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HomeMy WebLinkAbout038-1087-20-000 ,r STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER le ADDRESS G✓ tab ~ Ccf ~ 5 ~o~ 7 SUBDIVISION / SM LOT # SECTIONr T~N-RW, Town of 5ta~ / rte. r~ °C- 2.1 . '2) t 8. 35 4 A ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM G 15~ { r S ~ 3Q<< la i k JIle INDICATE NORTH ARROW Provide setback and elevation information on reverse of this -form. Provide 2 dimensions to center of septic tank manhole cover. • f BENCHMARK: lJG s y CJ w c~~~ Se A%. -r `j ALTERNATE BM: SEPTIC TANK /(PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: SX''s /""f Liquid Capacity: Setback from: Well _ House_ X4 Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location .SOIL ABSORPTION SYSTEM Width: ~ Length Number of trenches t Distance & Direction to nearest prop. line: f~-a Setback from: well: 4oa House Other ELEVATIONS Building Sewer St ` Z^"-vinlet , outlet ~2. C. I PC inlet PC bottom Pump Off Header/Manifold q/ Z_ Bottom of system le, Existing Grade 7-3--2. Final grade q~..Z «bATE OF INSTALLATION: - y i- PLUMBER ON JOB: -9 .17 LICENSE NUMBER: INSPECTOR: at, 3/93:jt I!O s paAT"IQ8b# RIE 21. 31P 0A+J% Uj#XGjJySWM RD. C County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division ST- QRQTX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: 193378 Permit Holder's Name: ❑ City ❑ Village R Town of: State Plan ID No.: ev.: Insp. BM 4yClNXE___ STAR PRAIRIE BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9300035 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic cru41 'E~~~ Benchmark J-5 Dosing / 'rte,./!r Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic >/00 6 7 3 / NA Dt Bottom Dosing NA Header/Man. ~/,3~ oj~• / ?5 Aeration NA Dist. Pipe 0' Holding Bot. System /p 3 r b, 1 Z PUMP/ SIPHON INFORMATION Final Grade ~p16 Manufacturer Demand / Model Number GPM <7 TDH Lift I Lricti n Syesatem TDH Ft Forcemain Length Dia. HH Dist.Towell 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 CHAMBER INFORMATION TypeO r ! Model Number: System: > 1 o 7 ! /D 40 /(1 fi OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipes r A_f it / 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 l Depth Over / $ of ! xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center ~a Bed /Trench Edges Y Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: STAR PRAIRIE 21.31.18.358A,NW,NE, CO. RD. C J% t K l P o Y^ y 0 / Plan revision required? ❑ Yes ❑ No Use other side for additional information. I R fit` L f° SBD-6710 (R 05/91) Date Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: i ~ILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY ::!5r/_ STATE SANITARY PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than / ~j 8'/s x 11 inches in size. ❑ cr~COf 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 OWNER PROPERTY LOCATION 4- el o !^o fLr /4 S A/ T ~N, R~ E (o PROPERTY OWNE MAILING ADDRESS LOT # BLOCK # ,_,2&)46 6e c' G TY, ST PTE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 1 1~ o / low S 1~+1 rC II. TYPE OF BUILDING: (Check one) 1:1 State Owned VILLAGE NEAREST ROAD ❑ Public 191 or 2 Fam. Dwelling-# of bedrooms PAR T NUMBER(S) Ili. BUILDING USE: (If building type is public, check all that apply)- 1 ❑ Apt/Condo 2 El Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 El Outdoor Recreational FaciIitY 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. ❑ New 2. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 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 s , 1 L Feet - Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New AStin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank ~r S Lift Pump Tank/Si hon Chamber , D.- F1 1 11 F-1 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 nature: (No Stamps) MP/MPRSW No.: Business Phone Number: Plumber' ddress (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY fin itary Permit Fee (includes Groundwater a e ssue Issuing Ag nt Sig ure (No Stam ❑ Disapproved Approved F-1 Owner Given Initial Surcharge Fee) 40 Adverse Determination ' X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: ,,i6l *~&o * 7te.;, 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 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 (SBO 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 whe„ever 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. 