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HomeMy WebLinkAbout020-1280-20-000 41 t STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS L~g•~ SUBDIVISION / CSM# C LOT # S SECTION ~7. yT;W9 N-R-Z2 W Town of 13 40 ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OFk_VV 14 30 67 67i n i r n .>Jy Ir ! 9?1 • ti C'j INDICATE NORTH ARROW _Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: 5 11100,16, C_V Q2 N • j 70 ALTERNATE BM : i SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: e-&7tt"& Liquid Capacity: 12 aQ Setback from: Well a House .30 Other Pump: Manufacturer Model#NX Size Float seperation /V Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length Number of trenches ? n Distance & Direction to nearest pro 1 ' e: S~SJeOC Setback from: well: 71 House_JE Other ELEVATIONS Building Sewer ST Inlet g /Q3,3Q ST outlet '10.3,00 f PC inlet x p j/` PC bottom Pum Off Header/Manifold Bottom of system uo_ pry+ Existing Grade Final grade 03.7 S" 1'~.crc.~ DATE OF INSTALLATION: 1 PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt T+~is~ipertfMttfCCilfust' • 29.19.13RIVATE SEWAGE SYSTEM county: t Labor and Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: 199924 GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: Ild MAR A HUDSON v.: Insp. BM Elev.: BM Description: Parcel Tax No.: ' 0, 60 7 C r74 /0,, 020-1280-20-000 TANK INFORMATION ELEVATION DATA A9300332 12116193 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark , L Dosing Aeration Bldg. Sewer Holding St/ Inlet TANK SETBACK INFORMATION St/ Outlet' Verit TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet Air Septic NA Dt Bottom - - Dos g NA Headers 0 Aeration Dist. Pipe IV, - Holding Bot. System r ! PUMP/ SIPHON INFORMATION Final Grade M Demand Model Number GPM TDH Lift Friction S test Ft Loss e _ Force mafin _ Length Dia. Dist. To well 3651, 10757' SOIL ABSORPTION SYSTEM BED /TRENCH Width Length J N. Of Trenches No. Of Pits Inside Dia. uid Depth c DIMENSI N DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHING ufacturer: SETBACK CHAMB Model Number: INFORMATION Type 0 1''e_j ~cr(,- IT System: t4.rv, f~S DISTRIBUTION SYSTEM Header' a Distribution Pipe(s), xole Spacing Vent To Air Intake Length Dia. Length G~. Dia.' Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems On Depth Over Depth Ove xx Depth Of xx Seeded / Sodded xx Mulched 1 Bjfo/Trench Center tWTrench ges Topsoil o ❑ Yes El No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 34.29.19.1340 487 / a-, > c." L? ,-'`r~11 r Z- 9,17 ' 9 a9 ' l o, C 3 7, Plan revision required? ❑ Yes [a_146 Use other side for additional information. [/P21 /(O 9 SBD-6710 (R 05/91) / Date Inspector's Signat re Cert No. w DILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code .~...,,..v,.,..~,~.,,e. STATE S~IlT ERMI -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ f~~i 8% x 11 inches in size. c eck if r vis n re ous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY WN R PROPERTY LOCATION 12 w '/4 IVW 1/4, S 3 T ,;Z N, R l E (oa PROPERTY OWNER'S MAILING DRS,S LOT # BLOCK # 00 ~•l~f CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAM OR CSM NUMBER II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ cl LA GE : 0"41 NE~R6 T ROAD ❑ Public LJ 1 or 2 Fam. Dwelling-# of bedrooms A x Nu ( ~ 111. 