HomeMy WebLinkAbout042-1104-10-000
i
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 7 %
ADDRESS ~d 4z #Z 0 b -l
6z s' 61,-1G avh~✓~5
SUBDIVISION / CSM#/PasQ~~ LOT
SECTION ,2p T N-RAW, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
~r ~ ~~SPG!' !'G C^ IJ,PCf' / I', f I o _ ~ _ ,8 I
rx V
L-7-
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
j 4 1
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer:-Liquid Capacity: /zw
Setback from: Well House Nic Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
.,SOIL ABSORPTION SYSTEM
Width: Length 2 3 / Number of trenches -3
Distance & Direction ton~arest prop. line: 3y t./"/ 41.P
>k~rY¢r~r y~xf lena'
Setback from: well: ~7v House > 7o' Other
r-
B
6
ELEVATIONS
Building Sewer me ST Inlet. ST outlet ~7, zZ
PC inlet PC bottom Pump Off
,.~-1 e6 • ~8 ~ i qs ~6
Header/Manifold #-3 y,j, s, Bottom of system s 9r. rd
Existing Grade Final grade
~3q6, 7y
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
LG ~ °artr ~r ~rt~st~y0.29.18.5~jf&E j~VOJE jfSTEM• 12 County:
.Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division ST. R IX
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION 193410
Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.:
9R, RAY WARREN
BM E ev.. Insp. BM Elev.: BM Description: / Parcel Tax No.:
. 6D . cb" 0,5 042-1104-10-000
TANK INFORMATION ELEVATION DATA A9300069
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic S Z4v Benchmark .ry! y /Gt~.Cd
Do
Aeration Bldg. Sewer
~
Holding St/,t inlet 70.3 97, f4?
TANK SETBACK INFORMATION St/ Outlet 97, /7
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic ' Ilk NA Dt Bottom
Dosing NA Header•~►. 7 Q~ 9~0 7$
Aeration Dist. Pipe 96.60'
Holding Bot. System 7,76 D r
PUMP/ SIPHON INFORMATION Grade
97-5s4
S.7 S6$' r
Manufacturer mand 4.011
M del Number PM
TDH Lift I Frictio System Ft
Loss ead
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width i Lengtty~,~, I No. Of Trenches PIT No. Of Pits Inside Dia. iquid Depth
DIMENSIONS jf(J EN I N
Manuf urer:
LEACHING
SETBACK SYSTEM TO P/ L BLDG WELL LAKE"/'M
INFORMATION Type O Czd- V/ 0~
0 OR UNIT
System: ~QQ. o?S Isar T`<
DISTRIBUTION SYSTEM
Header /Manifold r~ Distribution Pipe(s) r x Hole Size x Hole Spacing Vent To Air Intake
Length Dia-~ Length -z Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over r, Depth Over el xx Depth Of xx Seeded/Sodded xx Mulched
per}+ Trench Center Bee}, Trench Edges _ C39 Topsoil ❑ Yes E] No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: WARREN 20. 9.18 573,N NE, LOT 1, HWY. 12 -
Plan revision required? ❑ Yes (9_IQo o
Use other side for additional information. o
SBD-6710 (R 05/91) Date Inspector's Signature Cert . No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code couNTY
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than El ~ O
8% X 11 inches in SIZ@. Chec if isionto previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPE OWNER PROPERTY LOCATION
'/a,S 0 T N,R (orOZ)
PROPERTY NER' AiLI LOT # BLOCK # r
o RE!`~- !
CITY, ST E ZIP CODE PHONE NUMBER SUBD SI N NAME OR CSM NU R
1A9921 twut o 2
11. TYPE OF BUILDING: (Check one) CITY NEAR ROAD
❑ State Owned ❑ VILLAGE
❑ Public 01 or 2 Fam. Dwelling-# of bedrooms _t PARCEL A NUMBER(S)
111. BUILDING USE: (If building type is public, check all that apply)
4
1 El Apt/Condo `
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 13 ❑ Other: Specify
IV. TYPE PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. L~J New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 51-1 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 0 Seepage Trench 22 ❑ In-Ground 420 Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 12. 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
16mo . J fr l.-Feet APi0 Feet
VII. TANK CAPACITY Site
in ailons Total # of Prefab. Fiber- Exper.
