HomeMy WebLinkAbout038-1068-20-000 T r
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
I~YIah'1 5~
ADDRESS
SUBDIVISION / CSM# LOT
~f r lrr
SECTION. _T N-R / b W, Town of
ST. CROIX COUNTye..WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
ae.7 f _
G ~
INDICATE NORTH ARROW `
~ G
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center Olt septic ank manhole cover.
{
rx~:
k
t
BENCHMARK •o~ 5 < ° J ~r d.r`~ r
Ojr r~ 1~.~
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION
Manufacturer: Liquid Capacity:
Setback from: Well
S-v House /,Z r Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: o? Length ✓~Sr Number of trenches
Distance & Direction to nearest prop. line: /m
1
Setback from: well: HouseOther
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:
PLUMBER ON JOB:
LICENSE NUMBER: t~
INSPECTOR:
3/93:jt
LOWclb1QX;artSTAR,rRWIE 16.31
Labor and Human Relations . GONEWAGE SYSTEM County: Safety.atid Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
91
Permit Holder's Name: ❑ City E] Village R Town of: State Plan ID No.:
XNA AR PRAIRIE
nsp. M ev.: M Description: Parcel Tax No.:
/0j. (116A 0-000
TANK INFORMATION `r ELEVATION DATA A9300318
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Oj a Benchmark 10d, 03 /DD ,
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
ir Ito ntake ROAD Dt Inlet
TANKTO P/L WELL BLDG. A
Air
Septic NA Dt Bottom
Dosing NA Header/ Man.
Aeration NA Dist. Pipe tg~ q~.3
Holding Bot. System &7 y 13
PUMP/ SIPHON INFORMATION Final Grade 1603 TbI6
Manufacturer Demand
Model Number GPM
TDH Lift Friction Syesatem TDH Ft
Forcemain Length Dia. If Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Tre ches PIT N0.Of_Pits Inside Dia. Liquid Depth
DIMENSIONS S DIMENSIONS—
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufac urer:
SETBACK CHAMBER
INFORMATION S, peof S` ) -S-,-), Aj OR UNIT Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia- I 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 ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRARIE 16.31.18.292D
f 4
r.
Plan revision required? ❑ Yes [~No ~3 r ;
Use other side for additional information. 1// 1/0
SBD-6710 (R 05/91) Date Inspector's Signature Cert No.
5 ADDITIONAL COMMENTS AND SKETCH -
SANITARY PERMIT NUMBER:
i
I
I'
T
Tom-HR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
_ G
=ZaQ,e,...,.., o
_ STATE NITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than
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.
PROPERTY OWN PROPERTY LOCATION
~..Q « /a 4, S T , N, R (or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
CITY r t NEAREST ROAD
11. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLAGE
D
❑ Public 191 or 2 Fam. Dwelling- # of bedrooms PARCEL TAX NUMBER(S)
111. BUILDING USE: (If building type is public, check all that apply) d-~/`r~ m p m p
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 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) 1.0 New 2. AReplacement 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: 11 '
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
/V 4 4-e 1 6 Cie se, '7 .7 ;;f Feet Feet
VII. TANK CAPACITY Site
in gallons Total # of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank 4~irJ O~"
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attache&plans.
Plumber's Name (Print): , Plumber's Si ture: (No Stamps MP/MPRSW No.: Business Phone Number:
Plu is Address (Street, City, State, Zip Code):
~ov
IX. COON /DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee)
p# / I_T3
Adverse Determination T 6
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
y f
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years. '
2. Your sanitary permit may be renewed before the expiration (late, and at the time of renewal any new
criteria in this Wisconsin Administrative Code will be appiicab'e.
3. All revisions to this permit must be approved by the permit i:.suing authority.
4. Change- in ownership or plumber requires a Sanitary Permit I ransfer/Reriewal Form (SBO 6399) to be
-,submitted to the county prior to installation.
5. Onsite sevfJa e S stums.must be row? maintatned. The w(e) • ~o
l y p P tan: E. r )I by a lien e~
pumper wherever -necessary, usually every 2 to 3 years. -
6. If you have questions concerning your onsite sewage system, contact your loc tl code aarriinistrator or the
State of Wisconsin, Safety & Buildings Division, 608-26673815.
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 1 of bedrooms if 1 )r 2 Family Dwelling.
III. Building use. 11 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 systerr. Check appropriate box depending cn systern type.
VI. Absorota-?n system information. Provide all informat.on reqE,'e!z;t~,± in #,L1•-7
Vli. Tank information. Fill in capacity od ::v-- ry new and of ia,,k. list t` e ti. f-O 1 1)mi, riumb=r of
tanks anc' *'an.JaCtUrer's l'an'e. lndica. fob Or site (,r: t ~r~C'iett' fcr 2a//
t.
septic, put,, p!s phon and holding tanks <D n,4 system. Crtt i ,or )'val .;eery it tanks received
oxPgnfii, i"ruduct ap,l .-tva! from DILH.P,
Vlll. Responsibility Statement. Installing piur^%-t~r iS to fill in nsam,- i-r;se n ri~F .0ih ar)r,ropnPie pre ix (e.g.
