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HomeMy WebLinkAbout020-1288-10-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER SAM AA IL L CA ADDRESS &6A *'2 s Z '5001 Pf u.4- a- L4,- llk wso n U/-r S y016 q1t451%1-1 SUBDIVISION / CSM#WE'//5 ;7,fe64D 7Z,471-6A.- LOT # SECTION 2 i T 7-1? N-R i9 W, Town of Nu A~Sc I yo'1 ST. CROIX COUNTY, WISCONSIN PLAN VIEW A SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i DRIVE WAY _ 14-046 2~ "rav~ i 8S ---------a Nou Sc - WELL ~ p0 _ i 4p o zs ~ " f~ AllERNATr a6- o _I < y VVo,t /oY HL B.M.`fop cF If ~p~ NW INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: /"/°E 47 N W/of 4ex..r` F/ = /DD. Oo 31/ ALTERNATE BM:_ ,r 116., re- VC. 'r-/ SEPTIC TAN / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: IAM2.21 Setback from: Well 40 House 2o' Other R-DAD Pump: Manufacturer- Model# - Size - Float seperation - Gallons/cycle: - Alarm Location - SOIL ABSORPTION SYSTEM Width: /8' Length Von Number of trenches Distance & Direction to nearest prop. line: zs' Alar-N !ey Setback from: well: /oo' House (.z' Other ELEVATIONS Building Sewer ST Inlet 7-oz- ST outlet 79z PC inlet ` PC bottom - Pump Off - (-4/+) CRN) Header/Manifold7,9s - To Bottom of system Sze Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: ,mss,-1✓ir-~ Z LICENSE NUMBER: INSPECTOR: 3/93:jt I,QUG' i";f r' Q apart Q~~ .29.19,P$MWEWAGE SYSTEM County: -Labor and Human Relations INSPECTION REPORT Safety and Buildings Division ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: 193452 Permit Holder's Name: ❑ City ❑ Village [R Town of: State Plan ID No.: ~Twq HUDSON CST BM Elev.. Insp. BM Elev.: B escription: Parcel Tax No.: 14, Ob ' /,:::;0 . 60 e Qs TANK INFORMATION ELEVATION DATA A9300110 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 7027 1~,~ Dosing _ © Aeration Bldg. Sewer Holding St/ Fw inlet 7, 9 TANK SETBACK INFORMATION St/X Outlet B, 37 Vent TANK TO P/ L WELL BLDG. A irIto ntake ROAD Dt Inlet Septic NA Dt Bottom Dosing NA Header. 8 Aeration NA Dist. Pipe 90oZ,~ Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Man acturer Demand Cove✓ 3. B'9' Model Number GPM TDH Lift Friction Syste TDH Ft oss Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT f Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHIN Manufacturer: SETBACK INFORMATION Type O /7_ac.,,2 CHAMBER Model Number: System: A94 ~ OR UNIT DISTRIBUTION SYSTEM Header / Mott fe}d 40 Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Z:P! Dia _S4: Length Dia. J-Z 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,PRAIRIE LANE, LO # 2 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: f , DhLH a SANITARY PERMIT APPLICATION COUWY, v~ In accord with ILHR 83.05, Wis. Adm. Code - r STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than / 9,3 e/a e 8% x 11 inches in size. ❑ Check if revision to previous 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 C Lts r k f S E '/4 NO S Z~ T zN, R/ E (ory PROPERTY OWNER'S MAILING Af)DRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER r -so', u S oV4 27.4 9 ZJ6 s 7a,- o 9'tkt,os4 11. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) State Owned VILLAGE OF: 14 P,,tair/G A4#d ❑ Public L 1 or 2 Fam. Dwelling- # of bedrooms PARCEL TAX NUMBER( S) 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. 0 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 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 y-~d 77-0 7Z p e. 7 9 S. oo Feet 9 8 .So Feet VII. TANK CAPACITY Site INFORMATION in allons Total of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. New lExisting Gallons Tanks Concrete strutted glass App' Tanks Tanks Septic Tank or Holdin Tank OOO / tkJ,~ ,'s Q Lift Pump Tank/Si hon Chamber F] Fj 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 Signa re: (No S mps) MP/MPRSW No.: Business Phone Number: `art-r/ AI P^ g 3 2 Lef 3Z33 Plum 's Address Atreet, Ci>y, State, Zip Code): 'Re IX. COUNTY/DEPARTMENT USE ONLY Disapproved S nitary Permit Fee (Includes Groundwater I[7ate u Issuing nt Signature (No ) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination Al"L 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. •Yo'ur 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 ProRerV owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the •sysfem'is to, be installe_d.. 