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HomeMy WebLinkAbout020-1290-90-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER SH m /YI. GG EoZ__ ADDRESS ego)( -;!gz--- SUBDIVISION / CSM# LOT # SECTION __Z 7 T_2N-R ,,W Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 6AQA6x DkIVC' ~ ,t lawsF , -a 45 W►r ;S At.7 ZN ' T I q6 _ 'o~ =ra v 1 7s' n r r r 3 sou-rl- Lo, ® B. m. ro (o~ Z "~.p • ~7" Sw Cc/a ¢ / l~ /OO.oe.__ _ INDICATE NORTH ARROW Provide setback and elevation information on reverse of this-form. Provide 2 dimensions to center of septic tank manhole cover. 1 BENCHMARK: f 2 ~O`► ~f S!y Ce7la~hsr ~~D. Od /O. ALTERNATE BM: of /f'®~t~ ~Q`- _ ~.~5 SEPTIC TANK / PUMP CHAMBER / HOLDING.TANK INFORMATION Manufacturer: 6rla,'s a,- Liquid Capacity: /Ooc9 ~9Q Setback from: Well House Q-' Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location- . :SOIL ABSORPTION SYSTEM Width: i, Length O ' Number of trenches Distance & Direction to nearest prop. line: 7-c- To 6v,,tk Setback from: well: ~'ro ' House .9~ 9 " Other ELEVATIONS /1iQ,, •fe% z,e, ~t Building Sewer . ST Inlet; 7 S 6 ST outlet 8. 2 z- PC inlet PC bottom Pump Off Header/Manifold /U, 01/ Bottom of system Existing Grade 7 ° Final grade 7.o , DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt LQ AWsTQ#P;,tgW&5Q#,n-Wy7. 29.19 ( VAf E SEWAGE SYSTEM County: Labor and} Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) Sanitar rlhit GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village Cl Town o : State PI v.: Insp. BM Elev.: 7 BM D scription: X Parcel Tax No.: /~d , 40 do e 6?.~ 020-1290 90-000 TANK INFORMATION ELEVATION DATA A9300261 cl o3 93 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 101 Za Cj} Dosi a 4), /7 0,7, OS Aeration Bldg. Sewer 0-au-q-4 Holding St / 0 Inlet TANK SETBACK INFORMATION St/ Outlet 9 ' TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake AA- Septic ~l S y JA_ NA Dt Bottom Dosing NA Header NUUm- /0, 2 Aeration NA Dist. Pipe 06 Holding Bot. System PUM / SIPHON INFORMATION Final Grade ( 9~ Ma ufacturer Demand TOP 0IS.7 39 Model Number GPM TDH Lift Friction S eadm Ft Forcemain Len pia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PI No. Of Pits Inside Dia. Liquid Depth DIMENSIONS l~ d DIMEN I LEACFITRF6.,~• Manu actur SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM INFORMATION Type Of n Crnv; ~~f CHAMBER Model System: 9y~ DISTRIBUTION SYSTEM Header /Memifoid Distribution Pipe(s) r „ x Hole Size x Hole Spacing Vent To Air Intake Length _ZAZ Dia. _~L Length 3-7 Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Depth Over 0 Depth Over q ! xx Depth Of x ed / Sodded xx Mu c ed Bed/Trench Center 3T -qo Bed/Trench Edges 3~l46 Topsoil ❑ Yes ❑ No ❑ Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: UUDSON. 27.29.19 (LOT 9) Plan revision required? ❑ Yes 9'1;~o G Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND. SKETCH d SANITARY PERMIT NUMBER: DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY 'S- coo/ STATENITA Y R IT -Attach complete plans (to the county copy only) for the system, on paper not less than //yyll [[77~J 8% x 11 inches in size. ❑ Check if revis on pr ious 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 si9 /vi Af /LLFA Xlpol '/4 '/4,S Z TLN,R (oryVf) PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # Z Z CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER s o/ 3 G z is ff4 ~ ,'LL II. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) State Owned ❑ VILLAGE ti ❑ Public ❑ 1 or 2 Fam. Dwelling--#~ of bedrooms 3 PARCEL T NUMBER(S) 7 III. BUILDING USE: (If building type is public, check all that apply) 020- 12 qO O 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 i 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 M 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 72 v 72-0 D. 7 3 9F/7, -SO Feet /DO, S0 Feet ySU VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank 000 Z aG; S Q 2 F] 1-1 i F1 -M Lift Pump Tank/Si hon Chamber ~ I F-1 F] F-1 Fnj I E-11 I VIII. 