HomeMy WebLinkAbout020-1132-40-000
s
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS je 450a,/
SUBDIVISION CSM# =d e LOT #
SECTION T N-R W, Town of &&Z.-ya., Z
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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ry
INDICATE NORTH A ROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: sa s
ALTERNATE BM•
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer:& lid AJ4 S T =g.T- Liquid Capacity: ,Dl
Setback from: Well House ` Other
Pump: Manufacturer Model Size
Float seperation Gallons/cycle: T02
Alarm Location ~Sls A-I
SOIL ABSORPTION SYSTEM
Width: Length S'? Number of trenches ;7
Distance & Direction to nearest prop. line:
Setback from: well: House Other
I
ELEVATIONS
Building Sewer ST Inlet; ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB: ~
LICENSE NUMBER: Age
INSPECTOR:
3/93:jt
LQ(i± iT10AAarWJQ$Mu2f9• 29.19.63FRI MW-* ?MR) County:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division
' (ATTACH TO PERMIT) Sanita hni
GENERAL INFORMATION
.
Permit Holder's Name: ❑ City Village l Town of: State PMM1151161-9
e fMAjn-lnsp.BIV1E1ev.: BM Description: Parcel Tax No.:
&12 , /",o , a -,P 020-1132-4.0 00-0
TANK INFORMATION ELEVATION DATA A9300157 p
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing r~ 75O 116.
Aeration,.. Bldg. Sewer
Holding St / Inlet t/s o? 3%z~ 0 9, Z~
TANK SETBACK INFORMATION St 1A Outlet
m/ r
TANK TO P/ L WELL BLDG. Ventto Air Intake ROAD Dt Inlet
r Septic NA Dt Bottom /a D/ yet, to,
r
Dosing NA Header/-)! .3'0 ' ri"lD7"~ a 9~
Aer Ion NA Dist. Pipe 167 35/aV 77
Holding Bot. System
PUMP / INFORMATION Final Grade
/o oLS7 "
Manufacturer J/ Demand i~ 7~ 0 73 r
Model Number 2tz- GPM
TDH Lift 11 Lriction System TDH Ft
Forcemain Len th ' Dia. Fi /
g Dist. To Welly
F
SOIL ABSORPTION SYSTEM
BED/TRENCH Width r Length No. Of Trenches PIT No. Of Pits inside Dia. Liquid Depth
DIMENSIONS - o;~ DIMEN IONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type Of os r CHAMBER Mode Number:
System: fie OR UNIT
DISTRIBUTION SYSTEM
Header/ Manif Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over _ xx Depth Of ed xx Mulched
Be& Trench Center y8 - (p 4e& Trench Edges x f Topsoil ❑ Yes ❑ No No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 20.29.19.637 (WILLOW RIDGE ROAD)
Plan revision required? ❑ Yes S-N-0 d/
Use other side for additional informati n.
SBD-6710 (R 05/91) r Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH i
r
SANITARY PERMIT NUMBER:
ANITARY PERMIT APPLICATION
17MLHO S COUNTY
In accord with ILHR 83.05, Wis. Adm. Code
STATE SA TAR P?M #
-Attach complete plans (to the county copy only) for thq system, on paper not less thany
8% x 11 inches in size. ❑ Check f revision/to revfous 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
'/4, S T , N, R E (or)
.2 j
PROPERTY OWNER'SMAAIILING ADDRESS i LOT # BLOCK #
C , STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
wr E `
II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD
II~~II ) ❑ State Owned ❑ VILLAGE pAo' (,d, `llocd
LJ Public W1 or 2 Fam. Dwelling-# of bedrooms !Y- 'PARCEL AX NUMBER(b)
111. BUILDING USE: (If building type is public, check all that apply) 0- 11,3
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. Q New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 511 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 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
00 REQUIRED (sq. ft.) PROPOSED (s q. tt.) (Gals/day/sq. ft.) (Min./inch) 071 JS' Vey looe A2 ac." 40121
r54et //,1Z 6ri ~~i'~ t
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 &zda_e5-~ -M 11 i _X~_ FIF. El El L1 I p I El
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system show on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stam s) P/ PRSW No.: Business Phone Number:
Plumbers Address (Street, City, State, Zip Code):
IX. COUNTY/DEPARTMENT U ONLY
L] Disapproved Sa¢itary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
'Of
Approved ❑ Owner Given initial f{ J5 Surcharge Fee) 0'
Adverse Determination
X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) 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 saritary 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, 618-266-3815.
