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HomeMy WebLinkAbout038-1125-30-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER_dteL 'K ,4~~ Z','Iexl ADDRES F~ 14 /1, SUBDIVISION / CSM# LOT # SECTION .J/ T 9Z N-R_g_W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW HOW VERYTHING WITHIN 100 FEET OF SYSTEM oust I ,3 3 INDICATE NORTH ARROW Provides tback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. r BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: h)Z_SLs Liquid Capacity: Setback from: Well House _;F0 Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length Number of trenches Distance & Direction to nearest prop. line: Setback from: well: House Other I ELEVATIONS Building Sewer 4 ST Inlet. ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system z~ Existing Grade WLZ Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt L s~'~►'s part l`r', ilr,~ i RIE 31.3~KIVA~t t .46fJyS~E~ 4, PALE ounty: .Labor and Human Relations INSPECTION REPORT Safety and Ba~ildings Division (ATTACH TO PERMIT) SanitaryPit& GENERAL INFORMATION ^erm 1 93390 Permit Holder's Name: ❑ City ❑ Village `X Town of: State Plan ID No.: S M Re v Insp. BM Elev.: BM Description: ng-l o.: ~ oo . 0 fi 6J 31 t/ - - TANK INFORMATION ELEVATION DATA A9300039 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic S Benchmark 0/ 3y /Q6 Dosing Aeration Bldg. Sewer Holding St/Ht Inlet -1,g6 93,C/9 TANK SETBACK INFORMATION St/ Ht Outlet aJ q3 Vent TANKTO P/L WELL BLDG. Airito ntake ROAD Dt Inlet Ar Septic NA Dt Bottom Dosing NA Header / Man. 3 Q 3, 03 Aeration NA Dist. Pipe 3g 9a Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade 5-, d-t' Manufacturer Demand 6 S '6 95,7 Model Number GPM TDH Lift Friction Syetem TDH Ft Forcemain Length Dia. FFii Dist.Towell SOIL ABSORPTION SYSTEM BED/TRENCH Width Length , No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION /a / DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O n t - ~ t CHAMBER ) ,1 CHAMB Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold a Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake n.t Length to ' Dia. ~ Length _3_3 Dia. Spacing 6 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 c Bed /Trench Edges Topsoil El Yes ❑ No E] Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Viz! LOCAION: STAR PRAIRIE 31.31.18.515A,NE,NE,%L6T 4, RALEIGH RD. A "I R V t _ 1 ~ t 'j, ~1, tnC.1UfG111-0 1,60 Plan revision required? ❑ Yes ❑ NO b Use other side for additional information. SBD-6710 (R 05/91) Date ` Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: " i D~LHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY 1.= STATE SANITARY PE MIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 K8% x 11 inches in size. c eckfif Jil previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPER OWNER PROPERTY LOCATION '/4, S2 T 3,L, N, R E (or) PROPERTY OWNER'S A 1 G ADD S LOT # BLOCK # / 91! 4Z, 2Z CI STATE ZIP CO E PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER CITY NEAR T OA II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE ❑ Public M 1 or 2 Fam. Dwelling- # of bedrooms C2 PAR LTAX NUM ER( ) III. BUILDING USE: (If building type is public, check all that apply) 1o7~~~D©d 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. ® 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 12 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. rich) ELEVAT ON Feet 91, Feet VII. TANK CAPACITY Site INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. New Existing Gallons Tanks Concrete glass App. Tanks Tanks structed Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber El I F F] El 1-1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installati of the onsite sewage system shown on the attached plans. RSW No.: Business Phone Number: Plu a 's Name (P t)~ Plumbatur v MP/MP / , 1 Plum s Address ( rest, City, State, Zi C de): W. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sa ry Permit Fee (includes Groundwater Date Issue Issuing Ag t Sign NT!~~ Surcharge Fee) Approved El Owner Given Initial d/~~!~~ Adverse Determination D(~~l 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-Pprmit is valid for two (2) years. 2. 'Youfrsanitar,l 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. Ill. 