Loading...
HomeMy WebLinkAbout020-1288-30-000 (3) STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER SA INI iV (L ,4E 2- ADDRESS BOX '207 uL5"ls SUBDIVISION / CSM# LOT # SECTION. z- / T z9 N-RAW Town of y(~ SO/,/ ty o~ ST. CROIX COUNTY, WISCONSIN &M- rop o z^ ~.Ps drNwcatce,,,~„ PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 4 _ _P/2 A Iz l p E 341 12S , r Ho w N d l'~CJU SE ~ GA~'AGE I SCE./a.- /y ~ /o '~FWFL~ A;oG I~-3-53 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this -form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: To P of 2 t a7/P[ A l A( v) Cosa a v E 1. = /O/a ov 7 2 ALTERNATE BM: ~oQ of f/ovs~our~~,on/ - y/O SEPTIC TAN / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: (ti@; sQ Liquid Capacity: /oo oQ Setback from: Well 92 House a Other 3 Allel, , Pump: Manufacturer O Model# Size Float seperation Gallons/cycle: -f Alarm Location - SOIL ABSORPTION SYSTEM Width: W Length -io Number of trenches Distance & Direction to nearest prop. line: Setback from: well: T z House 3 7 ' Other ) z S to wQ /~;j r , ELEVATIONS /VIA h yo% S-, 7S Building Sewer ST Inlet, 9,o y = 1 ST outlet PC inlet - PC bottom - Pump Off Header/Manifold 9,-7 z~ Bottom of system e. S =yG,3s Existing Grade Final grade 4,15 DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt L(d"Ta4M~ ,rtMUQ,9 RrsQyL• 29.19W "PRIVAT E Sf %*8A f W TATION County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) sanitary Permit o.: GENERAL INFORMATION Permit Holder's Name: El City El Village C7 Town of: State Plan ID No.: Ur I SAM Insp. BM Elev.: BM Description: i~ Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9300292 K/ 1,93 3 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Benchmark ~l, Lh Septic g ~ ( AZT . 7_2/e,3' Dosin / Aeration Bldg. Sewer, Hol St/ Inlet 9.67 1117~ ,Vf TANK SETBACK INFORMATION St/ Outlet Id,eb" .7,8 TANKTO P/L WELL BLDG. Vent to ROAD Dt Inlet Air lntake Septic >5~ sir a~ NA Dt Bottom / Dosing NA /-MEM Aeration A Dist. Pipe a Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manuf Demand Model Number TDH Lift Ystem t Flea Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH width , Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS / DIMENSI N LEACHIN Manufactu SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM INFORMATION Type0 e~ nv: C Model Num System: / / 76 OR UNIT Ad I DISTRIBUTION SYSTEM Header/ RPrartifald W Distribution Pipe(s) ~E ! x Hole Size x Hole Spacing Vent To Air Intake Length 1~ r Dia. Length .-.L Dia. Spacing (C3 SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over rq f, xx Depth Of xx Seeded/ Sodded xx Mulched Bed/ Trench Center ~qb Bed /Trench Edges -~U Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION, HUDSON 21.29.19W (LOT 13 WELLS F GO STATION Plan revision required? ❑ Yes E NO Use other side for additional information. -5- SBD-6710 (R 05/91) Date Inspector's Signature Cert. No SANITARY PERMIT APPLICATION couNTY =ZZ97-1 L HR In accord with ILHR 83.05, Wis. Adm. Code ..........~..a. STowns ATE A TA~tY,?~ T # /7LQ~/ -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inch es in size. ❑ revision o evious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER _ pp PROPERTY LOCATION a- ,-7 SE %#14) S.21 T.29, N, R E (O W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # aoz~L. 13 CITY, STYE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER fr4llSa Gc~1 S-j/t7 2_749 (~~~5 tea/ o Sf4 f oN II. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) ❑ State Owned O VILLAGE : WRIF: uho" Fro., r a-- L4 vA ov ❑ Public [A 1 or 2 Fam. Dwelling-~# of bedrooms 3 AR L TAX NUM ER( ) III. BUILDING USE: (If building type is public, check all that apply) a Z O - Z 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 1100 Outdoor Recreational Facility 30 Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 120 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. New 2.E1 Replacement 3.E1 Replacement of 4. ❑ Reconnection of 5.0 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 420 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 T S~ 4:;.' 