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HomeMy WebLinkAbout016-1008-40-000 vG ~ h ~ c E f•. N t9 O m ~ I M O N O v o ~ > I u 0 O oNa U O ~ h G i O i 1 O ~ O O O V- x O C .C O V! w O O O > ~O O C C 7 N m O U U N C ~ q N aL N E Q In 3 U O V a O £ O Z m m a co ° v I- Z o Z v °c .U a, r 03 ~ ! Q~ Z ? c fA F- r m N ` N N O y N C In N Q) O Cl 0- ~N N o w~ o Q z°mz zo M O ~ LO N H > y ~ y C T O T V O o a a m ° I 0 E '2 0 F- 0 0 0 0 d m •►V a a a (MN "Q S` N N Fly 7 O N U1 _7 U U) 0) rn O /1A~ w o ~ } -o; p N T in O O 0 0 0 O N m m N v a r a y~y C" O s W W Fyi C ° 3 N W C LO OD E ° (0 F ~ N C c CL a) 00 !3r O "O 'O cn .Y Y 'O 00 N O O ° N N = 7 N w O O > G o 3 a) M y Q) in .w O O N m ~ (D 1: C) C/51 ® :a ~ E d a ~,a o a w • R a d u N E yU, Cw 7 Q U a rL II, O fA U ,'x AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP ~~i? ~eJC> c/ SECTION----~/_T,~N-R W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LbT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I V` Irk ,."---„.✓,~i''~ INDICATE NORTH ARROW BENCIU4ARK:Elevation and description: Alternate benchmark SEPTIC TANK:Manufacturer: - A Liquid Cap. off- 6-&' I Rings used: VManhole cover elev: 4inal grade elev:_ 614' J Tank inlet elev.: ,°C .5-- Tank outlet elev.: No. of feet from nearest road:Front , Side , Rear Ft.z,:LN6 i From nearest prop. line:Front , Side , Rear Ft. ~0 No. of feet from: Well- 1419 , Building:- (include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE 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 T ype: Location Distance from nearest prop, line: Front-, Side_, Rear,_,_Ft. Distance from: Well Building SOIL ABSORPTION SYSTEM 1>1 Bed: Trench: Seepage Pit: Width: -,L4j&_Length' Number of Lines: 2 Area Built Exist. Grade Elev. L °L Proposed Final Grade Elev. G Fill depth to top of pipe: cf y y No. feet from nearest prop. line:Front Side', Rear Ft ry 3"az No. feet from well: LNo. feet from building ,moo 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: I INSPECTOR: DATE: 0.1 PLUMBER ON JOB:. LICENSE-NUMBER: 6/90:cj w LOCZJON: GLENWOOD 4.30.15.66,NW,SW,4,290TH ~W sc nsin Department of Industry, Lab rand Human Relations PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: 149317 Permit Holder's Name: ❑ City ❑ Village § Town of: State Plan ID No.: HELGEVOLD JOSEPH MYRON & JU IGLENWOOD CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 01O Cr S~ S 016100840000 TANK INFORMATION ELEVATION DATA A9200162 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic D Benchmark S Dosing Aeration Bldg. Sewer Holding St / Ht Inlet ~oz U (o, SS TANK SETBACK INFORMATION St/ Ht Outlet ~~(J 3S TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet Air I Septic NA Dt Bottom Dosing NA Header / Man. q,05 q l a 7 Aeration NA Dist. Pipe M q-3, 9 Holding Bot. System C) a S PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft oss mead Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED / TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS © DIMENSIONS SETBACK SYSTEM TO. P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type O CHAMBER Model Number: System: 1 acL OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) 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 Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges ~V Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, pers ns present, etc.) Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. L ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ~ G ~i 0A r SANITARY PERMIT APPLICATION =Z7D11LHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY OMENS swnn,~wrso STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than El J? 8% x 11 inches in size. chec 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 OWNER PROPERTY LOCATION Z t/o 0/a %,S T;0 , N, R E(or PROPERTY OWNER'S MAILIN ADDRE LOT # BLOCK # D CITY, S A E , ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ,.I J/ sy of 21 _p- 3*Avror II. TYPE OF BUIL ING: (Check one) ❑ State Owned ❑ VILLLLA =N OF: GE ( NEAREST ROAD wit gal) d d ❑ Public I31 or 2 Fam. Dwelling-# of bedrooms%/-- EL