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HomeMy WebLinkAbout020-1288-40-000 (3) STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER -54 M /V/// -=A 't L ce ,n e411 ADDRESS AP* C*-• A SUBDIVISION / CSM#_ky-1-// S -7.4 _60 ~Tj~T/p~I LOT V SECTION Z/ TAN-R!I~ Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 F 6At~IGE DRIVE VVAY 11, wEn I{o u 5 E sz 29' X So' W _ q s' 9z' a ~I V I6 v~ 4( V T LOT 4 7./y A4_ 41 rENIT ` W - " A? Ax S L A L E l/y,.` to yp 0 F D Z N ' ie~ya O B.M•Top of 1"Lot11:/~ " o-4' s E to r Rs t E-)= IOO.OV " -5y 7l al' 6 ~ D rrtJ L13 F Lo+ s f ~ I S~A6E ~oAf// 7~ieR/L BM INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: Tor eF I LOTP; ay" SE e,,,~ L° ALTERNATE BM : u Is G-_ EPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: GtJac~'S.✓ Liquid Capacity: 1040ga-,11 Setback from: Well 5'2A House /4 Other V2. s?i,oM Ar.;N a~14 Pump: Manufacturer 1c-1A Model# Size Float seperation - Gallons/cycle:,--. Alarm Location ,SOIL ABSORPTION SYSTEM Width: Length '/10 Number of trenches Distance & Direction to nearest prop. line: q-? to Ssa.7~~ L.'f'/~~•- Setback from: well: 9 House L 8 Other 44 s tD 7-,A* ELEVATIONS = /D/• 6 Z Building Sewer4•S0 = /0Z• ST Inlet .(Oz = /0% f Z ST outlet 7.02. PC inlet PC bottom - Pump Off -4 N 7. SS _ /0/-D9 Header/ManifoldRY77s: /00.27 Bottom of system $•40 = /DO./~~ Existing Grade Y~ 7e):: 1010 Final grade `V 70 /6 yo MANNoL& z Rowq 3 3.S!p = /oS-/y DATE OF INSTALLATION: PLUMBER ON JOB: st c LICENSE NUMBER: INSPECTOR: 3/93:jt °'-'Qht4;Q4;,t WP§P#,st4? . 29 .19 , N~ R ATH&AOGE gYffWOACH T% nty: Labor anO Human Relations INSPECTION REPORT ,SMety and Buildings Division (ATTACH TO PERMIT) sanitary ermit o.: GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village Town of: State Plan D o.: Elev.:, BM Description: Parcel Tax No.: CST BM Elev.: Ins BM TANK INFORMATION ELEVATION DATA A9300055 745 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic UJJ Benchmark g~ Dosi n pg, s o7. /O , D Aeration Bldg. Sewer Holding St/ Inlet 7( TANK SETBACK INFORMATION St/ vrOutlet TANKTO P/L WELL BLDG. ventto ROAD Inlet Air Intake Septic > NA Ys" Dosin NA Header/_tdar1. `dsO' G2.d Aeration NA Dist. Pipe Holding Bot. System 7~ ~ PUMP/ SIPHON INFORMATION Final Grade Manufact Demand fly/' /Q Model Number GPM 20' d~ TDH Lift Friction Syeaem TDH Ft Forcemain Length Dia. HH Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width , Length No. Of Tr nches f Pits inside Dia. Liquid Depth DIMENSIONS /,o 1 0_6 DIMENSIONS LEACHING SETBACK ufacturer: SYSTEM TO P / L BLDG WELL LAKE / STREAM INFORMATION Type O ~ CHAMBER Mo el Number. System: / C -71 OR UNIT DISTRIBUTION SYSTEM Header/ma" .aQ d- i Distribution Pipe(s) / x Hole Size x Hole Spacing Vent To Air Intake Length L~ Dia. Length 7 Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over G it Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed / Twiinsk Cente4, ~c . Bed / Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No. COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: ~HUDS!ON" /2~1/.. 22/9.119 , N.