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HomeMy WebLinkAbout020-1220-50-000 e i STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER SAM M I L L E g ADDRESS 86x .W-292 hUDsou w= s4o/~ SUBDIVISION / CSM# ?ask V;,.; F-'TATC S SC LOT # //8 SECTION / -2 T2 1~ N-R / W Town of HdDS'O 41 ST. CROIX COUNTY, WISCONSIN PLAN VIEW _ SHOW_ EVERYTHING WITHIN 100 FEET OF SYSTEM ~ ?crsa.. La•+v \ Scv~m- t 2s ~ &A4- Le a D AL~~ ` OVA ? i ~ IF ~g'~ G Lrt I I T ~ ~ 0 ~a.41 ~I VC `mss- qou s E INDICATE NORTH ARROW ag'Xys Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. c BENCHMARK: TaP o~ ~:pm- art (.y L*,,Ns✓ F _ /00, Qc7 ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: we,t S r~ Liquid Capacity: Do D Setback from: Well / House /7' Other sf ' to lcrA Pump: Manufacturer - Model# Size Float seperation - Gallons/cycle: Alarm Location :SOIL ABSORPTION SYSTEM Width: Ig Length 40' Number of trenches Distance & Direction to nearest prop. line: s S uja Srt Setback from: well: g~ House 3 Other 6f 7Tc 7a,r /G ELEVATIONS Building Sewer - ST Inlet; ST outlet. lS PC inlet - PC bottom Pump Off Header/Manifold c- Bottom of system? Z Existing Grade G Final grade DATE OF INSTALLATION: PLUMBER ON JOB: ~l-~----,_ LICENSE NUMBER: r4 ?2- INSPECTOR: 3/93:jt FLAI~r`~S'i;ne*art rt IQistr~g7.29.19.1h~v+~~,T,~O'YEHERMAN LAMP County: Labor and Human Relations INSPECTION REPORT Safety and e'uildings Division ST. CROIX GEN AL INFORMATION (ATTACH TO PERMIT) nitary Permit No-: 186513 Permit H Ider's Name: ❑ City ❑ Village [Town of: State Plan ID No.: SAM HUDSON NPBMI, ev.: Insp. BM Elev.: BM Description: f Parcel Tax No.: DO,U lv0,0 ~ 'a lts..~ 020-1220-50-000 TANK INFORMATION ELEVATION DATA A9200398 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 0 ~ Benchmark 1C)5.~ ~Dosing Aeration Bldg. Sewer Holding St/Ht Inlet g qL TANK SETBACK INFORMATION St/ Ht Outlet 01, 15 (,35 Verit TANK TO P/ L WELL BLDG. A ir Ito ntake ROAD Dt Inlet Septic oZ j ' 17 NA Dt Bottom Dosing NA Header/ Man. G1 ~(o ~Sc15` Aeration NA Dist. Pipe Holding Bot. System 10.j S PUMP/ SIPHON INFORMATION Final Grade yL/ Manufacturer Demand o - p Model Number GPM TDH Lift Friction Syestem TDH Ft Loss I Forcemain Length Dia. FFii Dist.Towell SOIL ABSORPTION SYSTEM BED/TRENCH Width Lent No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS O DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type O OR UNIT model Number: System: 6410 O DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length/ Dia-~ Length -34 Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over /J Depth Over / xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges ' Topsoil ❑ Yes [I No El Yes ❑ No COMMENTS: (Include code discrepancie/s~pns present, etc.) LOCATION: HUDSON 17.29.19.1217,SW,SE,LOT 118, SHERMAN LANE r Plan,,revision required? ❑ Yes ❑ No 7 - Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION cou In accord with ILHR 83.05, Wis. Adm. Code ZEEC:OILHR 1 mom STATE SANITARY PERMIT # -Attach c8mplete plans (to the county copy only) for the system, on paper not less than 1:1 GIs 8% x 11 inches in size. Cn re isi 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 $et~r ' /~,r-- UJ '/4 5 ~ %4, S -7 T 21, N, R I? E (or o PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # ,/3o X 8, Z f if CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER s h w.r s c z 6y j k Y;d-W -ftt4--S 11. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) State Owned O VILLA MN OF: R -1 GE : u !L o n S h aT m m a - ❑ Public 1 or 2 Fam. Dwelling- # of bedrooms 3 PAR LTAX NUMBER( b) 111. BUILDING USE: (If building type is public, check all that apply) Z Z~ r 5O 110 Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 90 Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. L.~ New 2. ❑ Replacement 3. El 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 1120 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 430 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 1 -7 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION SO 2-0 7 Z.0 04 2- 5 9S~S Feet 98 00 Feet VII. TANK CAPACITY in allons Total #of Prefab. Site Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank /00 a,w .5 ¢ T- 1 171 Lift Pump Tank/Si hon Chamber Vlll. 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 Signature: (No tamps) MP/MPRSW No.: Business Phone Number: - 1 F ( a r 00 A to - S 3 7 z el, 7) Z 3 St 11 b . Plumber's Address (Street, City, State, Zip Code): go,( Iy/' NAwr 9(67 1Dh0 (~l`/ ~^7 017 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Iss Agent Sign Stamps) Approved ❑ Owner Given Initial Surcharge Fee) A Adverse Determination o X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: BD-8398 (formerly Plb-87) (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. 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 J 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) I I I; U ~ w p U ~i U)w ~o , o o LiJ ~i Lli I p Y UO J O~ oo F- 1 L LI I I LT, CL rn J ~ ~ o, l ~ i i p E-- II, h ~ ~ F= ~ ! II n \ I I a d- 'S < f3 V) z w a ' I'I III ~I ~ il! o I~ I~ ,II o 11 ;I I; I I Z I ICI Z J Ifl Cl_- a Q jl ~ I ~ n I I' Ln a- III ii Q uJ I I I f- I U ~'i III II I n as I) LLJ I I I' it O I ~li II II, ¢ I i;i II IIi I I i Ijl id w 1 II > I l III II! III cr-, I I ! I'~ I 1 ~ I i i; I i ~1i w lI ~j~ ~ I ji w III a l,! w i ill' IiI jli ! II! m I I I i a II Iil U I > III Z j j I C9 'I Iii I > F- Ld ~ III I ~ I i w U I ' I j!i ! 'I > II o L------ =J~- _ Ld - -JI I i ..n, • ~i~ f !(Idw~:... ..w... ...rA....•..q Ti.. {...a ~ ~ iu~..,tnd.ad,~a.;ate, ,~;rll~;..~n zr~.r,F :.T,... g .wiFiM Tye . . ~...o?t..... ..a... _~-,i S ~ • y f8ee legal desariptigo on s r" 74 may, ~ R 8~ r~iT TI Pv- t T.....t.N{•.G.x•. 7" ~t ......o•....r. ter, ` 1f1 J ' J 410 77, J t X .4 ~ Cry IIIrT ` ~ I w..~if.....uws tr4i.L.~ ,.1ffi+f v Jar .Y' Jim s 14 Y it r1 J: Y a w t v1f ~ 4y k ~ ~ Y R. and tbo.,so 104, IW 5 ~b0639 aid : tit Qf' Dl11~~ "ro Croix bOLl1', ~z 'trek ,aArsAafape* purss3# t 1; ° statutes. I~A :k 3 ~y i S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER `f ADDRESS__,EoY Z FIRE NUMBER . CITY/STATE AuSo,ti_ vJ ZIP S yz)h' PROPERTY LOCATION : 5W 1/4,,5E _1/4 , SECTION, T N-R TOWN OF "t, St. Croix County, SUSDIVISION4kt k V_Nvu) LOT NUMBER !1 g . 