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HomeMy WebLinkAbout020-1287-20-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 511M 114/L L OF2 ADDRESS NeY ""Zf SOw~~~ ew-r i SUBDIVISION / CSM# GC/F~1-5 -711e60 LOT # Z- SECTION z 7 T 27 N-R Town of~~~.r/ ST. CROIX COUNTY, WISCONSIN - r PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF:,.SYSTEM 5 sys7~ E~ = 97 ~y " ~:A I I~ ~~l TDpOT PrlP p0, 00 / 7": :r)v sri4ll EOj SE ~D/vii. ~I~AGt ~ No,~sE g v'r ~v' 59 ~$''Y 3D r n' w 7y o~~ L9--- IN Iq' r Y N A tTLR NA'T E i r J g_ pM. Tope ~~o,. INDICATE NORTH ARROW Provide setback and elevation information on reverse of this-form. Provide 2 dimensions to center of septic tank manhole cover. R BENCHMARK: '&4 ALTERNATE BM: %R~ o~ ~o~lse Tod{n¢t (iD/~ E~ `/,ZD (SEPTIC T / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Gvd,'s Liquid Capacity: Setback from: Well r9 House 19 Other S ~fra m ~stsT 707`/,'„ Pump: Manufacturer Model# Size Float seperation' Gallons/cycle: Alarm Location ;SOIL ABSORPTION SYSTEM Width: / Length N,c Number of trenches Distance & Direction to nearest prop. line: 6/ T /07` Setback from: well: 7% House ~S Other iv ELEVATIONS 1~e0ld~ z'e'n9 s S• 8' Building Sewer - ST Inlet; 9. z 3-ST outlet 9 PC inlet _ PC bottom Pump Off - Header/Manifold I9y Bottom of system Existing Grade ~yy Final gradeS`~ DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt Lam' ~',UMl;art#> WWV,st7.29.19 LYKIVATE AGt SYS 1 E1Vf ION County: Labor and Human Relations INSPECTION REPORT ° Safety and Buildings Division IF (ATTACH TO PERMIT) SanitaryPermitd GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village R Town of: State Plan ID No.: v.: nsp. a BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9300305 -AZ TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Bencch~ma~r-k~ ~ Dosi ~~Z / as S Aeration Bldg. Sewer Holding_ St/ t Inlet TANK SETBACK INFORMATION St/ Vt Outlet 7~ vent TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet ' Septic 70 NA Dt Bottom ` 17 Dosing NA Header T ~7' Aeration NA Dist. Pipe Holding Bot. System - ~ 97 7Y PUMP/ SIPHON INFORMATION ial Grade 4/ t anufacturer Demand'' Model Number GPM TDH Lift Friction stem orcemain Length Did. Dist. To Well SOIL ABSORPTION SYSTEM DIMENRENNH Width Length , / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN I SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEA Manufact SETBACK INFORMATION Type O /1euJ orrrf / 4<:5- CHA . ~E s 775 UNIT Mo er: System: DISTRIBUTION SYSTEM Header / Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length _ Dia. Length 37 Dia. __5_Z/ Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over q,-), I Depth Over .r q xx Depth Of xx Seeded/ Sodded xx Mulched Bed/ zrrL~nter 3$- Bed/T.r$k+rPdges - T~ Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HjTDSON.27.29.19 ry~ ~JLOT 2 WELLS FARGO STATIQN / 7Z, , r (v v Cam.j Plan revision required? ❑ Yes o Use other side for additional information. J` Q f SBD-6710 (R 05/91) Date Inspector's Signature Cert No. bILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY ~o STATE SA TRY PERM T # -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. ❑ ChdfrlialW~pr,,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 416 LU E 1 Sfl`n //`R- S F %Nw s z7 T 2- 9, N, R / E (o PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # ox 4flz8~__ Z CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER s o~ wz s yo i s- 3 y~ z 7~ y A%01-1_5 7A,e 4 o 57.E 7"10 nl II. TYPE OF BUILDING: (Check one) El State Owned ❑ VILLAGE : NEAREST ROAD ❑ Public 1 or2Fam. Dwellin g-# of bedrooms -_F_ PAR L TAX NUMB ) III. BUILDING USE: (If building type is public, check all that apply) 6Z o- /ZS7- Za 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. kr;~7S11 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 N 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, ABSORP. AREA 14. