Loading...
HomeMy WebLinkAbout026-1108-60-000 • t", a i; STC - 104 t AS BUILT SANITARY SYSTEM REPORT OWNER ~Q ►r' lf` 1~ 0 tip, ADDRESS SUBDIVISION / CSM# V/.,e, D r` WDk q AAA +l uv%- LOT # p SECTION_, $_T 30 N-R~W, Town of R Ickwmr A ST. CROIX COUNTY, WISCONSIN PLAN D EW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM d 3 -C Q r/ 1 . j4V 37 INDICATE NORTH ARROW .As i Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. 1W l r BENCHMARK : ~OOY+'t y/ S/ 4~/ M'~I f ALTERNATE BM: SEPTIC TANK /.PUMP CHAMBER / HOLDING-TANK INFORMATION Manufacturer: Liquid Capacity: /o-y r Setback from: Well- y~ House Q b Other Pump: Manufacturer Model# Size Float seperation / Gallons/cycle: Alarm Location AI/1i .SOIL ABSORPTION SYSTEM • ~~n 3 Width: IV Length 3 7 Number o i Distance & Direction to nearest prop. line: lA•A4-47 1 D .00 Setback from: well:- House (go? Other ELEVATIONS Building Sewer ST Inlet; 9/,,53 ST outlet 9/ 61 PC inlet PC bottom Pump Off Header/Manifold 9~•tJ Bottom of system 8(t, 5 Existing Grade 1jl Final grade 9~, 6 DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: 156 INSPECTOR: 3/93:jt t 4gg r~ L LQC;U; Ql~l;,A; APy,4.30.18. IVAQ~E SEWXray GE S T~~ County: Safety ety and a Human Buildings Relations Division t INSPECTION REPORT S GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: 193495 Permit Holder's Name: ❑ City ❑ Village W Town of: State Plan ID No.: Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: dd, GCS mP Q~ C 026-1108-60-000 TANK INFORMATION ELEVATION DATA A9300150 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic I Benchmark ' a' /Od, Dosing Aeration Bldg. Sewer eyd Holding St/ Inlet TANK SETBACK INFORMATION St/ I Outlet 1;70'5 . C~ Vent TANK TO P/ L WELL BLDG. AirIto ntake ROAD Dt Inlet Septic NA Dt Bottom Dosing NA Header/' Aeration NA Dist. Pipe (gyp Holding Bot. System (0 8 PUMP/ SIPHON INFORMATION Final Grade 9 70 b' Manufacturer Demand pp Model dumber GP l Q'/ , 3,T. t ' ,e = 741 TDH Lift Friction S S TDH Ft oss ad Forcemain Length ia. Dist. Towell SOIL ABSORPTION SYSTEM DIMENSIONS BED/TRENCH width Length~~ i No. Of Tenches No. Of Pits Inside Dia. Liquid Depth S~_' / IMEN I SYSTEM TO P/L BLDG WELL LAKE/STREAM LEA G Manufacturer: SETBACK INFORMATION TypeO CHAMBER MbtelL_Ir System: OR UNIT DISTRIBUTION SYSTEM Header kid 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 y Depth Over Depth Over xx Depth Of xx Seeded/ So xx Mulched Bed /T+ow +rCenter / - Bed / Temank Edges r tCV Topsoil o ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) - A LOCATION: RICHMON 4.30.18.60 .605A (CITY RD A) t-C.✓-'l.r l~''~ ~i (',(~~".'"/Yle L~, Jyl" '~`-~'rp~• rn"-c- 7 /yru,~ T Ewa °,cl G Plan revision required? ❑ Yes L/d'No Use other side for additional information. V SBD-6710 (R 05/91) / I Date Inspector's Signature Cert. No s ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 4 fl DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE S~IVITARY P RMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ (7},(r/S 8% X 11 inches in size. eck revisio 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 _L,r V% ct-~ ../UF- %5,J!F %4, S T30, N, R or) W PROPERTY OWNER'S MAILING ADDRESS LOT # S BLOCK # /l ?s' 'Aue CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CS NUMBER II. TYPE OF BUILDING: Check one CITY NEAREST ROAD .410' ( ) State Owned ❑ VILLAGE 171 4OWN BER C ❑ Public LAI 1 or2 Fam. Dwellin g-# of bedrooms FAMEL TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) 