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HomeMy WebLinkAbout036-1005-30-000 3-:31. n 3,5 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER R6~4 C b S e ADDRE 6 SUBDIVISION / CSM# LOT # del SECTION. 3 T?~ N-R W, Town of Cw~ ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 49 ~~.nre 1011 rx 1 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: 00 ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING-.TANK INFORMATION Manufacturer: Liquid Capacity: IdZV i Setback from: Well 171 House Other Pump: Manufacturer Model# Size Float separation Gallons/cycle: Alarm Location N) A :SOIL ABSORPTION SYSTEM c./ neo Width : Length Number of trj ~ Distance & Direction to nearest prop. line: Setback from: well: 0?l4 House Other ELEVATIONS Building Sewer ST Inlet. 77, 71 ST outlet / 7r o2 7 PC inlet PC bottom Pump Off Header/Manifold ?5,57 Bottom of system .7 Existing Grade 9tY~ Final grade 9~~5 DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: L. Q 3 INSPECTOR: 3/93:jt LOf''~ar^~'B'~Qhfstry~ • 31.17.35PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar rFnit ` Permit Holder's Name: E] City El Village 1J Town of: State Pan 0- Permit Insp. BM Elev.: BM Description X Parcel Tax No.: i 036 i005 TANK INFORMATION ELEVATION DATA A9300250 1606 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration -w Bldg. Sewer ~ r Holding St/0 Inlet 14,57 9 7, 71 TANK SETBACK INFORMATION St/0 Outlet p 9,7, 6,9 TANK TO PI L WELL BLDG. AirI to ntake ROAD Dt Inlet rl f Septic 5 ?-`Z/ 21 NA Dt Bottom Dosing NA Headed.. d Aeration Dist. Pipe Holding Bot. System x'75 9 ,s~ PUMP / SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction tem TDH F Forcemain Length"" Dia. Dist. To SOIL ABSORPTION, SYSTEM BED/TRENCH Width , Length i No. Of renches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHI Ma SETBACK c rp ` c CRS R Mo umber: INFORMATION Type Of System: 7J OR UNIT DISTRIBUTION SYSTEM Header l Distribution Pi e(s), x,,Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length IL Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Sy LnOnly Depth Over Depth Over xx Depth Of xx Seeded / xx Mulched Bed / TFewcki enter Bed /44a" Edges Topsoil El No No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: STANTON 3.31.17.35 ~I 4-12 Plan revision required? C] Yes Ca ryo Use other side for additional information. j) O(o A 0~s9o~§ P I ?I SBD-6710 (R 05/91) Date Inspector's Signatur Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: I I E (3 DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code Co :7 STATE SAy1,TARY 7PR1T~ -Attach complete plans (to the county copy only) for the system, on paper not less than (('ff!!- 8%x 11 inches in size. ❑ Check f revisio I pr ions application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROP TY OWNER PROPERTY LOCATION (AJY4 ifl %,S T 31, N, R J or W PROPER OWNER'S MAILING ADDRE LOT # BLOCK # ,;t3 5 AI CITY, STA ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER w IV114 11. TYPE OF BUILDING: (Che k one) CITY NEAREST ROA( ❑ State Owned ❑ VILLAGE ❑ Public X1 or 2 F m. Dwelling-# of bedrooms'-3 R L Nu ) 111. BUILDING USE: (If buildin type is public, check all that apply) 6 3 / 4 S _ 0 1 ❑ Apt/Condo 1 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 1130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2gReplacement 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 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 430 Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY rREQUIRED . ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION y~5o a5 //aS 7 N . *eet 9&#V4 Feet VII. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank 15 er' 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. Plumber's Name (Print Plumber's Signa re: to Stamps) I111111P/MPRSW No.: Business Phone Number: (3a/utn ev~ 15~~ 7~.s a yd :5/3..5 Plumber's Address (Street, City, State, Zip Code): /,9192 10,5 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sani~gry Permit F (Includes Groundwater a e ssue 9 Age pt re ( Stamps) jSurcharge Fee) proved ❑ Owner Given Initial / /~d Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (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 renr;wa.l 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 awnership or plumber requires a Sanitary Permit ransfer/Renewal Fo,rn ;F :1 63:ac') to be submitted.to th(:,: c:o: r)ty prior to instailatipn. 5. OrK ife`seWJage cyst his must tie properly maintained. The se,W; ; tank(s) must t: , rp, d 1. H n ed• pumper whenever necessary, usually:evgry 2 to 3 years. 6. If you have questions concerning your dnsite sewage system, contact your local cote administrator of the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be cpmpfbte acrd accurate this sanitary, permit application must include: y 1. Property owner's name and mailing address. Provide the legal description and parcel tax numlb,sr(s) of where the system. is to be installed: II. Type of building being served. Check only one and,-,omplete of bedrooms if 1 or 2 Fam y DWE:Iling. III. Building use. If building type e is Public, check all appropriate boxes that aPPI t 9 Yp Y• 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 can system type. VI. Absorption system intormation. Provide all information request:r;f in ##1-7. VII. Tank information. Fill ;n the- capacity of L•v+Nry new and/or eK s°: .ar k, .ist the too I rug ;ber of tanks and !manufacture=r's name. Indicates '>refab or site Cons' ' ! uvt ad and tank hater i£al. f o t~e'atrt fc,r all septic, purnp/siphon and holding tanks for Niis system. Check (,:*r.erimerital aoproval o :f :inK,; received experimenia! oduct approval from DIt.HF Vlll. Responsibility LtWement, instailing plumber is to fill in name, nr?mbE~r wrfh ~+,sr ror.~rit+>.e prefix (e.g. 4iP, etc.), address and phone number. PIu:72 ber must sign apps+c:fc-rn IX. County/Department Use Only. K County/Department Use Oan'y. Complete; liars and specifications not smaller than E11/2 x 11 incl ; ~ -:~t he r.,bmitted to 'he- co inty. The Pans mi.:7i i:u.lude thr frniowing: A) plot p!,=,r_ drawn to sca!e • + , :;o=np r rjirne- , on of holding tank(s), septic tarok s) or other tern*`l;,c rnt tanks; build r water r r i v te:r service; systesitew a ry t.)kes, purnp or siphon tanks, distribution boXFti rn s rel >rrr~ ni system a,-ea:.