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HomeMy WebLinkAbout030-2091-60-000 4. p v ° 3: C; o 0 to a v 0 4 0 ~ I ~ I N w .O.I CT L N H 01 - a O O C C C ~ C co O E f6 p O O. i N CD 0 w U Y I O C C z 0.0 {L C C O N O N .O N N Q w h ' II 3 co (D m z E z = o L z `m m ° N a m F- U) O O Z Zt c d Z d' ! O ~ O m F- r O N z c E a O Q- o N 0 ~ w U) L ~r c O 0 0 Q z ~ z z° I E O ~ - N A I U) U) L d o a w Y c -j 2 m o w O C a a E - (0 co H F H 3 cLi w CL U) o z •rv o m m a a w ' Cl) Cl) i :1 O w 2 rn rn 0 in J U- rn rn z r- 'a n. 00 Cl) H f- O O 6) O O O O O O N N O O 7 0] d w N O N r d iy Q O o1 y O c N c2 3 y c 0 O a o o i ° o (0 o c °o a) °0 0 L ° n L O w Y 'B N_ _ N N_ C:L C ° o o E v o 0 rn N C) (6 i~l O M N M N N c0 U O N U) J O N z (O I' iw O ~ v w;# M da w CL Z 2 a) wV ~ E 0 c ~ A v a 0 in 0 ..=+jO .rte ~A K AS BUILT SANITARY SYSTEM REPORT OWNER_ 0f` r t/ .Z e w 1f4/1- TOWNSHIP S'7- To s-d!0 SECTION T N-R_W ADDRESS S'~, ST. CROIX COUNTY, WISCONSIN SUBDIVISION .css 4,z fl-e- Syt~Tfi LOT_aLOT SIZE ;7, ,S PLAN.VIEW SHOW EVERYTHING.WITHIN 100 FEET OF SYSTEM m© a t 01 x /`cfG~6 ON 76r' Qp~ 'V Ccs„ bc, ~o e ? i li INDICATE N+ TH ARROW BENCHMARK: Elevation and description: See. a s i~ 5 Alternate benchmark SEPTIC TANK: Manufacturer:_-modlJVzddeP77- Liquid Cap. 16 3 Rings used: Manhole cover elev: Final grade elev: Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front , Sides, Rear Ft. 0 From nearest prop. line:Front , Side'x", Rear Ft. /?rdy- No. of feet from: Well Building: 9,"' (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE t PUMP CHAMBER Manufacturer: AgVOeS7- Liquid capacity: 7Gd 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. 4 Distance from: Well 1 Building SOIL ABSORPTION SYSTEM Bed: Trench: Seepage Pit: Width:- Length ~S Number of Lines:_,-.Z__Area Built Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top of pipe: No. feet from nearest prop. line:FrontX, Side , Rear Ft.?Qf No. feet from well: MDyl- 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 : © Y7 PLUMBER ON JOB : /.d ` /7k.~ y LICENSE NUMBER: 6/90:cj I I I I WC4y,T, ~.;t ATtUfIhTQ4 PH. 26.30.ORIVA)VMAt7ETMM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: 193492 Permit Holder's Name: ❑ City ❑ Village ❑XTown of: State Plan ID No.: F MK T. nTR ST. JOSEPH T BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 030-2091-60-000 TANK INFORMATION ELEVATION DATA A9300151 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Vent TANKTO P/L WELL BLDG. A irIto ntake ROAD Dt Inlet Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. Fi 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 LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER Model Number: System: 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 xx Depth Of xx Seeded / Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes El No El Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: ST. JOSEPH.26.30.19 (AWATUKEE TRAIL) Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: • SANITARY PERMIT APPLICATION 'bILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY 5,,, , STATES ~1N RYR IT# -Attach complete plans (to the county copy only) for the system, on paper not less than 2htdavious; 8% x 11 inches in size. ❑ Check if revisiapplication -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 j '/a %4, S T3®, N, R ZjP E (or) V0 PROPERTY OWNER'S MAILI G ADDRESS LOT # BLOCK # r e _r. I CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) ❑ State Owned VILLAGE - g-## of bedrooms PARCEL TAX 4012 09: ❑Public 1 or 2 Fam. Dwellin B NUMB Ill. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo V 20 Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 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. ® New 2.E] 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 420 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/scyft.) (Min./inch) qS1 20 F 7AIION /_/S_0 2S 2 S" ._4jr h C p. ,3d 2 .,~d Feet Q J ION CAPACITY VII. TANK Site in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New lExisting Gallons Tanks Concrete glass App. Tanks Tanks structed Septic Tank or Holdin Tank e Lift Pump Tank/Siphon- Chamber VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system show on the attached plans. Plumber's Name (Print): k Plumber's Signature: (No Stamps) PRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code : IX.19 COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanits Permit Fee (ISurchagerFeej Water Date ue MMignature ( Stam ) }mw Approved El Owner Given Initial 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 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 systern 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'f 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 .reatment tanks; b0din 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 a;,d vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; fri-tion 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 for a alum > r of regulated practices which can effect groundwater. The monies collected through these surcharges are used for r ii)nitoring groundwater, gi ourid'water contamination investigations and establishment of standards. SBD-6398 (R.11/88) r 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 ~n 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 Location of* propert}~ ~k1/4 Alk,~ 1/4, Section TLg±_N-R1,0~W Township Mailing address ~6- Address of site ye_c _22,t ',C Subdivision name Lot no. Other homes on property? yes__ A- No Previous owner of property F`G~ Total ,size of parcel a2y- ~,5a Date parcel-was created 'Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? YesNo Volume _and,Page Number aZ 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. , 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 -n _the office of County Register of deeds as Document N o . ~ l~e.`~cY ture of pp ant Co-applicant L) Date of Signatu a Date of Signature DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVED FOR RECORDING DATA gWARRANTY DEED REGISTER'S OFFICE b ST. CROIX CO., Wf ~ 3 Rec'd for Record Richard O Stout and Janet P .Stout, JUL 1' 1993 husband and wife survivorship marital property, at V8:00 a:M conveys and warrants to Dirk W. Leemkuil and Helen Registerof0eeds M Leemkuil, husband and wife, RETURN TO the following described real estate in St. Croix County, I State of Wisconsin: Tax Parcel No: er ef Lot 6, Plat of Bass Lake South, Town of St. Joseph. This is not homestead property. (is) (is not) Exception to Warranties: easements, restrictions and rights-of-way of record, if any. Dated this _ os ~l day of June '19 93 . (SEAL) (SEAL) Richard 0 Stouts by Janet P. Stout Kernon Bast P.O.A. (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN SS. St. Croix County. i-, authenticated this day of 19 Personally came before me this day of June .19 93 the above named Richard 0 Stout and Janet P. Stout 2nd Kernnn Bast, P.O.A. TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the person s who executed the authorized by § 706.06, Wis. Stats.) foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS D FTED BY Janet P. tout lice J 1353 w-Itu!~Ce rat r iC Hu.'su 1'1 );016 Notary Public iSCO ounty, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary) date: 19.) ' Names of persons signing in any capacity should be typed or printed below their signatures SB2 NTF 0021 WARRANTY DEED STATE BAR OF WISCONSIN Nelco Tax Forms, P.O. Box 10208, Green Bay, WI 54307-0208 Form No.2 - 1982 S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER. ,l~,FrY 1 ADDRESS %1' ,,,,t,1' Z41. FIRE NUMBER CITY/STATE.. ZIP PROPERTY LOCATION ::5~) 1/4 , 10,~) 1/4 1 SECTION a?6' , T.30 N-R_ ~t' W TOWN OF _7.1f'It-A-' , St. Croix County, SUBDIVISION__ /..7.4e •$Q &;71 , 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 te. 1 Y SIGNED: DATE: ~ of-4c- -2_ )CI CA St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 6, C6 L- -Q f `Vc DEPARTMENT OF RPORT ON SOIL BORINGS AND SAFETY & BUILDINGS ,INDUSTRY, DIVISION I.ABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 53707 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/fib : LOT NO.: BLK. NO.: SUBDIVISION NAME: 1914 14111/4 26 /T 30N/R19Lor)W St. Joseph 6 n/a Bass La?ce South WNr"_ COUNTY: OWNER'S ~IAME: MAILING ADDRESS: St. Croix richard Stout 11353 Awatd-cee Trl, Hudson, Wi.54016 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DES R PT ONS: ER LAT ON TESTS: I3~Residence 3 n/a clew ❑Replace 4-23-92 n/a RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) S U 1:1 S ®U 0S U S H U ❑ S EA conventional split level. trench If Percolation Tests are NOT required DESIGN RATE: I under s.H63.09(5)(b), indicate: C1aSS 2 If any portion of the tested area is in the Floodplain, indicate Floodplain elevation: n/a decimal' PROFILE DESCRIPTIONS page 42 OnC2 BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTINIO, ELEVATION OBSERVED EST. HIGHES TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- 1 6.82 98.70 none >6.8?. 1.00, 10vr4/4, s.l., 2.83, 7.5yr4/4, l.s., 3.00- 7.5yr4/6, S. 99.2,0 .75,10yr4/2, 1., 1.00, 7.5yr4/4, s.l., 5.33, 7.5- g_ 2 7.08 none >7.08 4 4 l.s. 95.80 .75, 10yr4/3, 1., 1.00, 7.5yr4/4, sil., 4.75,- 3 6.75 none >6.75 7>5 r4/4 l.s. B_ 4 6.50 92.60 none >6.50 •75, 10 r4/4 s.l., .75, 10yr5/4, sil., 5.00,- 6- 5 6.25 92.00 none >6,25 .75, 10yr4/2, 1., 2.50, 7.5yr4/4, sil., 3.00- 7 5yr-4/4, 8- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD PER( D2 P R PER INCH P- P- 0see P- P- _ P_ 2- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. 95.20=upper trench 92.30= lower trench SYSTEM ELEVATION s ~rx 1S f - -~1 t I t /may}J, 'tN . i w r ) I ; . l I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: Gary L. Steel 4-23-92 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): 1554 200th. Av.e, New Richmond, Wi. 54017 22991 7U-246-6200 CST S A E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) -OVER - _ s 40 e ~o y - klJ u1 ti 47 , 00V f~ h ' q rG' Z l 3 r M 3 y y I eF--2-, 7~ ,~i~' . ~J!✓f e e aG T~3~' ;D e1y 710I&J,JvF 0) of C/ .40 l II t (9,3 !;2 -64 _ ~f a d G° rt C jr 1I11 I~ VI / lU 1-7 3( i