6C14- N 68- (00 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) 1.0 New 2. Replacement 3. ❑ Replacement of 4.0 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 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 '/sO REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 7 & T~ 4 3 1 991-5 Feet 17~S' Feet VII. TANK CAPACITY Site in gallons Total # of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic A Tanks Ta structed pp' nks Septic Tank or Holding Tank iLs &4- h LLJ Lift Pump Tank/Si hon Chamber] 0 1 Lj 0 1 L1 11 Vill. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumb Print): Plum/tier's Signatu o Stamps) IMP/MPRSW No.: Business Phone Number: were /S&3 -S/.3s' Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e issue Issuing A nt Sign re (No Stqff ps) VApproved Surcharge Fee❑ Owner Given Initial 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 1 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 iJsuing authority. 4. Changes in ownership or plumber requiresa Sanitary Pein-iit Transfer/Renewal Form (SPE) 6:3991 to be submitted to the county prior to, installation. - 5. Onsite'sew ge systems must be properiy maintained. The ~„-.tic tank(s) must be purr p. d b~y : licensed pumOec 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'do_mpleteland 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 tb 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 request,(,, in #1-7. VII. Tank information. Fill in the capacity of every new and/or tank, list tl;e total gailane number of tanks and manufacturer's name. Indicate prefab or site constructi-- ± and tank material. zpmplete for all septic, pump/siphon and holding tanks for this system. Check (y r erimental approval only if tanks eceived experimental product approval from Dli_HR. VIII. Responsibility statement. Installing plumher is to fill in name, wertse number with appropriate prefix (e.g. MP, etc.}, address and phone number. Plumber must sign application form. IX. County&,jartment Use Only. X. County/r-3epartment Use Only. r y Comp: to plans and specificat'sorK not maller than 8'/s x 11 incl-: . Pi-,t=t be submitted to the county. The plans must include the following: A) plot plan, drawl to scale or ` r!plete dimen :,ns, location of holding 'ank(s), septic tank(s) or ether treatment tanks; bui'd . ;yells; water mii+ s rater service; streams and lakes, pump or siphe,i t-tnkw; distribution boxes -o - oso,ption systems r~r;; t:~r ert system areas; and the location of the building >erved; B) horizcnta _ft:cal elevation reference PCintS; C) complete specifications for pumps and controls; dose v(,ium , _sievation differences; faction 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 informatiQ,n. 'GROUNDWATER 'SURCHARGE 1983 WisconsinE Act 410 included the creation of surchar es (fe s) f<.r a number of regulated practices which can effect groundwater- The monies collected through these sijrFharges v r. i-sc e.,r s t ,;;i Y yro i ±,v gate 3 + ftc- water contamination investigations and establishtrcrr of SBD-6398 (R.11/88) + APPLICATION FOR SANITARY PERMIT i STC-100 I 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), 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 C" Location of property A_1/4 5 1/9, Section , T_30 N-R W Township Ri clk/yl c1 Mailing address Address of site Es o.