-,. an,-l w 'ocahon of the building >d 3) horizonta - t r, . It fir_n cif, re^ t; rc, nts: C) complete specifications for pumps anJ -Controls; close vo a rrt:, elevati,> , cifserence: fr tts)n loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absc;rp ion system if required by the County; E) soilttest data on a 1-154form; and F) 411 sizing informatiorn 4, - - - - - - - - - - - - - - - - GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 inciuded the creation of surcharces (fees) for a number of regulated practices which can effect groundwater. T;;e. rpor.ies c9ldected through these s~~rcharges are uked tor_ ip- n.tor,•:. -o _n 'tU at-)r, ,rr jr,3_ wal,"eo'r:o,,tamination invesfi3atio;s'a6d establishment of stanidard.,~ = SBD-6398 (R.11/88) l7 ~,g c 3-5~` -tcn ' syoo7 -3 chi S D Is63 Ray -~aGp~jSC° Y, PAGE OF }.Cr~SS Secrlun p Zeo SyJen-) Pawk 55160 7 Fresh Air Inlets And Observation Pipe (=-)---Approved Vent Cap Minlmwn 12- Above Final Grade 20- 42v Above Pipe _ 4' Cast Iron To Final Grade Vent Pipe Marsh May Or Synthetic Covering Mln. 2- Aggregate _ Over Pipe Oi~trl0alion - Tee Pipe 0 0 0 0 0 1 6- Aggregole a Beneath Pipe Perforated Pipe Below -Coepting Terminating At Bottom Of System PrpPoSe~ 1'Inkl ``gr~.~lc ~ g' 51,~co..T .SOIL FILL DISTRIBUTI01'•1 PIPE APPROVED $4►JTNETIC COVER 'O - ° ---I4 ATER141_ OR 9" OF STRAW w OF 1►6GR EGATE ~ OR MARSu HA` 2 (e OF 12-Zt/Z AGGREGATE ELEV.. OF9 , ~4E&T-, 3 -4 DI•S-rRIgUTIOtJ PIPE TO BE AT LEAST 11JCHE5 BELOW ORIGIMAL GRADE A►Jp AT LEAST20 IMCHES BUT 1.10 MORE THAI) H2 IMCHES BELOW FINAL GRADE i MAXIMUM OWN OF EXCAVATtep FXoM oR &WAL f KAOF. WILL BE -3~ IuCHES MINIMUm 9q" OF EACAVATION FROM Olkl(AWA . OR49E WILL BE I"CHES SIGAIED: LICEUSE AJUMBER: DATE: 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 8 1/2 x 11 inches in size. Plan must include, but 5-f 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 R \ TApp t~ GOVT. LOT 54J 1/4 IU15 1/4,S3 T 3,1 _ N,R Dr) W PROPER OWNER':S MAILING ADDaSS LO # BLOCK # SUBD. NAME OR CSM # CI 8STATE ZIP CODE PHONE NUMBER []CITY [-]VILLAGE [VOWN NEAREST ROAQ Q2 __23S [ ] New Construction Use Residential / Number of bedrooms .,..3 [ ] Addition to existing building ] Replacement [ ] Public or commercial describe Code derived daily flow VS6 gpd Recommended design loading rate 7 bed, gpd/ft2 S trench, gpd/ft2 Absorption area required aZ5 bed, ft2 !?6Z) trench, ft2 Maximum design loading rate bed, gpd/ft2 . S trench, gpd/ft2 Recommended infiltration surface elevation(s) ?Y, y4 ft (as referred to site plan benchmark) Additional design / site considerations IA. Parent material Flood plain elevation, if applicable It S = Suitable for system CONVENTIONAL M UND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U=Unsuitable fors stem S❑ U S❑ U ~7 S❑ U ❑ S E_U ❑ S g.U ❑ S U SOIL DESCRIPTION REPORT 195 C Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 19 5bk CW a 9-38 jbyg 5 $1 2 4 Sbk bij Ground b R 5 S~ /r1 sbk rn~~ i5 elev. t. Depth to limiting f factor 9 Remarks: Boring # 02 oZ °!-d7 S - S 2 S V r G ``1 Z i Ground elev. 0 9(~ /0 R 0 M 5 )M C ( , It. Depth to limiting factor Remarks: CST Name:-Please Print _ Phone:/mar a w v-S Y- Address: X11d1W 10X7 Signature: S3 -yv-~ Date: A v93 CSTNumber: PROPERTY OWNER Rav T(ACJ05or SOIL DESCRIPTION REPORT PA of 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 TrerK:h UZ, :vxr:i.4: 77, ;26 . / Ss,k Mt) r C~ S o /v D / „ti vo--3L /049 Ground .3/ - 7/ / 2 m 5 b M Y , S elev. 9ZAt 67-~ S a m s m c w % .1 8 Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor. Remarks: Boring # kKi:::::::•T'i: iiiY \:v,Lid:•itii:•i:•i:•: Ground elev. ft. Depth to limiting factor I Remarks: Boring # gg, t Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) I -I I t 61 I r ~ 71 I I - r I i- 1 : I I I : I ~ i _ i i ; i , I I I I r ! i I 1 i 6 S2 _ i l I ~ I ~ I i j ~ I I I I I - - - - I - - f - I T L r-1- - 4 a ~ I ~ I I i I I C { f ~ I I I l j I I ~ I I I i I _A3!