HomeMy WebLinkAbout020-1292-40-000
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER S L
ADDRESS -1
SUBDIVISION / CSM# hl,'1/S LOT #
SECTION_? 7_T- 2! N-R / y Town of
lygr
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
o; 2" P --41
D. AA. Tod ~i E ~ y("(Nose al~)
A~N,lU, lo7Goins~'f/, =.~oU.ec~ Fg
1 138 ~1
~
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Ae~ UE WAS; caK~~-
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Wc- LL-
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~9 0~ Z" /oe.6A P~ Q~ N lU for nor ~l. _ /DO.oo ' ' ~S, CX~
ALTERNATE BM: -7;,e o~ Q/yam E on 6,- go!4 - ":-,A4 7'1',6,o-?
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: W LSE Liquid Capacity: Ioac qoJ.
Setback from: Well q? House 3,? Other !41,gth /07" /,'i,¢_ orb
Pump: Manufacturer Model#- Size -
Float seperation - Gallons/cycle:-
Alarm Location
SOIL ABSORPTION SYSTEM
Width: /g' Length !Vo.' Number of trenches
Distance & Direction to nearest prop. line: Te
Setback from: well: 107r HouseS8 ' Other a W T c EA r7- /fly`
ELEVATIONS
Building Sewer ST Inlet; 5 5 y'/01-~"'ST outlet PC inlet PC bottom Pump Off
Ibo 7, iv
Header/Manifold- ~r,2o `ro►_9° Bottom of system $y
Existing Grade Final grade U . S
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
c, ,
L I<ONoarTli DSONwsR7.29.19,NWgRWA VVAGOtVag&4►RM ROAD County:
Labor and Human Relations INSPECTION REPORT
safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar kni
Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State P .
X
tv.: Insp. BM Elev.: BM D scnpti W.V Parcel Tax No.:
.O
TANK INFORMATION ELEVATION DATA A9300181
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Benchmark
Septic ~ p .
Dosin c
Aeration Bldg. Sewer
Holding St/ Inlet 16)9
TANK SETBACK INFORMATION St/ Outlet p5~
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic 7$b g 7 3 7 A. NA Dt Bottom /l
Dosing NA Header4WA6?Ifi g (o$/ IN, Aeration A Dist. Pipe OJ
Holding Bot. System p(,
PUMP/ SIPHON INFORMATION Eat Goa e (,/S ' d
Manuatm Demand r° o s, ;rl 4-4
Mode u
TDH Lift Friction em TDH t
Forcemain Length Did. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width , Length / No. Of 3renches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 1 DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE / STREAM LEAC Ma acturer:
SETBACK _
INFORMATION Type Of /I c1 i CHAMBER Moe Number:
System: 127 OR UNIT
DISTRIBUTION SYSTEM
Header Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length ~L Dia. Length 37 Dia. Spacing tO
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Syste
Depth Over Depth Over ////n / xx Depth Of eded /Sodded xx Mulched
Bed/ enter Bed /X wr,+,Edges 6 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON.27.29.19,NW,NE LOT 15, ILL FARM ROAD
I ~ ~ ~ ~~"'N1 ,Q,c~ r."~` ~-fn~7 ~p~ ,1, , ~ , r~,: a~ /~'~c~ C~2h~-~ .
Plan revision required? ❑ Yes to P41/1A
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
- SANITARY PERMIT APPLICATION
~ OILHR COUNT
In accord with ILHR 83.05, Wis. Adm. Code
STATES ITARY PERMI
-Attach complete plans (to the county copy only) for the system, on paper not less than
8% x 11 inches in size. ❑ check If revision ~o . sous 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,4/vl A4 LIER V14 1/t t/4, S z TZ9 , N, R/ E (offT
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
6oX z e z /S
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one) F1 State Owned ❑ VILLLLAGE : NEAREST ROAD
Ea =N : ~/tc r/ SPj HAIL ~`A/Z/Y1 /~oAQ
II~~
❑ Public 1Z 1 or 2 Fam. Dwelling-#of bedrooms PARCEL TAX NUMBER(
4
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 ❑ Aestaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
b ❑ 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.E1 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) le6,olJ !WEST ELEVATION
7L0 O. 7 10dA&10S7/o'.r'rt!