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, etch. 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. I SBD-6398 (R.11/88) I 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/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 Er Location of property_ 1/4 AfW 1/4, section zJ , T -29 N-R Township //4~ .S0N Mailing address Address of site }M111R.1~5 ZAIO„F Subdivision name Z~ZZ7-/Jrj~'/ Lot no. -S Other homes on property? yes-,Z No Previous owner of property .Tod r/~~~ f Total size of parcel 3• j Date parcel -was created Are all corners and lot lines identifiable? ____Yes ! No Is this property being developed for (spec house)?•„Y 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. 4/V/64/ own the proposed site for the sewage disposal and t system ) orr I e(we) obtained an easement, to ruin 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 ZofS~', licant Co-appli cant e Date of Signature Y - e r f 5 F. r` V Tt.., 1 5 p ~ F.., 9 1 (Si~':aLl a~,n ~ S t C rev _ ti ss. a Nonni S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER F~:c Lcc~~~/ / Siff%~/mar ADDRESS ,BCJ Z9'~ FIRE NUMBER - . CITY/STATE 41GOjoff wx _ ZIP S-VO/6 PROPERTY LOCATION: S 1/4, IFV 1/4, SECTION T zS N-R / W TOWN OF A~61hS ON , St. Croix County, SUBDIVISIONfdLE1/S 2(4,40 57-X 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. IV 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. Cr 'x o. Zoni officer within 30 days of the three year expirat' n date. SIGNED' DATE' YTiV A-~ St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 A , r 1 i'l U' 1 'S X 1:e, -1--- - "e - i r-.-- i III N 6 r`' , 67 (A rn F N si A VA b o` N Nt H W ~ 0 u U Ilk lA W 0 ^1 O o\ A I ~uf4 /of A'a. 3a S!/~ ' lye See ioJ Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT D Page 1 of l abdr.arr Human Relations bivisi3n 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 OWNER: PROPERTY LOCATION Q p 'SAM MLLL, t GOVT. LOT 1/4 Wj1/4,SZ / T Z [ N,R /9 E (or) W PROP TY OWNER" .MAILING ADD SS LOT BLOCK # SUED. NAME OR CSM # -4 KN (/DELLS RGO S-74 I Dnl ❑VI L GE OWN N EST ROAD CITY STATE 6 ' S CODE I (HON) NUMBER ❑CITY ~ U ~ 1 b 1~11f Qf~ 1~4~1~ W+ [N New Construction Use ( Residential / Number of bedrooms [ ] Addition to existing building I ] Replacement [ ] Public or commercial describe Code derived daily flow S gpd Recommended design loading rate -7 bed, gpd/ft2 O'% trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2 Q,$ trench, gpd/ft2 Recommended infiltration surface elevation(s)ARLJ~ I (as referred to site plan benchmark) - O6 Additional design / site considerations A4 A Parent material Flood plain elevation, if applicable It S = Suitable for system CCo IVENTIONAL MO ND IN ROUND PRESSURE A -GRADE STEM IN FILL HOLDING K U= Unsuitable for system ~I S❑ U ~S ❑ U 9S ❑ U S ❑ U S❑ U C] S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Mxxiary Roots GPD/ft in. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. Bed Trertdl ,44✓.v}:i•:il ;•i?4 ~ 5 ~ i~ c r /mar 1 2 O.S k\ i+ i Z-7 Ground $ 7 -A3 4 4 r 2 c f_ /ti 2i C / O.4 (j.S~ IoyP- elev. c I lbze- V4- 0' -M, 911) ni Depth to limiting facto 3 • q Remarks: Boring # A L ~>r C Z 0.4 aYf2 m C 0.4 o.s k, p.S 0 /b Z c c MP Ground elev. - 3 4 rn Q 1 .0 g213rt. Depth to limiting 4ctor Remarks: CST Name: PI a ML'/ P 'nt Phone: p 11,~so to `t Address: Signature: Dater l [~3 CST Number:M-T PROPERTYOWN/ER ~Ar4 >~bUt 4 SOIL DESCRIPTION REPORT Page Z of PARtrEL I.D. # L l~ Wt L LS T,4 QG b Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Bax>dary Roots Bed Tn~ 0-1Z /OYK 3 I 7 n, c r ►'bl C O •S Rz-7 WIP, Z S, L 3 c c r rye C 1 s b 6 Ground 27-$41a o 3 4 5 m r~ co e10 /9t. -I -7.S Y f, 4 S rh i 1 d.7 o.k Depth to limiting factor Remarks: Boring # A GA /oY~3 L. 1 n, Cr M ~ C ~ O-4 p.S $ _I~ o ~;L C 1 as 6k ,r 1132 /6YR, z S i L 3 c c r e~~ C j U.S Ground D elev. 4 .rtX,X_A ft. Depth to limiting factor Remarks: Boring # 0-6 c C r rh 1 OA 0.5 v $ o >0 3 - 1 sb mfr c 0A 10.S 0-47- /OYe 4/4 S Q L I M sib' o Ground elev. g 2-//7 J'by~ 3 s ©n~ rti1 4 /OOA~ ft. Depth to limiting ? 7 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) N J M - e i j N d 4 6~ a- L41 a ~J~ In- ct CIA J , ~Qt I CA I ~ 1 ~tt~ N ci- ~j ut Yoi.1528 PAGE 146 EXISTING SEPTIC 62674 9 SYSTEM AFFIDAVIT KATHLEEN H. WALSH Document Number S CROI OF DEEDS 5TT. . CkOIX CO., WI Name & Return Address RECEIVED FOR RECORD Jeffery H and Marv B. Evens 07-20-2000 10:30 AM 509 Prairie Lane Hudson WI 54016 AFFIDAVIT EXEMPT R CERT COPY FEE: COPY FEE: 020-1288-10-000 21 29 19 1407 TRANSFER FEE: Computer I . D . Number Parcel I . D . Number RECORDING FEE: 10.00 PAGES: 1 The existing septic system which serves the dwelling being added on to must be verified by an acceptable soil report or be inspected by a licensed soil tester for compliance with high groundwater and/or bedrock separation requirements as set forth in s. COMM Chapter 83 WI. Adm. Code. The results of that inspection must be made available to this office. If the existing septic system meets these minimum requirements, and is properly functioning, an addition may be added to the dwelling without updating that system. This addition must not, however, encroach upon the required septic system setbacks as set forth in s. COMM 83. Property Owner(s) Jeffery H and Mary B Evens Property Mailing Address: 509 Prairie Lane Hudson WI 54016 Property Legal Description: Lot # it CSM/Subdivision Wells Fargo Station _N Sec. 21 , T_2_9 N-R_!_~_W, Town of Hudson Comments: The existing septic system was sized and installed for a three bedroom dwelling. There are currently 5 people living in the residence. The building remodeling project will involve remodeling the basement, which will result in the addition of a bedroom in the lower level of the structure, and as such may result in septic system to be undersized for the structure being served. An office is also being added in the basement, but will not contain a closet and will not be considered a bedroom. Any further change in usage of the structure or increase in wastewater flow may require modification of the septic system to comply with current septic system codes and regulations. The existing septic system was installed by Doug Strohbeen, for Sam Miller Homes, in 1993. St. Croix County zoning staff performed a visual inspection of the septic system at the owner's request on July 19, 2000. All setbacks from the system were code-compliant. There was no visual evidence of septic system failure at the time of inspection, but it was noted that there was 5 inches of standing effluent in the vent pipe of the drainfield. I, as the owner of the above described property, hereby affirm that the septic system serving this dwelling meets the above referenced state private sewage system codes. I realize that this addition may cause the existing septic system to become undersized for a dwelling of the resulting size, and I will make this information available to any future parties interested in v chaa sing this property... M i~ SNNts,y Signed• •~yyat'~' Public Subscribed and q. I afore e o th's date: ` Q: 13 Date • -70010 -6-D Q ! JA Lgli t{~{-~, rug GtJiLI ski V_ 1 sion expires: My Zoning De~tment Approval Date: 15 - ~y1