{E, SW,/ LOT 14, n STAGE COACH S ~WAI,~ lJ U.X ~~e''?'7rCI'-r ® ~ ! ~r~f 1 ,T A~~C^~'rf,3✓~ ~/~1/~ ~ 'r_- / ~ c"L~✓ f" . Plan revision required? ❑ Yes 0 Use other side for additional information. s SBD-6710 (R OS/91) Date Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION •,LHR In accord with ILHR 83.05, Wis. Adm. Code couNTY r STATE SANI ARY IPM -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 7"s 8% x 11 inches in size. c re slon to pre 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 S~/~ L/ ~2 '/a (,1 X, S 2.T , N, R E (or PROPERTY OWNER'S MAILING' ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER GIDSO/J~ I, O/S. 38't, L7G9 ELL 5 x/4/2(00 ST4 O~ II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLAGE NEAREST ROAD S o ST G E GoAr_N T,e,t L .0 =N OF AR TAX NUMB ( ) ❑ Public ®1 or 2 Fam. Dwelling-# of bedrooms 3 P 111. BUILDING USE: (If building type is public, check all that apply) D Z O _ v 1 ❑ Apt/Condo 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. ❑ Replacement 3. ❑ 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 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 0 (o ~3 -7zO D-7 ~DO.OD Feet 0Feet VII. TANK CAPACITY Site in gallons Total #of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App.' Tanks Tanks structed Septic Tank or Holdin Tank ~~~PJ EI 5 E/Q Ll L El EL Lift Pump Tank/Si hon Chamber 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 tamps) 2MP/MPRSW No.: Business Phone Number: 001, 11 1 Z- Plumbe 's Address (Street, City, State, Zip Code : 10, -S- IX. TY/DEPARTMENT USE ONLY Disapproved tary Permit Fee (includesg roundwater a e ssue issuing o ent re N 60 s Approved El Owner Given Initial t r Initial mination Adverse Dee I 72/OL2 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 L INSTRUCTIONS , 1 A sanitary permit is valid for two (2) years. 2. t 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. Vlll. 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/contractor,(spec house), thensa 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 444&9_4 l SI#/n Nil 11r-Z Location of property.&L_1/4 IZZ1114, section 7-1, T z 9 N-R Township ticSOy Mailing address AV` z8'L _ Ale s6.01 &_/_Z7 ley oz Address of site Loy` /y STif1G ®&,,,Oe 7,M1L fixer//S Z ego 7o~71,*41 Subdivision name lU~,Z/S 7,-Mg(v0 5-T,4710 Lot no. Other homes on property? yes_ X No Previous owner of property Total size of parcel Z./y AC;eFS Date parcel -was created Are all corners and lot lines identifiable? _ X Yes No Is this property being developed for (spec house)?„Yes No Volume_q~and.Page Number Z 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. 51916eo/ , 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 recor in the office of County Register of deeds as Document N `f g o Signature /of applicant Co-applicant } 2 4 Date of Signature Date of Signature S we k``♦ O x _ ~ ~ rry/ e na~,,,, 4,.'x'51, ~r r. r _ ii Vy jN♦ Y ~C} ( •-.l ~ 441 ,~J A.~ 1)~'.a I~ 1,~ : ~ ^yt~r ~ ~ ~y •~Ai~ r~~ jv ~ ~ ~ v~ rpf~ G ~ . y% r vt ~,CN.. f~ 1 sp'X Mr 2~~u ~J~, I T yr -.y .17 4 y,~ i _~s t ),rid !i . .i✓z jr s .a N B yi A Z I / d P F s.. L fi ~ , (~J WOO. +tiq 0.•t \ `r~dr, i.. MA.:- `R/~/ OQ.\ ` to I y s1 ~tt-.' ~ t ~ -jk N w \ \ i z aw u M I ♦ D p N OD OY 7.y Nq OD \ \ S xA 00 N a,` e ~z M _ y lit if . • Z.S . P.Y. y ~ l Q~ •1 ;rN a _ _ .JI 252. r-. k CP NN O • .G '2 04'52'53'r a yY v ; r r e f, ,n 01 r tl O f ' N A v y 1e C _ O^ ~ tl A N~~ ~ ~ r A Ig I / ! P ~bo v ; w•e9• .sr „ /214 _ rr 10 "Ov N / 0, rs z 0,~ Oj. fI'S r O O/ • O O J^ I 2 J OyD ~ a.,,w 1 r s FF~ ~ Q r • / t~l F '.7 ,UO n y I ~ ; r' GECOAQm 00 TRAIL of/", a~" I R r ~ - ~ - e t a` i a ~ IPj ~t .0s 1~ t I - 7r. 072 3 a T T" M s o9• »'.e'r 387 79' I 1; i STAGECOACH_ _ TRAIL w p~pM 9- 1 r / -y^6- - - - - - - - K' / r 4ANDS (AWNED @Y-- FEAT TL!jS, t NPLATT€Q • ~eas~•Y•YN.iTI / r I WNEO_BY OT~E,R; n~ y zarzzazzaza / /r :e " cry n 1 r g i a:ti•i"itewr+,ri: I i lu Asq p. I I r I - ( • ••w s ; c i it \ 1 493 F 5C' F,. tr" Irc~n_ , I 1 - A'~ r 5 