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HomeMy WebLinkAbout030-1017-95-130 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER /~,C!/Z//2 AA Zd3'1 / P l~r f'J / ADDRESS 116,v b4 Srr~~ 611 SUBDIVISION / CSM# d'/ 2-2 LOT # SECTION T'Z'T N-R -Z~F W, Town of S~`, --✓o~ ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I I/ A..zG_ Zr - ~ T . IV, r =:r ~xi Sf ir?y lJ~l/ d Y a ttP ~ l INDICATE -NORTH A Provide setback and elevation information on reverse of this-form. Provide 2 dimensions to center of septic tank manhole cover. i BENCHMARK: 4 yYa~. r , /Ov --o ALTERNATE BM: QSEPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: lo-rx0 Setback from: Well House 'S~lo Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location :SOIL ABSORPTION SYSTEM Width: Length &f Number of trenches ,z Distance & Direction to nearest prop. line: Setback from: well House '1_3 Other ELEVATIONS Building Sewer ST Inlet. ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: 7- Z - f-3 PLUMBER ON JOB: r 77 "W0,A_ LICENSE NUMBER: INSPECTOR: 3/93:jt E County: WQ#T,X *;,trn,%Tt-of J9§s PH 05 . 29 . ~R1jA SEWA ~d5Y ING HILL Labor and Human Relations Safety and Bui,4dings Division INSPECTION REPORT (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 193424 Permit Holder's Name: ❑ City ❑ Village EkTown of: State Plan ID No.: PMMVrPT_T O EPH E ev . Insp. BM Elev.: BM Description: j Parcel Tax No.: % f , ~o~> Q C< 030-1017-95-130 TANK INFORMATION ELEVATION DATA A9300087 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ O Inlet %i le TANK SETBACK INFORMATION St/ Outlet TANK TO P/ L WELL BLDG. Airl to ,take ROAD Dt Inlet rl Septic >/'lr.' NA Dt Bottom Dosin NA Header/Man. 2-7 Aeration NA Dist. Pipe Holding Bot. System 91;. 0 PUMP/ SIPHON INFORMATION Final Grade / 7- Manufa Demand Model Number GPM TDH Lift Friction System H Ft oss Fie Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width I I Length _ No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN I N DIMENSIONS LEACHING Manufac er: SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM INFORMATION TypeO i? CHAMBER Model Number: OR UNIT System: ` > f~/ 7)~ DISTRIBUTION SYSTEM Header /ieW**feid Distribution Pipe(s) ! x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. T Spacing_ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over I,r Depth Ove ~ xx Depth Of xx Seeded /Sodded xx Mulched 9ei# /Trench Center - B; /TrencR'f'dges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: ST. JOSEPH 05.29.19.76A-30,SW,NE,ROLLING HILLS TRAIL,LOT h ,r 12 Plan revision required? ❑ Yes 021Vo' Use other side for additional information. M&M SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION COU Tay In accord with ILHR 83.05, Wis. Adm. Code 7UR03 LHA STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than El ~ 4 8% x 11 inches in size. Chet i rev s on to pfevious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPER OWNER PROPERTY LOCATION (~'/a - '/a, S T Z j, N, R `f (or PROPERTY OWNER' MAILING ADDRESS LOT # BLOCK # tq r "ti< .3 1 CITY, STATE ZIP CODE PHONE NUMBER SUBDI I ION NAME OR CSM NU NUMBER IL TYPE OF BUILDING: (Check one CITY N REST ROAD ❑ State Owned ❑ VILLAGE ❑ Public 01 or 2 Fam. Dwelling-# of bedrooms A EL TAX N 111. BUILDING USE: (If building type is public, check all that apply) )1 p 4 30 L :1~ 1 ❑ Apt/Condo 20 Assembly Hall 6 ❑ Medical Facility/Nursing Home 100 Outdoor Recreational Facility 30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 90 Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ~ New 2. El Replacement 3.E1 Replacement of 4. ❑ Reconnection of 5.E] 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 R 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~a /sq. ft.) (Min./inch) ELEVATION 964VOFeet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete strutted Con- Steel glass Plastic App Tanks Tanks Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plum er's Name (Print): Plumber's ignature: (No Stamp MP/MPRSWAQ.:~y Business Phone Number: Plumb 's Address (Street, ity, ja p Code): s 70 2 IX. COUNTY/DEPARTMENT USE ONLY ~J ❑ Disapproved Sanit ry Permit Fee (Includes Groundwater Lae ssue Issuing Agent Signature (No Stamps) Approved ❑ Owner Given initial surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: 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:sa-4itary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applica ;e. 3. All revisions to this permit must be approved by the pernfit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transf€-/Rep ewal Form (SBD 6399) to be subm7'ted to the county prior to installation. 