TAX NU R( ) Ill. BUILDING USE: (If building type is public, check all that apply) 016 1 ❑ Apt/Condo 20 Assembly Hall 60 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 OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2. Replacement 3.E1 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 f~ REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION .57 6 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 Septic Tank or Holding Tank C _9~_ I F1 Lift Pump Tank/Si hon Chamber F1 I El E1 1 0 1-1 VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Si nature: (No Stamps) MP/MPRSW No.: Business Phone Number: Z~z z6 L'(10 2 Plum s Address (Street, City, State, Zip Code): 100V - f~- o IX. COUNTY/DEPARTMENT USE ONLY p Disapproved nitary Permit Fee (Includes Groundwater ate Issue R uing Agent Signature (No Stamps) L JY Approved Owner Given Initial L/ Surcharge Fee) V-30- erse Determination //h4 Al? I L I/ VV 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 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. dnsite 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 a// septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. Vill. 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'A 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 (A.11/88) S i C 100 i This application form is to be completed in full and signed by the OWIIcr(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 a 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 Iv e Location of property ~l/4 1/4, Section TZ61 H-RZ,~-,-W Township Hailing address fL,(~~ Address of site Subdivision name Lot no. Other homes on property? .~_veB- Ho Previous owner of property ~h ~i crrcf 7~r~if7e-14 t'r7~ Total size of parcel. acv c r ~S Date parcel was created Are all cornors and lot lines identifiable? _yes No is thins property being developed for (spec house)? Yes X No Volume and Page Number f as recorded. with the Register of Deeds. 114CLUDE WITH THIS APPLICATION THE FOLLOWING: A WARILMITY DEED which includes a DOCUMENT HUIMER, VOLUME AND PAGE, NUMBER & THE SELL Or THE R>;GISTGR 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 Hap shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of ny (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. L1 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/pffice of County Register of deeds as Document No._~~~~Z Signa ure appli.c nt Co-applicant , Date of Signature Date of 8 gnature J- ' V. i SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER `l e e j Q" rya ADDRESS: FIRE NO: LOCATION: 1/4, SEC.- TOWN OF:_ C~ ' wIi!I: c ST.•CROIX COUNTY SUBDIVISION: LOT NO. 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 put into the system can affect the function of tp. What hepseptic 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 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 the St. Croix Count 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: DATE: 3 - y St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 . NDUSRY, OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISON WI 537 P.O. BOX 769 HUMAN RELATIONS 07 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: WNSH MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: 'Y4W1a /T a N/Rc~3 i /Ph n COUNTY: OW ER'S UYER'S NAME: MAILING ADDRESS: Grog' " t ' o / ch oo G/ , &-I/ -;$~g 743 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION T STS: Residence J_ ❑ New Replace -,11 RATING: S= Site suitable for system U= Site unsuitable for system V t-C/0763- 1131"17-& jt+ Q rMS ONVENTIONAL: JMOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) ❑U ❑S U , S ❑U ❑S U EIS U 6 eah~ If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: /Y Q PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. OnD0rr1VED EST. 11GHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- -0 ~y ;7 7 ° ° yr /10 f 4 -3a Ste, ~s s 6 . ~c'~.4 ,y ° ~'O't3 ~►5, ~a "f/ars~, . B-2 'Ovo ? B- Sfu C B- B- PERCOLATION TESTS TEST DEPTH. WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER OIEMkFB AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERTIOD2 