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE Z/ S 6 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION L/ S 720 0,7 9 T 00 Feet /00,1 Feet VII. TANK CAPACITY Site in gallons Total # of Prefab. Fiber- Exp INFORMATION App New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank /000 LJ-; 5 g Lift Pump Tank/Si hon Chamber Vlll. 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) MP/MPRSW No.: Business Phone Number: Douc STi~a HB;cE/u - z srl 7 32- 3 3 Plumber's Address (Street, City, State, Zip Code): ox zZ /l~E~ -fle-f 1;90NV W Ile/ IX. C UN DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date issued Issuing Agen Mro4m Approved E] Owner Given Initial 3Surcharge Fee) Adverse Determination / e/0 Z X. CONDITIONS OF APPROVAL/REASONS 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 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: 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 establi§hment of standards. - SBD-6398 (R.11/88) R Ll),Npt LL / SAm MILL-F-F~ wj5ZL S ~A~GoST7/off/ Lo7' Z 7VO 'K Lo r c/NC 7- 4~- z,Sz- LFGER) S y s fi~ ,~,c F = 9710 e4: a-r SE LoTeornad Fl..-/o o. o0 SD !o pe ar i 4.- Lau t t ' PoNpZ/VG f(N/> I ~ D~AIKA~E h E A sEM 6ffT- I o L I ~ 0 WELL lMou SE I v LOT Z' w LoT 3 z' 0 y ' S7.0 d ALTEk- ' HATE 1 I i t ~ ~AkEA ~ q,~ 70 i I _I I )o I ISS 75' I~ g ~ a-3 I 1 M vl ~ ~ I Sou 7h ioT S B M o~ l~/PE S t I NoT ~oR PRARIE LAA(p L C -NO I ---------r-------- -f- II m :I O • I ~ I I I v\ cl I < I j ~ z I t I c~ I g~ ~ I 1 ,D I ~ I I ~ I A ~ m j z I I ~ I ~ a m I I I m I N w I rn I rn I w -411 0 I I I o j ~ I I I oDO I I I ~ 0 I j -O I I I 1 -p I I I a -P I m I I -0 cn I I I I o 1 C1 a M ~ I I I I i I I 'U I r~ I I I CA I o I I I w-p- l I I I -o I m i I I- I W ~z I cn ru I ~ C7 . 1 0 o L4 I z I ~ o m R~ x o 411. O -A O C O _ cfl N --1 0 N. 0 0 O ~Z Fn m x < 9y 56 O -i 7C m z 'p b m X0 b 00 ~i c m m o O O z p o Li F1 i i Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT p r-- Page 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 S 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 A /q O NER: PROPERTY LOCATION Q &L O, GOVT. LOT'SE 1/4 N W 1/4,SZ7 T N,R / / E (or) W 00 PROPERTY OWNER':S MAILI ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # 5 CITY STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE OWN NEAREST ROAD v U&Sa Q s4dl~ > OTu 'tA t& _j New Construction Use`] Residential/ Number of bedrooms _ ( ( Addition to existing building j ] Replacement ] Public or commercial describe Code derived daily flow ASO gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2 Absorption area required 6A:5 bed, ft2 SAS trench, ft2 Maximum design loading rate (3.1 bed, gpd/ft26,i trench, gpd/ft2 Recommended infiltration surface elevation(s) SEE dL• 3 0 3 ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system C NVENTIONAL MOUND IN-GROUND PRESSURE AT GRADE SY TEM IN FILL HOLDING T K U= Unsuitable fors stem S❑ U RS ❑ U ❑ U S❑ U S❑ U ❑ S 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 Tienctt { A -9 3 - ; L 7 t- 5 .6 Ground S~ ` ` ' I 7 elev. 10> 97 ft. Depth to limiting ctor >9.zs Remarks: Boring # _S /45/ S: L 2 c r V C Z S 6 } /1 S C c r C / D.S Ground I~-25 D`/f2 SL M h-f 7 B elev. !9-P 1o'19414 S /h 1 / 7 O S lift. Depth to limiting fart Remarks: CST Name:-Please Print Phone: Address: ~:'D.~X ql JQ~~N Signature: Date/-6 h2/9,3 CST Numbe 55 PROPERTY OWNER SAM MILLER SOIL DESCRIPTION REPORT Page Z of 3 PARCEL I.D. # e-b?' Z (n)ib 4C3o Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trer& .z a 3 Ground -17Z Q°/ 4- S d /Lj A7 7 elev. Ip2.2 ft. Depth to limiting factor >!C~ .OO Remarks: Boring # ~`J<~ 14 D ~~re.3 s i I.r>7 c c i .Z X0.3 /0 -v 1 Ground 3 3 SC l r~, c M ©•6 `0.7 elev. 1QYK4 4 ® r Depth to limiting Actor >f Has Remarks: Boring # A RM~ / 6- Jue ; C I rib m 3,' C i Z 3 Ground elev. /d2 97 ft. Depth to limiting ~ ctor~ Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) Q d q Q m Q - 10 