Loading...
HomeMy WebLinkAbout020-1176-50-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER r-rW k GJE•.iDY 110C4,enAAJ ADDRES koRD LrtNF ~OSov W ~ SS/o/G SUBDIVISION / CSM~'E~'jfF/1<t S ~ST~iTES LOT SECTION. q?lr T K N-RAW, Town of /740S01A/ ST. CROIX COUNTY, WISCONSIN PLAN VIEW , AJ4,gAj 4fP' SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM a?~Pa v T Al. W. Pao/-fRrV L'v, A1er 39, ~C /Cfma -6~V E NTs - kv` er ~v~~c ✓l Sc/f 1/0 EfFNt CAJ7 oUT/iVSOE47/wt1 Q/QL- (N/TH 1414f ~~/C $c./ 5~a 7EWE~ L//vim Sp,.7N~Ro~EP%k,~/NE NO Sc/~LE INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. i BENCHMARK: ~e~ X-T I\I.C✓ P/~v~E/rT__1~✓ ~aQiy£►f EIcV, ap• ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING.-TANK INFORMATION Manufacturer: G✓~ESE/~ Liquid Capacity:lnoy aE~Tr Setback from: Well . House 331 Pump: Manufacturer gA Model# A/A Size AIA Float seperation NA Gallons/cycle: /VA Alarm Location k/14 :SOIL ABSORPTION SYSTEM Width: S Length !on ' Number of tren -,hes a Distance & Direction to nearest prop. line: N0?7// Setback from: well: '54,_ House r0p61?-rY ELEVATIONS Building Sewer ~'5 -?O' ST Inlet; V. o3 ST outlet. ~j 9- PC inlet AJA PC bottom AJA Pump Off AJA Header/Manifold (o Bottom of system M- 05 Existing Grade /0Q,00' Final grade /Oa, Oo' DATE OF INSTALLATION: /o O G / PLUMBER ON JOB: LICENSE NUMBER: 3385" INSPECTOR: 3/93:jt LWAN4MFtartNle306MusQA. 29.19.1 Wfk#ENAWMtE6S W LANE County: Labor and Ruman Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) Sanitar rmit GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI Av.: p. BM Elev.: JB. g Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9300223 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ; Benchmark Y, 7 'eo~ Dosi g I X'Z,,crJof Aeration Bldg. Sewer Ho St /?(t Inlet TANK SETBACK INFORMATION St/art Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic 3G/ea r NA Dt Bottom r~ Dosing NA Header/ ZZ 7s" Qs, Aeration Dist. Pipe S 98 Sg Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade /d/ /T Demand d~.9s/ M ac urer m" kde 60-4-- / Model Number GPM TDH Lift Friction a TDH t L Forcemain Length Dia. Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trq/ches PIT Of Pits Inside Dia. Liquid Depth DIMENSION J G, DIMENSIONS urer: LEACHING u act SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM INFORMATION TypeO rJ¢,,j urr 01 i CH o e Number: System: ~r ,jr bS 27 -27 OR UNIT DISTRIBUTION SYSTEM Header /Ak_M ~f Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems On Depth Over ri Depth Over it ii xx Depth of xx Se a xx Mulched Bed /Trench Center 34-3 -7 Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: ,HUDSON 28.2.9../119.11fQ6,SSE,NE,LO 6~, 0 ,LANE, rah I Plan revision required? ❑ Yes plo / L /7j other side for additional information. 2 07 SBD-6710 (R 05/91) Date Inspector's Signature/ Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION 17103 ILHR in accord with ILHR 83.05, Wis. Adm. Code cou _.o....,.,~.,..~,.... C STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than El 19~/. Zoprevious 8% X 11 inches in size. Check i revision 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 (4),,-,Aj 'Wo 64 516~_ '/4 Ab~/4, S I?r T, N, R E (oft P OPERTY OWN R' MAILING ADDRESS LOT # BLOCK # Y CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSNUMBER flu ~Sa~l C,v, S4/vi G 9~S g C'EO lt~ <S TE II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLLLAGE : NEAREST ROAD ❑ Public 01 or 2 Fam. Dwelling of bedrooms AR LTA NUMBER(S) 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 ❑ 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"KNew 2.E1 Replacement 3. ❑ Replacement of 4.0 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 0 Seepage Trenchxa2 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 y~o S(i~ S 04 S • ~sr AJA4 p / ~57-DO Feet /0-?