MR, etc.), addr ss and phone number. Pia smust sign , itlon form.
IX. County/Department Use Only. ,
X. County/Departrpe.nt Use Only.
Complete ; lont,. and specificatiom,', not :_rw,aller than 3Y2 ! , -t be a-ub nit~:er' to tt-- counly. The
plans must io(, w 11.e foiicwing: A) plc,1 drawn: to r)catic'a Of
holding :a 'rc.'.. s .;•:i" t=s tk:,.. c'r other e4 ;-?-:.Jt tanks. .v , c
fi
zter '5ervice,
streams lilts iapuma ~iph(-ii tank loutic ;e, +r ;t a,,1•• rr,, , r,~?y; system
areas-, ar'c' location of U{kUing icr: ?f-Eft.
t
C) complete; .pecii`icat,oris fr;i' purips and ro.nE:uis; dose voiUrno -2-Vevatior' eri-nGes>, f ,ct:att loss; pump
performance curve; pump riodel and puma manufacturer; D) crass section ci the soil absorption system if
required by the county; E) soil test data on a 1'15 form; and F) all sizing informati )q:
- - - -
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number cf
regulated practices whici rear' t'`fcct g-;3undwater.
The es Collected thrOalgtt ttEt,se sE rr:ha,ges arc. „~c ~t.mc , u,c' ~;l ^ ,v at= ,
water'+'onlarninatiori investirgatioFEs ano establishment of standards.
I SBD-6398 (R.11/88)
PLOT PLAN
PROJECT__ ~ ADDRESS g?1,, V Gd G~.,
4~ 1/4 • 1141S14 /T N/R~gV TOWN ' COUNTY oljr
MPRS Byron Bird Jr. 3,5'1'8 DATE -
BEDROOM CLASS PERC_--75- CONVENTIONAL, IN-GROUN RESSURE
CONVENTIONAL LIFT MOUND_ OLDING TANK
SEPTIC TANK SIZE LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA L/,4' ~ PERC RATE 7 BED SIZE
16 Benchmark V.R.P. Assume Elevation 100' -
Location of Benchmark
0 Borehole Q Well Scale Feet
0 Perc Hole System Elevation
Uent
12"
Grade
TYPAR COVERING
12' 3' 6 3'
.i '
6 " Sewer Rock
12' i
r,~Kf B ;
'All
d"
~ ~ Jt Spa ~
v
A
I
Plot Plan
Project Name Byron Bird Jr.
System Elevation CST# 3479
B e n c h m a r k
H. R. P. 0412k
d Boring d Well
to . a~ j~
00
J .f
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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 ~
~lro t
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
PROPERTY OWNE PROPERTY LOCATION
tyj C GOVT. LOT _ 1/4 s 1/4,S /(OT N,R / (or
PROPERTY 0 NER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
CI T E /ZIP CODE PHONE NUMBER []CITY []VILLAGE MOWN, NEAREST ROADS
[ ] New Construction Use Residential / Number of bedrooms 3 Addition to existing building
Replacement [ ] Public or commercial describe
Code derived daily flow 45M gpd Recommended design loading rate - 7 bed, gpd/ft2=J~trench, gpd/ft2
Absorption area required 'a bed, ft2 trench, ft2 Maximum design loading rate • , bed, gpd/ft2 . ?trench, gpd/112
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material 0""k C,-.-5 4i Flood plain elevation, if applicable ~ ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem WS ❑ U SEh [NS ❑ U S❑ U ❑ S ..k 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
_ a
Ground Q° d
elev. 10
Depth to
limiting
factor
Remarks:
Boring #
X! O ` sY+- n r G~ r.
_ '0 4
Ground
le .
ft.
Depth to
limiting
factor
7 /ozO
`-L Remarks:
CST Name:-Please Print r Phone: r
Address:
Signature: Date: CST Number:
PROPERTY OWNER ~L1~c ~l ir~.c-r *~4 SOIL DESCRIPTION REPORT Page of
PARCEL LD.# '
Depth Dominant Color Mottles Texture Structure Consistence Bounc~ry Roots GPD/ft
Boring # Horizon in. Munsell ()u. Sz. Cont. Color Gr. Sz. Sh. Bed Ttendi
All
A99W -9!0 i 0(
Ground
elev.
Depth to
limiting
factor. ,
Remarks:
Boring #
:w
:4i+ V'•'
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
S13D-8330(8.05/92)
t 4~1
No. 266 Warranty Deed-To Hoaband and Wife as Jao;(an V ' PublleDed by Eau Claire I3mk & Atetloneq Co
III Ali
This Indenture, Made this 22n J day of :a c In ,19
between t't,l,r;- C,'c''. . ri« Cco' usbanl ~aci i I~.
