HomeMy WebLinkAbout032-2090-70-000
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AS BUILT SANITARY SYSTEM REPORT
OWNER ABU L ~ +2.S'O&
ADDRESS )3ayC
6forQI►f /.Clj` vr~1d/fQ
SUBDIVISION / CSM# A&grf/Gr,?~ DA_,Cf- &-XTi4T~TC LOT # I
SECTION . I6j T_31 N-R__Lf _W, Town of Sonz 5"
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
AvE
x-
10
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this-form.
Provide 2 dimensions to center of septic tank manhole cover.
l }
BENCHMARK : ZEEL PC-
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity: /000
Setback from: Well House Other
Pump: Model# Size
Float seperation Gallons/cy
Alarm Location
SOIL ABSORPTION SYSTEM
Width: 6- Length 5-2 Number of trenches -2
Distance & Direction to nearest prop. line: /1jjj=c, 8S
Setback from: well: House jL Other
ELEVATIONS
Building Sewer 110,P q ST Inlet; ST outlet
PC inlet AA PC bottom Ar,4 Pump Off
Header/Manifold Bottom of system 373Fot
Existing Grade IC)3, 4 r Final grade
I
LATIO
DATE OF INSTAL
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
TT[[~~~ ~sr~-r 1
LJY~1[t)11S~R~iartrl1~15Cf~, 15.31.19PAUATLFIEWA)GE SYSTEM County:
' ,Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
193497
Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.:
SOMERSET
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
032-2090-70-000
TANK INFORMATION ELEVATION DATA A9300155
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
/ r 1
DosinT-
Aeration Bldg. Sewer
Holding St/P11 Inlet 1
TANK SETBACK INFORMATION St/ Outlet Vent to TANK TO P/ L WELL BLDG. Air Intake ROAD Dt Inlet
" .r--
Septic NA Dt Bottom
Doing--' NA Header. !
Aeration Dist. Pipe
Holding - Bot. System r . r
C
3
PUMP/ SIPHON INFORMATION Grade ~
{
Manufa rer Demand
{
Model Number GPM
TDH Lift Friction m _ TDH Ft
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width r 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 TypeO CHAMBER Model Number:
System OR UNIT
DISTRIBUTION SYSTEM
Headed-NAaw Ql.&- r Distribution Pipe(s) r ~r x Hole Size x Hole Spacin Vent To Air Intake
Length` Dia Length f 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
/Trench Center / Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: SOMERSET 15.31.19.894 (CTY I)
r /
f l I ~r 1 ~ r
i J.
Plan revlslon'required? ❑ Yes ®-bo
Use other side for additional information. Fy
SBD-6710 (R 05/91) Date Inspector's Signatur Cert- No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
DILHR SANITARY PERMIT APPLICATION
In accord with1LHR 83.05, Wis. Adm. Code COUNTY`
NUNN STATE S~ANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than / 93 Z/ 9
8% X 11 inches in size. ❑ Check 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.
PROP RTY OWNER PROPERTY LOCATION
%/a,S Tej ,N,R W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
Z S ATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
av f d" ,
II. TYPE OF BUILDING: Check one CITY NEAREST ROAD
( ) ❑ State Owned VILLAGE :
❑ Public 1 or 2 Fam. Dwelling-#~ of bedrooms a P L ARCH TAX NUMBEH(b)
III. BUILDING USE: (If building type is public, check all that apply) ~3z~ Z (J' qo ' 7 y,1
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 80 Mobile Home Park 12E] 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. X 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
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
~~o
Feet 163, feet
VII. TANK CAPACITY _ Site
in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION. New istin Gallons Tanks Concrete structed glass App'
Tanks Tanks
Septic Tank or Holding Tank
Lift Pump Tank/Si hon Chamber
Vlll. 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 s) P/MPR Business Phone Number:
Vy. -5"' l i ,S
Plumber's Address (Street, City, State, Zip Cod :
IX. C UNTY/DEPART ENT USE ONLY
❑ Disapproved Sanjtary Permit Fee (Includes Groundwater Date Issued Issuing ant Si a Nos mew
Approved ❑ Owner Given Initial Surcharge Fee)
Adverse De rmination
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
INSTRUCTIONS
1. A sanitary permit invalid 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
sub(itted 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 administratoror the
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
L 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; 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 145 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.
