HomeMy WebLinkAbout020-1180-70-000
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER P/-!f rj LrARSON
ADDRESS ffl lid 150
Y~(..~ryl
LOT # 3`~
&-t- S
SUBDIVISION / CSM# Coi>r N { I '
SECTION a8 T D ~ N-R~ 9 W, Town of I l'A r JrJ
I l :~'1
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
3 BepKoom
Home
i"
i'
a~, o Bobo gal SeFt' c TR~J>
7'
I'
I J
I I
I J ~ax 5~ ~ep
I I
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: ~cIpAK I~QkI ~A~ ~I~11 " Id~•~
ALTERNATE BM•
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity: 100b9A1
I
Setback from: Well N~fi 1 >J House a Other
Pump• c urer MudeTF S i z,-
Floaterer~ Gal
Alarm
Loe -
SOIL ABSORPTION SYSTEM
Width: I c~ Length 5,q Number of trenches
Distance & Direction to nearest prop. line: I6
r
Setback from: well : ~ d ) N House a Other
He~2~ Y.
/c)a 9 ELEVATIONS Cov e ,
/007 ~a~ IUI•~9
Building Sewer ST Inlet OZ Q T ST outlet I Oa • (3~ I03)( 7
PC inle~ PC botto Pump Off
Header/Manifold- _ Bottom of system iyU.Va
Existing Grade MI D Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER: 3V O
INSPECTOR:
3/93:jt
i
L partust~r"29'19'iWIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION
199908
Permit Holder's Name: ❑ City ❑ Village Town of State Plan ID No.:
R.PREV )SON
v.: Insp. BM Elev.: BM Description: Parcel Tax No.: 020-1180-70- 0
TANK INFORMATION ELEVATION DATA A9300312
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 1000 Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
I Loss Friction System TDH Ft
TDH Lift
Fie
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN I N DIMEN IONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION Typeo CHAMBER Model Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold 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 Only
Depth Over [Depth Over xx Depth Of xx Seeded /Sodded xx Mulched
Bed /Trench Center /Trench Edges Topsoil ❑ Yes ❑ No El Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 28.29.19.1137
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
SANITARY PERMIT APPLICATION
=Za701LHA In accord with ILHR 83.05, Wis. Adm. Code COUNTY
61,614
STATES RR #
-Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. Ch previous 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
.C' a .l V a,l" SuJ %a '/a, S,48 T L ON, R /Q E (or
PROPERTY OWNER' MAILING ADD SS LOT # #
,7 NA
143 " a w+ g,6314
TY, STATE ZIP CODE PHONE NUMBER SUI VISI N NAME OR,CSM NUMBE
i e ~A ~es
II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE : NEAREST ROAD J
,q clro
MW 99' 4. .
❑Public L I, 1~ / A4
~1 or 2 Fam. Dwelling-# of bedrooms 3 WFIGEL TAX NUMBER(5)
111. BUILDING USE: (If building type is public, check all that apply) t0A,0 /z/00 lop
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 80 Mobile Home Park 1120 Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYRP~E OOF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. L~6 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
120 Seepage Trench 22 ❑ In-Ground 420 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
REQU RED sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
qS C5 ~ ~y 1 bb. Feet 6 I - 7 Feet
VII. TANK CAPACITY Site
INFORMATION in allons Total # of Prefab. Fiber- Expp.
New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holdin Tank 1" 1130Z
Lift Pump Tank/Siphon Chamber __L+ - El 1 0 1 El El I Ej I F-1
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 Signatur : (No Stamps) MP/MPRSW No.: Business Phone Number:
?/f _ r10 d
Plumber's Address (Street, City, State, Zip Code):
of u&
2L -A& ~ v LL
IX. CO TY/D ARTMENT USE ONLY 70 ❑ Disapproved S itary Permit Fee (Includes Groundwater a to Issued uing A nt Signat
Approved ❑ Owner Given Initial 1/&ro Surcharge Fee) 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
~I
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 renevial 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 (SBO 63c_K9) to be
submitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be ptirnped`cy a'l~censed
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. Oheck-only ene 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 in- oimation. Fill in the capfac.ity of every new and/or existing tank, hst the total gallons number of
tanks and manufacturer's narne. Indicate prefab or site coinstr~cted and tank materi,~jl: Complete for all
septic, pump/siphon and holding tanks for this system. Check (!xperimental approval only if ranks received
experimenal product approval from DII.HR.
VIII. Responsibility statement. Installing plumber is to fill in name, F+~se 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'/Z k ' 1 i-.,hes mina be submitted to the county. The
plans must include the following: A) pict plan, drawn to sc• ic c ~ with .nompiEtP dimensions, location of
holding tank(s); septic tank() nr oher treatment tanks; bui'1 w ils, wate, rnaii- va#ter service;
streams and lakes; pump or sipho+r tanks; distribution boxt-s -)i; abs<Ii,oflon systems, r(-r~p;dc:emert system
areas; and the location of the bui ::;jog served; B) harizontLil ertica; 1.levation reference prints;
C) complete specifications for pumps and controls; dose Voium=.; elevation differences; trict,cn loss; pump
performance curve; pump model and pump manufacturer; D) crass section of the soil absorption system it
required by the county; E) soil test data on a 115 form; and F) all sizing information.
