HomeMy WebLinkAbout026-1025-10-100
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER DAVID & E c k N o,-Fe1?
ADDRESS
SUBDIVISION / CSM#LOT #
SECTION__7 T~2N-R_t_E_W, Town of 1\1CJ}/"lil~t/"~
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
7a T~ E
_ 14 vcrs F
i
~~r~ CGS
Avo ir[. Sir,
S X 7 S fRE~lc~~s
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: STE'L:___L R/ 45-
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING-TANK INFORMATION
Manufacturer: iE/C'S Liquid Capacity: /®,00
Setback from: Well House Ave) Other
Pum acturer Model# Size
Float seperation e:
cation
-:SOIL ABSORPTION SYSTEM
Width: 6- Length 75' Number of trenches
Distance & Direction to nearest prop. line: 43 j Sc~u1-~
Setback from: well: House__,jjL5' Other
ELEVATIONS
Building Sewer ST Inlet; ST outlet ~ d
PC inlet AA PC bottom &A - Pump Off ZY A_
9 3, ~S~D
Header/Manifold 9'7, O 5o Bottom of system 14,00
Existing Grade Final grade
DATE OF INSTALLATION: ~-~3° 3
PLUMBER ON JOB:
LICENSE NUMBER: 302® S
INSPECTOR:
3/93:jt
IsA "i~ artrr ~ i~ 7-30-18 *IVWeR"V E SYSTEM County:
tabor ano Human Relations INSPECTION REPORT
Safety and Buildings Division ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No--.
19 496
Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.:
~Ffflpllv_: Insp. BM Elev.: BM Description: n Parcel Tax No.: o c)
6~0 026-102 50=000
TANK INFORMATION ELEVATION DATA A9300154 3
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
17. 0
l r
Dosi rur- n(.
Aeration Bldg. Sewer
Holding _ St/ Inlet
TANK SETBACK INFORMATION St/ Outlet A/. 03
Veritto
TANK TO P/ L WELL BLDG. Air Intake ROAD Dt Inlet
Septic >/Car :4,, J ' NA Dt Bottom
i
Dosing NA Header/4 aca'?✓ ~o, 33 ?
?,G_
Aeration A Dist. Pipe 96'~ GU
Holding Bot. System x-
t 9~`b ~y33
PUMP/ SIPHON INFORMATION feral Fade
Manufacturer Demand
Model m er GPM
TDH Lift Friction etem TDH Ft
Forcemain Length Did. Dist. To Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ` DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/ STREAM 'LEA CHING Manu acturer:
SETBACK CHAM11EjR
INFORMATION Type O M Number.
System: _ r; t ilk ~~S 7 OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold i/ Distribution Pipe(s) x Hole Size x Hole Spacing nt To Air Intake
i
Length ~ Dia. ~ Length Dia. Sparing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Syst s my
Depth Over Depth Over xx Depth Of xx ded / Sodded xx Mulched
~ed-1Trench Center B&6/ Trench Edges Topsoil ❑ Yes C] No s
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: RICHMOND 7/.30.18.91 (170TH AVENUE)
tyaJLlti•,.`~%'7 Ic rfC!",,.~ .
Plan revision required? ❑ Yes to q
Use other side for additional information. / R3
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH '
SANITARY PERMIT NUMBER:
DfLH SANITARY PERMIT APPLICATION
R In accord with ILHR 83.05, Wis. Adm. Code coS/ .
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than d3
8% X 11 inches in size. ❑ Chec/k 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
i2ALILD - - j5: S T..30,N,R /49 SM W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
rH 5
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
) NEAREST ROAD
II. TYPE OF BUILDING: Check one CITY
( ❑ State Owned O
pa =NQ VILLAGE y,q
❑ Public rV"OX1 or 2 Fam. Dwellin" of bedrooms -.31 PARCEL TNUMBER(S)L C-)
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 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 M 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
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 93r y~ ELEVATION 9.0
SQ . , s Feet ,7 . U Feet
CAPACITY
VII. TANK Site
in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New Plating Gallons Tanks Concrete structed glass App'
Tanks Tanks
Septic Tank or Holdin Tank
Lift Pump Tank/Si hon Chamber M F-1 I El L-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): Plu 's Signature: (No Stam M MP Business Phone Number:
lumbeerr's Address (Street, City, State, Zip Cod : I)AL/ &L 5a f L!~' 5Z L_ 7
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sa ary Permit Fee (Includes Groundwater Date Issue Issuing ent Si a NO Sta
pproved ❑ Owner Given initial Surcharge Fee) ~7
Adverse Determination
X. ~CONDITI~F APPROVAL/REASONS FOR DISAPPRO„
SBD-6398 (formerly Pib-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.