- j ! i i I I ' I I i i I I ~ I ~ J - I ' I I _ I 1 ! I I i f + f _ - t I t-- I II I I i ~ i i i- I I i ~ I I . i I I I I - r I I I j i } T I I I I I .i I 4 I 1 t ' I ~ ~ I I I . I _ I I - I I ; ' i ~ Y t I I_ I I I I I I ~ I i I ! I ~ I ~ I I j I I I I i I I : I _ - r 7 -t I I I ; I I I ' ' I I I I I I ~ L i i - I ~ I ~ I I I r r I f ~ I i i i I ~ j ice- I 7--- ~ - ~ - I - I I-f-- I : 1 S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County ©bS 2 h OWNER/BUYER 1?6" ADDRESS FIRE NUMBER CITY/STATE Oe-p-r, vw ZIP_ ~5'Do7 PROPERTY LOCATION: 5G1 1 4 F 1 4 SECTION -3 3/ - -f- / ~AI_ / , , T N R_Z2 W TOWN OF S 1 B.n ~O~ , St. Croix County, SUBDIVISION +Q , 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/tile, 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. ~[r SIGNED • DATE: 9-- d'- 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 ~n delays of the pormit 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 _ Roy 7~La 6 5;c r Location of property- ~W i/4 IVE_1/4, Section T 3,~N-R-Z?_W Township Mailing address QZ2, r w Wx 7 Address of site d U-.Q- Subdivision name n1 j A- Lot no. Other homes on property? p yes- No Previous owner of property C13 Total size of parcel Date parcel -was created 'Are all corners and lot lines identifiable? __A__Yes No Is this property being developed for (spec house)? Yes ,LNo Volume -5-ind,Page' Number L~. as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICA'T'ION 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 f ce 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 in the office of County Register of deeds as Document No. Sign ture f applicant Co-applicant Date of Signature Date of Signature k UNITED STATES DEPARTMENT OF AGRICULTURE FARMERS' HOME ADMINISTRATION WARRANTY DEED F (Wisconsin) ROBERT CLEE'LAND WALKER and THELMA- F. WALKER, husband and wife, Grantors, of St. Croix County, Wisconsin, hereby convey and warrant to ROY H. JACOBSEN, Grantee, of Deer Park, Wisconsin, for the sum of SEVEN THOUSAND FIVE HUNDRED and No/100ths Dollars, ($7500.00), the following tract of land in the County of St. Croix, State of Wisconsin, described as follows: The North One-half of the Northeast One--quarter and the North One-half of the Northwest One-quarter and the Southwest One-quarter of the Northeast One-quarter and the West One-half of the Southeast One-quarter of the Northeast One-quarter of Section Three, in Township Thirty-one North, Range Seventeen West, excepting a tract of land Three rods square in the Southwest corner of the North One-half of the Northeast One-quarter of Section Three, ALSO SUBJECT TO a 100 foot right of way, as recited in deed recorded in Volume 16 of Deeds, at page 381. WITNESS the hands and seals of said. Grantors this J day of 19 q T In the presence of: EAL) Ro,b rt G. a n Robert Cleeland. Walker (Husband) (SEAL) lKark v c own Thelma E. Walker (Wife) A C K N O W L E D GM E N T STATE OF WISCONSIN ) • ) SS COUNTY OF ST. CROIR ) Personally came before me this f FG` day of , 19 , the within named ROBERT CLEELAND WALKER and THELMA E. WALKER, his wife, to me known to be the persons who executed the foregoing instrument and acknowledged the same. r^ son v: 1 w9e f Notary Public. "....:-C-t.-L.- County, Wisconsin. My Commission Expires: Y ' Y MiMO 7 1 SWJa. ♦ h`4^ 'k wi 'Jig I, o y J co L I wi e t _ I i Y d' .r;