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.
Ili. 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; lose volume; elevation differences; friction loss; pump
performance curie; 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 W; -,consir. Act 410 r;cluded the creation of surcharges (fees) for a num( er of
regulated practices which can effect groundwater.
The monies i ollec-ted through these: surcharges area used fcir rnonitoring gkoundwate:r, ground
water contamination investigations and establishmonf of standards.
SBD-6398 (R.11/88)
CIA ;zo i a l~f. Taut c%a~ ds~„~/ •~dTaPlv,i/.rr
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PAGE OF
PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
VENT CAP
4"C.I. VENT PIPC WEATHER PROOF APPROVED LOCKING
JUNCTIOAJ BOX MANHOLE COVER
25' FRCM DOOR,
WINDOW OR FRESH 12 M"`~ I
AIR INTAKE
GRADE
I tiu MIN.
I8" MIN.
CONDUIT
I®"MIN.
f~ll_.f=l PROVIDE (
AIRTIGHT SEAL I Iii V
II
APPROVEC JOINT A I III APPROVED JOINTS
W/C.-I. PIPE. I III W/C.I. PIPE
EXTEM0lKJC+ 3' I II ALARM EXTENDING 3'
ONTO SOI.10 SCt.. B I I ONTO SOLID SOIL.
I I
. I I ON
c
I
PUMP
~I ~ OFF
D
CONCRETE BLOCK
RISER EXIT PERMITTED UNL`J IF TANK MANUFACTURER HAS SUCH APPROVAL
5 PE C. I F I CATI QKJS
SEPTIC AND
DOSE TANKS MANUFACTURER: NUMBER OF DOSES: PER ,DAY
TANK ; IZE : GALLONS DOSE VOLUME
ALARM MANUFACTURER: ~ClJB~ f~{u~c;~;ryt INCLUDING BACKFLOW: GALLONS
ydt''
MODEL NUMBER: --121A Al CAPACITIES: A= 11-12) OR GALLONS
SWITCH TtIPQ: A ej-c B = L~ INCHES OR GA'_LOUS
PUMP MANUFACTURER: C= 6 INCHES OR 17/ GA'_LOUS
MODEL NUMBER: - 7 7 D=INCHES OR GALLONS
SWITCH TYPE: NOTE: PUMP AND ALARM ARE TO BE
PUMP DISC.HARVE RATE - GPM INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE B'1?WEicu PUMP OFF AND DISTRIBUTION PIPE., eSC3 FEET
+ MINIMUM NETWORK SUPPLY PRESSURE . . , , , . . . . . , .P'te" FEET
+/_20 FEET OF FORCE MAIN X~- '~1FYorTFRlCTI0Q FACTOR,L~ FEET
I'' = TOTAL DYNAMIC HEAD = FEET
INTERNAL DIMENSIONS OF TANK: LENGTH ;WIDTHL ;LIQUID DEPTH
5 IGNE0:~ LICENSE IJUMBER: S DATE:
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S T C - 100
This application form is to be completed in full and signed by
ithe owner(s) of the property being developed. Any inadequacies
will only result ~n delays of the pormit issuance. ,Should this
development be intended for resale by owner/contractor,(spec
house), thenta 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 ~~il~ , g d~✓
Location of property,:~/
L114 c(J 1/4, Section .T-` N-R~W
Township so,•J
Mailing address _Z03 Address of site _ /,).`l~o~J
Subdivision name /~1f'%~ /r► Lot no.
F.
Other homes on property? yes- A _No
Previous owner of property _A?,Cdfi ~l J J /;2 6
Total size of parcel a_ r.,-.o
Date parcel -was created
'Are all corners and lot lines identifiable? ----t-Yes ___2e__No
Is this property being developed for (spec house)? Yes No
Volume 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 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 applicant
D to `of Signature Date of Signature
jU
h. , . e
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
ADDRESS / 05' 7? T/F• FIRE NUMBER
CITY/STATE .5' L✓ ZIP_ S~lld/t'
PROPERTY LOCATION: A1411/4 ,,a,01/4 , SECTION Ve , T_fL_N-R_Z,-P_W
TOWN OF St. Croix County,
SUBDIVISION. flew , 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 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 expiratiop--date..
SIGNED:
u - DATE..