N - 'N op m YY 1 ti cP M \ NJ r ~ I T r € d M J ~cp V' i S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER_ FXIC' Z o1y,0L LL /SA177 J1 /Z r~ ADDRESS 1~o X z Z~ FIRE NUMBER "J CITY/STATE Zip c PROPERTY LL~~LOCATION : ' e 114 , N W 1/4, SECTION Z. 7 , T -2 9 N- W_ TOWN OF_ #UJ-5 , St. Croix County, ' SUBDIVISION Wf -_,TA 7161Y, 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 expiration f e. SIGNED: DATE:_ St. Croix co. Zoning office 911 4th St. Hudson, WI 54016 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 ~n delays of the pormit 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 F_~/~ Lu,D ELL ~x-,- Location of• property sL 1/4 tuw 1/4, Section Z Z, .T -29 N-R /y Township AlJL'Sf,'? Mailing address ~vx z ~u sa rt r~Z yy4, Address of site 5-04- ` llu~so, C U:T S y o subdivision name _l u E L L S- 774 R e. o STR71 ON Lot no. other homes on property? yes_,Z _____No Previous owner of property -,4,7;-f-- Total size of parcel Z. ~"3 AL Date parcel -was created z 'Are all corners and lot lines identifiable? _ X yes No Is this property being developed for (spec house)? Yes No Volume 922' and. Page Number L2 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. 477 z9/ , 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 Date of Signature Date of Signature DOCUMENT NO. WARRANTY DEED I THIS SPACE RESERVED ►OR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1982 1 f vot _9:~S , vt .319 ! REGISTER'S OFFICE 4'7477%91 7 -7 - ST. CROIX CO., WI Recd for Record _ ,•--Anita. G. We11s, a.-single woman j DEC 3 01991 i °t . 2 : 40 P; M conveys and warrants to ..'John- A. Elbert and Eric J' Lundell as...Tenatnts..in .Common,..an..undivided..one-half..i.nGergs.t:....... Regh*of6" i ..e.a.c.h . RETURN TO . the following described real estate in .....St•,,,Croix ounty, C State of Wisconsin: Tax Parcel No: All that part of the Northeast Quarter of the Northwest Quarter (NE}NW}) lying Southerly (Sly) of the Railroad Right-of-way; The Southeast Quarter of the Northwest Quarter (!~E}NWO; The East Half of the Southwest Quarter (E}SW}), EXCEPT r part to Alfred L. Ekblad , in Volume 498, page 484; part to Leslie L. Swenson in Volume 498, page 504; part to Donald F. Johnsin, in Volume 500, page 525; and part to Donald L. Jordan, in Volume 580, page 354, all in Section Twenty-One (21), Township Twenty-Nine (29) North, Range Nineteen (19) West. This Warranty Deed is given in full and final satisfaction of that original Land Contract between the parties, dated December 4, 1989, recorded December 13, 1989, at 11:30 A.M., in Vol. 858 of Records, on page 633-634 as Document No.454203, Office of Register of Deeds for St. Croix Co., WI. This i . not homestead property. (is) (is not) Exception to warranties: Easements, restrictions and rights-of-way of record. Dated this _2.7.t.h._......... day of -..December............ , 19. _ ..................................(SEAL) f ......(SEAL) • ..Anita. G....We11s...... _ .............(SEAL) _ ......(SEAL) • AUTHENTICATION ACKNOWLEDGMENT Signa e(s) OF Anita G. Wells, a STATE OF WISCONSIN si 81 woman ! as. County. act ' a d t _Z?91la of.-.-- December 1991 Personally came before me this ....da of 19........ the above named Leo A. Beskar TITLE: MEMBER STATE BAR OF WISCONSIN (If not . authorized by § 706.06. Wis. Stats.) to me known to be the person who executed the fore,,oing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Leo A. Beskar, Attorney "lfodY-i-;' Beskar..&..~.oZ.e.s~ .~:.C .219--NorFth71.MainT--SStS)~ .n...................... Notary Public _...........County. Wis. ( iigyi ~llr2saln 1~ beWaLf ffe3lEl ted or acknowlcdn~ed. Both My Commission is permanent. (If not, state expiration are not necessary.) date: 'Names or persons signing in any capacity should be typed - prinlhl h.l,,w th,,ir signnt-vs. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co . Inc. FORM No. 2- 11j.42 Milwaukee. Wisconsin