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 S mps) MP/MPRSW No.: Business Phone Number: 6 91'1 6QCT Al S 3 z 5`~ 3Z 33 Piumbe Address (Street, City, State, Zip Code): U~ ~Z C /`IG'1 b~U w 1 S IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved SaQitary Permit Fee (Includes Groundwater Date issued issuing a it Si nature (No m Approved ❑ Owner Given initial 757~1'C` ~~Surcharge Fee) Q Adverse Determination 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 riiaintained. 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 i 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 GROUNOWATER SURCHARGE 1,983 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. a. SBD-6398 (R.11/88) 5A M M /L L E R~ 7-off i{/ F,c°/y~S f/U/li1 /~E' 1> //"//-T La 71 i4' q T~ BQre 4 Pe rc s s f s rte"' ~v % 7. Sd • E/.. ipo, oo : Aar- : Tk,,t, W¢ st F N p of syst'- To It. eaf 41 y ',71. e ~P- ti_~3~_ -7 /z7/q) F-A5 r Lc'r zlwE 2 7. sc' 5~./s fc ~`_z Wc~St r / v ; ~ ~ Fo ✓ c. l k o ac'~ v l Curt" a-bo~rt ~ ~fi-, 00 w, / h 0.1 4-s ~ p_~ 3S 0 ~ I o x 1 a1 P-1 ~3 ! 1 r I.OT ;w 10 LOT 'h I !1 ~ ' ' ' 1 h EDI 7~A, SS III WELL I O ~ i Q 1 qt' g.M • el p o F z at 5 w CoiMa✓ El= IOO,oc' i yv~stLoT<iN~ 2~c.~s' Ni L ~ ~~/QM _ RD~7Q DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS IN15USTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISP.O. BOX 7969 ON W1 37 HUMAN RELATIONS 07 (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: ITOWNSHIV/YUNICIPALITY: LBLK.NO,:SU DI VISIONNAME- Nw ~/a NL~ a -z? /TZ9 N/R19 E cor)W ~ Holso~ - XM61RA fl ILLS COUNTY: Oi'++Ef BUYE 'S NAME: ; MAILIN ADDR SS: STceo)x ~ N4 USE . . . DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESRIPTION: I ROFIL S I NS: R LAT~IDN TESTS: XReside ~N~ 4New ❑Replace Il '3 25 9~ -3 z(j -9 -~z )44 V, 4 Si - SarTlee RATING: S= Site suitable for system U= Site unsuitable for system 1Z:e, L' K1.,AZA7 LDI EM: COZ JTIElu . IN_JV~. ~U , IN-GROUND PQ URE: S-I❑~LH❑ sG TANK: RECOMOM~~ION ALptionall If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the A under s. ILHR 83.09(5)(b), indicate: CL. i4 Floodplain, indicate Floodplain elevation: A PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH 4). ELEVATION OBSERVED ES HIGP-ESf- TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) i B- I ]/06.67 No t4 E > /2.0 /3'&J -I s / &Za&a ,LB•~L$aoA6iGe79 8Q n, Z/'&_LrS /3'SRuSI L 13 "8,R, SL-Y-e. Q 13- '2- o.4z 1oZ.3~ r4of4 Cl,~ > z-7~~caetihs~~,~ sJ"60.iMS B-3 <6- 3 103? / 26`&L-s /&NSiL 16 "'4-r AvL SL L~ > :s,3 26-,gt,Bkti,fins -F6R BRA, MS 2 /"QL[.'1 s /S" R.i.A /Z-"Za wSL 8 QN B- 1D.-SO /o ,73 0d ie' > /o.SO 76&g ,A)S- c60Z B- S /n 33 0 .aS 46o6: 033 16'09Lc-$9"BeuL 19'19ANS~Sr~a q6 "$/2N M B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER AFTERSWELLING INTERVAL-MIN. -PERIOD1 PERIOD P RI PER INCH P. I ~.sn o o6.0o >7 > 2 7 Z < P- Z b No A0 7 7Z >7- P- -1 .zA N .16 > 7Z 2- P_ P. LILT 10IN 4T EaL P PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land ope. SYS EM ELEVA ION q~ l~oT~ ° -emu r-s-v E,-j,& q- -rH E- + ! ~ ~S~s--~ r~ ! w i L.(_ f3 C CUT ' ScA~.rt'- 1 ~ 3D~ Z 'I ko f,2041 r q) L L ~,va~ u toD L - P~ PZ A 4- ~ ~ ~ g"3 I ( I H i 4 C4 I- I At L L-i a A0. 1, the ndersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME) (print): TESTS WERE COMPLETED ON: ~NAQJE`l JduNsa~ J N Son/ o 1"4 m ck ZS 1992 ADDRES : CERTIFIC,ATI N NUMBER: PONE N 1BER((optional): Dsou Soo) 3"At wC06' 4 CST SI 'URE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBO-6395 (R. 10/83) - OVER - I a \h 1-4 W O LLJ e~ V) O W = _ O CL w a a, w OY W = F- F- Y ~ X 0) 8° _ 41 o C3 O D r- R~ z ~ ~ w I I I~ uo Z I M w I I I I aw I 4 r j I { I nCL I I I I~ I w a I I I uj i I I I a. 0 ~ i _ F- I I j CL j U LLJ b a- I I I m I V) i I a I I w I I ~ I > I U~ I I I ~ I M I ZD I ZD Ky I I I j ~ I o I w n. I I I v cl a I I IL 3 I Li I j I o ~ I ¢ I I I w I I v i U i i F > i m ~ I j LQLJ U I 3 O ~t s i I a~3 j 10 I I I > = I O aLL L, i --I ---1 S T C 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER S 14& /w lIZI-Y /e ADDRESS S © ~I' Z H 2- FIRE NUMBER CITY/STATE zip PROPERTY LOCATION: P41' 1/4,V 1/4, SECTION a 7 , T2~ N-R__LLW TOWN OF U d ;0 , St. Croix County, SUBDIVISION ~Y 4~ 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 scu,n . 