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HomeMy WebLinkAbout006-1075-80-100 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS III SUBDIVISION / CSM# ~ LOT # SECTIONS T N-R _W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW L If 11 VERYTHING WITHIN 100 FEET OF SYSTEM S L l ~ /V L _(y s wF// 37©p INDI ATE NORTH Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. s BENCHMARK: ALTERNATE BM:~~~~ SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION Manufacturer: LIB , Liquid Capacity: Setback from: Well House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location :SOIL ABSORPTION SYSTEM r Width: Length Number of trenches Distance & Direction to nearest prop. line: ~/Q J Setback from: well: ~T House_Z,5f_ Other ELEVATIONS Building Sewer ST Inlet; ST outlet PC inlet PC bottom Pump Off Bottom of system S / Header/Manifold ,'Nbs - 94~, 7S Existing Grade T~r 6z- Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: crc INSPECTOR: rU F 3/93:jt I40 a'~ifld> Tartrr~lh~ p ~{Qiat~r C . 3 3 , T3INP .E(f ` I' Sffi County: labor and Human Relations INSPECTION REPORT Safety and Buildings Division ST- CRQTX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: 191486 Permit Holder's Name: ❑ City ❑ Village EIXTown of: State Plan ID No.: ev.: nssp BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9300148 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic /J o Q Benchmark , Dosing 16~:US~ ioo Aeration Bldg. Sewer 3,76 /0 ti. a y Holding St/ Ht Inlet , 3,6, S TANK SETBACK INFORMATION St/ Ht Outlet 3,4 TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic / to Y~6 NA Dt Bottom Dosing NA Header/ Man. 19 910,1 Aeration NA Dist. Pipe b `75 Holding Bot. System 7,0 / q5 g~ PUMP/ SIPHON I FORMATION Final Grade Manufacturer Demand J ri,Hflcall ~ g /66.07 Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ IV ~ DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type O Model Number: System: &."q 0 V /,4 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.)' ,.&tv LOCATION: SW,SW,SEC.33,T31N-R16W (COUNTY RD S) Y3 ` d,,~ <03 Plan revision required? ❑ Yes ❑ No Use other side for additional information. jo SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COON , STATE SANI RY PERMIT # / y -Attach complete plans (to the county copy only) for the system, on paper not less than q 8'/z x 11 inches in size. E:] Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFO MATION - PLEASE PRINT ALL INFORMATION. PPE ER PROPERTY LOCATION RO r '/a '/a,S N,R PROPER OWNER'S MAILING ADDRESS LOT # BLOC 7 # I CITY S ATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CS NUMBER 11. TYPE OF BUILDING: (Check one) CITY NEAREST R AD ❑ State Owned VILLAGE i OF: ❑ Public ®1 or 2 Fam. Dwelling- of bedrooms - A AX Nu ) III. BUILDING USE: (If building type is public, check all that apply) 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. ~ New 2. ❑ 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 12. ABSORP. AREA 3. ABSO. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gal s/da /sq. ft.) (Min inch) ELEVATION Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION I New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Se tic Tank or Holdin Tank - - eL~ .4 L~ - W F I Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for instaliati of the onsite sewage system shown on the attached plans. PName (Print): Plumber' S• hat e: S p [MP/MPRSWNo: Business Phone Number: Plumbs ' Addleg-s (Street, City, State, zi Code): r IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Vtary Permit Fee (Includes Groundwater ate Issued Issuing A nt SiQnature (N Stamps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination / / G/ X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) 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 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: i 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. 11. 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'h 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. SBD-6398 (R.11/88) STC-100 This application form is to be completed in full and signed by jthe 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), thensa 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 ~~I(uj Location of, propertx~ /4 </4 , Section Ts~1N-R W Township _0.