5. Onsite sewage systems must be properiy maintained. The tank(s) must be purnpsd by a licenser} - 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: y 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. il. 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. Ab.-orption system information. Provide all information requesle. in #k1-7. VII ?ank information. Fii; in the capacity of v rf new and/or i st the total gallop,,, ~ rr,laar of tanks and - hanufacturer's name. lndicri, prefab or ~Jte consc,,:_.,GS7 and tank material C on-i f i arc: or all septic, pump/siphon and holding tanks 'rr this system. Check fix.oe imertal approval cniy yanks received experin-ic,ritai product approval from DILHR. Vill Hesponsibiiity statement. Installiwi plumper is to fill in nan ?icerse m nber wits appropr ate prefix (e.g. MP. etc address and phone number. Plumber must sign application form. IX. County/Department Use Only. X County/Department Use Only. Cornpiete plans and specifica,t or; not smaller than WX2 x 1 i!-cl t rnu!;t be ~subrnitted tc the Cunay. The plans r^:ust 'i~ciude aiiF- tollowing. plot pian, drao,,n to sc t'z complete d l c =tion of hoin ng tank(s), septic 'ank(--1 or c ,:her treatrriert tanks, vi , weks, w cei n s , . Eater service; streams and lakes pump or -.iph,! Tanks, distribution boxe< b:: , t,ticr! Fyst ins- i t) fnei-4 system areas: a,-,J the location of tl,e but `,rig served, B) ihorizontat cal :few~tior °aferenoi> tints C) complete specifications for pumps and controls; dose voi;ime, eievation differences; friction !oss; pump performance curve; pump model and pump manufaclurer; 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 num er of regulated practices which can effect grcundwa`.=r. The rTlomes cci'!acted through, iriu,3e sfir,charge5, '-Sef- f.?r rtJ;'i':Orit CSIo: vdwa°er, gro,ind- water contamination investigations and establistin-wi : of ;,tanllards SBD-6398 (R.11/88) TIMM EXCAVATING J08 r 2 Route 1 Box 192 SHEET NO. OF WILSON, WISCONSIN 54027 CALCULATED BY DATE f7 -f (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE . ii.rf......... . ! I - . . l~ g~.... 0 . . .-0 0 ._3 a s, ? . s: . - ;..6F..rt•9✓':L if~k...tg'Y d'. P.~✓. f ~YY . . j~Lt f (O t? a rr~~~ dX ~3 PRODUCT 205-1r" =L Inc., Groton, Mass. 01471; To Order PHONE TOLL FREE 1-800-225-6380 JOB /hhe2ah - TIMM EXCAVATING SHEET NO. T OF Route 1 Box 192 WILSON, WISCONSIN 54027 CALCULATED BY DATE ~3 (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE i i +i . . I A ! . _ 1~.... r t . ....N,... ...1 _ _ _ 1 ~ .r ~L PRODUCT 205-1 ~p Inc., Groton, Man. 01471. To Order PHONE TOLL FREE I-80225-M IJ1111:i111Y, 1 vl`! ut✓ro.. vats: r1.n..• • . IliVl;sits , Or fAt T•.mk-r`asT• -.~'7•C-S'!'^Y••••- 2. • • ••r•.••- AUUII AND 111MAM fiELA'f1UNS Pf ~ (ILIIR 83.08111 & a Chapter 1461 MADISON. Wi 3,'t) • f(i~i►~ IoN - , SEZ~i A29 TOWNS 1~ Pi IMMEN of o.: e . No.: u§'~"Ba~i'si6WAME: E SW NL 5 / T24 11/11 19r R for) W St. • Jose 1 3 in/a : n a F61jr•ITY: t1 NI?HT ULIYE€i'S"NAME: Ron "llloerules 1497 Cty. #E, Ihidson, Will 54016 M • DATES OBSERVATIONS MADE --1RS'BE61 W.? rMISCIALTfESLrltlv'1Taf7. IMMI[E'anefflirnim ntrarAl l7sal" E g j, Ilwalurts. 3 n/a F E&tw DReplaca 10-24-90 n/a IATING: Sw Silo suitable for atom Us 11he ulnullable for systrm !.t'bbvv 1 •"Nfib Kf i~iSCf iN"ct1ltAAdliNfti:SStjfI ITi•I~fii1~.M :RECOMMENDEDSYSTEM:1opdonoll S ~~U ©S DU .9s DU Ell N I D S ~U conventional - DESIGN RATi-- 11-Pvn:uluthm Tests ma NOT leyuired II auy portion of Ihr tested area h in the s,uthrr 11.1111 111u9(611b1, indicate: Clasa 2 Floodpialn, Indicate Floodplain alevation: n/a PROFILE DESCRIPTIONS page 49 JeB , decimal' 6()I114i3 CY AL A C NAME OF SOIL WTFFI-THICK , T XTURTA-ti UEP I _ TO 11E013(C USERVEp IEEE ABBRV.ON BACi<.1 - llMtlPfl )EP11. ELEVATION R. 1 7.25 101,00 none >7.25 .75bl.1. 2.50bn.ail. 4.00bn.l.s. R. 'L 7.24 99.90 none >7.24 .83b1.1. 1.58bn.sil. 4.83bn.l.a.&gr. 7.25 99.76 none >7.25 .58bl.1. 2.00bn.sil. 4.671)n.1.9.&gr. 0. 4 6.75 98.35 none >6.75 .50bl.1.1,331n.sil. 4.92bn.1.s.&gr. B. 5 7.00 99.80 none >7.08 .67bl.1. 2.33bn.ail. 4.08bn.1.s.