Feet ~ i. s'E. Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New (stin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank X000 / h S,e p_ El F] 1-1 11
Lift Pump Tank/Si hon Chamber El El F-1 F] El 1 0
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 Stamps) MP/MPRSW No.: Business Phone Number:
D 6 5rnoH9.4EN ofd FAA Ji 13 z v 3z
Plumber's Address (Street, City, State, Zip Code): /
P17 ~or ~ccr~ Nt,4?40hj Wt5 7 017
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date ssue Issuing A gnat ( ps)
❑ Approved ❑ Owner Given initial Surcharge Fee)
Adverse Determination ~J
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
i
:x
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.
Ill. 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 mnonitoring,ground6ter, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
SAM MiLLE/2 NVMGIP.0 HILLS LO-TALIS Sys-rFA4 E1 tAjcsT/O6.oo'FAST-/08.OO'
C]8e~2E s~f A~~CNoP) GB-M_ T_P o4 2-1P1P,E AT V.W. fo>2NE2 El.=Joo.oo' st41d yy
EASTLbT LINE 57. 00,
X001
- GSA
r kBEDA~E
s 70~.
~ E 09xyO'
HOUSE
cY S1`"'EST AREA 7 0~ 78 xso'
va ':~'AgA6E
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j AT N.W.LDrevAWER =7L7
EIV. - 100.110
WEST 49 7- 11 N6 236-eb
H I LL FARM ROAD
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page I of 3
Labot and Human Relations
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 C~2a 1! 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: PROPERTY LOCATION Q
'5AM M i L« k GOVT. LOT N W 1/4 Nk 1/4,S77 T Z9 N,R 7 E (or) W
PROPERTY OWNEF MAILING ADDRE LOT BLOCK # SUBD.~yAME OR CSM #
CITY STATE ZIP CODE PHONE NUMBER ❑CITY (]VIL GE OWN N EST ROAD
j~ New Construction Use [ J Residential / Number of bedrooms 3 [ J Addition to existing building
j j Replacement [ J Public or commercial describe
Code derived daily flow A5;o gpd Recommended design loading rate Q •_7 bed, gpd/ft2 trench, gpd1ft2
Absorption area required 64" bed, ft2 s6S trench, ft2 Maximum design loading rate 0•1 bed, gpd/ft2 Q'rt trench, gpd/ft2
Recommended infiltration surface elevation(s) ITT - /06.66 ft (as referred to site plan benchmark)
Additional design / site considerations CAST - 16T.00
Parent material Flood plain elevation, if applicable ft
S =Suitable for system CONVENTIONAL MOUND It~~PROUND PRESSURE AT-GRADE SESTEM IN FILL HOLDING TANK
U= Unsuitable for s stem 6,10S U S❑ U WS ❑ U S❑ U 91S ❑ U ❑ S
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BoLlr>cl3y Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
L 1 r r►, i 2 0, O.'
Ground /-34 16 4 3 S bK n~~i 6:4
elev.
/,2 ~g ft. 8 6-46 /vv 411 SL r►~ sbK 1 .4 0.1'
Depth to B _I p 6 5 rn/ 7 0.Z
limiting
factor
> /0.17
Remarks:
Boring #
A CO loye 4/ 0
Z 9,'Z~ TSW +A SL MI r~~r C .4 O5
3-30 0 g 4/4 O h m l r Q . :01
Ground
I el 6I ft. $ -lI g /ovpe 4A - S O M rh 1 n, l 0.7
Depth to
limiting
t6
> 3
Remarks:
CST Name:-Please Print drQ \ ~~SO>N Phone:
Address: U a LJ `J -O 16 OOOO''
Signature: Date: 24 CST Number: g /
'PROPERTLOWNERS4M M1U-&t SOIL DESCRIPTION REPORT Page Z of
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bour~lary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
. .
fi D - 9 a~ fz / - L Z abk v i C, Z 07 O .
vv< 9- l /Dy S i 1 6 mfr i C l 0- Z 0.3
Ground R-4 16YR- 4 SL ~r C- 1 0-4 O
elev.
Ail. ft. 193 -1 /40V k 4 - S A n, J 0.7 d
Depth to
limiting
f9tor
Remarks:
Boring #
6K 4~
37- 0 12 4/3 SL 2 M a►6K A ► C O.S
3-
Ground B 16Y el 4 S L a~ rh~Y e 1 0.4 0-1~
elev. $ -1 Z 0 re 4 4 S M t1 O? C~.~
ft.
