HomeMy WebLinkAbout020-1293-30-000
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER,'~}}/77 /nlLL
ADDRESS
SUBDIVISION / CSM#~ Lm(~ d L 4i o s LOT Z
SECTION. Z- T Z 9 N-R /r Town of ae Q'Z o
ST. CROIX COUNTY, IHISCONS IN e--~ ZS'
P~LAV IEW
SHOW EV YTHING THI 100 FEET OF SYSTEM
}4ows~ A,3. A IRON PIKE AAt
ON LOT I; n,Lt1,. loo,od'
41 :I.~ ~ ~ c...oT#" zs-
SI: 70
J.:~
I'
r 1o/ ~D IR
f / INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: Tof
ALTERNATE BM: b dpi ~aGC/Y~f .
PUMP CHAMBER / HOLDING..TANK INFORMATION
SEPTIC ~TAW
Manufacturer: Liquid Capacity: ,C~ 7 ,
Setback from: Well (0 ~ House `4 Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cyclL-:-
Alarm Locatipn
,:SOIL ABSORPTION SYSTEM
Width: $ Length `/O Number of trenches
Distance & Direction to nearest prop. line: Z/ S 't° /Va17A (off %n
i
Setback from: well: 7 S House Other
i
ELEVATIONS 7,2 O
Building Sewer ST Inlet: DSZ ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION: Q
PLUMBER ON JOB: ,.t;e. ~l e4> o
LICENSE NUMBER:
INSPECTOR:
3/93:jt
ST. CROIX COUNTY
WISCONSIN
ti~ ✓~`L ZONING OFFICE
► ■ ► a " _ _ NOUN ST. CROIX COUNTY GOVERNMENT CENTER
r.. 1101 Carmichael Road
► - - Hudson, WI 54016-7710
(715) 386-4680
April 13, 1994
Mr. John Sias
First Federal Savings
201 South Second Street
Hudson, Wisconsin 54016
RE: Septic Inspection for Sam Miller
Lot 24, Humbird Hills 1st Addition
Dear Mr. Sias:
An inspection of the septic system for the Sam Miller property was
conducted on March 15, 1994. This property is located in the SWh
of the NE; of Section 27, T29N-R198W, Lot 24, Humbird Hills 1st
Addition, Town of Hudson, St. Croix County, Wisconsin. At the time
of the inspection, this septic system was found to be code
compliant for a three bedroom home. Should you have any questions,
please feel free to contact this office.
ince 11y,
e om son /
'"Assistant Zoning Administrator
mz
(C(op'y
LOCATIgN: HU7,Ot 27.29.19W PRIV
Wisconsin epartmen o In ustry, K k t 7Rn GLEESVHM County:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division &ftEIIIN
GENERAL INFORMATION (ATTACH TO PERMIT) sanitary ,-flit
Permit Holder's Name: ❑ City ❑ Village Town of: State Pla
KILLER, SAM HUDSON
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
/ a , a 'sue QS 020-1293 30 Oee
TANK INFORMATION ELEVATION DATA A9300347
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ~G Benchmark
Dosi T( i-Z ( Y. 98~ /
Aeration Bldg. Sewer/
Hot St/ Inlet Q 5z~
TANK SETBACK INFORMATION St/yt Outlet gyp, 5/ 9,3,/,)/
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosin NA Header. 61,
Aeration A Dist. Pipe
Holdi Bot. System g8
PUMP/ SIPHON INFORMATION Final Grad
Manufacturer Demand p 10,r 7 Z(j ~
Z¢
Model Number PM
TDH Lift I Friction m Ft
Loss ead
FO ngt Did. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIO
, Manufa er:
SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM
INFORMATION Type O h ~ i , LECW}AICzMo el Number:
System: f &S OR UNIT
DISTRIBUTION SYSTEM
Header / mart fef+ Distribution Pipe(s) ole Size x Hole Spacing Vent To Air Intake
Length ~Z r Dia Length 117 Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems y
Depth Over 2- Depth Over xx Depth Of eeded / Sodded xx Mulched
Bed /Trench Center Bed/ Trench Edges O Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON.27.29.19W LOT 24 HUMBIRD HILLS
Plan revision required? ❑ Yes loo ;;4; Use other side for additional information. SBD-6710(R 05/91) Inspedor'sSignature Cert No
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
=~:7EDMIL RE SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
ST E ITARY PER #
-Attach complete plans (to the county copy only) for the system, on paper not less than c'/(~sJ1
8% x 11 inches in size. ❑ chr if ev lo Wtoevious 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
34M NI / c. ,E SW Y4 NE %4, S Z 7 T N, R /'y E (or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
as z. Z. 9f I
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
a /Zopt GtJ.~ S WC, 38'~ 2~ 76 10711S
L:I TY j
VILLAGE NEAREST ROAD
11. TYPE OF BUILDING: (Check one) ❑ State Owned 0
v so N~IC L r R o.~.~
❑ Public ~ 1 or 2 Fam. Dwelling-# of bedrooms PARCEL AX NUMBER(S)
111. BUILDING USE: (If building type is public, check all that apply) d Z Q -/Z ! 3 3 Q
1 ❑ Apt/Condo
2 ❑ Assembly Hall 8 ❑ 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 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. ❑ 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 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
140 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
s ® REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
ea V Zr 2 0 0, 47 94 40 Feet 9Z• so Feet
VII. TANK CAPACITY Site
in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New istin Gallons Tanks Concrete structed glass App'
Tanks Tanks
Septic Tank or Hold! n Tank 0000 ~ Q.; Sq ve F] Li
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 Stamps) aMP/MPRSW No.: Business Phone Number:
bok Stv-ot.. b41 Ark lj"A? Ly7 3t
Plumber' Address (Street, City, State, Zip Code):
IX. COUNTY/DEPARTMENT USE ONLY
Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Sig o Stamps)
❑ Approved ❑ Owner Given Initial Surcharge Fee) pr
Adverse Determination
rX CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL:
'1 (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety a Buildings Division, Owner, Plumber
bib
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 arid establishment of standards.