&gr. 0- _ PERCOLATION TESTS OEPTII AT OLE TEST-TME 011OP IN WATER LEVEL-INCHES nATF iiiiiii,; 1,111MhE11 INCIIES : AFTEnSWELLINQ INTEnVAL•MIN. PG it iii-11 !=__s ~e des' gn ra ems! _ PLOT PLANT Show locations of percolation testa, soil borings end 1119 dimensions or suitable soil areas. Indicate scale or distances. Describe w6ut alit LIrr11e1 mui Vertical elevation reference points and show their location on ilia plot plan. Show the surface elevation at all bodnas and ilia diracsk.n um+ ' ul land slupa. r SYSTEM ELEVATION 96.90 Pr 100 ;iA tti hil 6 ~z o.r I , I i 90s i I `.e y 8.3 ( of y~1 I I - 1.11 1 w snalenianod, hereby certify that the Of tats reported on this torm ware made by me in accord with ilia procedures and methods specllled In ilia wis Administrative Code, and that list date recorded and 1114 location of Ilia tests are cortect to ilia best of my knowledge and belief. A 91pr nt : .1 TESTS WERE COUPLE-TED ON: Gory I.. Steel 10-24-90 . b111it9 1 CERTIFICATION NUMBER: Pfl N JUE n, 1554 20001. Ave., New Riclunond-Wi. 54017 2298 !1. 6MI~-61111 CST TUR DISi I11BUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. ult IIII Sou 9398 in. 101831 OVER - i S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER_ ADDRESS_ 7•~/ /3'iv,0 i// FIRE NUMBER CITY/STATE- PROPERTY LOCATION: 5A-/ 1/4 ,1/4, SECTION : , T~N-R- Z9 W TOWN OF 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/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: . S I 'S DATE: St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 STC-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 (s ec house), thenla 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 Kenneth F And Irene C Zon Location of'property_&~L,_1/4 NE _1/4, Section 5 T 29 N-R 19 W Township _ ST Joseph Mailing address _ 1164 Rolling: Hills Trail 751 H San Hill Point North. Hudson WI 54016 Address of site 1-164 Rolling Hi11s Trail Hudson WL 54016 Subdivision name C5 Us -3 .4 zzg7 Lot no. 3 Other homes on property? yes X No Previous owner of property Mark add Deidra Williamson Total size of parcel 3.59 acres Date parcel-was created Xl6Y 11-26-90 'Are all corners and lot lines identifiable? _xYes No Is this property being developed for (spec house)? Yes X No volume /D6$ and. Page Number 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. </C E'9, 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, f`or the construction of said system, and the same has been duly recorded i the office of County Register of deeds as Document No. ignature applicant Date of Signature Date of Signature I 'I DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING D~ ` ! STATE BAR OF WISCONSIN FORM 2-1982 I' 49898 s VO 1008PAGE 585 . REGISTER'S OFFICE MARK A. WILLIAMSON and DEIDRE N. WILLIAMSON, husband i ST. CROIX CO. WI and wife, Grantors i Recd for Record . ~ MAY 131993 conveys and warrants to ..KENNETH F. ZON and IRENE "ON of 11:10 A.M GraBtees....................... Can l~ Register of Deeds j RETURN TO ! the following described real estate in St........ CroiX County, State of Wisconsin: ^ 3V \C\ aq. Part of SW's 'of NE4, Section 5, Township 29 North, Range as follows: Lot 3 of Certified Survey Map filed December 0 Volume 8, Page 2297. TOGETHER WITH and SUBJECT TO reservations, restrictions, easements and rights-of-way of record, if any. . FElki This is not . . . . . . . . homestead property. . (ig) (is not) Exception to warranties: , 19...93.. Dated this 12th. day of .May . •---...(SEAL) ..Gl. (SEAL) MARK A. WILLIAMSON (SEAL).... ......-(SEAL) _ DEIDRE_N,..-WILLIAMSON AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN SS. St. Croix authenticated this day of 19...... Personally came before me this --12th day of May 19----93 the above name,i - Mark A. Williamson and - TITLE: MEMBER STATE BAR OF WISCONSIN DeidrE N. Williamson - (If not, authorized by § 706.06, Wis. Stats.) to m know be the persors------------ who executed the for going t ument and acknow same. THIS INSTRUMENT WAS DRAFTED BY ,II - - - - - - - Attoe Barry C. Lundeen M RGrn$~cPOa'TLR&eet, Hudson,C T mars K. Herbst WI 54016 x - Wis. - .County, Notary Public _..._t.......... - (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) 12-17-95 date: . 19. ,Names of persona signing in any capacity should be typed or printed below Choir signaturej. lV fCrnp; S1*; wise nn sin I rgnl (Z I,I 4: r1„ ~ ~ -AnTl4NTV 77IT7FT) CTAT•r PAR OF