , 3
/vrR / we f r G s zf NP . 3
Ground 3 !JT-3!o /07, S~~ S l f f S 6 k u-c -S- v- C LO elev.
Zc s( rv, 4-'-- ck-) /Uf-
Depth to D-$Z 75-
!5 iP Sl(o S S
limiting
factor
Zo
Remarks:
Boring # 0-7 10% ~'/Z - Si f ~-c~ Q S AIP , 3
Ljj... 2 7-17 v k ` s; l if I c~ s zf /~P , 3
3
Ground v _
elev
ft. q -7Z , jy , Ste'
5 -72-76 25 YR /~c s; l / s bk f~ c s - N P , 3
Depth to
limiting 7 $ ' 5X.1 - SS ,Q
factor
Z62
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Remarks:
Boring # / C) ' D le lvp 3
15 lore /vp:,
Ground ~ 16 M 513 r C~3
elev. 7 5-W SI(o
W ft.
Depth to
limiting
factor
Remarks:
Boring #
1 0-7 /v;' ~z s;l t v~f~r ~zs N~, 3
2 7 7 A) YR */V c..s NP 3
3 17-3 /oLrR 9-13 zw, Lek L", f%r C_-13 if , .S
Ground
e?9 ft. ~'-?Z 7,5-YC zc s M J-Y- CL,) 1 f ,5
5 278sit ~fsbk kl-". f- QG i A)
Depth to
limiting
fact
Remarks:
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St.I Croix County
OVVNER/BUYER huts f' `y' Hid C2~
MAILING ADDRESS K 2
PROPERTY ADDRESSg I-
(location of septic system) lease obtain from the Planning Dept.
CITY/STATE le; VRAr f a u S [a~ i- 57 `j-0 Z 2--
PROPERTY LOCATION 1/49 1/4, Section Z T a a N-R W
TOWN OF /TIrcD N ST. CROIX COUNTY, WI
SUBDIVISION Jw..~ CtO W , S LOT NUMBER S
CERTIFIED SURVEY MAP , VOLumE5//, 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 require and agree to maintain the private sewage
disposal system in accordance with the standards se orth, erein, et by the Wisconsin DNR.
Certification stating that your septic has been maintai d must co and returned to the St. Croix
County Zoning Officer within 30 days of the three ear ex ' tion at
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
-
i
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
Location of property S 1/4 1/4, Section Zg , T Z~ N-R 19 W
Township _f`c>
Mailing address _FW-2-
Z-z--
Address of site S14 q
ool
Subdivision name Lot no.
Other homes on property? _yes No.
Previous owner of property 1, r`)
Total size of parcel c c ,re✓s
Date parcel was created /q -7~4
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)?Yes No
Volume 1511 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 & 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 a office of the County Register of
Deeds as Document No. /f1 A- , 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.2Z _
r re of applicant Co-applicant
Dat-tee f Signatur„ Date of Signature
+ DOCUMENT NO. ! I STATE BAR OF WISCONSIN-FORM 1
WARRANTY DEED
322080 '(HIS SPACE RESERVED FOR RECORDING DATA
T}IIS DEED, made between Earl Cernohous. Bernard Cernohous, REGISTERS OFFICE Rosella Cernohous Hendrickson, Margaret Cernohous Ahrens, $T. CROIX CO., WIS.
Lilliam Ceruohous Blake Recd for Record this--_Z$th
and Sykora Land Company, Inc., a W scona Grantor day of--W A.D.197L
Corporation at____$3~A:, M.
Grantee, '
W i t n e s s e t h, That the said Grantor for a valuable consideratiorr-- Twenty- Rag seer of Dee E
One Thousand and No/10o----($21,000.00)--------------Dollars
conveys to Grantee the following described real estate in- t, (*Mix County, RETURN TO
State of Wisconsin:
The Southeast Quarter of the Northeast Quarter (S *ff1k) of
Tax Key #
Section 28, Township 26 North, Range Nineteen West. This is not homestead property.
r
~'RANSFER
FEE'
E-
Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining;
And said five grantors and each of them
warrantSthat the title is good, indefeasible in fee simple and free and clear of encumbrances except e8ASA to of Mt%nZd_
and will warrant and defend the same.
a Executed at $Lyer Falls, Wisconsin and t s 2nd day of May , 19 74 ,
St. Paul, Minnesota` SEAL)
e o ous
SIGNED AND SEALED IN PRESENCE OF v
erno o en c on 4
(SEAL)
_,h BB - Cernohou8 Am~
Lilian Cernohous Blake
' 1S°►L)
MII&garet Cernohous Ahrens
t
Signatures of Earl Cernohous, and Rosella Cernohous Hendrickson
authegtitafeath(a day of lg 74
' Cila a I&.: Banta _
Title:
f,''•.
Minnesota Other Party Authorized under Sec. 706.06
STATE oPMUMOOM Viz. Notary Public , State of Wisconsin
Ramer County, as. My commission expires : 6/6/76
Personally came before me, this 13th day of W 1974
the above named Ber;,ard Cernohous, Lillian Cernohous Blake, aW margare erno ous Ahrens
i
to'meaknQwn to be the person S who executed the foregoing instrument and acknowledged thi~ same.
~tAStrumpnt was drafted by Earl H. Plante
a~
g' Notary Public Ramsey County, X&
Rive Falls, Wisconsin
II H. Pl.ariTE
The'Use of witnesses is optional. My Commission (Expire-5161) rAwr,
Nutao Nu( U.
",SAL),
Names of persons signing in any capacity should be typed or printed below their t res. r~ KrIcomw"
WARRANTY DEED-STATE BAR OF WISCONSIN, FORM NO. 1 - 1971
BOOK I'VA13 ® Mod