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 120 Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE PERMIT: (Check only one in line A. Check line B if applicable) A) 1. New 2. ❑ Replacement 3.0 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 D~Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 430 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) L14 it ;0~ ~ E~E,VVATION 1005 a. orv>sf 99A9eet /p3,co Feet VII. TANK CAPA Site In allons Total #o Prefab. Fiber- Exper. New F-xisting Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic INFORMATION App Tanks Tanks str cte Septic Tank or Holdin Tank ` /;Zoo 1~~ € S ©N fo Lift Pump Tank/Siphon 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) MP SW Business Phone Number: 111,5C-4 0 f l UE 3~ ss /s 9-33 Plumber's Address (Street, City, State, Zip Code): rv 0:,1-3 IX. CO TY/DEPA TMENT USE ONLY t, 't Disapproved an tary Permit Fee (Includes Groundwater Mate ssue Issuing A m Sig No mps) Approved ❑ Owner Given initial i/~ Surcharge Fee) d 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 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 takes; 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 and establishment of standards. SBD-6398 (R.11/88) DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, CC DIVISION LABOR P.O. BOX HUMAN REDLATIONS PERCOLATION TESTS (11J) MADISON WI 53969 (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSH I P/#A604G+P*t1'r-Y: [OT NO.:BLK. NO.: SUBDIVISION NAME- VF sw 3Y /T21 N/R/F E (or) W 0Sa..) S C44e-e R N i l/S' COUNTY: MAILING ADDRESS: S?e&ljr wA4 GoR IfAA I to + 'Tow E 2 'Ro l3EieT S k; tS 5-4o 23 USE DATES OBSERVATIONS MADE NO. BEDRMS : COMMER IAL DESCRIPTION: I DESCRIPTIONS: SIFERGULATM19TEM-71 [®R,,idence 3 ole ®New ❑Replace I4~OXW 10-6s0 tAxi/ ~c 5 i~ k [A R D 'T- RATING: S= Site suitable for system U= Site unsuitable for system % U - ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM:loptional) I I S _DU ®S ❑U ZS ❑U ❑S OU ❑S ❑U CO-JVg-J71' 1'0,)4L - 'TRE~tf~l1S r 0_ If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: c_j AS•S J+- Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. HET TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) i p ' 8N-Sy. S/ S ' L!• v • S/ B- 2C /00.4 j 8. 4 p of s -...1 f'3,~ . Is w 11ri2 . O ' GJ'.-Ra . Sr'/ S ' v R . sovRle B- 2- 7 Pu-. ~.2 s T1.a %-Sj . S. 2,0 4t. S1 :2. s ' N B- 3 Q~ •S 8lt Is /•/7' $'j• St) 2.33'~trir•o4 $N. IS D o 3. Sa ?'to 6' Q S/ w p- ire /VKA P . S 3 a--2 , B- d . Q r ~OS. 2 3 > D Sa l k' (S t 2 . $ ' lea • I S R•*, <r2 5. 6 ulr~v 'Q . C -S 16..0 OW 7~: B-,5 8 0 /0 16 Ito 0 ' s 31k s, s • M; f T INC, x,,,C 'rqAJ S S Ll R~hcQ PEQc E'Iev tTCia.,,S PERCOLATION TESTS = DEPTH WATER IN HOLE EST TIME DR IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING 1 ERVAL-MIN. PERIOD I PERIOD PER INCH P_ / /03 •S 2 2 Z S P_ Z /o / D l % ► r /O P- /OS'.2- P- P- 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 slope. c acr,{s~- i~F.t,~4 = q~ . SD 7AFov e =loo- d SYSTEM ELEVATION. 1 • z ; ~ .r i l SEE Pt-OT Ft-PtA-; ,r v SIP ~H I i 1, the undersigned, 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. I' NAME (print): - HOMESITE SEPTIC PLUMBING CO. TESTS WERE COMPLETED ON: c 655 O'NEIL RD., HUDSON, WIS. 54016 ADDRESS: ROBERT ULBRIGHT CERTIFICATION NUMBER: PHO E NUMBER (optional): WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. a yap 3IFrp - IP/ S CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. i~ DILHR-SBD•6395 (R. 10/83) - OVER - d1RKED Soi~- a►~,Kt,~°F PrT- St~l2 , a z 3' sfT I t~ ~c ~E~lrtcEME-~T E' l~v~+~~ a•~ PFQ~yt- /O D - O 66 4 i _ i P ► 2 x , I xQ3 , 135 t 13oRi a(~ v S CAQ L Mh12KFn „ GA 13 X103 F - A-PRF!ay I pr~pos~D fre I I I 1 1 I 1 ~ I 1 ~ I I E upt v . 'DR Ii V Q- . Lo-r 5 SG~4/E : / - ZD • = I3.4CIC~ ~O~ obi-'G-s HOMESITE SEPTIC PLUMBING CO. 655 O'NEIL RD., HUDSON, WIS. 54016 J( - GOG ~T/D.J CS ROBERT ULBRIGHT eSr 2- WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. MINN. mWALLER 6 DESIGNER LIC. NO. 00663 ob..r4G, cv~ - r 1 "C-Au,`)-LE 67 ~~-y 6 9 s I 1D 2 9 msNt ,u oo/ 67/ 1,4 top ~y►7~~''1 sue. ° T POX y cr T AV pia .