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HomeMy WebLinkAbout020-1220-80-000 4 ~ FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER