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HomeMy WebLinkAbout008-1019-60-050 STC - 104 AS BUILT SANITARY SYSTEM REPORT ADDRESS SUBDIVISION / CSM# A~A LOT # SECTION T-A_N-R_L~,_W, Town of ST. CROIX Y, f U.IR.P loo . 0"3 Pec( -)o-.Zl P VIEW SHOW EVERYTHING WIT IN 100 FEET F SYSTEM 50' INDICATE NORTH ARROW Provide setback and levq):Ik on information on reverse of this form. I Provide 2 dimensio so canter of septic tank manhole cover. ,c9 ry BENCHMARK: POO Oy ~~,A ~'e 1_eC~ ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION Manufacturer: M Ju3 -rri. PreCq:, Liquid Capacity: t Setback from: Well House_ Other Pump: Manufacturer L~ Model# Size Float seperation Gallons/cycle: Alarm Location ;SOIL ABSORPTION SYSTEM Width: Length /00 Number of trenches Distance & Direction to nearest prop. line: Nnrf~ Setback from: well: (3,~) / House Other ELEVATIONS Building Sewer %/28',37 ST Inlet: 107, 7 ST outlet /p7. 3 5/ PC inlet PC bottom Pump Off ~o Header/Manifold~°1u~ Qk.~ Bottom of system Existing GradeL&xyy _ f 4O Final grade k&uu ti, / -bp. 3 M DATE OF INSTALLATION: PLUMBER ON JOB: V&- LICENSE NUMBER: INSPECTOR: 3/93:jt artrr ~dt~f E 7.28.16PPIVA'1 E7STMa'SYSTEM County: La6ora1d Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) sanitary ermitNo GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village ❑XTown of: State Plan ID No.: ev.: Insp. BM Elev.: BM Description: Parcel Tax No.: /0 Ll"e /60 102171-30-000 TANK INFORMATION ELEVATION DATA A9300137 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ~,?~v~.:,. Benchmark 107,75 boa: VAk, Dosing Aeration Bldg. Sewer Holding St/Ht Inlet _ 4 / /07 v TANK SETBACK INFORMATION St/ Ht Outlet e9y /o(~ 'E/ TANKTO P/L WELL BLDG. ventto ROAD Dt Inlet Air Intake Septic 7 j(} ` f?1Ej/ NA Dt Bottom Dosing NA Header / Man. 79 t ,z Aeration NA Dist. Pipe ' Z4' z.: Holding Bot. System 17 PUMP / SIPHON INFORMATION Final Grade sy 4. '00, 7.r Manufacturer Demand ;oZ~ Model Number GPM TDH Lift Friction System TDH Ft Loss Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH width Length , No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION `5-1 ° z' DIMEN I N SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER Model Number: System:-7-Z,, ~ 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.) LOCATION: EAU GALLE 7.28.16.98A,47TH AVE. Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspe or's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH 4 SANITARY PERMIT NUMBER: + DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY ST. CROIX -MMS STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. El ~ 3 -~J! Check if revision to pr w s 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 JEROME WYNVEEN SE '/4 NW '/4, S 7 T 2Q N, R 16 E (or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # 1160 LOCKHORST N/A N/A CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER BALDWIN WI 154002 715 684-2842 N/A E:I VILLLLAGE : NEAREST ROAD 11. TYPE OF BUILDING: (Check one) 1:1 State Owned EAU GALLE 47TH AVENUE CL TAX QF: ❑ Public ©1 or 2 Fam. Dwelling-#of bedrooms 3 PAR NUMBER( S) 111. BUILDING USE: (If building type is public, check all that apply) 008-1020-30 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 80 Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑X New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ 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 300 Specify Type 41 ❑ Holding Tank 12 ® Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 140 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) 97.94 ELEVATION 600 1000 1000 .6 N/A 98.77 Feet 99.94 C.ef 7 VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank 200 1200 1 MIDWESTERN PRECAS X Lift Pump 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): Plu 's Signature: (No Stardps) MP/MPRSW No.: Business Phone Number: BENNIE HELGESON 3215. 715. 772-3278 Plumber's Address (Street, City, State, Zip Code): W1229 770TH AVENUE, SPRING VALLEY, WI 54767 IX. C NTY/DEPARTMENT USE ONLY ❑ Disapproved S itary Permit Fee (Includes Groundwater Date issued Issuing A nt Sig No S mps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety a Buildings Division, Owner, Plumber INSTRUCTIONS r 1. A sanitary permit is valid for two (2) years. 2.1 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 T ran.sfer/Renewal Fc rrn iSBF63°x) to be submitted to flhe ounty prior to instailat~on. 5. nsite sev~acge.svc,3rns must be property rnaintairred. The tank(s) mt,-t=.t ~,i-i ped f.' ' licensed pumper vheriever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, c+_.ntact 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 TM1-7, VII. Tank frJorITIOUn rill in the capacity of every new and/or existin , tla!ik. ':sl t1he t,,-)Lai s tarnber of tacks wid' -,nutic.turer's name. Indicate prefab or site constructed and ~a7ik. ni a,erisl, r E ,r:;', tr all sept!c rL;; sii. hcsn and holding tanks for this system. Check :approval c received approval from DiLHR. Vii! . -brill State rrent. installing plumber is to fill in name, license rya; nbe! with of rprc f ri-_,ru [i•efix (e.g. a!-, phone number. Plumber must sign application ir-rn. IX. Uour3t~aii)ei;ar+la;ertt Use Only. X. County ')t i-,,it i nent U ,,:,e Only. .1:po le t 1pris and specifications not smaller than 8% 11 inches M',t I've st.bmit`i ? to +Fc. "opt nty. The plans r , ;;.,I, following plot plan, drawn to scale or with ,~C 1 !e'.e dirn6: of -ink('z.) or oth2r rreatmet t tanks; buildir n, 3 N :ivel'3, w+3t8( w w,le set-vice; trM?dr- .Y -e•: nr siphoo tanks; distribution boxes; soil ab--oti-n systevy 0Ftlp1;t sVster?l a, au of the building served, B) horizontal ar'id v t; 1,, '3tj n ,J.-,o ;tk. C) compir ic, spectfi_:ations for pumps and controls; dose volume; eleval:un u,tfey rr,rt !-.n loss; pump performance curve; pump model and pump manufacturer; D) cross section of the scii absorption system if _r required by the county; F) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharge's (fees) for ~i rtumiber of recqu!nted prjcti,:;es ,,which can effect ground w,=.ter. i he r to e_. _ lected lhrc!( h hese s'.,rchar ! g P. Urt,tC!' rc -af a water t,7i7tatlli°tatiCn 4nvw~ii,, at ons ar.0 a•Star.!-si! SBD-6398 (R.11/88) APPLICATION FOR SANITARY PERMIT 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. Shduld 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 Jerome e, :Location: of Property SE i 14, Section 7 , T S N-R1j W Township Mailing Address //dD ZD&hdI'° d - r ® ~Q' ~ ~~ia L1~-~ ~'y44•? Address of Site let./ 141-K L I W-41 ..Subdivision Name Lot Number Previous Owner. of property / e r, Total. Size of" parcel Date Parcel was`Created !ire all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes_ No Volume• and Page Number is 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 refer- ences.to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION 1 (We) eeAti6y that att statements on this bonm ane true to the but ab my (oun) know.