~1 Subdivision name t~ l~~ v~o uK . Lot number Previous owner of property M-~-e,g VYl ca®r Total size of parcel • 4 Date parcel was created YY1 4 Y'c l 9 y Are all corners and lot lines identifiable? es No Is this property being developed for resale (spec house Yes 0 Volume L83 and Page Number wj~ 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, and 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 (ate) 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. ?21 S"Cb ; and that I (We) presently own the proposed site for the sewage disposal system (or 1 (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the ounty Register of Deeds, as Document No. ' Signature of Owner Signature of Co-Owner (If Applicable) 07 r OS -R3 Date of Signature Date of Signature r I- I t OCLJt+". ,,f N-7! WARRANTY DEED THIS SPk,:E RESERVED POR RECORDI STATE, BAR OF WISCONSIN FORM 2-1082 391500 VOL (M PA', 14 7 REGIUMS OFFICE ST. atoix CO., Wis. Reed for Recor-l this 1st Charles R. Magoon and Nan E. Magoon,' Nancy .._husband..and..... -ife as Joint Tenants day p# Mar A.D. 1984 conveys and warrants to Gerald E. Cody and. Cynthia C..Cody,... t 8:30 A rte; husband and wife as Joint_.Tenants mar gl DOW# I . . RETURN TO Century 21 _ . . . . . . . . . . . . New Richmond, Wi . the foilowing described real estate in St ..Croix ..County, " - - State of Wisconsin: Wly 63 feet of Lot 5 and Ely 62 feet of Tax Parcel No: Lot 6, Viebrock's River View Addition to the Township of Richmond, being a part of the North half of the Southeast quarter of Section 4, Township 30, North Range 18 West. Aff This homestead property. (is) (is not) Exception to warranties: no exedptions I)ated this 27. th day of . February 1984 (SEAL) ~%CGS~~ . %~f~Y\ (SEAL) C':arles R. Mago (SEAL) 4a )gey "o /%'//Q d (SEAL) • fancy E. Magoon AUTHENTICATION ACKNOWLEDGMENT Si- ,nature(s) STATE OF WISCONSIN St Croix ss. ~ ---------------.County. authenticated this ........day of 19.....- Personally came before me this 27th-day of Feb...................... 19.84... the above named . ..Charle-- R. Magoon and Nancy E. Magoon. TITLE: NIENIBER STATE BAR OF WISCONSIN . (If not _ authorized by • 706.04), , Wi s. Stats.) to me known to be the per=ol8_ _ . . _ . who executed the foregoing instrurAient and acknovle l t' e sa re. T-- i INSTRUM.ENT WAS DRAFTED BY John D Walsh John D Walsh • 1~ (1 .••'~M•~•••••. 'y~~'•. St Croix •urP(~ ~'AR r Note Public tSier.:rt;rr; ,+:ry he aut.enticat d or a, .nm!od c.!. [loth ~T r'nme+u<.inn is nermancnt.llf r.ot.~t t~ ez p:r:> on are not date: Dec. 15 X41) i UBLIC 4nin~ rn n::: A..r~r.y I 1 R'ARn1Y-Y DF:FD .,T,\CF. FlAn OF R"I:CC)Y61V N r. f•¢+I ~~DI84y15'0~, STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 6;',e_r L J E ~~ntfi~c Cc~d...r ROUTE/BOX NUMBER Il q l l7 q r± A u e- FIRE NO. X 91 CITY/STATE 11N.Q~L0 RaWt)nC4 Ct~~S• ZIP 6400 PROPERTY LOCATION: &E1/4 -p, 1/4, Section , T 30N, R W, Town of RIC-llyrr'3 , St. Croix County, Subdivision 12r oc s , Lot No.----s '01b 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 $3000 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 systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master 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. Certification form will be sent approximately 30 days prior to three year expiration. 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 Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED i' DATE © -7 -C):Z -`t St. Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 (715) 796-2239 or (715) 425-8363 Sign, Date, and Return to above address i 6t Co C'~Y, 17y=`4~e; ;tip- 3~ /L,~w;J ~/~Ol~ C~~ ~ j Rlch m 6hd sy0/7 ! I 17 1 t i a4 n-. Mw,A £ 1 (z i N of 6Y~~. I t , 1 I 1 ~ YVI I ' , r p r , r I ! i I ~ ~ i I i I 1 I I ! I I I I ' ; I ' ' ~ ! ' I , i r , , r r ~ , Co C\ PAGE OF ,Y~ 7e A'- roSC, SeeJlun o~ A 16e-f) SY44ce , S sew, Fresh Air Inle/s And Observation Pipe J Approved Vent Cap Minimum 12* Above Final Grade 20- 42" Above Pipe _ 4' Cost Iron To Final Grad• Vent PIP* Marsh Hoy Or Synthetic covering min. 2e Aggregate . Over Pipe__ Oletrlbullon - Te• Pipe o 0 0 0 6e Aggregate o Perlaebd Pipe Below Beneath Pip e o - CO%Ving Terminating At Bottom Of System 171, 9 p -5 roPoSeDi~tnkl LICJJ tGr1 - 20"I'&v SOIL. FILL D1STt'cIBUTI0L1 PIPE APPROVED g4►dPETIC COVER PIATF. OR R MRASH HAy'/OF STRAW OFA6GREGA?E O e e e ~ OF12-p AGGREGATE ELEV. OF 9S FEET ~ b. DISTFL15UTION PIPE TO BE AT LEAST INCHES BELOW ORIGIMAL GRADE AIJU AT LEAST LO IIJCHES BUT 1.10 MORE THAI) 42 IAICNES BELOW FINIAL GRADE 1' MIMUM DEPTH OF F-YeaVAT100 FROM OPI&#JA L 69ADR WILL BE ~S IKIC14ES 111KIMUM 9er" OFEACAVAnow FROM. 01KI(AWAlL GRAPE WILL BE oZD INCHES SIGIJEO: LICEMSE DUMBER: DATE: t! Laio and 1-luman Department Relations Industry, Labor r and SOIL AND SITE EVALUATION REPORT Paga of, 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 .5f~ C fro t K 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 P OPERTY OWNER: PROPERTY LOCATION C p GOVT. LOT fir 1/4 5& 1/4,S T N,R $or) W PRO~ERTY OW ER':S MAID ADD ESS LOT # BLOCK # SUBD. NAME OR CSM # ITY, ST E ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE (TOWN NEAREST ROAD Y11 O'n tr~ W o f (7/57 - 510 71 R, J,,-,,,..d M New Construction Use (~Q Residential / Number of bedrooms .3 [ ] Addition to existing building Y~ Replacement [ ] Public or commercial describe Code derived daily flow 15b gpd Recommended design loading rate 7 bed, gpd/ft2 • trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate #7 bed, gpd/ft2 • trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / site considerations Parent material (n LL* Lo C"b~~ Flood plain elevation, if applicable ft FuTunis able for system CQNVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING T ,ANK uitablefors stem S❑ U N s 13 U S❑ U ❑ S 14U ❑ S 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 Trench 4 ..:.w., Z o-al J,6 1? s s shK Cw A^ , S- ,L Ground 14 R 5 S m r V CL"') elev. ft. Depth to limiting factor -k-~ Remarks: Boring # 7 " O Ground M C Lo elev. ~5 ~ ft. Depth to limiting factour4 1__F Remarks: CST Name:-Please Print Phone: r 7 / .S- - S/G -5/ Address: ! ~S ~ fitlt Syb / ~ Signature: Date: CST Number: 7- & -9 CERTIFICATION STATEMENT n FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the residence located at: ) 1/4,_ S~ 1/4, Sec._T30 N, R_,~S W, Town of letCAN VV'_ J Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced Mc%rc,, 19 93 Did flow back occur from absorption system? Yes_No (if no, skip next line) Approximate volume or length of time: Sun gallons /e minutes Capacity: X Construction: Prefab Concrete Steel Other Manufacurer (if known) : ~4pjq S 6a+,,._~ P,no, Age of Tank (if know y rS A.: (2, C"'_ I 'j " '0 . V, (Signatur ) (Name) Please Print (Title) (L se Number) -G- 7_2 (Date) Form to be completed by licensed plumber (x.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR-83, Wis. Adm. Code (except for inspection opening over outlet baffle) Name • 1vl h PA &wrs SV-.- Signature . ilW/MPRS /SZ 3 5/88