*V(_t) Mailing address _ 10 (4- 7q 0 nqor~ Address of site .J Subdivision name_ Lot no. Other homes on property? yes_No ' Previous owner of property ' E124QLAGO Total size of parcel Date parcel -was created 'Are all corners and lot lines identifiable? Yes No Is this property 10eing developed for (spec house)? Yes LNO Volume andPage 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 own the property described in this information form b virtue by of a warranty deed recorded in the office of the County Register of 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. Signature of applicant Co-a licant I Date o ignature Date of Signature DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR CONSI ORM 2 - 1982 501580 41 !i REGISTER'S OFFICE Caton- Henderson-and.,_Ranan------Constance M. s ST. CROIX CO., W) ^ I i O a f~ wife, _and. Samuel--C- .Eric -s-- - Rcc d for Rccr.:rd Er~~k~ol1.,._kis-.wife--- - J U N 3 0 1993 conveys and warrants to ...._Wllliam.N..--Henderson-and it rt 2:45 P,, r Jacqueline- P. --Henderson,_ husband. and.wife.. as survivorship.-marita-l-property....... - - L:,-- - RETURN TO... 'I .i Stix the following described real estate in -Cro...- ix- ------------------County, State of Wisconsin: Tax Parcel No: A parcel of land located in the Southwest Quarter of the Southwest Quarter (SW 1/4 of SW 1/4) of Section Thirty-Three (33), Township Thirty-One (31) North, Range Sixteen (16) West, Town of Cylon, St. Croix County, Wisconsin; further described as follows: Lot 1 of Certified Survey Map recorded June 29, 1993 , in Volume " 9 page 2635 as document No. 501516 Subject to right-of-way for County Trunk Highway "S", and all easements of record. `6 Qo FED ,II This __ls..not------- homestead property. i (is) (is not) Exception to warranties: June Dated this ---------_1._.. day of - 19.93.... II i ' - - AL) . EAL) x o L N. Henderson * Samuel C. Erickson - - - -./1 (I - -Q .lam .C:y~ra~( F. L) -'--1--.~1.~a..±w- ---(SEAL) - - - Ranae J Aenderson X. Constance M. Erickson - AUTHENTICATION ACHNOWLEDGMENIty J~-~ = r Signature(s) STATE OF WISCONSIN Ss. ? St. Croix . Y --•-----------County. authenticated this day of___________________________ 19...--. Personally came before me this of .,.}amed Ii Jme---------------- 199a---- the,at e'1 Samuel__C.__Ericksm Constance M. Erickson TITLE: MEMBER STATE BAR OF WISCONSIN J,atm-N.. Henderson--and.-Ranae-- _-Henderson (If not, authorized by § 706.06, Wis. Stats.) to me known to be the person $ who executed the j! forego' nstrument and kn wledge the same. THIS INSTRUMENT WAS DRAFTED BY WAN DYK & NEEDHAM, S.C. REINSTRA,------------------------------------------- * ROg o Son New Richmond, W1SCOnS11-- 5--- _ Notary bssio-- is S oIf __not, _statCo nty, ion Wis. (Signatures may be authenticated or acknowledged. Both My Comm permanent. are not necessary.) date- 1~~~96 19--------- *Names of persons signing in any capacity should be typed or printed below their signatures. XARRANTY DF7,T) STATE RAR OF WlgrONSTN Wisconsin Legal Blank Co.. Inc. Cy N F I L 33 r"~i,~ iC zJ JUN 2 0-1993o-- G~`r r~ ~S/~f ~/~.?L'.~•S~ O JAMES O'CONNELL Jr JAMES 501516 Register of o, W1 SL CfOIX Co., N1~ CERTIFIED SURVEY MAP m Located in part of the SW4 of the SW4 of Section 33, T31N, R16W, N Town of Cylon, St. Croix County, Wis onsin. OWNERS J""", Henderson Erickson C/0 Bill E Jackie Henderson to 6lZ 3,) 1790 220th St. / w a c*) New Richmond, Wi. o = F U:) _ 54017 L W to W WI/4 CORNER M SECTION 33 cn oo C') p S r cD N s N = co d O N r tD O '7 '7 N O Ij~ t ID L r, I I n- -Lr_ rJ I nnlr ° N a 0 0 ~I i~v._ o ao O °O ort -3 Ln p cn rt n' a- s -n M M M R1 w M Cn M N NW41'33"W 450.00' r- o co [D V rC ] O . O O_ 1r rh a. ~ - T r rt N O - N i C m w n rt rn r a w rt crr m ~ ' n = n m o ' w rt Z ! z co W -a m I o w O I~ I~ -n 0 o oUZ U ° LOT 1 ° Ir- = O O I] m 1 y rn O 5.17 ACRES INC. R/W O I -I (n O 224,996. SO. FT. INC. R/W ~ O 1-I 1-I o A If TI En CO CD c d 11 A m (n 4.58 ACRES EXC. R/W W IL o Lo 17-) n 0 199,478 SQ. FT. EXC. R/W - (p rt LO 4-- m - n IF- If cn I> m Z8 I L~ 1( w p O I(I) I O N89°49'04°E 354.32' 2~ Ln LA $ COUNTY _TRUNK_ HIGHWAY 11 S 11 ~ S8941'33"E 88.33- SW CORNER S89°41'33"E 450.00' „ 4 SECTION 33 SOUTH LINE OF THE SWI/4 OF SECTION 33 Ci T- SI/4 CORNER SECTION 33 LEGEND Aluminum County Section JUN ~ j g~ Monument Found, 0 1" x 24" Iron Pipe Set, I I weighing 1.68 lbs. per IJNIOI ^ r. I