Ill. 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 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.
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k W.sconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 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 St. Croix
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.
REV WED BY DATE '
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION
c I
PROPERTY OWNER: PROPERTY LOCATION
-David K.ieckhoefer GOVT. LOT IT, 1/4 T-W 1/4,S 7 T 30 N,R 18 )E (or) W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLgqCCK # SUBD NAME OR CS
1626 95th. St. n/a n/a n/a
CITY, STATE z~P CODE P 0 N ❑CITY ❑VILLAGE MOWN NEAREST ROAD
PTew Richmond., VII. 54017 ( / 373 Richmond 170th. Ave.
New on Use M Residential / Number of bedrooms 3 [ ] Addition to ex~ uikting
#ieplacemenf [ ] Public or commercial describe
ode derived dail 450 gpd Recommended design loading rate • 5 bed, g;xW.16 trench, gpcw
Absorption area required n/a bed, ft2 750 trench, ft2 Maximum design loading rate -,5 bed, gpd/ft2 .6 trench, gpdtft2
Recommended infiltration surface elevation(s) 93.50-96.00 ft (as referred to site plan benchmark)
Additional design / site considerations step down trench system
Parent matefial - pitted otitwash Flood plain elevation, if applicable n/a ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable for s stem faS ❑ U )E S ❑ U Ghe ❑ U as ❑ U ❑ S laU ❑ S o+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
1 0-12 1 3/3 none L. 2/m/sbk mvfr c/w 2/f .5 .6
l
2 12-24 10yr4/4 none scl 1/f/sbk mfr g/w 1/f .2 .3
Ground 3 24-50 7.5yr4/4 none sl. 2/m/sbk mvfr g,/w n/a .5 .6
elev.
97.00 ft.
Depth to
limiting
/~factor
> 8011 Remarks:
Boring #
1 0-8 1 3/3 none L. 2/m/sbk mvfr c/w 2/f .5 .6
~.,2 2 8-18 7.5yr 4/4 none scl. 1/f/shk mfr g/w 1/f .2. .3
3 18-80 10yr4/6 none sl. 2/m/sbk mvfr P'/w n/a .-5 .6
Ground
elev.
97.2.0 ft.
Depth to
limiting
factor
>80"
Remarks:
CST Name. Please Print Gar L. steel Phone cp r
Address: f~ ~F
Signature:
6-30-93 Date: s ~C$T u
PROPERTYOWNER David K_ieckhoefe_r SOIL DESCRIPTION REPORT Page 2 !tf' 3
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tram
_ : gq
1 0-10 1 3/3 none L. 2/c/ P1 mfr c/w 2/f / n/
3
2 10-21 7.5yr4/4• none scl. 1/f/sbk mfr g/w 1/f .2 .3
Ground 3 21-65 7.5yr4/4 none sl. 2/m/sbk mvf_r g/w /a .5 .6
l
99.0ev. ft• 4 65-80 10yr4/6 none co.s. 0/sg m]_ na/ 1/a .7 .8
Depth to
limiting
factor
>8010
Remarks:
Boring #
J X ~~l ? v' i v\t' . v
I
Ground
elev.
ft.
Depth to
limiting
factor
E
Remarks:
Boring #
.
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
ati4
Y •iGround
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
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STEEL'S SOIL SERVICE ~.~~p0
15 54 20 *ve.
Gary L. Steel
C.S.T. 2298 Davir' Y,ieckhoef_er New Richmond, WI 54017
MPRSW-3254 NE-' ITV % S7-T30N-R181%T (715) 246-6200
toim of. Richrgond
17a~~ a70r
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kol- So 6-ow s
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Gary L. steel-
6-30-93
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER I r v roll f~ f P4Kh d F✓)
ROUTE/BOX NUMBER FIRE NO. /b dP
CITY/STATE / L4UJ IC'c14 V "C-L, at wl . ZIP S Lf017
PROPERTY LOCATION: 44:E 1/4 IU W 1/4, Section T 30 N, R LOl W,
Town of Ain, St. Croix County,
Subdivision , Lot No.