7~ 7 Z d D 7 Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION Manufacturer's Name Con- Steel Plastic New istin Gallons Tanks Concrete strutted glass App. Tanks Tanks _77 n I I] Septic Tank or Holdin Tank DDO leJm; Se 1' Lift Pump Tank/Si hon Chamber 1_1~+ I El I El . El . El I El El VIII. 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: b oc.4_ stro V\,VQa /7 Z41 7 3 2_33 Plumber's Address (Street, City, State, Zip Code): 0 7L 1't:.`Z. &w Awo s1 d~' aj S o IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sa~Jtary Perm't Fee (Includes Groundwater g e slue Issuing em Si Approved ❑ Owner Given Initial Surcharge Fee) Adverse Det rminaD n 7Q~' C " 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) 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) RL RT LA NC- A I -tQk L.! __J V 1~ ! N fj i P - v, T S T OD o y a c o O r, 1 T 1 ~ a l ~ i 1 Sou /0 7` / 9 3, CEO r ~ _ w w N O z I < I I I GA I ~ I f I I ~ I I °1 I I I I I 41. Z I I ' I c7 I g V) I I -o I I n r I I I I O h I I ~ I rn j z I I I O j ~ I I ~ I -U I I I I • m j I j m ~ W I rn I rn I (A I O ~A I ~ I I I ~I r I I I I aa) I I I N~ c j O I I I m j I I I C) I -D I I I w ~I. j m I I cn I I t O z rn o z I I I n C I j i i ~ m I 'u o I I I °w .ti i I I ~ .A I # ~ m I I Li w d I C/) W AY m IN, _ W I Z Od N -0 V z 411' I i R° X p -PY 0D n O co rn -90 0 1T1 ° x n 7~ z rri O No m T a s `v _ -D m O rr~O O _*1 m 4'• N m n P U°Q Laibor and Department ndustry, SOIL AND SITE EVALUATION REPORT 0, Labor and Human Relations P, Page / 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 IS 60'O 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 OWNER: PROPERTY LOCATION Q GOVT. LOT 5 1/4 fl/4,S) T 29 N,R I / E (or) W PROPERTY OWNER':S ]LING ADDRSS LOT # BLOCK # SUBD. NAME R CSM # 76 Ur 1,off I Wrf~LsC~Q CITY, STATZJ A 9 - / ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE OWN NE REST ROAD 1~` ;nom 1~\! t CTIq New Construction Use Residential / Number of bedrooms 3 [ j Addition to existing building j j Replacement [ j Public or commercial describe Code derived daily flow SU gpd Recommended design loading rate a . 7 bed, gpd/ft2o.S trench, gpd/ft2 Absorption area required 64S bed, ft2 SCS' trench, ft2 Maximum design loading rate bed, gpd/ft2O.7 trench, gpd/ft2 Recommended infiltration surface elevation(s) Q&Tr e0 96.6 g,j4 rs-,00 ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable It S = Suitable for system C, PPVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SY TIM IN FILL HOLDING NI U = Unsuitable fors stem 4J S ❑ U 13 S ❑ U LA'S ❑ U CAS ❑ U IRS ❑ U ❑ S L1 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trer>ch elev. Ground V-1 6a,3 ift.Ic~v~ 4 5 1 I o.~ r+ Depth to limiting factor > V) 2 Remarks: Boring # x..w:..:. rv► o o - , Z S .4 Z 'L13 a, L Ground " o, m y o~ 4 elev. I i.7 ft. Depth to limiting f Ctor > Remarks: CST Name. Please Print f Id Phone: Address: N o a~ ' ut~St>> Signature: Date: CST Number: t6 A PROPERTYOWNER SOIL DESCRIPTION REPORT Page of PARCEL I.D. # 46T f wp LL i, Boring # Horizon Depth Dominant Color Mottles Structure GPDfft Texture Consistence in. Munsell Qu. Sz. Cont. Color Bour>darY Roots Gr. Sz. Sh. ;Bed Trend (3-) ~ 7lJv 2 C> L 10-6 Ila, V-~,' t' i s O .C Ground elev.-// > py _ S rk r >r►, 1 I :0-77 p Inz.2`3 ft. Depth to limiting factor 7 9.33 Remarks: Boring # 0,4 Ground 3 2-r/r 16\ ' j ri,~ Q rd elev. ' l ~l .76ft. Depth to limiting factor 9-3 Remarks: Boring # Ground 41 ri n a.? g elev. ID/,3/ft. Depth to limiting f ctor T ~.56 Remarks: Boring # }i\4 Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) 30 A-r NW cvT C~,.11FR. g_Z 1 / sl 1 ~m ~ N I ► Wt i v k r 62 ~ S - - - g, ~ ~C.►4L r 1- 30 L~ ~ 13 Wl~~Ls F d~4 0 S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER L /a,, I I ~f7~► 7, IldV_ ADDRESS _t o k # Z, .Z FIRE NUMBER__~`® CITY/STATE tt 5 e` ZIPS Sao 1& PROPERTY LOCATION: S1 1/4, &d 1/4, SECTION 2 , T 2_f N-R 2L-~W) TOWN OF~+c ~ -So , St. Croix County, SUBDIVISION ~S ~QSy o Sf c~ -0,,7 , LOT NUMBER -L -3. 