-edge; that I (we) am (ate) the- owner (s) o6 the pnopeAty deb n i.b ed in th.i.s .inbonmation boam, by vi tue ob a waA&anty deed %ecotded in the Obb.iee ob the County Register ob Deeds as Document No. and that 1 (We) pnesentZy own the pnopos ed site ban the sewage dis nos ,e s y4tem (on 1 (we) - have obtained an easement, to nun-with the above desn bed pnopeAty, bon the constnuct,i.on ob said system, and the same has been duty recorded in the Obb.iee ob the County Regi6ten ob :Deeds, as Document No. _ 3x S NATURE OF OWNER SIGN U OF CO-OWNE (IF APPLICABLE) 7- 73 DATE SIGNED DATE SIGNED DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAIL OF WISCONSIN FORM 2-1982 _ jl ,4'5502 - VQt_-921PAGE 528-=------ = REGISTER'S OFFICE- ~I Joseph H. Lohmeier and Bernice D. Lohmeier ST CROIX Co., , WI - Recd for Record husband and wife _ "A J fY,i 1991 at 12:05 M conveys and warrants to _...Jerome -M.. Wynyeen and-_-_- 0 ~ II . l Jay.ce---Wy.nve-en.,.._h_usban.d...a.nd._.w .fe-,.._holdin.g_.._. ---------.a-s___survi vor_shlp__mazi.t_al...property.................. Re9isterofDeeds - - - I~ _ RETU _RN TO - ~f the following described real estate in -St-.-__C.TA1X------------------County, - (I II State of Wisconsin: I' Tax Parcel No: South Half (S2) of the Fractional Northwest Quarter (Frl. NW4) of I Section Seven (7), Township Twenty-eight North (T28N), Range Sixteen West (R16W), except a One-half (1/2) interest in a strip of land Twenty-six (261) feet wide along the North (N) side of said Ii real estate deeded to Henry Heebink for road purposes. The West ~i Fifteen Rods (W15R) of the Southwest Quarter of the Northeast Quarter (SW4 of NE4) of Section Seven (7), Township Twenty-eight ~I North (T28N), Range Sixteen West (R16W), except a One-half (1/2) interest in a strip of land Twenty-six (261) feet wide along the North (N) side of said real estate deeded to Henry Heebink for road purposes. AND further excepting that certain parcel described ~i in a Warranty Deed to Philip L. Nelson and Patricia A. Nelson, recorded May 12, 1972, in Volume 484 of Records, at Page 165, as Document No. 310214. 400 i This _S___________________ homestead property. (is) Nycx ot)c I~ Exception to warranties: Easements and restrictions of record. Dated this day of . 19.91.-. -----------------------(SEAL) - AL) - - - Joseph H. Lohmeier - (SEAL) x SEAL) II * -aern-ice---D... Lohmeier------------------ II AUTHENTICATION ACKNOWLEDGMENT I Signature (s) STATE OF WISCONSIN St. Croix ss. County. authenticated this ________day of___________________________ 19______ Personally came before me this 't______day of ~/4?IIPC!+_Gt'_. 19__91_ the above named Joseph H.--•1•,o-o,-er ana • Bernice D. Lohmeier a{ '`L TITLE: MEMBER STATE BAR OF WISCONSIN • - (If not- authorized by § 706.06, Wis. Stats.) to me known be the person foregoing ' u t and acknowl g THIS INSTRUMENT WAS DRAFTED BY`' ^ ':r9•~ .:..,1.