-00 'Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App. Tanks Tinks structed Septic Tank or Holdin Tank co i E] I El 1-1 1:1 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' gna re: (No m ) MP/MPRSW No.: Business Phone Number: P s 33 s g'~ - Aso Plumber's Address (Street, City, State, Zip Code): /S ,0 U,-j C~J! Ol IX. C UNTY/DEPARTMENT USE ONLY o S ps) ❑ Disapproved FT ryy~ Permit Fee Includes Groundwater Date Issue IS(N ZJ Surcharge Fee) Approved ❑ Owner Given Initial G / Adverse D t rmination V 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 Perrn't 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, 648-266-3815. 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 tacks; building sewers; ,wells; water mainslowater service; streams and lakes; pump or siphon tanks; distribution boxes; soli 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 ail sizing information GROUNDWATER SURCHARGE 'ci83 W's-consin Act 410 included the creation of surcharges (fees) for a number of rccgulated practices which can effect groundwater. The monies c6iecled thr(;tigh these surcharges are useei for i€s, rFilturing gruoridwater, ground- water eontamirtation investigations and establishment of standards. S8 D-6398 (R.11B8) /yCo~-- Nc~~rrl PLB 67 - ~S - w e7 PLOT & CROSS SECTION PLANS I LAPPA BROS. EXCAVAtING INC L' vE PLUMBING UNIT ♦ 6, 14 ga as r PROJECT SITE ~ i ~~w 14&(4or1QA) ~IPLNCfF ~~~/['UA.1 N/ P~ ^ /cam, c7c) r I L ~ I Y'~/L .S/J/~'3S ftjGtC~:V'r~~NE ~f15~ ~o000U p GUtL~ /t oo6Az 5- P71c TAIK c,,/T// ef5~FSr.I,Pu,U PR~P'~rrY T~Hr ~~LrG Sc~ r T M Afo,04f -rY 41A/1 NO SCALE FRESH AIR INLET AND OBSERVATION PIPE APPROVED VE14T CAP MAXIMUM 12' ABOVE FINAL GRADE .~--t- 4* CAST IRON PENT PIPE MAXIMUM OF 42' ABOVE PIPE TO FINAL GRADE y 1 SIGNED: MARSH HAY OR SYNTHETIC COVERING 1 i LICENSE: ® 3 MINIMUM 2' AGGREGATE _ I DATE: OVER PIPE I I DIST91BUTION PIPE :T • TEE SOIL ESTING BY: ELEVATION BED 6' AGGREGATE • BOTTOM PER SOIL., BENEATH PIPE PERFORATED PIPE BELOW TESTIS • I COUPLING TERMINATING 00' FT. AT BOTTOM OF SYSTEM r Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page l of 3 ,Labor 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 cez lX 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 PROK&j Y OWNER: PROPERTY LOCATION q GOVT. LOTS 1/4 f4j[_ 1/4,SZV T 129 N,R E (or) W PROPERTY OWN ':S MAILING DDRESS LOT BLOCK # SUED. !y~ME pR CSM 7S i.~fr4~u~ ~j C:/LL.S CITY, -kTE ZIP CODE PHONE NUMBER ❑CITY ❑VI GE OWN NEA ESTRQ D , N U >6 rQ W S40r ( 1 7-1 c~ lJScs 14 New Construction Use [kj Residential/ Number of bedrooms [ ] Addition to existing building j j Replacement ( ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate Q 77 bed, gpd/ft2 0 trench, gpd/ft2 Absorption area required 64 bed, ft2,5(,5~ trench, ft2 Maximum design loading rate Ci' Zbed, gpd/ft2 O .'~K trench, gpd/ft2 Recommended infiltration surface elevation(s) & `Em94 .Z Ati~, %.S' ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system COIIVENTIONAL MO IND IN-GROUND PRESSURE AT-GRADE SY TEM IN FILL HOLDING T NK U=Unsuitable fors stem ®S ❑U LAS ❑U as ❑U 0S ❑LI i S ❑U ❑S U 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 Trer& 0A 0 -2 by 3 SiraK >~~r C Z 0-4 S Ground 2/-33 fill C Z O_? elev. !Oa Z~ft. Depth to limiting f ctor > ~.7s Remarks: Boring # r 61 'StK Ground ' `-37 oY 3 3 S r~ C l o.~ elev. 7_ / UY,, 4/4 - S n ► O. 1 C3 -1~ ',(y ft. Depth to limiting factor Remarks: CST Name:-Please Print Phone: 7i ozn Address: P 0, 9 l U tssa nl ~J Signature: Dater Z 4 CST Number:~434 PROPERTY OWNER 90&-l 4-J SOIL DESCRIPTION REPORT Page Z of 3 PARCEL I.D. # Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench o-(~: 16Y01 C. 0 .4 (15 '7 V, skKI S T M Ground 7-~ ![)Y,( 34• ,7 6c6 elev. fa~.~ t. ~rS io>r 4 s Qj n~ l 1 Q-Y Depth to limiting Remarks: Boring # (3-i >Ov % - L 1 r cf r C 0.410.5 o.