I
SBD-6398 {R.11/88)
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor ar5f 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 8 112 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.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
Paul Anderson GOVT. LOT STq 1/4 n,T 1/4,S15 T 31 N,R lq )&or) W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLO # SUBD. NAME OR C$M #
Box 242 17 n/aK T~Torthern Oaks Estates
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE DOWN NEAREST ROAD
Hudson, WI. 54016 (n/a) Somerset Co. Rd. #1
kk New Construction Use to Residential /Number of bedrooms 3 [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate • 7 bed, gpd/ft2 - 8 trench, gpd/ft2
Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate .7 bed, gpd/ft2 .8 trench, gpd/ft2
Recommended infiltration surface elevation(s) Q9.80 ft (as referred to site plan benchmark)
Additional design / site considerations n/a
Parent material n„txas'h 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 fors stem faS ❑ U 93 S ❑ U 93:S ❑ U EkS ❑ U ❑ S F ❑ S P" U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Roots
Bed Trertcft
1 0-8 10yr4/3 none L. 2/m/gr. mvfr g/w 2/m .5 .6
< << 2 8-17 10yr4/4 none sil. 1/f/sbk mfr g/w 1/f .2 .3
Ground 3 17-35 10yr4/4 none Is. 0/sg ml g/w 1/f .7 .8
elev.
103.95 ft. 4 35-89 10yr5/4 none co.s. 0./sg ml n/a n/a .7 .8
Depth to
limiting
factor
>89
Remarks:
Boring #
1 0-8 10yr4/3 none L. 2/m/sbk mvfr g/w 2/m .5 .6
.2 .3
1) 8-15 10yr4/4 none sil. 1/f/sbk mfr g/w 1/f
3 15-33 10yr4/4 none Is, 0/sg ml g/w 1/f .7 .8
Ground
elev. 4 133-88 10yr5/4. none co.s. 0/s9 mt /a /a .7 .8
103.65ft. 9 ~O
Depth to
limiting
factor
>88 ~ C'f "rJ
Remarks:
CST Name:-Please Print Gary L. Steel 246-6200
Address: 1554 0 h. .Ave. ~Richmoncl, WI. 54017
Signature: 2298 CST Number:
PROPERTY OWNER Paul Anderson SOIL DESCRIPTION REPORT Page 2 of, 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 Trends
I MOM 1 0-6 1 r4/3 none L. 2/m/sbk mvfrr g/w 2/m .5 .6
4v«:«« 2 6-22 10yr4/4 none sil. 1/f/sbk mfr g/w 1/f .2 .3
Ground 3 122-39 10yr4/4 none ls. 0/sg m1 g/w 11f .7 .8-
M2.136' ft. 4 39-84 10yr5/4 none co.s. 0./sg ml /a n/a .7 .8
Depth to
limiting
factor
>84
Remarks:
Boring #
1 10-5 10yr4/3 none L. 2/m/sblc mvfr g/w 2/m .5 .6
U 2 5-13 10yr4/4 none sil. 2/m/sbfc mfr g/w 1/f .2 .3
3 13-2 10yr4/4 none 1s. 0/sg ml g/w 1/f- .7 .3
Ground
elev. 4 28-82 10yr5/4 noen co.s. 0/sg ml na/ n/a .7 .8
100.65 ft.
Depth to
limiting
factor
IP2
Remarks:
Boring #
1 10-9 10yr4/3 none L. 2/m/sbk mvfr g/w 2/m .5 .6
~5 2
•v22 10yr4/4 none siJ_. 1/f/sb)c mfr g/w 1/f .2 .3
3 22-32 7.5yr4/4 none Is. 0/sg ml g/w 1/f .7 .8
Ground
elev.
100. 85 ft. 4 32-82 7.5 r4/6 none co.s. 0/s r11 n/a n/a .7 .8
.
Depth to
limiting
factor
>82
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
STEEL'S SOIL SERVICE
t554 200tt. Ave.
Gary L. Steel Paul Anderson
C.S.T. 2298 SW';NW- S15T31N-P.19W New Richmond, WI 54017
MPRSW-3254 town of Somerset (715) 246-6200
lot. 417-Northern Oaks Estates
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STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER ~l`tV L AnrD~ f~ s~N
ROUTE/BOX NUMBER FIRE NO. '507
CITY/STATE JOM £_Z S "7- L ZIP 5-46 ZS-
PROPERTY LOCATION: SWl/4 kw /4, Section T~N, R~W,
Town of _'SO AA 7- , St. Croix County,
Subdivision NOE #7- 7,
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.