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 date. 6 SIGNED: 5~~,22L9&..e DATE: St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 I 4 Y j, 4f 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 in delays of the permit issuance. should 7-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. I~ Owner of property S5,4M tZl E'W Location of property4ZLO 1/4 tV t 1/4, Section 2 7, T Z 1 N-R_Z_fo Township l4uccl S on,-7 Mailing address 14 /,11 4D el W Address of site ✓ /'y1 1~4~( sol, 4J7 c-v¢~ Subdivision name //4 6; ~-d Ar l / 5 Lot no. Other homes on property? yes X No Previous owner of property tau m b;~ d1 L~ Cm_ Total size of parcel Date parcel was created Are all corners and lot lines identifiable? ~G Yes No Is this property being developed for (spec house)?XYes No volume /D and Page Number z 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. Z- Z. -0 7_, 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. Sri t_ Z a ature of applicant Co-applicant /s 93 Date of Signature Date of Signature .f DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 THIS $PACE RESERVED FOR RECORDING DATA 1 jl WARRANTY DEED ' i 502209 'VOL t ~ - REG!STEi~'S Ot=FiCE `I -021PRz2 ST. C~Z01X CO. 4ti'I This Deed, made between Humbird Land Corporation, fi;C'd for Record T ` A Minnesota Corporation authorized to do business in Wisconsin JUL 12 1993 ------•--r Grantor. 4:20 P. Mi....e1•-•...---•-•• at x Register of Deeds , Grantee, Witnesseth, That the said Grantor, for a valuable consideration...... F~ _ . ......••LO LX RETURN TO _ conveys to Grantee the following described real estate in 71~~ 0~ i County, State of Wisconsin: y~ Lots 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12 in the Plat of Htlmbird Hills, Town of Hudson as filed Tax Parcel No: and recorded in the office of the Register of Deeds for St. Croix County on April 7, 1993 in Vol. 5 of Plats, Page " 99, Document No. 497107. Lots 13, 14, 15, 16, 17, 18, 19, 20, 21,22, 23, 24 and 25 in the Plat of Humbird Hills tat Addition as filed and recorded in the Office of the register of Deeds for St. Croix County on April 7, 1993, in Vol. 5, Page 100, Document No. 497,108. -a. This i.'T_.nQh......... homestead property. UQ (is not) Together with all and singular the hereditamenta and appurtenances thereunto belonging; And-:-Huvlbi xtt--I.dad_.Co.rp.prat_on warrants that the title is good. Indefeasible in fee simple and free and clear of encumbrances except easements shown on the above mentioned plats. and will warrant and defend the same. Dated this 12th................................ day of __.JulY-.......................................................... Humbird Land Corporation, a Minnesota Corporation authorized to do business in Wisconsin .................(SFAL) BY............ Gi~7" -~¢7~. ......IAFAT•) Austin J. Baiilon, President •----•-•--------•---------------(SEAL) ..----(SEAL) . AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN as /y~ ' .~-County. I PLC/// SS/ljj3 authenticated this day of 19 Personally came before me this Aday of ---...---...Tilly 19._93_. t4a abbVP"Iatrled r • +J • Baill C _ ALI~I.(1_Jr °II~ Presideltt.o~' TITLE: MEMBER STATE BAR OF WISCONSIN y '1,' --•}Tumbi~d__~and__l;orporatiod3_ (If not. n ' ..,,.tiP authorized by j 706.06, Wis. Stats.) to me known to be the person O w P ecuted t } foregoi' nt andncknoledg~.24 0 THIS INSTRUMENT WAS DRAFTED BV Kueppersf__Hackel_.&_.Kuepp-eza L350__Capital.-Centre,___St.__Paul,_.MN..5.5.LQ2- Notaric -_--5.._...G- County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (if not, state expiration are not necessary.) date: -Names of persons ■igning in any capacity should be typed or printed below their signatures- _ - y - WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Leval Blank Co. Ina FORM Ne. 1 - 1592 Mil.sukee, Wis.