~ 04 Ground> r-A y~4 C- elev. -7 ft. 4L4 701 !W Depth to limiting tOr~, > Remarks: Boring # r-- Ground:. !o' 0.7 `0!"- Sift. -r~l Depth to limiting Actor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) J G ~l G - e, r e e~ i r ' r i 61. 5 r r•, W r~ . S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER LOIJ Ci S tZAPW ADDRESS / z1*N5_ FIRE NUMBER CITY/STATE ZIP__ PROPERTY LOC4TI9NN : 1/4, 1)1E 1/4, SECTION T-.*-N-R_,L?_W TOWN OF m , 3t. Croix County, SUBDIVISION 0wD) LOT NUMBER--6 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. Croix Co. Zoning Officer within 30 days of the three year expiration date. SIGNED- 4 a01-1 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 b the owner(s) of the property being developed. Any inadequacies will only result in n delays of the permit iss uanc dev e. elo Should thi s p be intended for resale b owner 1i by c ouse ontr ac / for 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 ,,LWE 77/ Location of property-1/4 - /yc- 1/4, Section -9dp- T_g!gL ~ N-R_Z? W Township ~sov Hailing address Address of site Subdivision name 47e,7 Lot no. Other homes on property? es Y ~ No Previous owner of property 1%Cv Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No in this property being developed for (Spec house)? Yes L,::JNo volume. gnd Page Number as recorded. with the Re ist of Deeds. g er INCLUDE WITH THIS APPLICATION THE FOLLOWING: - NUMBER & WART Y THE which includes a DOCUMENT NUIMER, VOLUME AND PAGE, A THE SEAL Or THE REGISTER OF DEEDS. certified serve In addition, a y, if available', ;would be helpful so as to avoid delays of the reviewing process. If the deed description references to u 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 the property described in this information form b e owner(s) of warranty deed recorded in the office of the County Registerfof virtue a Deeds as Document No. own the proposed site for the sewage disposal and t sI (we ystem) orr I e(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. Signat e f cant G~~ p ~l 4o- 41c a t 0 ? t - Date of signature / ~gn~~~ Date o e DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA ji tI 29PA E D y 504282 357 OFHY CR®d This Deed, made between Cedar. .Hills.. DeveloP In Re,0*d YUr 1Rew - Grantor- AUG 2 3 1993 - . and _ _ - Kenneth A . Houman and_ _ Wendy. _ _ Hoiiinan , husband 8:45 A. and wife. - ......................................•---__--•---I' "6 K~.Bt o4 IX;rs , Grantee, Witnesseth, That the said Grantor, for a valuable consideration...... _ S.t- RETURN TO. . Croix ,I conveys to Grantee the following described real estate in - L County, State of Wisconsin: Tax Parcel No: Lot 6, Cedar Hills Estates in the Town of Hudson, St. Croix County, Wisconsin. I' MA $ . 'Ab r; F i i II This _._is-not homestead property. I~ (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And----Cedar..Hi11s_.Deve1Q)2ment.,...Inc,------------------ j warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and rights-of-way of record, if any. i and will warrant and defend the same. Dated this - - - day of A•LlJ-list------------ 1993..... Ce Hills Deve op t, Inc. , (SEAL) by: X (SEAL) - * Dean R. Larson, President - - (SEAL) (SEAL) „ William C. Harwell, Secretary-Treasurer AUTHENTICATION ACKNOWLEDGMENT Signature(s) _..Dean_R.__Larson,........ • STATE OF WISCONSIN William C. Harwell ss. --------------------------------------County. authenticated this y of AggUSt 19.93 Personally came before me this day of 19--..---- the above named Kristina Ogland TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) to me known to be the person who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Kristina Ogland _ Attorney at Law Notary Public ---------------------------County, Wis. (Signatures may be authenticated 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 typed or printed below their signatures.