- I! ~holoas__ A: McCormack----------------------------- E Ba_1,dwin-,___WI-_ 54002 Notary Public ---St-•--_Cro1x------------------ County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiratipn are'not necessary.) date: *Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc. Fonts Pin. 2- 1482 PI;!pT.pkn w;F STC - 105 ' I SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYERjvr'Qme Jiorse 144mg" ROUTE/BOX NUMBER JPfT y;0Ave Fire Number i yDD CITY/STATE •r.tP 13c~f~t-tfh2 W_r I PROPERTY LOCATION: It, Section T ar N, R16_ W, Town of a41 917,A , St. Croix County, Subdivision Lot number _ i Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you ptft into the system can affect the function of the septic tank as a treat- ment 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 systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on- site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. 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 Depart- ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. S I G N E D _~n_ 1) ATE del 1993 St. Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. 4 l 4 W-frontin Deoj imert of Industry. :)UIL Ut:)%-h1r i ivi+ nor vr1 i Labor and human Relations = U Sox *^vl (Attach Soil Profile Location Map • To Scale • On A Separate, Signed Sheet) Madison,-::I Page CUMERNA foL,E K. OATS CVR►Blr LAO VIO COVEII ;:S MATEIIUL ILO►VAIPICT 1Looo ILL _~oS~ vhete~- /O Mfr t 71 NW /1/A 33 417 Ave C AA a); a► s CR01. smLoaon,oCPO" R 1t, RO~VA' 11)V 60 J IOCATCN sgiLN TP f4w UNCrKrrr 1Ax►AMILNAre1E111 1-5 E- 114 Al W 114 A 9ORM CSW1 SuaDIVISION - NLw WLACli ~ LOT BLOCK 3 _ HorTton Depth Dominant Color Mottles Structure Limiting Factor/ LoaoingGPD'sq. It. In Munsell u. St. Cont. Color Texture Gr. St. Sh. Consistence Roots Boundar Depth Trench Bad (;-l IvYR 3a o 6 ~r C. w ire .6 :Icv = t 4y- r0 v i l i <s r t1 otn e. / / Horizon Depth Dominant Color Mottles Structure Limiting Factor/ Loading•OPDsq• n• pC In, Munsell u. St. Cont. Color Texture Gr. Sz• Sh. Consistence Roots Boundary D+pth Trench Bed .~v 0-I to c~V1. > t- ~o 10 ov~•-e J 6 ~lev = a q~ 1 -37 I' t I mr S6 1 dT~ 3 S3-S-11 v t I S E r t J V SI-~S /D IK ` a r ~t tJ S -7 C) yR R t- t t GSw w B _ I Horizon Depth Dominant Color Mottles Structure llmfting Factor/ Loading..PID/5% h. In. Munsell u. St. Cont. Color Texture Gr. St. Sh. Consistence Roots Boundary _ Depth Trench Bed ao / v 6 aQo Cw y Elev = a 3 t t c, u) i 3 33-411 1,3 Yk 5~ C s a" Y no"e < v S t`` Ju -S set h. B_ I Horizon Depth Dominant Color Mottles 'Structure Limiting Factor/ *a in In. Munsell u. St. Cont. Color Texture Gr. St. Sh. Consistence Roots Bounds Depth Trench Bed Elev = B. Horizon Depth Dominant Color Mottlef Structure Limiting Factor/ Loading<3PDdsq h. In. Munsell u, St. Cont. Color Texture Gr. St. Sh. Consistence Roots Bounds Depth Trench Bed Elev = Additional Remarks: RECD ED SYSTE. E• retn c Les 50 2 ' loeo- Sect I i 1 c t, Other Site Features: q2.)7 L C/7•/1 cf6.~~e /o ~3 9 t~~S 177~-3~7~ L3 CST Signatur ' Date Siyt ed Telephone No. CST a Systcm Elcvation t ehn~~ 00~ co Sl:*-1#1 Wiz Sy~6;L_ CST Name (Print) City Stale Zip t - - `f7fiti Awe- _ - J - $ ~ ~ures~- fro aw c LX) a r- e-s Ven S f pvc (7ro ~osr cQ Igo 0 G. ~ Scp~~c New 3 40 ~yyc W I a L"Q- CX~Stin f~ayn-~.. a 6 yccL I q o y(ft ul Cti' 2 V c~w~t, W Lf ki V Gt i ~oS S `,fit Ticv~ ~d Tr ev,ck 54 5 . 41" SJi:~ PUL 1 ~hS v. tern Lv 2~ o J rC C lei, ?y 2 -7 l I 7, 9 1 \ ~cc}cl.MGu~ ~e ~ a~ XCa~a lc~~n ~rowx o,-I~ ),~ai NC~-eS w,0 ~ot --d~ r,c(n PS tJ~ ~ ~LnF ~ r a ` - NCarss~ pr®per~ Line i L~ ' a ay rJc r~s / ~ vUco~S Shed she O - ~XiS'f ~nS c. 1e t~_ `l0f