I--E_J I_A JD~ -.j • CRO IX COUNTY - - - - - - - linear foot x~r:prefiensive Planning SCALE IN FEET Zoning and • 1" Iron Pipe Found Committee 100' Roadway Setback 0 50 100 200 4f not. recorded tc Existing FENCE LINE ~in .30 days of This instrument drafted by Ed Flanum Job No. 93 approval date appmvel Shax b* Vol.9 Pg.2635 ►dk~YOrd SURVEYOR'S CERTIFICATE I, Allen C. Nyhagen, registered Wisconsin Land Surveyor, I have hereby certify that by direction of Jackie Henderson, surveyed, mapped and described the land parcel whicexterior represented by this Certified Survey Map, that the boundary, of the land parcel surveyed and mapped is described as follows: A parcel of land locat16WinTownpart offCythe lonSWSt4 CroixeCounty, of Section 33, T31N, R 16W, Wisconsin; further described as follows: Beginning at the SW corner of said Section 33; thence S89°41'33"E, along the South Line of the SW1/4 of said section, 450.00 feet; thence N00O00'00"W, 500.00 feet; thence N89o41'33"W, 450.00 feet to the West Line of the SW1/4 of said section; thence S00°00'00"E, along said West Line, 500.00 feet to the point of beginning. Above described parcel is subject to right-of-way for County Trunk Highway "S", and all easements of record. I, also certify that this Certified Survey Map is a correct representation to scale of the exterior boundary surveyed and described; that I have fully complied with the current provisions of Chapter O~a6nancefofhthe1CountynoftStutCroixdin the Land Subdivision surveying and mapping same. Each parcel shown on this map (plat) is subject to state and county laws, rules and regulations ($.e., wetlands, minimum lot size, access to parcel etc.). developing any parcel contact the St. Croix County Zoning Office for advice. Vol. 9 Pg. 2635 II y S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYE ADDRESS a -S FIRE NUMBER O~ CITY/STATE_ ' )2)KAI n(ntj!~- ' ZIP PROPERTY LOCATION 1/4,~/4, SECTIONi&,a_, T al N-R_L -W TOWN OF St. Croix County, SUBDIVISION_ 1/0r~ 9,Oq_ LOT NUMBER_L_ 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 a 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 Co. Zoning Officer within 30 days of the three year expiratio date. SIGNED. /JJu 4wtAL4~56 DATE : St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 wisd~sin Department of Industry, SOIL AND SITE EVALUATION REPORT Page _ of Labor and Human Relations * Divigan 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 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 OWNS : PROPERTY LOCATION GOVT. LOT 1/4 114,S SS T _3N,R (or & PROPERTY OWNER':S MAILING ADDRESS LOT BLO # SUBD. AME OR CSM # CI/, STAT ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE [MOWN NEAREST ROAD 2l - l pQ New Construction Use kj Residential / Number of bedrooms [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow J/ _ gpd Recommended design loading rate _ bed, gpd/ft2__,,s--trench, gpd/ft2 Absorption area required Z.,-q, < bed, ft2 Sii00 trench, ft2 Maximum design loading rate bed, gpd/ft21~trench, gpd/ft2 Recommended infiltration surface elevation(s) y-r 9 ft (as referred to site plan benchmark) Additional design / site co siderations Parent material ~~,a~T~ end 2, Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem ®S ❑ U 1X S ❑ U WS ❑ U [AS ❑ U ❑ S 1:9 U ❑ S f~ 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 Ground _ s- elev. ft. Depth to limiting factor > 9s i I Remarks: Boring # U.:` Ground::: ys / elev. s _ q~ ft. s Depth to limiting factor Remarks: CST Name: Please Print , Phone: Address: _ 1_12 &.2 91 Signature: , Date: CST Number: PROPERTY OWNER SOIL DESCRIPTION REPORT Page ol~'L PARCEL I.D. # Boring # Horizon in. Depth Dominant Munsell Color Qu. Sz. Mottles GrClont Color Texture StruSz. ctuShre. Consistence Bourry Roots G Bed PD/ft . Tn Ej Ground elev. Depth to limiting factor >-,97 Remarks: Boring # : -3-112 £y. 19- Ground elev. ,93,y, ft. Depth to limiting factor > S'y Remarks: Boring # e-J Ground elev. _ ,s- 171 ft. Depth to limiting factor 97 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) j I • i ' I N i i IU~ i : i ~ I ' i f II~~ r r~ ' : , ~ I w I , n I I I - • I = I I t I -1 - I I i I I i I e l I l j I i i ! r r I , I f I ' 1 i` ~ I { ~ I / i t{ I i o t I ~ , ~ I I i ' I I I I i - ~ ~ I I I I f ~ i r i r I I ' I ! 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