{f-4 y, /1 1 r 00 << S~tIG ° ~ i~ H fj; ~ • DD. oo ~ ~ ~ h 30 / ~s~i Thy o(J-5E -T' Pu.r o' y - - - •991so zow~St 'S C- Bo-c Bo i Nis i WaterPro Supplies Corporation „ 15801 W. 78th Street Eden Prairie, MN 55344-1894 waterpro Telephone 612-937-9666 Fax: 6 800-752-8112 Fax: 612-937-8065 -8065 PROJECT -DATE J 0 O V a S OC~2 0 ul (.C) 6y ~ , t2. rn N ~ Ile / Ll a / to d m S 89'56'40' W 102..3' O LAN i N E D I E N89. 56 - 40 - E 272 162.88' N 20.00' N OR' n q• 1 1983 ~O V S171g'63' O o N 02'2a • E ru CA z cA cA 14 ul e w 6 33.2 r ~tDO~ w rn i if t r' 4a3wiY~., W 210.77' v z a N 89 59' 35 E _ c c m (N89' 44 ' a6' E) Uf A N n a ~ a~ 10 1 rI+~i oz z ' © t° O o~ I< • 1 1►-Irn ~v> I 0 N ' 315.00 ' E 369.38' UNPL,ATTED LANDS S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER`, LL t1~ ~h-i2. LrA ADDRESS-(66)c a-X? FIRE NUMBER CITY/STATE ZIP 5-1.4 PROPERTY LOCATION : Sw 1/4, 11 w 1/4, SECTION 3 LA , T 2 9 N-R__L2_W TOWN OF v~ Spa , St. Croix County, SUBDIVISION C~-KZCLy LOT NUMBER S 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 h DATE: z'2 -q2 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), thenia 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 Location of, propertyS W 1/4 M w 1/4, Section 3 T a9 N-R \ W Township 1~vo4o„J Mailing address 73c»c -H oZ3 Address of site Ck t'-JZ_aL L ,-'k-Z) -~-rIn.- subdivision name _C-tc\GXLXY' (4-1-\-\_ Lot no. Other homes on property? yes No Previous owner of property -474 kSEM Total size of parcel LA • ~~1 P ce.-e:S Date parcel -was created Wes "S'c 3O, Are all corners and lot lines identifiable? V/ Yes No Is this property being developed for (spec house)? Yes 'L No Volume and Page Number L-39 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. J4Sr9 2-)y , 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. Signature of applicant Co-a pli ant 2-7- - C1 3 Date of Signature Date of Signature i DOCUMENT NO. STATE BAR OF WISCONSIN FORK 1 - 1982 THIS SFACE I zaERVCD FOR RECORDING OATA ' • WARRANTY DEED 4-'8'74 969wE638 REGISTER'S OFFICE This Deed, made between $T. CROIX CO., 1M Recd for Record ' Carmichael Residential Groupr Inc.. Crantor, f.' AY G 4 1~50 and am, 41 11: 4 30 A. ~ Willialti Gorham -and -Mari-lxn A. Gorh husband and wife Re014tel of Deeds Grantee, Wit~tesseth, That the said Grantor, for a valuable ~onsidrration._... of one dollar and other valuable consideration RETVRN TO conveys to Grantee the following described real '`state in ...St. Croix County, State of Wisconsin: Tax Parcel No: Lot 5, Cherry Hill Addition in the Town of Hudson, St. Croix County, Wisconsin. rR "sF o ~._d This is-_nOt..._..... homestead property. 1~30 (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And...•........Gran_i or warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except and will warrant and defend the same. t Dated this day of 4... ....May 19..90... CARM CHAEL IDE Gi (INC. ~ _ - - . - . (SEAL) - (SEAL) BY: Joseph `D. Bjor' a . Its: Vice•.-Presid2nt . (SEAL) . ....(S :AL) • AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ss. St. Croix .County. authenticated this ........day of 19...... Personally came before me this Z.......... day of ...--------.•-----..---..MaY...._•..... 19..90.. the above named Jose h D B ' ordal TITLE: SIEMBER STATE BAR OF WISCONSIN (If not . :-.aJ............. r: authorized by § 706.06, Wis. Stats.) f to me known to be the person ...ti:.1-. %v- b ex0fgteV6e i fore¢oinginstrument and nol a thtsapie._i THIS INSTRUMENT WAS DRAFTED eY r 1~1•/r~ E• ~1 Jose h D B'ordal ` 1?._..... 3 Term Pirl.us Not Puhlic St-'...Croix ' Cpunt},.Wis. (Signatures may be authenticated or acknowledged. Both My C -n-mission is permanent. (If not, state expiration ' are not necessary.) date: Mai! 30 19.93...) .Names of persona s!Enina in any capacity skou!d he typed or printed halos 1h. it +iq r.•.. rrs. . WARRANTY DEED STATE. HAIR 0F1wI:4 0 NSI.N in I.--J IYnnk C-% Inc. • FOIt Nn. - IlN2 R'is. I I f I (