S I GNED)
DATE U A./ 01 .3
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. Any inadequacies
will only result in delays of the permit issuance. ,Should this
development be intended for resale by owner/contractor,(spec
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 20A L _I_ErF?£
Location of, property~W 1/4 N01/4, Section 1J , T 3 _N-RW
Township fy l
Mailing address #S07 Z 1*7 AVM
5omf ZZS:7-, w 1 S-10 2
Address of site 217 AVf L r #iSoMfZsgT (.J ~ S-10 25
subdivision name _NUR 04 1Z„f CAV5 fSri4-t-f S Lot no. L 7
Other homes on property? _ yes No
Previous owner of property % ZL I -A 62j /V E> 6 /K
Total size of parcel 3 RCKa
Date parcel -was created Z5 MAY, 07 l
Are all corners and lot lines identifiable? =Yes No
Is this property being developed for (spec house
) ? Yes ,A_No
Volume 1010 and, Page Number 217 7 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.-42q _5 11a, 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
reco~rc e~d in the office of County Register of deeds as Document
o. 9Y~3 pS
Signat a of applicant Co-applicant
3 ~lw q.3
Date of Signature Date of Signature
STATE BAR OF WISCONSIN FORM 2-1M
499365 vac 1010PAGE 237 REG~IISTE/yR''SOFFICE
ST. C" CO.,
W• PETER P. TAUBENBERGER 'a R"faRWM(d
. MAY 2 01993
p~ 8:30 A. M
conveys and warrants to PAUL J. ANDERSON
n eA
~pid6f OI CMS
RCTURN TO
the following described real estate in ........$t.....Croix ..................County,
State of Wisconsin: Q Q,Q
Tax Parcel No: At'" &..°...-l__•. ..1•.[
63, p 0q grr..00
Lot 17, Northern Oaks Estates in the Town of Somerset, St. Croix
County, Wisconsin.
I
IR
EB
F
This is nOt homestead property.
(is) (is not)
Exception to warranties: easements, restrictions and rights-of-Way of
record, if any.
t
Dated this • day of .........1. Y.......--------•- 19.-. 93. 3
7~1 D ~ l -
.............-.(SEAL) ..(SEAL) t
.
PETER P. TAUBENBERGER i
s
• •
(SEAL) --•--•.........---....................(SEAL)
AUTHENTICATION ACKNOWLEDGMENT i
Signature(s) STATE OF WISCONSIN
as.
St. Croix
County.
authenticated this ........day of 19...... Personally came before me this ..1. -........day of
-.......Mai! 19.93.. the above named
•-•••-Peter- P. Tau.....
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorised by 1 706.06, Wis. Stats.) to me known to be the person who executed the
foregoing instrume nd ack ledge the same.
TNIS INSTRUMENT WAS DRAFTED RY ,
KRISTINA OGLAND - - ...:w:.........
Attorney. at Lahr •...~i--Ce--Joy
8£:...Croi~~~s~~
Notary Public
0427. . .Pta►siOVnty, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanv'~[fql(VVjriration
are not necessary.) date: 19.........)
.
,Names of persona signing in any capacity, should be typed or printed bAow their sljnatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc.
FORM No. ! - 1982 Milwaukee. llsconsin
1
ST. CROIX COUNTY
WISCONSIN
- '1 -
ZONING OFFICE
1 r r r N N r„~~ ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
- Hudson, WI 54016-7710
(715) 386-4680
March 21, 1994
Mr. Paul Anderson
507 217th Avenue
Somerset, WI 54025
RE: Be tic Ins action For Property Located
at 217th Avenue Somerset, Wisconsin
Dear Mr. Anderson:
An inspection of the septic system at the above address, further
known as Parcel No. 032-2090-70-000, was conducted on August 25,
1993. This property is located in the SW; of the NW; of Section
15, T31N-R19W, Lot 17, Northern Oaks Estates, Town of Somerset, St.
Croix County, Wisconsin. At the time of the inspection, this
septic system was found to be code compliant for a three (3)
bedroom home. Should you have any questions, please feel free to
contact this office.
Sincerely,
/s/ James K. Thompson
James K. Thompson
Assistant Zoning Administrator
I
mz
(C(Oply