- - - - - - - - - - - - -
GROUNDWATER SURCHARGE
1983 Wisconsin Act 4'0 included the creation of surcharges (taus) for a number of
regulated practices which can effect groundwater.
Tie monies collected through these surcharges are used f r ? ~ stairirr; greindwater, gruynd-
watercontamination inves'6gatirns and establishment of .tan- arr,s -
't
i
SBD-6398 (R.11/88)
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 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 81/2 x 11 inches in size. Plan must include, but S)- (r01)
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
T ATION NE
.Je / GOVT. LOT 6U 1/4 ~ 1/4,S 2 qT 19 ,N,R~ fi(or&
PROPERTY 0 E ':S MAILING ADD HESS LOT # BLOCK # SUB N E OR ~
f- a o ~ a , ~1 " F<4 s -
rily, STATE ` ZIP CODE PHON NUMBER E]CITY, ❑VIL GE OWN N EST OAD
G(J" ~Ud (`Ii.T) rd
New Construction UseX Residential / Number of bedrooms [ ] Addition to existing building
[ ] Replacement [ ] Public or commercial describe
Code derived daily flow ysa gpd Recommended design loading rate _L~bed, gpd/ft2 trench, gpd/ft2
Absorption area required bed, ft2 S~3 trench, ft2 Maximum design loading rate -.,-T bed, gpd/ft2 • 8 trench, gpd/ft2
Recommended infiltration surface elevation(s) dow AV It (as referred to site plan benchmark)
Additional design / site nsWer bons
Parent material r r /SN. Flood plain elevation, N applicable ft
S = Suitable for system WENTIONAL MOUND "ROUND PRESSURE AT-GRAD SYSTEM AV ILL HOLDING TAJVK
U = Unsuitable fors stem S ❑ U ❑ S U tjS ❑ U ❑ S VUJ ❑ S '®U ❑ S Lill
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Qu. Sz. Port Color Gr. Sz. Sh.
! in. Munsell Bed rertrtt
M vg
2 !9 z a IJA S / ✓ r S fi'7 5' L
r..
Ground 3 27-,,9i le x !O .5 v 0.5 1 g
elev
ft. _
Depth tD
limiting
z
Remarks:
Boring #
-IS' z z 14~ 5/ ab~ Vf~- /~S z~' S
Z 113""La s Z i w
l rH v~ C w ~r- 7
Ground 2 2".-P09 0 n 5 r co i
el
Depth to
limiting
taCtDr
Remarks:
CST Name:-Please Print Phone:
Address: 0 7v w 3~ S"/orL
u Say.
Signatur. Date: CST Number:
I IMIJ r►r-rvn I Page Z of -3
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure GPD/ft
in. Munsell Qu. Sz. nt. Color Consistence Boundary Roots
LI- Gr. Sz. Sh. Bed L S' L
y y S7/
Ground 6 /D y,~ ` $ ✓ s r,
)leev.
.
Depth to
limiting
in
IN.
Ip
Remarks:
Boring #
L z /v l 5
g z~ s y~ y l s~~
C z4
Ground 3 =77 ' D y,~ G S ✓ w. J - - 7 s
elev
Depth to
limiting
factor
Remarks:
Boring #
13 ~ ~g=zi ~ sy~ yy l Isb,~
Ground
elev.
Depth to
limiting
Remarks:
.Boring #
Ground
elev.
ft
Depth to
limiting
facto
LIE
Remarks:
SBD-8330(8.05/92)
G.
64
1
8~ ~y
0
~y
8s
~ ors
/00
r~
l
,I-. ES
~bp p0 / `S Qe ♦F `
v j ~ PGA
ohm h~~2. 4;
• 45 11ao23
O 98386 SQ. FT.
2.618
pl~o~ 2.259 ACRES
V~ • d .
y~
do VV
~Ory fpNO
_ GJ G!
S N 31 35 W 1~ 9•
.M ~ _ _ RO Ze 1 ,~Z
00°31'35"E
95 18' \
FT. 4
94661:
ES 77 \ 2. 178 <
s, \
NI0042' 7" •004
° • Op +q 99
t p56 ; + - w
36
~ ry b 90610 SQ. FT. '~9,
2.080 ACRES `d4
a 26 fij S 00 ° 01' 4 "E
s , -J 348.39
~v \ 1
yb 1
~ l
°p b ° 418.20
40
f 7.72 S 02'06'22'E 87199 SQ. FT.
e! E 455.92 I 2 .002 ACRE
02
l
57 6
98721 SQ. FT.
I 2.266 ACRES
0
N N \ • a
W
~1 a4s 6j
_
m W lll~ S 00'11'450W
466.71 •
a 1 7t
W
• 1 M Z 3 9
h g twIt,' 806 FT. LOGO
z o 38
-oE
° 0 91772 SQ. FT. (2.107ACRES) EXLC. i I ft?T. 0.144
CUC- DE-SAC ~L•DE
,n N 97974 SQ. FT. (2.249 ACRES) INCL.