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: xroo_J,5 St. Croix co. Zoning Office Q -30 911 4th St. ` Hudson, WI 54016 Wscorlsiry Department of Industry, SOIL AND SITE EVALUATION REPORT Page I of Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but ST C>~IX 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 ~M f h jLLe e_ GOVT. LOYjw 1145 ' 1/4,S /`j T Zg N,R /9 E (or) W E OR CSM # YXI~ PROPERTY OWNER':S ING ADDRE LOT # BLOCK # SUBD. _T1k6 _ T,bc do ~&A Q 4 W S Tk CITY, STAT ZIP CODE PHONE NUMBER ❑CITY ❑VIL GE OWN NEAREST ROAD &Sau -5-401b ) SkskP14' L,tnt~' New Construction Use K Residential/ Number of bedrooms 3 [ ] Addition to existing building j ] Replacement Public or commercial describe Code derived daily flow gpd Recommended design loading rate 03 bed, gpd/ft2 (),'Z trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate 0, 7 bed, gpd/ft2 O-Z trench, gpd/ft2 Recommended infilVation surface elevation(s) •Z~ -ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable - ft S = Suitable for system CO VENTIONAL rOUND 1rROUND PRESSURE AT-GRADE SsTEM IN FILL HOLDING T K U = Unsuitable fors stem s ❑ U ® S ❑ U WI S ❑ U [~1 S ❑ U E3 S ❑ U ❑ S EU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. ConL Color Gr. Sz. Sh. Bed Trench A 0 _ Y O 'SL 1 r~ C Z 0.4 O.S7 Ground '76" 16\6A,414 Ns M I1 l 0.7 elev. 100.0 ft. Depth to limiting y factor >A.09 Remarks: Boring # 7-59 21t) -Z 0A 61~ Z . 4 io All S:ti4:•i:•iiiit::ii I LOY ::•nU3tintiti:: 4/ 6a Ground 39'' 4 ~'I S C eao zsft. 47 0 3 3 ~c.~ 3i ni l o g Depth to limiting factor >9.so Remarks: CST Name:-Please Print dlp"k S ,N Phone: 3'S6- AOw Address: Sj~oi1 v o Signature: Datei / 9Z CST Number PKPERTYdWNER SOIL DESCRIPTION REPORT Page? of-1- PARCEL I.D. # Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # 'Horizon in. Munsell Cu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench k7-76 /m mr C Z 0.4O w:-::}.r.>::;;> /Oyk Z SC r rn ~r C Z 0.4 D Ground z 3 a 0 YV1 S C ©7 g elev. lbyQ 3 s~c► rn m 1 1 Q? o Depth to limiting ? ON Remarks: Boring # , Z o S vL,~r,r C 0.4 'O.~ } }'•4•}}};iii: Ground 4 S W► I A, l C •7 Og elev. $3 6~i 3 hti rn O.1 99? I'I ft. Depth to limiting > ~t~z Remarks: Boring # SL r C 'Z OA::()-'g k. 4 a4l s 16-YR Z,/-Z Ground ) elev. !b re 3 3 S~ 4 r3,, Depth to limiting i Remarks: Boring # tt Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) PV Co24e2ov ter t~~~ Z ~Ov.Od ~E~ a r ~ M 09-4 1 J 23' ,r i S T C - 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 in delays of the pormit 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 _bg_rgal V,Jm.rr /sp rri f~7; Ila,~ Location of ('property 5 1/4 S-c 1/4, Section , T-~ L N-R Township ~A. C n,n Mailing address _ILU a gZ_ Address of site :T -o r-u_ vi I-Z . Subdivision name-]W- L/, cw Lot no. other homes on property? yes X No Previous owner of property _F ~KS S rri,~h Total size of parcel -D Date parcel -was created I - q ' cT 0 '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 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. y S y77 y , 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 office of County Register of deeds as Document No. ~s-17-7 i ~f lica t Co-applicant L® ~;I- Date of Signature Date of Signature ~ENs~N I.AN~' M. is ~ 1 as I \ 2 SO ~ ~ r I r , , yon it R Q3 V y~ L -k e, bo 3S~ ~L (-Ipus ~ w~11 ~ I v ~ r fi it ~a bo o~ ~ U h M IN m ~Q m r ~ r c ~ ~ II~ - J