l Plastic
INFORMATION Manufacturer's Name oncrete Con- Stee glass
New istin Gallons Tanks structed App' -1 -1
Septic Tank or Holdin Tank Tanks Tanks tG
Lift Pump Tank/Siphon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plu er's Name (Print): Plumber's Signature: (N Stamps) -MFYMPRSWW No.: Business Phone Number: 31 if 7
Plumber's A ress (Street , City, State, Zip de):
1
IX. CO NTY/DE AR MENT USE ONLY
❑ Disapproved Sanitary Perrpit/Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
) o
Surcharge Fee
Approved ❑ Owner Given initial
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Pib-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 Ydur, sinitary 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 ; .
ubmitted;to the county prior to installat_~pqn. r ,
5. nsite s4*dge systen'1!~`must be properly ihaiAlih d. The septic tank(s) must b2 pumpedrby a licensers
pumper whenever necessary, usually every 2 to 3 years. '
6. If you have questions concerning your onsite sewage system,?contact'yobr local code ad)rmnlstratot or the,
State of Wisconsin, Safety,& BuIldings Divisip_n .608-266-3815
To be'complete nd acourate t#ii*jpanijqQ( 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'f 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
} K performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
5~-fequired 'bj_the county; E) saiJ.test data on &.4)5 form; and F) alf 6* n$,,information.
GR0U*6VA1tWdURCHARGE "A"• ° }
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The r konies:--ctollected through these,s~charges are use for mgnitoring groundw ter, ground-
water c`hta0nfh4ion investigations an establishment'of~§lAiJe' d
SBD-6398 (R.11/88)
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor and Human Relations
Oivision•af Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
St. Croix
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 OWNER: PROPERTY LOCATION
Ray Swagger GOVT. LOT TTE 1/4 nTE 1/4,S 20 T 29 N,R 18 fir) W
PROPERTY OWNER':S MAILING ADDRESS ~a BILO KK# SUB D. NAME OR CSM #
504 Ibinter Hill Rcl. #2
CITY STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE MOWN NEAREST ROAD
RWI.son, WI. 54016 1715)386-6469 Warren 89th. Ave.
[hcNew Construction Use [ ] Residential / Number of bedrooms 4 [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 600 gpd Recommended design loading rate . 5 bed, gpd/ft2 .6 trench, gpd/ft2
Absorption area required 1200 bed, ft2 1000 trench, ft2 Maximum design loading rate • 5 bed, gpd/ft2 •6 trench, gpd/ft2
Recommended infiltration surface elevation(s) 95.85 ft (as referred to site plan benchmark)
Additional design / site considerations rarnmmancl trenchPs
Parent material till plain Flood plain elevation, if applicable n/a ft
t=U Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
Uns uitable for s stem ~ S 1:1 U )l S❑ U ,l S❑ U t~ ❑ U ❑ ❑ S )BU
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trer>ch
1 1 0-10 10yr 4/2 none L. 2/m/abk mfr c/s 2/f .5 ,6
2 0-22 10yr4/4 none sil. 1/f/sbk mfr g/w /f .2 .3
Ground 3 2-80 7.5yr4/4 none sl. 2/m/sbk mvfr n/a 1/f .5 .6
elev.
100.3 5t.
Depth to
limiting
factor
Remarks:
Boring #
1 -12 10yr4/2 none L. ?./m/sbk mfr c/s 2/f .5 .6
2 12-27 10yr4/4 none sil. 2/m/sbk mfr g/w 1/f- .5 .6
3 27-82 7.5yr4/6 none sl. 2/m/sbk mvfr n/a n/a .5 .6
Ground
elev. 9
9q'601 ft.
Depth to
limiting t
factor
>82
Remarks:
CST Name:-Please Print .f"Z
Gar L. Steel 715-246-4i
Address: 1554 2 Ave.,, Ne Richmond, WI. 54017
Signature: Date: CST Number:
2-8-93 2298
PROPERTY OWNER 'lay Swagger SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D. # r
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh.
~.„xBed Tn~ch
1 0-12 10yr4/2 none L. 2/m/sbk mfr c/s 2/f .5 .6
2 2-21 10yr 4 none sil. 1/f_/s114-, mfr g/w 1/f .2 .3
Ground 3 1-40 7.5yr4/4 none s.cl 2/m/sbk mvfr Ow 1/f .4 .5
elev.
