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HomeMy WebLinkAbout026-1115-30-000 k STC - 104 AS BUILT SANITARY SYSTEM REPORT a oy 4~, ©Glid`ER l 0 u S ~'e ADDRESS J S`0 S S z7- 5 SUBDIVISION / CSMI WL~x~ fl"0 c..,t5 LOT /3 SECTION . /'3T 360 N-R1~W, Town of a ST. CROIX COUNTY, WISCONSIN PLAIN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i ~g i 75' ~D (A c NDICATE [FORTH A C 'Ro d, fro, ilrovide setback and elevation info"rt,t.ion on reverse of ttlis form. Provide z d 111?enS L J;l to Centel 01 to iOl mallllOl e COV~'I C/o, 3 q 7, 1 V 31-a~~~ ST. CROIX COUNTY WISCONSIN ZONING OFFICE e u a rrrr6 ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 ` (715) 386-4680 April 25, 1994 Mike Stevens Derrick Construction 1505 S. T. H. 1165" New Richmond, WI 54017 Dear Mr. Stevens: On April 22, 1994, a septic system was installed on the property located at Lot 13, Willow River Meadows, SE; NW;, Section 1, T30N- R18W, Town of Richmond, St. Croix County, Wisconsin. At the time of inspection this system was found to be code compliant for a four bedroom home. Should you have any questions, please contact me. Sincerely, (~*Ovr' Mary Jenkins Assistant Zoning Administrator File I 01.30.10 A~t d 5&Affi~JIFAY RD „GG„County: Labor and Humap Relations INSPECTION REPORT Safety and Buildings Division ST. CROIX (ATTACH TO PERMIT) sanitary Permit No.~. GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village IR Town of: State Plan ID No.: TVFR,,TOTNrP VENT RICHMOND A IT B `M Efev.: Insp. }B/M Elev.: BM Description: J, } Parcel Tax No.: ~ -z- 026-1115-30-000 TANK INFORMATION ELEVATION DATA A9300371 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. SeptichI J l) Benchmark I /0/0/1 Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet 3 TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic 7/0` >jv` 7bo >3o' NA Dt Bottom Dosing NA Header / Man. e 7, Aeration NA Dist. Pipe 7a 9t,H' Holding Bot. System F,7- 9,5-,82 PUMP/ SIPHON INFORMATION Final Grade v 4y 9 lq5 Manufacturer Demand 6 ~ y 6 o , Model Number GPM TDH Lift Friction System TDH Ft _oss Forcemain Length Dia. HH Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width ..j Length z No. Of Tre es PIT No. Of Pits Inside Liquid Depth DIMENSIONS DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM INFORMATION Type O CHAMBER Model Number: System: / /D9 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 i xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: RICHMOND 01.30.10.665,SE,NW,LOT 13,C(TY RD "GGII J~ < " t f 'h2QL~c r d'-c a. 4J 14-7 Plan revision required? ❑ Yes ❑ No (6 Use other side for additional information. W-11 6 6 SBD-6710 (R 05/91) Date' Inspector's Signature Cert . No. ADDITIONAL COMMENTS AND SKETCH , SANITARY PERMIT NUMBER: Ear, OILHR q SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY F moms 51, C V- (A STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than /~i 1/0 P 8% x 11 inches in size. 1:1 check if revision to 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 W) GJ ~rY` c _55 '/a NGvl'/a, S TJp, N, R r W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # / 05 & CIT, 7 Y ST TE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CS NUMBER (Al L 5~'Q✓ c, ~SI(:-~3ao W ( 8 6 (a a oc it yn&,,&C4ias II. TYPE OF BUILDING: Check one CITY p NEAREST ROAD ( ) ❑ State Owned VILLAGE 1~tC~rrwinGly C v `i ❑ Public1 or 2 Fam. Dwellings of be PARCEL Ax N G~ Ill. 