HomeMy WebLinkAbout036-2003-95-000
FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER -TOWNSHIP-
SECTION T
L_. Z,/ N-R-2-7-_W
Ljh~ ADDRESS ST. CROIX COUNTY, WISCONSIN t- .1j z'
SUBDIVISION~,~ cf~s LOT 119 LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDICATE NORTH ARROW
BENCHMARK:Elevation and description:
Alternate benchmark
SEPTIC TANK:Manufacturer: h iZ'e~r!c Liquid Cap.
Rings used: Manhole cover elev:9,f,,~qq Final grade elev:. 9~_
Tank inlet elev.: Tank outlet elev.: ,2L~"7
No. of feet from nearest road:Front , Side, Rear Ft. fro ,
From nearest prop. line:Front , Side , Rear-A/ Ft.
No. of feet from: Well ~4 Building: 91
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
i
fe
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:_ Trench: Seepage Pit:
Width: 2' Length ,jZL' Number of Lines:, Area Built
Exist. Grade Elev. ~ 5,-7 Proposed Final Grade Elev.
Fill depth to top of pipe:
No. feet from nearest rop. line:Front , Side~Y , Rear Ft
No. feet from well : No. feet from building ,--,,~2,~''
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:-
6/90:cj
J
$ Xjk%;t 9jy 31.31.17 .k~A ,s tl, M'TEY& K RIDGE ounty:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
193409
Permit Holder's Name: ❑ City ❑ Village ❑X7ovvn of: State Plan ID No.:
s
T.T_j'FANRTTF M STANTON
ST lev.: Insp. BM elev.: escription: Parcel Tax No.:
2 /G?~
7,~9
TANK INFORMATION ELEVATION DATA A9300070
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 77 S aw--"c Benchmark 19
Aeration Bldg. Sewer /
Holding St/ f Inlet
TANK SETBACK INFORMATION St/ Outlet 57
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic j 9 NA Dt Bottom /
Dosir g NA Header /fin-
Aeration NA Dist. Pipe /d5
Holding Bot. System c9
-V 9171 PUMP/ SIPHON INFORMATION Final Grade
Manuf Demand
Model Number GPM
TDH Lift Loss Syste
Ha TDH Ft
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT Pits Inside Dia. Liquid Depth
DIMENSIONS
/off S DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING facturer:
SETBACK
INFORMATION TypeO c,_,? CHAMBER Model Number.
System: , 0 d OR UNIT
DISTRIBUTION SYSTEM
Header / mefti+& d Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia- 4L Length 50 Dia. _~c Spacing i!
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over G xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /TvataIi Center - G~ Bed /Tpomeig Edges 1_ (V- r9 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STANTON 31.31.17.639,SW,SE,LOT 1 , OAK RIDG DR.
`7 / ~ i irk ~y✓~-4,av _!~-I' ~'C-('.CT!..`"~FI~-c" /O ~C~
rr,
~C')-7~ ~✓-lr~~. /~-~-=~C~
Plan revision req fired? ❑ Yes
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspect 's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
z
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SANITARY PERMIT APPLICATION
MILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
T
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 f~Q~§t 6
8% x 11 inches in size. c ec if rbio revi us application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROP TY OWNE PROPERTY LOCATION
").Ed -
PROPERTY OWNER'S MAILING DRESS LOT # BLOCK #
CI STAT 1 ZIP CODE PHONE NUMBER SUBDIVISION N ME OR CSM NUMBER
w
14i 11 (1.41 II. TYPE OF BUILDING: (Check one) El State Owned VILLLLAGE NEAREST RO' D r
JOWN QF~
❑ Public ®1 or 2 Fam. Dwelling4 of bedrooms --2L PAR EL TAX • NUMBER(b)
III. BUILDING USE: (If building type is public, check all that apply) Qo o7t~3-1S
1 ❑ Apt/Condo
2 ❑ 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 120 Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Off ice/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. M New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ 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 (s q. ft.) (Gals/day/sq. ft.) (Min./' ch) ELEVATION
Feet Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Se tic Tank or Holdin Tank F1 I
Lift Pump Tank/Si hon Chamber F] 1 1 11
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumb is Name (Print) Plumber's ignature: (No S mps) MP/MPRSW No.: Business Phone Number:
umbe s Addr (Street, City, S te, Zip Codey
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sa nary Permit Fee (Includes Groundwater a e Issued Issuing gent Si re tam s
Surcharge Fee)
proved ❑ Owner Given Initial ge,
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 & Buildings Division, Owner, Plumber
f
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 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:
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 tarks; 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; (lose 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)
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), then 1a 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 C ► _,~p A."I %A Q m , Location of propert ShI 1/4 ,E1/4, Section, TN-R~W
Township - S+m N _ . K
Mailing address
lgz~ _
Address of site r,,'AQ
Subdivision name__I~a < NI [ ap) Lot no.
