HomeMy WebLinkAbout026-1076-95-300
AS BUILT SANITARY SYSTEM REPORT
OWNER ~/i TOWNSHIP
SECTION ~G T~_~N-fR1Z W
ADDRESS N ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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BENCHMARK:Elevation and description:
Alternate benchmark ~az7z
SEPTIC TANK :Manufacturer: Liquid cap. 11,12~
Rings used: Manhole cover elev:'QQ_Final grade elev: 915--
Tank inlet elev.: Tank outlet elev.: R9,11<`
No. of feet from nearest road:Front , Side,, Rear Ft./„7~?
From nearest prop. line:Front , Side, Rear Ft. _
No. of feet from: Well , Building: (Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
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PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufact.: Pump Size
Elevation of inlet: Bottom of tank elevation
Pump on elev.: Pump off elev.: Gallons/cycle:
Alarm: Man.: Switch Type: Location
Distance from nearest prop. line: Front-, Side_, Rear_Ft.
Distance from: Well Building
SOIL ABSORPTION SYSTEM
Bed: X Trench: Seepage Pit:
L-Length Number of Lines:-,z-2 Area Built-4&
Width:
Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth to top of pipe:
No. feet from nearest prop. line:Front , Side-, Rear Ft.Z--,"*
No. feet from well:_,,~)O/_No. feet from building
HOLDING TANK
Manufacturer: Capacity:
No. of rings used: Elevation of bottom tank:
Elevation of inlet:
No. feet from nearest prop. line:Front , Side Rear Ft.
No. feet from: Well , building , nearest road
Alarm Manufacturer:
INSPECTOR:
DATE: PLUMBER ON JOB:
LICENSE NUMBER:--X2S-Cl
6/90:cj
LL) ~ ert ns 26.30.18 PRNAfNEWAGE S61 11 YSTEM 130TH county:
Labor and Human Relations INSPECTION REPORT
Safety and F3uildiFlgs Division ST. CRCIIX
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 193353
Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.:
THOMA5 RICHMOND 0,)* -/07 - 1~S a0U
B E ev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9300013
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic f~ Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet
Air
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand ` B,d 2 90.74
Model Number GPM
TDH Lift Friction Syestem TDH Ft
Forcemain Length Dia. FFii Dist. To Well
SOIL ABSORPTION SYSTEM
BED / TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia.
DIMENSIONS S~ DIMENSIONS
SETBACK Liquid Depth
SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHING Manufacturer: INFORMATION TypeO yju,) CHAMBER Model Number:
System: / ~7ti1 OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To A+rtn'ta e
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 Bed /Trench Edges Topsoil El Yes E] No ❑ Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: RICHMOND 26.30.18, SW,SW, HWY. 65 AND 130TH
r
Plan revision required? ❑ Yes [A No ,
Use other side for additional information.
SBD-6710 (R 05/91) Date F Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: 4
SANITARY PERMIT APPLICATION
DILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than E] /Q
8% x 11 inches in size. C .c if lJnrVre ous 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
'/4 / '/a, T , N, R (or
PROPERTY OWNER' MAILING ADDR SS LOT # BLOCK #
STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
IL TYPE OF BUILDING: (Check one) ❑ State Owned 13 VILLLLAGE NEA ` ST ROAD - -
a X ZQWW OF: 2L~,Wo ❑ Public g 1 or 2 Fam. Dwelling-# of bedrooms A L Ax N B ( )
i l-07 6_- ~w~c,
Ill. BUILDING USE: (If building type is public, check all that
1 ❑ Apt/Condo apply) c~~ 20 Assembly Hall 60 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. 141 New 2. ❑ Replacement 3. ❑ Replacement of 4.E] 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
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Mi ./inch) ELEVATION
Feet 9,2 Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New lExistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Se tic Tank or Hold in Tank -S I El
Lift Pump Tank/Siphon Chamber
Vlll. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installat' n of the onsite sewage system shown on the attached plans.
Plumb 's Name (Pript): Plumbe s natu ) MP/MPRSW No.: Business Phone Number:
-
lum kers Ad ess (Street, City, State, Zip Code): 1
le 11j1
IX. COUNTY/DEPARTMENT USE ONLY
Groundwater a e IsAuedl Is ing Agent Signature (No Sta s)
❑ Disapproved S nitary Permit Fee (Includes Surcharge Fee)
Approved Owner Given Initial Adverse Determination
YA
. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-8398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s 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 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 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; close 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)
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ELEV. OFEZ~, FELT b4` P. .'a, AGGRCGATC
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DATE: y~
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of
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
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 LOCATION
GOVT. LOT 5 1/45 1/4,S ZT_?o N,R , J(or&
PROPERTY OWNE .S MAILING DRESS LOT BLO # SUBD. AME OR CSM #
~-2 A) A
CITY STATE ZIP CODE PHONE NUMBER ❑CITY~PVILLAGE ®rOWN NEAREST ROAD
(,//S-) ~Gy ty
New Construction Use Residential / Number of bedrooms Addition to existing building
k(1 ~ [ 1 j ] Replacement ] Public or commercial describe
Code derived daily flow gpd Recommended design loading rate bed, gpd$ S trench, gpd1ft2
Absorption area required W- bed, ft2 SZ s' trench, ft2 Maximum design loading rate -,-~bed, gpd/ft2_,_,y _trench, gpd/ft2
Recommended infiltration surface elevation(s) R 7, l ft (as referred to site plan benchmark)
Additional design / site consi erations
Parent material ? _ Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U=Unsuitable fors stem EIS ❑U 0S ❑U ]4S ❑U 10S ❑U ❑S ®U ❑S ®U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bound3y Roots GPD/ft
in. Munsell Qu. S Cont. Color Gr. Sz. Sh. Bed Trench
Ground _
291 Ao
elev.