Depth to
limiting
factor
> /0.06
Remarks:
Boring #
O k3 I Z y►, abK Mv~; O.S 0.~
Ground D ll~i /0 t~4 4 '"5 n, l ~ D? Og
elev.
11Ln ft.
Depth to
limiting
? c~rZ
Remarks:
Boring #
tip
Ground
elev.
ft.
Depth to
limiting
factor F-T
Remarks:
SBD-8330(8.05/92)
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S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER_,S~I~1 /17//Lam
ADDRESS_ ~D,t~ZBZ- FIRE NUMBER
CITY/STATE__A'u.,/4 ZIP_ fe
PROPERTY LOCATION : ,21/4 ,_X~1/4 , SECTION _z, T_ Z9 N-R W
TOWN OF St. CroiX County,
SUBDIVISION-~/, ~,`r~ 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.
I/Ile, 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.
-271 ZVC--)
SIGNED: pp
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 by
the owner(s) of the property being developed. Any inadequacies
will only result in delays of the permit 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 o¢/Jj ~rfJ, %/d
Location of property i/4 Section, Z, T_~LLN-R L
Township TcD 4
Mailing address QoY#Z8
Address of site -72 7 r,y? A0,9 ,D
Subdivision name Lot no.
Other homes on property? yes-j~_No
Previous owner of property
Total size of parcel
Date parcel was created//Z ~9 3
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)?X Yes No
Volume oz and Page Number Z g"L 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. S!~ L z D5;, , 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. SS0 Z z_09
Signature of applicant Co-applicant
L7
DDatle of-Signature Date of Signature
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-19621 THIS $PACE REseRvao roR Raconoime oATA
%
WARRANTY DEED
502209 f
VOL IL1ppz - REGISTER'S Ct FICA
This Deed made between Humbird Land Corporation, ft c'J fol Record '
i A_Minnesota..... Corpp~tion authorized to do business 1
In Wisconsin - -
~ J U L 12 1993
*&'n "d e i , Grantor, at FR .20 ~i /JP. DA
l CxJ(
e g1stW of Deeds ~
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration......
j conveys to Grantee the following described real estate in RcruRH T% GNte~r.' i`)
f County, State of Wisconsin:
' Lots 1, 2, 3, 4, 5, 69 7, 8, 9, 10, 11 and 12
Hudson as filed Tax Parcel No:
in the Plat of Humbird Hills, Town of and recorded in the office of the Register of Deeds for
St. Croix Couaty 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 i
in the Plat of Humbird Hills 1st 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.
Nl- 0 1
This i;3..nQt......... homestead property.
4iaJ (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And--- Hu1mUrd..Larkd_.Cocp9ra ion.....
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.
19.93... }
Dated this 12th day of ---July..........................................................
Humbird Land Corporation, a Minnesota Corporation authorized to do business in Wisconsin
.....................................................................(SEAL) BY........................... .9:!!Sft.c*119 .........(SEAL)
e a Austin J. Baillon, President
(SEAL) ••-•---•---••---••..._...---....._.......--•-•----•-............----(SEAL)
•
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
a' sa
authenticated this ........day of 19
Personally came before me this -
~t T-day of
July 19.13.. the aDLObl+ayted
r
_
' .._Au~~i,tl_.d,.. Bail lopr.. Presdent ~°1 I,• /~y
TITLE: MEMBER STATE BAR OF WISCONSIN
---Humbi4F.d_.Land--for oratioi~-;'-- R
(If not. L].
j r , w
authorized by § 706.06. Wis. Stats.)
to me known to be the person C) 1ov r ccuted t
foregoing ' strument and acknowledgAi4e sa d p H•tV t
THIS INSTRUMENT WAS DRAFTED BY L H N b. If v D•Q•k .
{F_..II.. ,t ,
Kueppers,._Hackel..&.%ue-ppera......................... 1.
1350-.Capital.-Gentrer..St...paul,__M]I_5.5102- Notary lie .._.S. ------.G .Q./. County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration'
are not necessary.) date: i'
19_.._----•) r-I
*Names of persons elenin` in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wiseomtn ieaal Blank Co. Inc.
J_
FORS! Ne. 1-1552 ldllwaukee, Wis.