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 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 Oe 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 6114 V' !Location of prop erty"/&5~- 1/4 1/4, Section, T_:LLN-R_L~- W Township f-7 -2 Mailing address Address of site subdivision name - Lot no._. Other homes on property? ves L, -NO Previous owner of property J D O~v alLr Total size of parcel Date parcel -was created Y Y ` Cdh / 7 9 3 'Are all corners and lot lines identifiable? - Yes No Is this property being developed for (spec house)? Yes "JZNO Volume_I&OV and. Page Number f Z~ 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. 4,/ 9?& Z6 S" and that I (we) presently own the proposed site for the sewage disposal system oro (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. 9:4S--- Signa re of applicant Co-applicant .t D e o Sig ture Da a of signature I ~ a I '1 i; I Ji L) -t V G;j I _ } Q it ii I i I - - t} _ II SFy of i1 mom AI~ I, This dee;l is givi. rn p+zY F i~it to an o flez of di4 r.ce d=tteU M. iri b 17, 1993 in St. Croix Covmty, F'i.:c<_,zzs;.n. it This i5-- (is) (is --n--o-t-) horarat ppoer±y. 9 Ds.te, this - , - da of Mat' :s ,i Ir _,4 4 A 1, - Q M at t k M F.ivt - f/k/a STATE 07 a : s P Cu A :I - coon! i... K'. ~ :ft.:' t•...j diy Ge autl,-t teat,c3 this - de.✓ o£ 19 - ~ lE'I (1 lIy 1- M--~ r n 14 9 3 the a v5 e ndm-d arid - ---------..M_r.J TITLE! MSS7Ii", RS'fA±-r'- BAR OF Itis~:J`ON (If no*> " - a"ut%rorr-ea by § 706,.V,, Wis. Sta,s.) to ma kr.; _.q 'v h . the Fwna S -who max.ml the { THIS INSTRUMENT %I~S DRAFTED BY R} t i.i l ON LAW L iv L J'adrra A R i :gy n. k.ur fft/1k1~1 !j_ ` a - ! t J i y ..New R chno,1' _.5401---- co - h una, Wis. - , tbe DS" Ct, twit's 00u". nmy b_~ U ~ ^:c 3 Et e~., a ~~,r. d - r~ Sa?7a CT-`,. t+r ` 'L}A k-: _ - T. B_.k Fr M,. W:,. Ml J. SV (~J C r e i_y ~C .fi k r Z {t 7t, i t+~ 8;! ti dct i re : ' 2 9 -S oo fi R,"•i i?.,', °y 7s 4 ~3,~ "~4~.. ~l~tN'0 29 5 C ,a 7 r clx:a=' irk - C e F r 1 Lc:~~ 3 o 1+' e 3 E t k r! `i i S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER o ADDRESS ` FIRE NUMBER Q O G CITY/STATE, ZIP_ S--1K0 / PROPERTY LOCATION:Q[_l/4,j~',1/4, SECTION, T,-?_LN-R_Z2 W TOWN OF , 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 ate. SIGNED: G DATE: St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Pa e Of Labor and Human Relations g Division of~Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COU NTY 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 PROPER OWNER: PROPERTY LOCATION GOVT. LOT A~r _ 1/4 114,~3 T / N,R E (or PROPERTY OWNER' RAAILIN AD S LOT # BLOC # SUBD. NAME OR CSM # CITY, STATE ZIP C DE PHONE NUM ER CITY VILLA OTOWN LIT SJ ROAD "1,17 V1 / - - New Construction Use Residential / Number of bedrooms [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate 1~bed, gpd/0_.,~trench, gpd/ft2 Absorption area required bed, ft2 5-C,_~? trench, ft2 Maximum design loading rate __,7 bed, gpd/ft2_, S_trench, gpd/ft2 Recommended infiltration surface elevation(s) 9 7 ft (as referred to site plan benchmark) Additional design / site considerations Parent material - 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 IBS ❑U R] S ❑U 0S ❑U IBS ❑U ❑S ~U ❑S ®U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. C;ont Color Gr. Sz. Sh. Bed Twich ti:t i Ground E -7 elev. IqLL ft. / - 7 K", A71 Depth to limiting factor Remarks: Boring # 04d cL Ground elev. > - Z6t. -ze Depth to limiting factor Remarks: CST Name: Please Print J Phone: Address: Signature: r' Date: CST Num er: ij PROPERTYOWNER,~~,P~~~ SOIL DESCRIPTION REPORT Pagep~,2 6f , PARCEL I.D. # ' Depth Dominant Color Mottles Texture Structure Consistence BoundEky Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. nt Color Gr. Sz. Sh. Bed Trench tiff:...... ~ , ;h<> D, Ground _ elev. 9s2ft 0 - - y Depth to limiting factor Remarks: Boring # Ground elev. s- r ,9~ ft. Depth to limiting factor Remarks: Boring # Ground elev. _ ~~ft. [57- _ .S , Depth to limiting factor Remarks: Boring # ti Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) : I _ ~ I 1 ~ i I I ~I ~ i ~ ' 1 i 1 I I 1 1 I J I ' I I I I *Y„''..--Y-T~-----y- I----r- - - -TT A 1) 4 -I - - I 1 , I I I I ~ I I I , ! I I I i J ? 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