t`, ~,3>- E t .t G i e r'o ~ e e- z; A. 1.. q, ct v I . , ~ ~ a . ~ ~ ~ ~ t it - Wiscoland sin Human Department Relations Industry, Labor SOIL AND SITE EVALUATION REPORT f2 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 -S C d~' 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 PRO ERTY 0 NER: ~,n PROPERTY LOCATION A )LC E K GOVT. LOT /`J C 1/41!W 1/4,Sz 1 T Z9 N,R E (or) W P r2w PERTY OWNERS nyy ING ADDRE~, o BLOCK # SUBD. NAME OR CSM # ` ~ITt ct ~ -k Za,44 & ZLS J CI, STATE ~11 ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE OWN NEAREST ROAD, b W I SAU ( ) ~SOTJ N New Construction Use KI Residential / Number of bedrooms to N K, Addition to existing building j ] Replacement ] ] Public or commercial describe Code derived daily flow gpd ISM Recommended design loading rate Q .7 bed, gpd/ft2Q5Ltrench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate QZbed, gpd/ft2o_trench, gpd/ft2 Recommended infiltration surface elevation(s)4QQ At z CX) It (as referred to site plan benchmark) Additional design / site considerations j Pd 2 . 99 .00 Parent material Flood plain elevation, if applicable It S = Suitable for system CONVENTIONAL MOUND t-PROUND PRESSURE ARADE SYSTEM FILL HOLDING TANK U=Unsuitable fors stem S OU 10 S ❑U XS ❑U S ❑U ❑S U ❑S 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 Tiench F- Ground 1$- 3 ~J1L 3 ahK n,v t, C I N{~ D.~. elev. tckl -l ft. C 4 Depth to SI -lI /0'x' 0.7 limiting factor 7175 Remarks: A A 6?,(Zo 5 A a '94-dCKY 7 4.A S; +R(JCTuQ Boring # L rh qA r4'- 0, 6-S Ground elev. Tj 2A 0 4A 0 - S C M C. ' 0.7 ©S Depth to 8 4-1261100e S f I O FS limiting factor , 6L Remarks: CST Name:-Please Print ' Phone: Q~JEY a~1NsaY~ • 3'~ - ~G Address: l.)"OS(~N tSGc~A)Silu Signatur Date: CST Number: PROPEF YOWNER 'S4MMlLiC0'- SOIL DESCRIPTION REPORT Page? Of 3 PARCELI,D.# L14 f t4k(1o Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench : - 3 d 3 i. / n~ r Ct 4 © d.S q 6ve V/ L 3 C gel; 1 nl ((vf C Z- N a Ground g j~ /OY►e S> c ab i►,Yt, N 1" elev. 4 3 5 c r' C I d.7 0.~ Depth to limiting a r Remarks: Boring # ti m c 0.4:x,. 03" 16YO11 ot 10i C NIP :6 "Z LM $ 3-2f 3 3 S,L h A / MP ,z Ground eo ev. $ ~'3q 4A 1 j C n, I C / 0.7 3912'i 16ye Depth to - S 1 1 ~.7 `•®.g limiting factor > /A17 Remarks: Boring # f _3 <Mr -t /d 3 z - L 1 M rn~r Z 4.4 0.5 1\ Ground 'Zi-33 3/1 S, L 3 41 w'~y`1 N P Q.Z elev. .09 Depth to limiting f ct~ or_ FT Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) I ~a a I ~ I N 11 0 ~ I d ~ ~ O S7 ~A fi z r • 0 _ Q~1 -f 7W LDTLIA'E /Gd G i ' ~'1 r 0 1 I M T I D 1 m~ y Im w C `t Lij N_ z .70 f.7 m a f^ m m t m, mr I ~ 3 s Tn ~ 1-l7op ~ ~l ~ ~ m ~ u c GI I\ as 't/ Ic / 0 m r n, `zn m m Fi tI, To r~ t O Q w O LA L kA3 I I I ~ (~14 r0~ \ ~ C loop, I Q ~ Ts, 1 ~ ~ O ' v Zoo ON - t_ 72.oz ' So~~-% LoTLINE b,: o, srAcE cas}clflTiPArL S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ADDRESS 80X Z. OZ FIRE NUMBER--- CITY/STATE ZIP PROPERTY LOCATION: _~1/4 , S4i 1/4, SECTION, T 2-1 N-R 1 ` TOWN OF _A-/ijDS St. Croix County, SUBDIVISIONzIJF//S 7/ R60 STAT /aN , 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 nor 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. _T/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 h een maintained must be completed and returned to the St. Cr x Co. n' Officer within 30 days of the three year expirat' n date. SIGNED. DATE' St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 ' j NV -IJ C) i.? 1j I!j I 1~1i ILA l~ 1 ~iyl~! I ~ i Vii! III ( ~ V Q I j i ! 1111 ~ f IIf ff) r's 14 ~ .1 :t l