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 ❑ Cathpground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 50 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.;9 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 El Specify Type 41 E1 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 6 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 65 ELEVATION 858, k6 7 9/O Feet 9.7 Feet VII. TANK CAPACITY Site in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New lExisting Gallons Tanks Concrete structed glass App' an s Tanks Septic Tank or Holding Tank 50 Lift Pump Tank/Si hon Chamber El F] 1 1-1 El I F] I F] Vlll. 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 Sign : (No Stamps) *1P/MPRSW No.: Business Phone Number: U ' W&r /1 A Plumber's Address (Street, City, State, Zip Code): 1191,19 l r20 LA-4- , » .z. s y& IX. UN DEPARTMENT USE ONLY mit Fee (includes Groundwater Date Issued issuing gent ture (No tam ) A roved Surcharge Fee) pp ❑ Owner Given initial c~ Disapproved 77P;;~%11110 Adve a Determination X. CONDIT IONS 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 U 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. 111. 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 foam; 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 usE!d for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) P) CK W ~1 O uc~ 1 W ~p ~~.1 ~vr ~I'f~ G~l a rte" 7~~¢.,Cr"F-►'►fS /S65 r4417 4.5 o W rnoY-t.C M. 7vp ~r sin Q B~~D JA X 7 a 1. cv Ul n w.L rs 1 v ~ IV 40 o ` v _Q ~z 8~ I(~o• 40 d~ ,l. ct a M ~ . y a l ~ ~ \ r. ~ + f r~ $ I< _ •k a ~ ` a . w. i ~ ~ ~ i _ ,a ~ . V scunsin'bepartment of Industry, SOIL AND SITE EVALUATION REPORT Page of 3 tabor and Human Relations Division of Safety 8 Buildings in accord with ILHR 83.05. Wis. Adm. Code COUNTY / ,p Att ach complete site plan on paper not less than 8 1 /2 x 11 inches in size. Plan must include, but PARCEL I.D. # not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. REVIEWED BY APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION DATE PROPERTY OWN PROPERTY LOCATION C K G GOVT. LOT,gL- 1/4/Vft)1/4,S ( T 3 N,R f L9 1X(or) W !D_6_nC y N ~ PROPERTY OWNER':Z' ING D ESS MCO]CITY BLOCK # SUBD. NAMyIE OR M# d~ yvf~ w,'6/vuJ - L- I , TAT , 1 ZIP CODE PHONE NUMBER ]VILLAG E forOWN NEAREST ROAD w S 7 (7 5L(0 -z 3 z0 G ~O • ''f f 64 New Construction Use ( Residential ! Number of bedrooms Addition to existing building (j Replacement [ J Public or commercial describe Code derived daily flow oo gpd Recommended design loading rate ~ _bed, gpd/ft2 c9 trench, gpd/ft2 Absorption area required (9358 bed, ft2 Z D trench, ft2 Maximum design loading rate r _bed, gpd/ft2 6 trench, gpd/ft2 Recommended infiltration surface elevation(s) 5F I; ° s ft (as referred to site plan benchmark) Additional design / site considerations 11-04 Parent material Flood plain elevation, if applicable lti.4 It S - Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE U SySTEM IN LL S HOLDING TANK U = Unsuitable fors stem I PAS ❑ U S_ U U A!11~ 1:1 o S 15-U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Bourtary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench AZ y _z/ o s. a e,< 11n 1- of 4:'o VVA Ground, S ,z a d elev. 7v , z S S Depth to limiting factor Remarks: Boring # /0 02 rn Sift rn e4k 'S k:: . li /O M ~Z/I ej, drt / ~n-7 54,j !'yI l ."5Ground a "P/ k S D s 4/ . S elev. K, 5 Depth to limiting factor 7 ~ Remarks: CST Name:-Please Print Pbone: l5 ~ Z - ~o Address: Signature: Date: CST umber: PROPERTY OWNER OArr~et~, &ons-f - SOIL DESCRIPTION REPORT Page Zof-3 PARCEL I.D. # Boring # Horizon