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HomeMy WebLinkAbout020-1287-50-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER d.)r _AM /2ZY ADDRESS 8 Z S~Z/ct ; _ l_ SUBDIVISION / CSM# / f),t / 1 s rg~ s"~m~i a rr LOT # SECTIONZ_T Z 9 N-R /gyp Town of ti k 1.5 ct Ai ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I ~ I,vE t L ~I I Dri✓¢w4,y 60.45 - -I Hoc4 Sc- J I. .30 ;F !A B ~ E T D i Igl ND ` q l , I I !5• , INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: T~o_ aT SE LDT Ca/~ r d" EZ= /00.00 Q✓ s ALTERNATE BM: ~o p e ~e S~INan/ ~ee/ S•'/~ 3S= /C6/~ / T SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION Manufacturer: Liquid capacity: /,006cQ/, Setback from: Well -),Do House 90 ~ Other t`,#s7/a7- 4, Pump: Manufacturer - Model# Size - Float seperation Gallons/cycle: Alarm Location ;SOIL ABSORPTION SYSTEM Width: /0"" Length Gfo Number of trenches Distance & Direction to nearest prop. line: /s ~fo sakf4 /07"~~ h Setback from: well : --1ZS House ys Other /oS ~~o ~a s y"%~` c. ELEV7ITIONS /VI R f /e = g,S~ = 96 _ yG / Building Sewer- ST Inlet. 7.$.5= 9s /9~ ST outlet /o,l.? = 9sK- 9/ PC inlet 4R@,!~' PC bottom - Pump Off - Header/Manifold 10.3 4 = R ;b Bottom of system 11.31-e 7,o Existing Grade 7, Se✓- ~17,5`/Final grade 7.6-0'2 DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt sttfrtrsTrrr aftm ~f~n~ tr 1.29.19,WI~ITEtVV~"► ~Q'~ 163EPSYSTEM LANE V County: Labor and Relations Safety and Buildings Division INSPECTION REPORT ST- CROTX (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village Nown of: State Plan I193420 D No.: ILLER HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 020-1287-50-000 INFORMATION ELEVATION DATA A9300078 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet rl Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM riction Syesttem TDH Ft TDH Lift F Loss I -I Forcemain Length Dia. Fii Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches p1T No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type Of CHAMBER Moe Number: System: 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: HUDSON 21.29.19,SE,NW, LOT 5, PRAIRIE LANE Plan revision required? ❑ Yes ❑ No Use other side for additional information. 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 couN • ' STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑~0.9 8% x 11 inches in size. C ec f revisi tapplication -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 X le r G vN ELL nom Intl l- 1. F A S26 Y. 4% S L ~ T-2 N, R E (o PROPERTY OWNER'S MAILING A DRESS LOT # BLOCK # CITY, STAJE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ~4~ sXo% z 74p j;L 749-Go STET/v,V II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD State Owned O VIL W#N OF: 4e LAGE : ~S 1'KA l Ile / E L ❑ Public ®1 or 2 Fam. Dwelling-# of bedrooms PARCEL AX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) /Z 1 ❑ Apt/Condo / J 2 ❑ Assembly Hall 60 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.E] 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 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 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION `f TO (.,13 -7 Z o o" 7 - 9~fa Feet 7, Oo Feet VII. TANK CAPACITY Site in alions Total # of Prefab. Fiber- Exper. INFORMATION I New f-xisting Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank /000 Lift Pump Tank/Si hon Chamber El I ED] 1 1:1 Li 1 1:1 11 Vlll. RESPONSIBILITY STATEMENT 1, 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: Uo t c St"i 0 k b c." t~ 1 y 7 3 L 3 3 Plumber Address (Street, City, State, Zip Code): 2 i N VX S f0,'0 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved S itary Permit Fee (Includes Groundwater a e Issued Issuing Ag nt Signature (No Sta ps) E] Owner Given Initial Surcharge Fee) Approved Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-8398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS t t . • 0.'t t 1. A sanitar permit is valid for two (2) years. 2. )?OUK sanitaryipermit 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. IIL 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) 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 the owner(s) of the property being developed. Any inadequacies will only result in delays of the pormit issuance. , Should this development be intended for resale by owner/cohtractor,(spec house), thenla 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 ~'LG Lune// Location of propertySE _1/4 #&.