11' building type is Public, check all appropriate boxes that apply. IV. Type of permit, Check only one in line A. Complete Sine 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 plan;, and specifications not smaller than 13% 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 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. s S8 D-6398 R.11/88 STC-100 7'llis application form is to be completed in full a the octincr(s) of tlle nd signed by property being develop ed. Any inadequacies will only result in delays of the issuance. Ss development be intended for resale bytowner/contr ctori s hec house), then a second form should be retained and completedCwhen the property is sold and submitted to this office with the appropriate-deed-recording_ - - Owner of property c orj Location of property-Alt/ Section ► T„_F/N-RAW Township Mailing address .2Q GC ZZ/ C O Address of site Subdivision name rot no. Other homes on property? es x Previous owner of property ~ e Total size of parcel Date parcel was created Are all corners and lot lines identifiable? ~T No Yes Is this property being developed for (spec house)?---_,Yeso Volumel_ hand Page Number as recorded. with the Register of Deeds. ~-------7- - INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARIWITY DEED which includes a DOCUMENT NUHDER, VOLUME AND! PAGE NUMDI R & THE SEAL Or THE IZEGISTrR 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 curve shall also be required. y Map PROPERTY OWNER CERTIFICATION I(wc) certify that all statements on this form are true to t best of my (our) knowledge that I (we) am he the property described in this information form b e owner (s) of warranty deed recorded n the office of the County virtue of a Decds as Document Ito. Y Register of own the proposed site for the SeWa e' and that I (we) presently obtained an easement, to run the boveid scrib system or I (we) the construction of said system, and the same hasopbeen,duly ert for rdp Noce l~ office of County Register of deeds as Document Si na ~ 9 re of applic t Co-appl cant i 7~,3 Da a of signature I Date of Signature i a 3. LL k I(i. I' r 9 4 ' l 17 , l r ➢ i ' 1 v , r l Q L y..- - 111 0 0- I. r' # - ` R , - - - W V T I, to v 4 r=. F h' 1 i SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER O r r .c ADDRESS: ©?O~fG FIRE NO: . LOCATION:. l/41 1/4, SEC._,---7,/ T_N-R_L2LW TOWN OF: ST. • CROIX COUNTY- x SUBDIVISION: LOT NO. Improper use and ainten m ance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of out the pumping se tic sooner, if needed, by a licensed s e c n tank p three years or put into the system can affect the function of thepseptic t nkyas a treatment stage in the waste disposal system: St. Croix County residents may be eligible to receive a grant to help with the cost of the replacement df 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 the 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 from 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 DNR. Certification form must be completed and returned to the St. Croix County Zoning officer within 30 days of the three year expiration date. SIGNED: 01 -ley Olu 6r447~ I. DATE:- St. Croix County Zoning Office 911 4th St. - Hudson, WI 54016 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT A FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have ma~ins/~pected the septic tank presently serving the ~Go r"y G /!~ra~ /Z/e residence located at: r 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? Yes;Z_No (if no, skip next line) Approximate volume or length of time: VZ%It~~gallons minutes Capacity: /p Construction: Prefab Concrette,_X_Steel other . Manufacurer ( if known) : 0 c~c ✓`S Age of ank (if known): ~ f^G h ~-ll Y~ (Sig ure) / (N e) Please Print - /GC 31 (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 Signature MP/MPRS 5/88 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 Gro i . Attach complete site plan on paper not lest;: than 81/2 x t 1 ~inohes 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 OWNER: ~ PROPERTY LOCATION y e /L { Y GOVT. LOT 114 1/4,So2 T N,R E 14 PROPERTY OWNER'-.S MAIL NG ADDR SS LOT # BOCK # SUBD. NAME OR CSM # CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAG MOWN, NEAREST ROAD [ J New Construction Use % Residential / Number of