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.Cr x County Zoning Office within
30 days of the three year expiration date.
9
SIGNED
DATE
St. Croix County Zoning Office
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016
(715) 386-4680
Sign, Date, and Return to above address
STC-100
This application form is to be completed in full and signed by
the owner(s) of the property being developed. An inadequacies
y 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 _Z //"P,2 r (d K,cc_ K~ a elee✓)
Location of, property AUE 1/4 [)01,1/4 , Section T 30 N-R~_W
Township
44,
Mailing address IS 1r~✓ " L(I e7T~ CZ W- y. I
Address of site .704,f- Ale w c-4 lfi c-n &J'I: T -~01-7
Subdivision name Lot no.
Other homes on property? yes No
Previous owner of property S,gi*e
Total size of parcel 4/0 61cvej
Date parcel-was created
Are all corners and lot lines identifiable? V" Yes No
Is this property being developed for (spec house)? Yes ✓No
Volume 6/6 and. Page Number 6-3 7 as recorded with the Register I
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 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
- el
Si nature of ap icant Co-applicant
76 A3
Date o S gnature Date of Signature
OoKAISdaT NO. sTATZ LIAR OF trIsCONSIN-FORIt l
OUIT CLAIM DUO
YOL 616 PUE09 1"16 VACC atscRVto too RICORDINO OATA
3b tm
R~'CriS7:RS OFFICE
Albert r. Kieckhoefor and Bernice M. Kieckhoefer, ST, C',ix CO., W:5. -
us an anndwt*as - each in t e r owf~ndivid- ivr °xord this 30•
ua capac ti y
pa<le~ te~4.11~II9__H~111iPa~;SCE-~1~_~4(i:3~4a111II. day o{_ apt • A.O. 19 P
rvaration anv interest thev may haye<and of 8:30 A M.
stafteirigaill-tha-li ff~BUD=t aareemPnr inn- e
--e'inad In ha art in_.ed`.betweei the
Yiaekhe~ fer*ee 910«d,
1,ra_ trlri hared! a_ ~ ('ssrald A_
tMfdiswin{ dsrteribed real eatMe is -.St[`rnite County.
eLece..in: oarUI1N m g
dab of
US Bey No. wompt 77.25(13)
The East Half of the Northwest Quarter (Elf of NWIt) and the Southwest
Quarter (SW4), ALL of Section Seven (7), Township Thirty (30) North,
Range Eighteen.(18) West.
j
***and Rita M. Kieckhoefer, husband and wife as joint tenants, dated
February 25, 1966, recorded March 3, 1966, at 9:00 a.m., in Volume
14211, page 290, as Document No. 283564.
FEE
E firiP?
°i
This is not^ homestead prooerty.
(is) (is not) 41
Dated this - day of --Sentember 19&(L.
ktj -,(SEAL) (SEAL)
Albert F. Kieckhoeter
(SEAL) (SEAL)
+r
aernice M. Kieckhoefet
AUTHENTICATION/y( ACKNOWLEDGMENT
Signatures authenticated this_.-L.__day of STATE OF WISCONSIN ( i
Se 19 ss.
tY
Q County.
3 (,C.C ( W ~~t((-C.__ Personally came before me, this day of
. Hendrik W. Van Dyk the above named
TITLE: MEMBER STATE BAR OF WISCONSIN
y avthorYZet!-byr47t1~2tT-:'1s-3tz+ts7 -
This instrument was drafted by _
to me known to be the person who executed the fore-
Rei natra, Van E4tk E. Needham, S. C. going instrument and acknowledged the same.
Attorneys at Law
Near-8 i.chm^ 54017
(Signatures may be authenticated or acknowledged. Both Notary Public Count„ Wis.
are not necessary.) My Commission is permanent. (If not, state expiration
date: , 19_-)
' QUIT CLARA DaaD-STATa BAR OF WISCONSIN. FORM NO. 3-1911