St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
RICHARD A. WHITCOMB and GEORGIA A. WHITCOMB husband `3 i (:ROIX CO., WI
R3 c'd for Record and wife, Grantors
- - J U L 6 1993
- - - - - - 8:05 A
conveys and warrants to QH4D _F,__ ANTJN.SQN.-ausl..pYA~I.N_.._AIIUNS.ON,_.. C husband and. wife.,, as -survivorship--marital_ pro pert ~a
Grantees .;F _ ReglsterofDews
-
RETURN TO
- - Chad Anunson _ 313 Locust St
the following described real estate in St. Croix r ci County, odd-~-~ 9 ~a
State of Nti isconsin
Tax Parcel No:.! `~~--=-11---- yL'
Lot 28, Willow Ridge II, Town of Hudson, St. Croix County, Wisconsin.
This is a like-kind exchange of property under Section 1031 of the Internal
Revenue Code.
II,
TOGETHER WITH and SUBJECT TO reservations, restrictions, easements and
rights-of-way of record, if any.
!I
This is not homestead property.
(is) (is not)
Exception to warranties:
Dated this .29th - day of Jun - 1x._93
_ - - - (SEAL) ~ - t - --...(SEAL)
RI ARP A. WHITCOMB
-
1... . -(SEAL) (SEAL)
GEORGIA A. WHITCOMB
I
~I
AUTHENTICATION ACKNOWLEDGMENT
j. Signature(s) STATE OF WISCONSIN
ss. ii St. Croix
---County.
authenticated this --day of 19__Personally came before me this 29th---- day of
June---------- ---19.-9-1- the above named
-Richard A. Whitcomb and Georgia A.
TITLE: MEMBER STATE BAR OF WISCONSIN Whitcomb
- (If not- -
authorized by § 706.06, Wis. Stats.) to me known to be the pe on B-.. who executed the
foregoi i u en a no edge the same. THIS INSTRUMENT WAS DRAFTED BY
h~ -
Attorney Barry C. Lundeen l OTAAY t~UtLtG~ HuMr---- PRTE LUNDEEN;-S :C. ~ n►r ~
#8;0 :LOt117i 110 Second Street' Hudson, WI 54016 St/'I . Croix Notary Pub i .--County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission ys peranent.(If not, state expV ion
are not necessary.) date: - 19-- - I II
`Names of persons signing in any capacity should be typed or printed below their signatures.
I 71 4 rxp -7- T1 1-P11 rr n^ nm WISI-I1nSin I Heal Rlank C'n Inr
ST. CROIX COUNTY
.fw WISCONSIN
ZONING OFFICE
ST. CROIX COUNTY COURTHOUSE
'M 911 FOURTH STREET • HUDSON, WI 54016
(715) 386-4680
June 5, 1992
Mr. & Mrs. William Carlson
1723 Cudd Circle
Hudson, WI 54016
Dear Mr. & Mrs. Carlson:
Thank you for your telephone call requesting information about the
requirements of excavating through a drainage easement at 892
Willow Ridge Rd. It is my understanding that the excavation will
be for the purpose of installing a pump chamber for a septic system
which is-to serve a future dwelling on the property.
Excavation through the drainage easement can occur, so long as
original grade is restored and there is no alteration of the
original drainage pattern of the area. I would not recommend doing
so, but should it become necessary, the pump chamber may be
installed within the easement provided these same considerations
are met.
If I can be of any further help in this matter, please feel free to
contact me at this office between the hours of 8:00am - 5:00pm,
Monday - Friday.
Sinc rely,
S°
mes K. Thompson
Assistant Zoning Administrator
Willow Ridge Homeowners Association 5/26/92
c/o Tom Aitchison
888 Willow Ridge Road
Hudson Wi. 54016
It is my intention to purchase lot #28 of Willow
Ridge II with the contingency that I can have the
drainfield on the southern ridge towards the rear of
the lot.
To do this I need to pump from the septic tank by the
house to the drainfield. In doing so I will have to
go under the drainage easement that runs through the
property.
Tom Nelson of the county has no problem with this, but
say's I need your permission to cross the easement.
I realize I can't disturb the the drainage ability
of the land and will replace all soils to their
origional state.
Please let me know if this is agreeable to the board
of directors so that I may procede with our building
plans.
Thank You
Bill & Lynn Carlson
1723 Cudd Circle
..Q JZHudson Wi 54016
386-1048
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