bedrooms a3 [ J Addition to existing building Replacement Public or commercial describe Code derived daily flow gpd Recommended design loading rate _ 2 ed, gpd/ft2 `d trench, gpd/ft2 Absorption area required ~Z~ bed, ft2 6 trench, ft2 Maximum design loading rate a 7 bed, gpd/ft2- __J~(trench, gpd/ft2 Recommended infiltration surface elevation(s) 9,D ft (as referred to site plan benchmark) Additional design / site considerations Parent material D u/a s Z Flood plain elevation, if applicable iJ( ft S = Suitable for system CONVENTIONAL MOUND IN ROUND PRESSURE AT GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem S❑ U S❑ U El U a S ❑ U [:3 S ❑ S Kil SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles ` Texture Structure . Consistence Bw-daly Roots GPD/ft in. Munsell Qu. Sz. Cont: Color Gr. Sz. Sh. Bed TmrK:h # z / O /O 6 / n ,mac G t > k p' /d rz 3.2 S j v G ~J d;~- . 5 Ground c! d ~lI 9`T 40 5r, elev. / Depth to limiting factor Remarks: Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Tferich 4, g/1 Ground d D /n 00 elev. Depth to limiting factor Remarks: Boring # Ground elev. Mzft. Depth to limiting I NV, Remarks: CST Name: Please Print Phone: Address:. Signature: Date: CST Number: . ~ w ~ ~m ~ ~ /f61~ ~ ~ ~i L t9o ~ • 1 5 o ~ ~k. S { „t.,~li/. ~ X04, C ~~3 ~ ' ~ G ~ ~g- R ~ ~ ~ ~ 3~``/ 1 G~Z \ /f~,-~, ~ sly ,r ly Q ~ 36 ~ ' v 1 ~ ~ ~o 7y/ 3 GG ~ ~d~ Ta a PLUT PLAN PROJECT A Nl, 1 /4 1 /4/So?/ /T,7/ N/Rl?' W TOWN , - COUNTY Cra/~ R•S Byron Bird Jr. 3318 DATE - BEDROOM CLASS PERC CONVENTIONAL_~XIN-GR'3U PRESSURE CONVENTIONAL LIFT` MOUND_ HOLDING TANK SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA / r~ PERC RATE G BED SIZE hL Benchmark V.R.P. Assume Elevation 100' Location of Benchmark * H.R.P. - L Borehole (D Well Scale = Feet O Perc Hole System Elevation Uent 12" Grade TYPAR COVERING f 2- 12" 3' 4 6' O 3' I Sewer Rock 6 i 1.2' 04), Gam. y~ S~• ~lJ ~ 5 3 ' pro -3 k & ~7 G\\ t 2 r~ 1 8 FILED JUN 2 91989m- JAMES JAMES O'CONNELL Deeds ! Ragistei of Wl 449277 St C17 I - CERTIFIED SURVEY MAP LOCATED IN THE NE 1/4 OF THE NE 1/4 OF SECTION 21, T31N, RISW , TOWN OF STAR PRAIRIE, ST. CROIX CO., WI. OWNED BY: GEORGE AND YVONNEBROTZLER RT. 2 NEW RICHMOND,WI 54017. JOHN NELSON RT. 2 NEW RICHMOND, WI 54017. NI/4 CORNER SECTION 21, NE CORNER SECTION 21, T31N, R18W. (COUNTY T31N, RIBW. (COUNTY MONUMENTFOUND) . MONUMENT FOUND). • M m 21,0 TH. AVE. M EAST WEST .l 845. 20 NORTH LINE OF THE NE 1 N .:M M y' EAST EAST 202.24 I 40. 28 ' I 0) + I i n S1/ co 40 x/ o y: Z' L 0 T I Z W E 0.53 ACRES o a' 2 (22,986 SO. FT.) S `W: S83017'00"E 7. 00' 6' N w . N I _ N WEST 222. IS' O: co W• I: I.. : M SHED o'-venl I,. uj rank 7f~ ~ Q,• 01 V1 ( O ~ Hous E. L 0 T 2 -Ib 0.60 ACRES I (26,330 SO.FT.) I " 50 33' ~Alaa- I 20~ WEST 235 .72 ' 'Iuh 2 5 1989 U N P LA T T E D LANDS ST. Cr.'UIX C:UUNY'l . COtvtAREHEtJSI\IFF ~)11c5i'i.;~i+!:VIi C. 0 AND Wlvf~ L:: NOTE: BEARINGS ARE REFERENCED TO THE c~ BEARING. . JAMES = NORTH LINE OF THE NE 1/4 1 RECORDED a ~f CSPRitqc-, . ~ y rt LEY 1 p 0SET I "X 24" IRON PIPE WEIGHING 1.13 LOS. PER LINEAL FOOT. . %u R%j SCALE 1 50' - JAMES M. WEBER S-1804 0 2 5 50 100' DATED FEIi Z6 \-~gc\ SHEET I OF 2 89 - 09 THIS INSTRUMENT DRAFTED BY J VOLUME 8 PAGE 2120 Parcel 038-1086-30-000 12108i2006 12:25 PM PAGE 1 OF 1 Alt. Parcel M 21.31.18.357C 038 - TOWN OF STAR PRAIRIE Current XST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - JOHNSON, KARL KARLJOHNSON 2095 CTY RD CC NEW RICHMOND WI 54017-0000 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 2095 CTY RD CC SC 3962 NEW RICHMOND SP 1700 WITC Legal Description: Acres: 0.600 Plat: N/A-NOT AVAILABLE SEC 21 T31 N R1 8W LOT 2 OF C.S.M. 8/2120 Block/Condo Bldg: .60 ACRES Tract(s): (Sec-Twn-Rng 401/4 1601/4) 21-31 N-1 8W 0 Notes: e67, V\ Parcel History: /Q/-~ "o e Doc # Vol/Page Type VV ~(2 09/08/1997 1263/30 LC V V 09/08/1997 1263128-- WD VI , 07/23/1997 845/551 j2 2006 SUMMARY Bill Fair Market Value: Assessed with: - z S r~. 175371 127,300 Valuations: Last Changed: 10/14/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 0.600 26,300 86,200 112,500 NO Totals for 2006: General Property 0.600 26,300 86,200 112,500 Woodland 0.000 0 0 Totals for 2005: General Property 0.600 26,300 86,200 112,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 115 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00