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. Croi o. Zoning Officer within 30 days of the three year expiratio ate. 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 b fthe owner(s) of the property being developed. Any inade uacies will only result ~n delays of the g t this development be intended for resale ~ byowner/ ontra~tourd spec house), thenla second form should be retained and completedCwhen the property' is sold and submitted to this office with the appropriate-deed-recording---------------- Owner of property Location of property S~ 1/4 ~.c,, ! _1/4, Section _k-/T a--7, N-R L 1 Township •c sow Mailing address o Address of site 57 LeL "a- - Subdivision names-1 cc.~( Lot no. Other homes on property? es Previous owner of property Total size of parcel C_ Date parcel -was created & - < r Are all corners and lot lines identifiable? __K___ ' Yes No is this property being developed for (spec house)?_K_Yes No Volume 28' and . Page Number .3 I of Deeds. as recorded with the Register INCLUDE WITH THIS APPLICA'T'ION THE FOLLOWING: - - A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & THE SEAL OF THE REGISTER OF DEEDS. certified survey, if available, would be helpful I o asd oloavoid 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) property described in this information form, by owner(s) of warranty deed recorded in the office of the County Regis of a Deeds as Document No._y 7 '7 •i c~ and Y ter of own the proposed site for the sewage disposal t syI (we stem) orr I e (we) j obtained an easement, to run the above described prerty for the construction of said system, and the same hasopbeen,duly recorded in the office of County Register of deeds as Document N o mac{ 7 7 z ~i Signatur pplicant Co-applicant /C) Date of Signature • bate of Signature + . DOCUMENT NO. - WARRANTY DEED ~I THIS SPACE RESERVED FOR RECORDING DATA I~ STATE BAR OF WISCONSIN FORM 2-1982 VOL :319 REGISTER'S OFFICE 4'7477291 - - - - Sr. CROIX CO., WI Recd for Record Anita G. Wells, a single woman DEC3 01991 - , 2:40 P. M conveys and warrants to John- A.___Elbert and Eric J. Lundell, .as-.Tenant s._in..Cammon,.-.an..undivided-_ane-half-_: n>terest-----.. ~9~~Deeda ..e.ac_h----------- II . - - RETURN TO - . the following described real estate in $t...-Croix _ ---County, State of Wisconsin: Tax Parcel No: All that part of the Northeast Quarter of the Northwest Quarter (NEkNWJ) lying Southerly (Sly) of the Railroad Right-of-way; The Southeast Quarter of the Northwest Quarter (SE}NWJ); The East Half of the Southwest Quarter (E}SW}), EXCEPT part to Alfred L. Ekblad , in Volume 498, page 484; part Z, to Leslie L. Swenson in Volume 498, page 504; part to Donald F. Johnsin, in Volume 500, page 525; and part to WPM 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., W1. This is not homestead property. (is) (is not) Exception to warranties: Easements, restrictions and rights-of-way of record. Dated this - 2Zth............ day of December 19..91 . ------.(SEAL) .....(SEAL) * .-Anita. G..--Wells...... (SEAL) - - . . . .......(SEAL) AUTHENTICATION ACKNOWLEDGMENT OF Anita G. Wells, a Signa e(s) STATE OF WISCONSIN si gl woman SS. County. y 27t December act a d t a of 1~_ - Personally came before me this da of 19. the above named t. 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 forcgoin~r instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Leo A. Beskar, Attorney Rodli, Beskar 6- 967es3-1 .219.-Nortl1i.Ma.iaTTS-~tS), -n------------------------------------------ Notary Public -.------.-Count} Wis. ( i Yi ilr~5a> ~'be au'tie~tflc ted or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: 19 *Names of persons signing in any capacity should be type,] or printed b0ow their ignat;: rr,. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin legal plank Co Inc FO M No. 2 - 1138 2 Milwaukee. Wisconsin