Depth Dominant Color I Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ITmrch A L5 / Ground ZId L S 1W 17 elev. 7 5 yj~- Depth to limiting factor Remarks: Boring # cd /t/ w ~2 ,l - 4o Ground Depth to limiting, factor Remarks: Boring # tl C1~ S Gf~ GjC S rv -2 w5V,< Ground z d S 4z L 9S elev.g 5 Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) STEEL'S SOIL SERVICE Gary L. Steel c. C.S.T. 2298 New Richmond, WI 54017 MPRSW-3254 S (715) 246-6200 13 11o, ~d 1. o f s+;AKL f a `off' ~ z ~o j °1v ~ e- 30%T C)-4"M Co tN,~ L. V-c-c6 ~Z- P- F3 f~S 1, 6iJ ~ C r o S S ~ ~t C I l~ r'1 0 ~ ~t ~ t ~ S ~ s ~ e n-~ • • ~l 4i;7 13 ` flash Air 1111911, And Observation Pipe r~- Approrle VmOI Cep Mlnlmum 12' A°orm flnol Grade 20- 42' A►ero Pip' _ •1* Cost Iron To final Graff Vmn1 Pipe Mean Hq Or SrntMtk Ce ulny lttn 2' Aywage's Oral PIP! Diotri4v110n , Plpa 0 0 0 - Tom s . AoareOalm 11001901% Pipe ° P.rloroted Plpm Beier e ~Cep1In2 Te.mtnmtln2 At 110810m Of fr►tsm 7 ProP05tD pin..I 9rA(I,. £.Icv•.~'ton ~ SOIL FILL OISTRIBUTI01.1 PIPE 'r APPRovEO $49p4ETIC COM 2"OF AGGREGATE MATERt^_ OR 9" OF STRAW s.'.x OR MARSH HAy q~ 6 rCr t• t. r• OPlL'2/ AG L GRCGATE it 015'rRIBUTIOM PIPE TV INC AT LEAST INCHES BELOW ORIGINAL ORAGE ANU AT LENST40INCHES BUT 1.10 MORC THAN 42 IACNES OELOW FINAL GRA OC /WLMUM OEPtH OF EXCAVATIOP Rom oWWAL 69AaF- WILL BE •zINCHEs 'ng)MVM 0Ep7-11 OF EXCAVATIOM r-PO \ 0~164JAL, (jRnDf- WILL BE, INCI•IES SIGUEO: LICEUSC LJUMBER: JJ p I DATE: 110 r SC°':'.C "~L.Mt~ !RL:1TL•:lA::Cz iLa:t Sr.. C.o Lx C°o~run~y //L LU ccJ /at Vt7Z JU I "T EN ?'(.[&A-67 ` EiQUTEl9a.°_ YV:~:BE:: 150S Alyy IQS F try "cumber /76 CZ1.071 ST ATM c4imo a L), (yx ZZ° 5~a~ P^7PSRT7 L0CAT:0N:SI c:. Section "own or )CI C44M0 M'D . St. Croix Caunc7, W/mow k'cv~~z. • Subdivts ton /'LEG S . Lac cumber tapraper use xad Matacanance of your septic syscam could result i its premature failure co handle wascas. Proper maincanance con- stses ad pumptag out the septic caaic aver'7 three years or sooner, i= aseded. by a licensed 3e_ v e e cynic ou oe r . %hac you puc Taco the syscam _mn at act the Cunccion of mho septic tank as a c.eac- cmenc stage :a the 'lasca disposal $?scam. St. Croix CaunC7 rasidencs neat be az :gisla cc receive a g:anc car a Mast=um ud 6az ud the case ur replacement of a eailiag syscam, vhtch sas is ooeracian prior co July L. L478. St. aroix Cuunc7 accapcad :his program is Auxusc of L980, catch the requi:ameyne tha owners oe all ae•.r sysc nts agree Co kaeo Mhos-r systems prooerly naiacaiaed. The ?racer=s owner agrees .o submi.c co St. CrOL= CJunc7 Zaniag a marci:icacton lore, signed by the owner and by a mas.car plumber, laurnsyman plumber. rescrtccad pLsmber or a Licensed pumper veri-- 17tag chat (L) the on-site sascawaeer disposal system is:in ?race oceraciag condition and (Z) ad':ar iaspection• and pumping.. (i: aec- assar7) , cha seccis caaic is Less than L/3 Eull of sludge and scs C., rti:icacion fora :ill be sent acoroxiasacal.y 30 days prior co three rear aspiration. td !;Z. the uadersigned, have read cite above recuirsn+encs and agre co Mai :main the art"ace, savage disposal system :n accordance •ai:. cite standards sac AO.Orth; heraLn. as sac by cite '•JLsconsin 0epart- Mont oc lacsral lasources. Cacti=icamiOn fora must be comoLacad and rmcar:ied co the Sc. Crois Caunc7 Zoniag 01=ice jtcaia 3'0' day, of the three Fear as~ir~'cion dace. :A-- 12--/0 -g3 Sc. C=o _ = Caunc? :ac=ct Ut=_cs P.U. Sox 4ammc-a. aL 5 ti i..'T A(L 1ClQ ?.