I
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part ' of the first part, and
j it....,. < ....i t :ic:_ni1 ~i:~
husband and wife, as joint tenants, parties of the second part.
That the said part of the first part, for and in consideration of the sum of
ZrlItI1 FOaFt
h 'I
Dollars,
to in hand paid by the said parties of the second part, the receipt whereof is hereby
confessed and acknowledged, ha. given, granted, bargained, sold remised, released, aliened, conveyed
and confirmed, and by there presents do give, grant, bargain, sell, remise, release, alien, convey and
confirm unto the said parties of the second part, as joint tenants, the following described real estate
to-wit:
i 3 of Wisconsin,
situated in the Cvt..Jt
Wj'i
e 0 with all aid sin ulnr the hereuitamcnts and appurtem-mues thereunto Lelon~;ir;z; or irJ ::nywi.tie
zrfems', cl:rirt c;r dern;uul nvlr•tsoever, of the
ol for fist p;tr:, (hli, n L: w or c r 'ity• either in posre~si•~n or exrpectaucy of, in a^d to tb,' -;bov:' b.r;.?incvl
.n.4 tLoh rc ci£.~r,J:~:Jrs c.::1 appurr^~Jances.
J .'dt'; ttn w ? i<'? remises ca above described with the heredita.noms and r<piJZ:z er..rnces,
. t! .,..id l%::rties e.` CLo ten::nts.
>iitu'ig t:,Ab,
< ri of the first part, for heirs, executors arrt :.n 'z:avrs,
do covenr:nt, {rant, bargain and agree to and with the said parties of the second l;:rt, r r:;l to and
with the survivor of there, his or her heirs and assigns, that at the time of the ensecding -':Id delivery of
t:ics2 presents well seized of the premises above d_rscrihcd,
i
'rs of a food, sure, perfect, absolute and indefeasible estate of inheritance in the law, in fee simple, and
that the s;rme are free rtnd dear frorn all incurnbranceswhateve.r.
;wd that the above hrtrt*ainerl premises, in the quiet and peaceable possession of the swirl parties of the
p:rrt.:rs inirit tenants, nl;sinst all and every person or persorrs lavfully cl::irnirrn the whole or arty
rl .rt tl:. of ~s:11 fora: er 1,7AT-'.i'.1 ?!T /i `rT) DI~FP'.".r7>.
~ _:(f t _ i.. •'iaf, tLr .>..i l rt of Lc;t p:!rt La hcreorto set li'-1114 arid
:tl tais i.ty of 1[r
1
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i "N _.1." r r r . s lint u.;lnr,a,•c:. .n L , ,li 1 Ii.... I" Lit t' t
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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 permit issuance. ,Should this
development be intended for resale by owner/contractor,(spec
house), thenta 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 H'
Location of property~,~l/4 11/4, Section ZC TZ/N-R_,e~gfW
Township
Mailing address ~ 45;1 All"
Address of site
Subdivision name Lot no.
other homes on property? yes-- No
Previous owner of property f~Lr~c~H e~o~
' f
Total size of parcel
Date parcel -was created
'Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes ,.,No
Volume and.Page Number 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 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
recor4e` 4,n th- office of County Register of deeds as Document
No. ~55
signat a of applicant Co-applicant
Date of Signature' Date of Signature
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
A
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently
serving the 44'0 ' residence located at:
1/4, 1/4, Sec. , T N, R W, Town of
Upon Inspection, I certify that I have found the
tank and baff'les"'to be in good condition, and it appears to be
functioning properly.
Last time serviced
Did flow back occur from absorption system? YesNo(if no, skip
next line)
Approximate volume or length of time: gallons minutes
Capacity: (Pwc.~-- xe..' O~K I 2~
Construction: Prefab Concrete
-2<_steel Other
Manufacurer (if known):
Age of Tank (if known): a7SG/
(Signat (Name) lease Print
(Title) (License Number)
(Date)
Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes)
or Licensed Disposer (NR 113 Wisconsin Administrative Code)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
condition, I certify that the tank to the best of my knowledge will
conform to the requirements of ILHR-83, Wis. Adm. Code (except for
inspection opening over outlet baffle).
Name Al ~ r
T Signature MP/MPRS
5/88
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER l h ,Ji?.rGcrr~ sAc/
ADDRESS Cd G FIRE NUMBER dZ/~
CITY/STATE e w~Y/ir~i~-rd ZIP
PROPERTY LOCATION :,;x,1/4 ,,~1/4 , SECTIONZ.4~_, T,&_N-R W
TOWN OF /i~air G-- , 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/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 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:-
DATE: St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016