-'1/4, Section T a 1 N-R_Z20 Township _10DSOAl Mailing address _&W Address of site subdivision name_ u1J5_11S Fot le6 U S;T,07_/0/V '-Lot no. Other homes on property? yes _No Previous owner of property _Td k N /-I Total .size of parcel _2_18 AC RE S Date parcel -was created 3~1G~S'L 'Are all corners and lot lines identifiable? ~_,Yes No Is this property being developed for (spec house)?X_Yes No Volume 9y/ 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. _S19 60C / , 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. ii signatur of applicant Co-applicant Z2 Date o sign Lure Date of Signature i n t; ~ r_ >r T,. AL1. is ~ I A 4 .'zti,. A` S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER_ E ~L.G L l1.dOG SA/17 /->`//a-r° ADDRESS_ &Y Z82 FIRE NUMBER CITY/STATE_rI/DSDiI .~.Z ZIP_S~04:~ PROPERTY LOCATION: SE 1/4,4/"/1/4, SECTION 2 / , T_I~ILN-R / 7 1~T7 TOWN OF St. Croix County, SUBDIVISION LCJF//S -74,f (00 C'74_ 71e y LOT NUMBER S 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 600 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 septfde been maintained must be completed and returned to the St. Cr . Z n Offi cer within 30 days of the three year expirat' n SIGNED: DATE: 2 St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 _ o Z Q L o ry ~a£5.75.1'9 S w ,90 992 0 0 O N J N O N 4J 0 ®i 1 (U y-1 \ W O O cn \ m ' cd 0 Z \ \ O cd H (0 u J co m L k \ \ N o v U \ o` p n co 1 \ N m m a, °0° \ O p \ 00 Wl N W 0 \ 00 OC to .sv-86 - ® ,02• / \ 9"1 / © \ m 61 .5b 86 J / a m to tr) o c¢ / o o OD 00 N N N Q1/ p~ O ~ N / z 0 N / td / N A G! b N cd ~ ~ C3 O / a Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page / Labor and Human Relations _ of [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 Cleo k 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 OWNER: p,~ PROPERTY LOCATION I )uF_ 1- GOVT. LOT SE: 1/4 /e~(,) 1/4,S z 1 T 2.9 N,R E (or) W PROPERTY OWNfR':S MAILIN(; ADDRESS LOT # BLOCK # SUBD. NAME OR # -mbUT' i5K6dk T~ 57 i i.JEtLS 11 tl?Gd 7)ON CITY, TATE ZIwwP CODE PHONE NUMBER ❑CITY []VILLAGE OWN NEAREST RIO S D " u rte` ` o l K ( l sa,v C~714 41 New Construction Use Residential / Number of bedrooms [ ] Addition to existing building j ] Replacement [ Public or commercial describe Code derived daily flow gpd Recommended design loading rate (2).7 bed, gpd/ft2o.3 trench, gpd/ft2 Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate Q-7 bed, gpd/ft2 ©g trench, gpd/ft2 Recommended infiltration surface elevation(s),4RLr-A j - 9:?. So ft (as referred to site plan benchmark) Additional design / site considerations AREA q4_30 Parent material Flood plain elevation, if applicable ft S =Suitable for system CO VENTIONAL 0 ND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING T K U= Unsuitable fors stem 129SEl U S❑ U S❑ LI Rs El 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 7T -w& 0- Ground 1AW 4/4 b 1 .7 0.8 elev. 99.19ft. $ Irl'3 /Ak4h S I ®.g Depth to limiting f~ctof~ Remarks: Boring # io e-tI 4 X0.5 bye J/4 S M r~,~fr~ C 1 C~2 ?p3 Ground 2S-4 iR t~ elev. ~_I Z 4 13 n C__ 44-112 0,714.25 9~ft. 8 Depth to limiting >f~t~33 L Remarks: CST Name:-Please Print /`Y ; JAP i \J614 NSA, Phone: Address: Signatur Date: CST Number: 4K L_ ~1~_ d~r - I PROPERTYOWNER S4A r I LLCM SOIL DESCRIPTION REPORT Page Z- of 3 WCELI.D.# LOT S- Wit~ZS fiAR66 Boring # Horizon Depth `Dominant Color Mottles Texture Structure Consistence Bourxlary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed TWIch -14 >avr~ 3 7 14'3 16A41,? - 'Sit C 1 2 p3 Ground 3Z SZ /OY,Q 4- 4- s r-, C ©7 01 elev. /OW-5ft. E -lZei 16Y44 S c p 7 0 in, l 1% A Depth to limiting factor r /600 Remarks: Boring # c)-// An C r »~r C p _4 6 .5 $ o-U oYj24 4 Ground elev. /Q/ ft.-fZi''J~y~4 Depth to limiting factor Remarks: Boring # 0- it V/ L / ~ C r ~ C ~ o *10 E k:'• . E.::..::.. ► S Ground n-s-z 16Y4 414 S o^ ~1 m r L 07 iU•~ elev. $ sZ-i/ 4 3 l a.? :off ft. Depth to limiting Remarks: Boring # r%d Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) y ~ I i 5 / LV~/ ~Q M D1 n 1 3 Q ~ ~ r a / ~v,,oe N 1 ~ 1 i 'I w 1 I i i VW4 m ~oRrN A n ~ A E RSV / " ~ ~ Ne u ~ m d m 70 r ~ N r- ~ W 3 1 x ~ m a~ H m a rp > Q o av It m kA o V1 N \ N ~n S a O i I _ . x o 0 t d LIT p , de + 1 stn z w -40 _ ..._w_..•, A LOT LING :0 o to q ~ 3 o M Z a o o W z jli eti n ~ I I 1 f ! w 60 r o ~I~ j I N t Ng lI~ ~iI I I ilk t~? a~, a G? C~ I 1 \R1 rr, ( ( r , 10 ;iI O ?i Ii~ I {I I Ilf i -7CJ_ { ! ! IFT I I I ~ p ~~I I 1 r I W y.l D I(~ I j ^p fn , 11 1 w ` T iJ1 p Log 411. O A~ p 0 C: ° p r U x < r1l 'Tj i o n ~ i 4a O .771 IL p I r 1, ~ v 0,3 ~ 0 5 0 ~a~~~ z ~ ~ ~ s~ ° r~~S~ ~a. 1l. 3 Z