99 tin ft. 4 0-82 7.5yr4/4 none sl. 2/m/sbk mvfr n/a n/a .5 .6
Depth to
limiting
factor
>82.
Remarks:
Boring #
1 -11 10yr4/2 none L. 2/m/sbk mfr c/s 2/f .5 .6
2 11-25 10yr4l4 none sil. 1/f/sbk mfr g/w 1/f .2 .3
.
3 25-78 7.5yr4/4 none sl. 2/m/sbk mvfr n/a 1/f .5 .6
Ground
elev.
Depth to
limiting
factor
>78
Remarks:
Boring #
1 0-12 10yr4/2 none L. 2/m/sbk mfr c/s 2/f .5 .6
1... 5 2 12-24 10yr4/4 none sil. 2/rw1/sbk mfr g/w 1/f .5 .6
3 24-84 10yr4/4 noen sl. 2/m/sbk mvfr n/a n/a .5 .6
Ground
elev.
99.55 ft.
Depth to
limiting
factor
>84
Remarks:
Boring #
n\•
F:S
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
STEEL'S SOIL SERVICE t554 2000t./f Ave.
Gary L. Steel
C.S.T. 2298 Ray Swagger New Richmond, WI 54017
MPRSW-3254 NE~,ZTE'~ S20-R18u1 (715) 246-6200
Warren, township
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S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
ADDRESS /I~70e FIRE NUMBER
CITY/STATE ZIP_ 'Vo
PROPERTY LOCATION:-E_71/
, E 1/4, SECTIONADTAd_N-R_ g W
TOWN OF St. Croix County,
SUBDIVISION
,~,j S , 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 thin
30 days of the three year expiration d
SIGNED:
DATE:__
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 permit issuance. ,Should this
development be intended for resale by owner/contractor,(spec
house), then i second fors; should be retained and completed when
the property' is sold and submitted to this office with the
appropriate deed recording.
owner of property
Location of ' property A= ll.I JV E1/4 , Section vim, TA N-R1?'W
Township /aT.?_. I~°~~,a Cs"~S
Mailing address Dy 11,n to. AeliLf /mod AW_J_ A,
Address of site //yo dl "JA1c.-e
Subdivision name Lot no. 1
Other homes on property? yes- X No
Previous owner of property 6-1SI e_
Total size of parcel
Date parcel -was created
'Are all corners and lot lines identifiable? __,X_Yes No
Is this property being developed for (spec house)? Yes _)!~No
Volume293 and. Page Number 155 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 t;la:: i (we) am (are) the owner(s) of
the property described in this information form, by virtue of a
warranty deed recorded i the office of the County Register of
Deeds as Document No. 'yV_s /6 7 , 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 off a of County Register of deeds as Document
No. kpS"io 7
4~
Signa ure of appl nt Co-appli nt
t' I
Date of Signature Date of Signature
"DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING D
STATE BAR OF WISCONSIN FORM 2 -1982
4~ ~1..~`~------ - VOA-- 993PAG~_3_5_5_ FJI~G TERS OF C~
ST. CROIX CO., V-11
Elsie D. McKenna, a single person`
ST I'
B 1 6 1993
5 A
~i`
conveys and warrants to Raymond E. Swagger and Kathryn R.
:gagger, .husband and_wife___________________.._________--_ _ Register of Deeds
-
RETURN TO
the following described real estate in ______-St-.--Croix--------------------•--County,
State of Wisconsin:
Tax Parcel No:
Lot 1 and the East 20 feet of Lot 2, Pleasant Acres in the Town of Warren, St.
Croix County, Wisconsin.
This 18__TlOt-------------------- homestead property.
(is) (is not)
Exception to warranties: easements, restrictions and rights-of-way of record, if an
93
February , 19
Dated this = = ay o
(SEAL) (SEAL)
-
Elsie D. McKenna
(SEAL) - -----'(SEAL)
*
AUTHENTICATION ACKNOWLEDGMENT
Signature (s) STATE OF WISCONSIN
St. Croix ss.
- ----------------------------County.
authenticated this day of___________________________ 19 Personally carne before me s ---l5 -."-___day of
February
ly the above named
-
-
____.Dlsie -n:-"Mcl~enna r'~nra~TS
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