I
SBD-6398 (R.11/88)
a
N
• J
IV M
V d ~
IV
v F- ~
~ W
v
4 Q
y [7
%L lip
x r
t~
Ovo
r' \L
iA ~'c4 \ lV ~ 1A 1
44
i W
\K o~~ael 4 v'
ale
,I
i
r
•
I
i
s U
O
~ _ O
w a
4
CL w 0
XO O 00
0) F- 0
w
O ~
a~ 0 X $f
i
ad. Z
0. I
I a
`ry a
V- Z0 I
I
U
w ~ I
a d I
i~ ? I
I w
'I I I a
1 Q-
I 01 1 1 I
M I
~N I LLJ d I I 1
I a U I I 1
_ aa
11 I T ~ i CL 0
U) a 1 1 w 1 d I-
J I I I ~ I U
~ I I I ~ a i I_.L_1
m I
~ a
UJI
m I I I I
I I I ~ 1
I I I I w
w a
I
Q- CL
O I a I 1 '
I
~ I
'NQ i ° 1 1 > I m
v I
\ 1+` ~ 1 a~ I i z 3 1 ~
10
I I
r-
H I I I `d- 1.
I I I
I---------~ I w
rn
Wisoonsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page / of
Labor and Human Relations -
ePivision aSafety & 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 h
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
lei' ' ) ~ GOVT. LOT'S L-J 1/4 t4E 1/4,S27 T 21 N,R 9 E (or) W
SA
OWNfq-
E ':S MAILING CRE LOT BLOCK # SUBD. N ME OR CSM #
CITY STATE ZIP CODE PHONE NUMBER ❑CITY ❑VI GE EITOWN N EST ROAD
93 2"S0Y j ( Vv nA1 ~4
[q New Construction Use [pQ Residential / Number of bedrooms [ j Addition to existing building
j J Replacement [ J Public or commercial describe
Code derived daily flow SU gpd Recommended design loading rate Q.-7 bed, gpd/ft2 0~trench, gpd/ft2
Absorption area required 6 bed, ft2 S6'~' trench, ft2 Maximum design loading rate f 3 bed, gpd/ft2 (3,'R trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design / site considerations - .60
Parent material Flood plain elevation, if applicable ft
S = Suitable for system CO VENTIONAL ND IrfkrROUND PRESSURE XT-GRADE YSTEM IN FILL HOLDING TANK
U =Unsuitable fors stem S ❑ U S ❑ U f,S El U ~,S ❑ U[ S ❑ U ❑ S [3U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Baxxiary Roots Bed Tmnch
,
Ground L~ Z-14 6yg S I~ f/ f .7 Q
401 ft.
Depth to
limiting
0
A Remarks:
Boring # _
2
. /bye- T M 11-IT, r
Ground .f 1~..f /(S r, 4- ~ S 13 r hi
eley..
ft.
Depth to
limiting
?~C`',
Remarks:
CST Name:-Plea Pr' t Phone:
.4 V 0WWS4 6- 080
Address: JO ~J r t 1,
Date: I/ n CST Number:
Signatures
i 7
9i
PROPERTYOWNER~4/hILLCe, SOIL DESCRIPTION REPORT Page Z of
PARCEL I.D. # L c T 2 4 /4cu M$ r Q-h Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Bourxiary Roots Bed Trends
x
'k
Cr 01 3A
L 11
Ground -•l2 Iby~ 4- S /h 0.1 Igv.