PER PER INCH P- rs-~rQ /`0 P- o s' ;VIA P- ~ 3 s P-- P- P- > PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or is nos. Desc,0 who 3~he zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all I g the clod i ~d per of land slope. y0 ✓ `O N SYSTEM ELEVATION f.57-7 .A 69-T" i to P~, € l ~ 7 + f E I i i ;t GK~ i 0, + 3 f 4 + + €t E I I 7-al if 1! Xee, O p fj~ I, the undersigned, hereby certify that the soil tests reported on t V f:rwere made by m in accord with the pro urs a d m~thods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): m er od/ 3 7 / CST SIGN E: w DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - • , I `S INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete I d riescription; 2. The use se lust clearly indicate whether this is a residence or commercial project; 3, MAXIMUM ~ m?)er of bedrooms or commercial use 0anned; 4, Is this r ar placement system; 5. Co lity rating boxes. A SITE IS SUITABLE FOR A HOLDINCI TANK ONLY IF ALL OTHE._ ARE RULED CUT BASED ON SOIL CONDITIONS; 6, PLEA'-E ° .)reviat:ions shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LE'~.IBLE diagram ace rtely locating your test locations. Drawing to scale is preferred. A beet may be used if d( o. sere your benchmark and _._I elevation reference point are clearly shown, and are permanent; 9. C: nplete all appropriate boxes o dates, narnes, addresses, flood plain data, percolation test exernp- tion, if appropriate; 10. If the info in (such as flood plain, elevation) does apply, place N.A. in V ,)riate box; 1 1 . Sign tl i -'ar your current address and your _-AiOn number; 12. Make air-1 distribute as re(tuired. ALL TESTS MUST BE .:LED WITH THE LOCAL t Y WITHIN 30 GAYS OF COMPLETI( ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures # Symbols st - 1011) BR Bedrock cob C . - 1011) SS - Sandstone gr - Grrjel i. der 3") LS- Limestone *.s _ Saw, HGW - High Groundwater c { Pere Percolation Rate reed _ W - well _Bldg - Building l > Greater Than irn < Less Than L, ~anl - Brown sil - It Loam Black si - Sill - Gray cl - Clay Learn Y - Yellow sci Sandy Clay Loam Red sicl Silty Clay Learn t - Mottles sc - Sandy Clay with sic - Silty Clay fev,v, fir' , 'aint Ic - CI''y conin, .'se pl - P Many, gum rr - M: - distinct - prom HWL - High w, , level, Six general soil textures surfa er for liquid waste disposal Bench M 'k Vertical R Point Td THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may rectuest verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. . . PLOT P AN PROJECT Olt / ~ ADDRESS AOA 14 ,1~~1 /4/S /T,o N/R,~ TOWN ~v o !%i .41 r MPRS Byron Bird Jr. 18 DATE °O COUNTY . Gro i BEDROOM CLASS ,27 - x CONVENTIOfN-GROUN PRESSURE- °Z CONVENTIONAL LIFT MOUND_ HOLD G TANK SEPTIC TANK SIZE © LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA _Ae,,j~ PERC RATE g BED SIZE Benchmark V.R.P. Assume Elevation 100' Location of Benchmark Q,Se * H.R.P. 62.0-1-1 ~ O Borehole Q Well Scale = ________Feet O Perc Hole System Elevation Vent 12" rnd TYPAR COVERING 2 " 12" 3' 4 s, 0 9' 1 6 " Sewer Rock 12' ~it hM y,BA v ~o yr `f ~r✓ ' ~l 0'' REPT131 GLENWOOD ST. CROIX COUNTY ZONING PAGE 1 056/14/92 16:03 REQUESTS FOR INSPECTION WORK SHEETS FOR: 5/15/92 AREA: MJ Activity: A9200162 5/15/92 Type: CONVSEPT Status: PENDING Constr: Address: GLENWOOD 4.30.15.66,NW,SW,4,290TH Parcel: 016-1008-40-000 Occ: Use: Description: 149317 Applicant: HELGEVOLD, JOSEPH MYRON & JUDITH Phone: Owner: HELGEVOLD, JOSEPH MYRON & JUDITH Phone: Contractor: BIRD, BYRON JR. Phone: 268-7616 Inspection Request Information..... Requestor: BYRON BIRD JR. Phone: Req Time: 10:05 Comments: Items requested to be Inspected... Action Comments 5- 00012 FINAL INSPECTION Time Exp Inspection History..... Item: 00012 FINAL INSPECTION REPT131 GLENWOOD ST. CROIX COUNTY ZONING PAGE ] 4#/14/•92 16:03 REQUESTS FOR INSPECTION WORK SHEETS FOR: 5/15/92 AREA: MJ sse.:s-s:sssss.-ss ss=ssssosss.-s~^_=.-=sxss.-=sssscc:~.-=-sssss-ss~ss;oss~Ysas=sesmss==sas= SELECTION CRITERIA INSPECTION DATE - 5/15/92 INSPECTOR AREA - MJ REQUESTS SELECTED - 1