`!S . i r APPLICATION FOR SANITARY PERHIT STC-100 phis application form is to be completed in full and signdd by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit esuence. Should this development be intended for resale by owner/contractor, ("spec ouse"), then a second form should be retained and completed when the property is old and submitted to this office with the appropriate deed recording. ar of Property j~V T- LLOuJ lCtvc'n• --~oi 1"'&AJjL4 aE; AW/C.'E/4'eL- 'e, 57 ~~s cation of Property A/L-,LJ h, Section ownship L411 M0 N D iling Address _ /SOS /may !oS )el C44 AA-0 "D, sVo -7 Address of site -7 W ST New ~-rn~o N o, - Wi SVo 7 $ubdiiiiion llama /LLaW v /Ll~/~~OwS 3 Lot llusber , Previous Owner of Property _ &;tMV1-tlbc ~G/fjtr~p~- Total Bise of Parcel 2 3 Date parcel was created - Are all corners And lot lines identifiable? ) Yes No to this property being developed for resale (epee house) ? Yes No Velma 9(-0 and page Number 7_ g ~O as recorded with the Register of Deeds. INCLUDE WITII TIIIS APPLICATION THE FOLLOWING s WsrEant~ Deed ich includes a Document number, volume and oaAe number, and the Sesl v[ the Register of btedB. In addition, a certified survey, if available, would be he so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Hap, the Certified Survey Hap shall also be required. - - - - - - - - - - - - - - - - PROPERTY OWNER CERtipiCAt10N 1 1100-1 c#,AV$y that da Atatementh on this ohm she thue to the best 06 my (ouk) hncwtedge; that i (we) a►n (eAel the otuneA(sl 06 tke phopehty descAtbed in this 4"Aonn+dVon 6ohm, by vi tut o6 a wanhanty deed heconded in the O6 ice o6 the County Regi s teA o g Veeda ah Doewnen.t 140. `ASS Z (o ; and that 1 (we l phew en ty c.vn the phopoeed site 6oh the selvrtge cUApos eyes em (o)t i (we) have obtained an taaement, to Run with tIto, above deg cAtbed pitopehty, Met, the eonstA"r-uon o6 satd eye.tem, and the same tine been dutheconded t o6 the County RegCeteJt o6 Veed4, a0- Docment No. 5 s ZO b 1. t - ol'olle Ke , SIGNATURE of OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) /Z `/a -93 DAIS SIGNED * IZEUOLK'S ulflu flichael P.. Eftevenst. William 11., Dergick► I~ St. CROIX CO.t WI ReC'd for Record William. Mo . Derrick, Thomas.. . Qerrjck, alld•,...... Ronald L. Derrick as. terlatlts-in-aommvn JAM 11 1AU at 8: 30 ~1• M ront~I•~N sllul a:n•rssn!►~ la ...Willow. Rivet. t.oin......... 1 .....Ventura t~hdM V C „ I Roold" of Deeds ' MtrUnN t0 . . .....................1....... ! . .cliX of)Ilnts► III!! tellnahu. dc..I 1 tl 111 rent t. lnle In It. 91.»le nl It IFCOmin: Tait r.«el Not Southeast Quarter of Northwest Quarter and Nol`theast Quarter of Southwest Quarter of Section 1, Township 30 North► Range 18 West. ~1dhlFitdoll loth 1 i III ho! • 1 ~I 1 f r reg~ eaeemehte Ind linen •:icrcI+llsan to a•ntrdnikAl Municsipel dnd toning yr tdotrictiond of records .ISNALI • . derzlck William 11r. VIMA 1.) 1it Ck >:.ick 9n r . ...lli... if. be x • 11=t1TltltNTldATl U N ~'xRBti~ l tl rt M IM N T I. lvnns i.......... " 9TAT1: OF Wt9t1t)N91N .11 i~nl'iia(:ii f~1i~~1~.4~•...It: n!1. w1.. t_Lam 11._t7ert t}nII nsrnul:trl,r wAli anA n t - - un tl ln1 t..I~IIIIIic ...i n Q 4N' i'nw i4F ron • rM 1t. (1('iiol, elit!o rn t ",1 p 0 " tisnl"It 1» lIlt1l}g11! ( Oft 111} ~`Imm M1 .I date l ~ ~',C!<l~ gI•Ic1I11u1cIi•ta,l, 11n1h (911pInl nlcc~"n C jc nulhrul.icnlcJ nr ~ nre not Ilb • ' }w• ,•..I wt 1•IIIII/YI 1.44"w 11W1, Af10 I11wNI1 ~nrwrll} „hmdd t}1 ...,,,,.t ut hrtann! •irninf in wnr BtAt(! tt~ pt trl4~'n;i!IIN t•.•nnnnNr~ n}•r.» • ' t I