Depth to
limiting
factor
> /Q-00
Remarks:-
Boring #
A.•-.Y;.Y<- r -fir
1o4 o.s
r 1),
C5 71 1'
d 2~-1 /7 r h, 14
14
Groun
elev.
8~S •,X ft.
Depth to
limiting
f ctor
>
F
Remarks:
Boring #
C)-/1
i err o _4 0.5
Kati 3 - L
;;tit.::i2z:::vt:
S t~ O? O
Ground 3~-l /lS` 4/4-
,,elev~
Depth' to
limiting
factor
s,
Remarks:
Boring #
M
ti
Ground
elev.
ft.
Depth to
limiting
factor:
Remarks:
`330(R.05/92)
Lai o
co Lar L,tit E~V~Y~o►~ ' ICSD,CY~
A
Sc,dcr 1=3a'
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER Sa n~ /7~/, L L2✓
ADDRESS /-?oX L Z-- FIRE NUMBER 7 6 y
CITY/STATE //4 4( o k c./? ZIP_ r "le A.
PROPERTY LOCATION : S 4/ 1/4, N- 1/4, SECTION_Z, TZ:f N-R
TOWN OF-141-1 O(Sa w! St. Croix County, '
i
SUBDIVISION /V b:~•~ 5 , LOT NUMBER Z5f .
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.
SIGNED•
DATE:_
St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
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 ~n delays of the permit 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 -54141
/yJjLG,~,e
Location ofproperty-5k..1/4 NF114, Section 92_1
T~N-R
Township ze!464
Mailing address &ax 2- .
~k 4:so n . W~ rye
Address of site :74rM i2pckl~/
Subdivision name__yK m 6•i re71ff /L L ? Lot no, Z Y
.
other homes on property? yes X No
Previous owner of property
Total size of parcel - ss9 14
Date parcel -was created 7-/z-93
!'Are all corners and lot lines identifiable? k yes No
is this property being developed for (spec house)? X Yes No
Volume/02/ and. Page Number Zg2-- 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. So zz o9 , 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
r
ecorded, in the office of county Register of deeds as Document
No. Z0Z Z- 02
4Sh4u*2e4
of applicant Co-applicant
Date of Signature Date of Signature.
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-19821 THIS SPACC RESERVED FOR RECOROINO DATA
II• WARRANTY DEED
0L 1_S1~1P1;lr _ _ REUSTER'S CFFICE `
• This Deed, made between Humbi.rd Land Corporation ST. C;ZO;X CO., 4%'1
.
for Record
A Minnesota Corporation authorized to do business
in.w>sconsin JUL 12 1993
Mi
an d PM.,Grantor at 4:20 P. ~d
.E •
Register of Deeds
Grantee
Witnesseth, That the said Grantor, for a valuable consideration......
-
RETURN TO
conveys to Grantee the following described real estate in ...$.re._GF_4ix--•••---•---- ~4y
County, State of Wisconsin:
{{{J 1
Lots 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12
in the Plat of Humbird 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 L;.
99, Document No. 497107. f+
Lots 13, 14, 15, 16, 17, 18, 19, 20, 21,'22, 23, 24 and 25
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.
This iA..nQt......... homestead property.
(.ia) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And...H=t!i rd._Ita_nd_.CO.lpgrar_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.
Dated this 12th................................ day of •••JulY.......................................................... 19.93._. .
Humbird Land Corporation, a Minnesota Corporation authorized to do business in Wisconsin
.....................................................................(SEAL) BY............................ (SEAL)
Austin J. Baillon, President
•
...................................••••••••••-•--•-••••(SEAL) ------•-----•-•.._._._....._._._._._..-•-•-•--_._.--................(SEAL)
i
•
AUTHENTICATION ACKNOWLEDGMENT
Signature(a) STATE OF WISCONSIN
County.
authenticated this day of___________________________ 19._____ Personally came before me this .t. /~'day of
July 1 19..9_3_. the abbIt
f-vngted
1•
Aus!~iA__j:._ Baillon, President o'f::j.:'
TITLE: MEMBER STATE BAR OF WISCONSIN HLlmbird•_and• Cor oratio _ -
(If not. P 1_
authorized by 1 706.06, Wis. Stats.) +r M }
to me known to be the person qL kvh~ ecuted thF~ r
forego4,ngtrument ' and acknowledgAl v sa 4 THIS INSTRUMENT WAS DRAFTED BY ~,fN N . Il 1- ~7 t.4Kueppera,..Hackel_.at_1Cueppeza______________•---•--•---
f.-
_1350_Capital.-Centre__St._ -Paul .MR--5.510.2_ Nie ...T._.._.G. .a.l.,K1 . County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. ((f not, state expiration
are not necessary.) date:
-Names of persona danint In any capacity should b* typed or printed below their ■ltnatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co, ins'
FOTAX No. 1 - 12192
Milwaukee, Wis.