CUL - DE - SAC !
fool 455.71 - 1 1
J - __•w ` I n --330.00'--
1~~' ` 'A~AI X11. -►A-~~ ~ 1 ~1 I•I. MI. • -I
P L
LOTA H 1)
E AT-1 I~I CE N S E:
I: _ _ _ _ I.) A T
PLO T
.17. OS
~o nP h 1p "
® V~ ~Qbp~. ra URO'A~~~
Nel Opx t L,
F-4 QUO
N~fie . ~J ell s
f 10)
2vti~~~~ .F ~t~St°r.. 1b
3Y,
D
V C' It,
. k-' Ben ~ a
d S S- ~ SS
y ~
30, OQS-
is dWr ~Z oa o _ _ V -
FRESH All'. INLETS AND OBSERVA`P1()N Pz.BE
C11OSS SECTION
Appr.Dved Vent Cap
Minimum 12" Above I Uy.7aNp~„
Final
"M A" Cast Iron
Above Pipe Vent Pipe
To Final Gracie- j"
Marsh Hay Or Synthetic Covering
Min. 2" Aggr.cg';il
Over Pipe J
Dis tribu l:ioi~ Tee Pipe
Aggregate r1er-F.orated Pipe nelot•,
(ot~.ya Bencath Pipe ----Coupl.ing Terminating' T
~ . Rol• tom. of System
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
NE BUYER JP_ [re~a /4. ut4d T_ U r~Sn~
ADDRESS -7 SO A\dro Rc~ FIRE NUMBER -7 5O
CITY/STATE 4,elSO'n ZIP- Sg0l te7
PROPERTY LOCATION: SW1/4,, ME 1/4, SECTION ~ % , Tc9 N-R [9 W
J
TOWN OF UA6,4 , St. Croix County,
SUBDIVISION C-CAor A IIS L576j" TT , LOT NUMBER_3_.
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/tae, 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: -lO-2U:: ,
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
fthe owner(s) of the property being developed. Any inadequacies
will only result ~n delays of the pormit issuance. ,Should this
development be intended for resale by owner/contractor,(spec
house), thenta 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 T _,12-PP rem X erL Zar,Z 4
Location of property 1/4 IVE 1/4, Section D.& , T a9 N-R_9 W
1J IA/ S
Township ,l~aaP~~n
Mailing address /q X;"r y Wj
Address of site -7 50 AlAro R, ;4 ().d chr) W S yQ) to
Subdivision name__1/_'eAar -4a I/s ~v f~3 TT Lot no.
other homes on property? yes No
Previous owner of property _11A~~ ~,.Q ~
Total size of parcel 04.08.0 Aer' S
Date parcel -was created r_~ I I Q g q
'Are all corners and lot lines identifiable? - Yes No
Is this property being developed for (spec house)? Yes _L _No
Volume I0 yU and. Page Number IU6 as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICA'T'ION 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. e!L_ C//J7 , 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. 0AP,
ssiqfiWZ1
r of app icant Co-applicant
Date of Signature Date of Signature
DOCUMENT NO. STATE BAR OF WISCONSIN FORM i - 1982 THIS SPACE RESERVED FOR RECORDING DATA
.
8d6907 WARRANTY DEED
von 1040PAGE106 RECESTER•-r-11
:a'1:"fRt G".
This Deed, made between
K TI EN. R DAIBR_UZZ_T, a ••s in-g] ger.s.on t ea'Q kw Recn•d
OCT 7. 1993
, Grantor,
and---- JEFFREY_ A- -_LARSO.N._AND..PAMELA._LT...V_._..LIARSON.r...... 1:30 30 - P
husband._and_._W!.£e..................... 1 r. ~ib^ef of Deeds
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration......
conveys to Grantee the following described real estate in St..---• RETURN TO
County, State of Wisconsin:
Tax Parcel No:
Lot 36, Cedar Hills Estates II in the Town of Hudson,
St. Croix County, Wisconsin.
I'RAN"WER
EM
This _5__X1Qt....._._... homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And..... Ka-thleen_._ .---DAbrIAZ I .
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.
and will warrant and defend the same.
Dated this .1.~ day of CtOb_e_r-------------------------------------------- 19.._91.
~ . --wz~l
..._.....(SEAL)
(SEAL)
Kathleen R. Dabruzzi
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature (a) Kathleen R.-_-D3bY'•uzz.... STATE OF WISCONSIN
88.
Qiiv+ ................•---....County.
authenticated this-----day of ..October 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
------------Attorn _v' at __Law.-------
- - Notary Public -•-------County- Wis.
(Signatures may be-` thenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.) ..'s date:
~ 19.........)
*Names of persons signing iE1 any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE. BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc.
FORM No. 1 - 1982 Milwnukee, Wis.
0 L~ OVA
~ - i
LO
x.35
7