ft.
Depth to
limiting
factor
'-99
Remarks:
Boring #
-S-11"
ti.><
zf, 36 n
Ground••t' ~ s
~
elev.
ZQ ye 'Z
ft.
Depth to
limiting
factor
Remarks:
CST Name:-Please Print _ Phone:
Address:
Signature: Date: CST tuber.
PROPERTY OWNER Z~ -sN SOIL DESCRIPTION REPORT Page of
PARCEL I.D. # .
Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon in. Munsell Qu. Sz. nt. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench
e-1 -/,2 AQ Ye- VJ
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
- ~fn w '14 t~ -7
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
414 Ir '7
Ground
elev.
ft.
Depth to
limiting
fact
Remarks:
Boring #
Li4
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER_
ADDRESS
FIRE NUMBER
CITY/STATE I v \ (CA myn O L41 l t ZIP_ - 1/ 7
PROPERTY LOCATION:, 1/4,Sw 1/4, SECTION-L-, T,2(-) N-R-Z?_W
TOWN OF_ L 171 0 / 1 U , St. Croix County,
SUBDIVISION , LOT NUMBER
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/[le, 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:,
9
St. Croix co. Zoning Office
9,11 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 f' IC Rol- W
Location of, property 1/4 W 1/4, Section T~n N-R 4 W
LL
Township I C ~ h't O 27 4
Mailing address 1 * 6D V ~p ) FAu) »7y n Imz
Sjo 12
Address of site
subdivision name Lot no.
Other homes on property? yes__ x No
Previous owner of property
Total size of parcel
Date parcel -was created
'Are all corners and lot lines identifiable? __X__Yes No
Is this property being developed for (spec house)?,Yes No
Volume and, Page Number `.,LZL 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
No. t L County Register of
Deeds as Document ,T 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-applicant
.3
2- I
Date of Signature Date of Signature
i
• ',~ocuMENT No. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
STATE B4 L-OF §J,)NSIbFORM 2-1082
494795 'roe 4,0PAGE
_ _ - REGISTER'S OFFU
~I Marvin L. Utecht and Debra J. Utecht, ST. CROIX CO., W)
husband *mid-wife Recd for Record ,
FEB 5 1993
conveys and warrants to .......TbOnl a.E...KYxaYltl at /oI~I,~/a~,.~~p•~ M~
Register of Deeds
i ~
I;
.i RETURN TO
i
the following described real estate in St Cr09.X .County,
State of Wisconsin:
Tax Parcel
j; S 1/2 of SW 1/4 of Section 26, Township 30 North, Range 18 West, St. Croix
County, Wisconsin EXCEPT Lots 1 and 2 of Certified Survey Map in Vol. "9",
j Page 2486, Doc. No. 484017 and EXCEPT Lot 3 of Certified Survey Map in Vol.
11911 , Page 2569, Doc. No. 492313.
I
I'RANSFEls
li ~200
f~ .
.i
This ...-_..iB.riQb......... homestead property.
i; (is) (is not)
Exception to warranties: easements, restrictions and rights-of-way of record, if any.
..........February...................-......---............, 1x.93...
Dated this day of
:I
. .
f~.../ -.....(„~'~>/~~~7~'!./• ( ) (SEAL)
I~ti`1•4.... SEAL
Marvin..L.....Utecht Debra J. cht
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
I
Signature(s) STATE OF WISCONSIN
SS.
_ St. Croix .County.
authenticated this ........day of .119 - - -P rsonally came -before me this ........day of
ebriaar1993.... the above named
-Y .
+ ........Nfai..viri.D:..~tecrit.3.. Debra....DtecYit.....
TITLE: MEMBER STATE BAR OF WISCONSIN
~i -
(If not,
II authorized by § 706.06, Wis. Stats.) to me known to be the person S noledge who executed the
f g ' g instru and ack the same.
TMIS INSTRUMENT WAS pRAFTED BY
Kris ina . a , Alice Joy rs
_
Attorney at Law .
St Croix . .
i~ Notary Public county, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanegUI& ft .,Cftnajj~iration
are not necessary.) Jul 12 ~3
i j date : -Y ...........Notarypybfip )
Stat,~_of Wisconsin
*Names of persons signing in any capacity should be typed or printed below their signatures.