I
other homes on property? _yes__./~No
Previous owner of ProPertY ~l
S t
Total size of parcel 0
Date parcel -was created AW 11 24 45_
Are all corners and lot lines identifiable? Yes __No
Is this property )peing developed for (spec house)? Yes -X_No
Volume-CID _and. Page'
Number 1 s 1 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. 47 ) , 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 thesame has been duly
recorded in the office of County Register of deeds as
Document
N
gna cure o applicant Co-applicant
Date o signature Date of Signature
DO : U STATE t3AF!OF'JV iSCQNS]e4 Tw, f.Ft EJ vEp F_ r1t OrV D N~ i>TA
i' _~`t T N O
RjUSTER"S
Diane B. D;x3~°ws'ci S. C) CO., "'I
V' - - - - / - R R;;c rd
JUL 101991
l - - I al 10-10 A.. M
conveys and wa ran?s'o - -
_ -,l ve att r' c~~R'o ;glerolaot3's
. _ E
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-
RETURN TO
the 'oliowing described real estate in CXa1x--------
State of Wisconsin.
b-200-°5
Tax Par--el No._ 03
A parcel of 0,9 acres located in the SEA of Section 31-31- .
desc bed as follows: From an iron pipe stake at the S:: - er of the
;El- of of said Section 31, go NS30'W a distanc 12.0 feet,
thence N8 l'E a distance of 941,29 feet, the '8n 301E a distance
of 1438.63 fee along; the centerline o` It ighway as being constructs
In November, 1963, hence N3 30'w a ~nCe of 40,0 feet to point o
beginning on the N rig t-of-way saij IiiLhway fo the parcel to b
conveyed herein, tbence ' E along said N right-of-way line a
distance of 181.5 feet enc N15 42'~4 a distance of of 201.0 felt,
Thence S85 06W alo a a fence lir, a distance of 165 feet, more or less
tXXxxxxxXXXX::XXXXX> ~xXxxxxxX
R@4 }lIC `CXXKYXXXXXXXXXXXXX, xa'<x~:Y . . Xy:K`~ ~Y`c:i`:XX.KXXXXX\XX\ XX\_ XXXX
t~tshore of the stream, thence Sly alo said strew-' to the N I i-%e
ighway and the point of beginTtln6.
LOT 'JINKEEM (19) O'.. RIDG F,ST+T:, ^)TTIO:. TO Ti.. T ..:I OF .T_NTON
:ItA Ozo
Yt1ry
This_ 15 -not -homestead property.
(is) (is not)
Exception to Warranties:
Dated this _ Tenth - -day of July-
(SEAL)
------(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
$igna!ure(s) STATE OF'vV!SCONSIN
- - -
ss
~7 ♦'c X County
/Fi7f
authenticated this_ __dayof Pers na'Iy ca ne be'ore me this day of
19- T1 the above named
L rwl n~E_
TITLE MEMBER STATE BAR OF WISCONSIN
(If not,_ to m known to be the pP san who executed the
au!horized by § 706 08. VVis Stats I foreyt,, ng instrument and ack wedge the same
THI, NSTNUMEN DRAF TEL) BY _ - ' -
NUt3 y vuh!IC-
($IgIdt Ufea .Tay hn authen,.,at6•d Or dr. ^,w~ e•.tye~ Biitrl My COn, rnSS^Jn i5 G° - jCa (I( n !.kta'd a.p,r dt'J
aru not necessa•
)
N,..,ee •„F1 ,l z 5 3 ~c
iY O F E G fve.ca Ta, F ,,ms, -3 R). , 2rH u•`t 8ay WI Si_d 0208
II KA A~~ A N STATE BA? OF N SCON;IN
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Eleydion data 4.
Mi water mark 93.90'
Estimated low 87.50'
Elev. June 24,65=90.10'
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
l ,
OWNER/BUYER_
ADDRESS FIRE NUMBER /
CITY/STATE ZIP_ -7
PROPERTY LOCATIO jJ 1/4, -5.g 1/4, SECTION T_-EL_N-R_LZ_W
TOWN OF St. croix'County,
SUBDIVISION 6;Zd ,a~E sf c , LOT NUMBER-Z_ .
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/lle, 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. Croi Co. Zoning officer within
30 days of the three year expiratio d te.
SIGNED
DATE: St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
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
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
PROPS TY OWNER PROPERTY LOCATION
GOVT. LOTS" 114S:1/4,S_.3, T ,3 ,N,R i(ore
PROPERTY OWNER':S MAI ING A RESS LOT # BLOCK # SUED. NAME 0 CSM # Al.- 22 1,1h CI
STATE ZIP CODE PHONE NUMBER ❑CITY LLAG [MOWN NEAREST ROA
d
91 4- J~-/ -7
111) bj
],~J New Construction Use [~(J Residential / Number of bedrooms _42 [ ] Addition to existing building
Replacement [ J Public or commercial describe
Code derived daily flow 36K
2 gpd Recommended design loading rate bed, gpd/ft2--,,/trench, gpd/ft2
Absorption area required 6160 bed, ft2 trench, ft2 Maximum design loading rate „ r bed, gpd/ft2,,/trench, gpd/ft2
Recommended infiltration surface elevation(s) 7 ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable &_9 ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem W S ❑ U OS ❑ U WS ❑ U ®S ❑ U ❑ S J~ U ❑ S ® U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench
hti'j. f
7 1,01%e
Ground
elev.
ft. ,
Depth to 7, Z 4_1 Li -
7
l
imiting
factor
171?- '90 1 _ 1" e/
y - G -
Remarks:
Boring #
1,4
Ground r
ele .
ft. s - -
Depth to
limiting
factor
Remarks:
CST Name:-Please Print j: Phone:
i s-
Address:
Signature: Date: CST Num r:
i
PROPERTYOWNER SOIL DESCRIPTION REPORT Page,~) 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 Trench
2, 2
\4
bk .........."I
Ground
elev.
,z ft. _ S- -
Depth to
limiting
factor Remarks:
Boring #
i
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
FT ---F
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
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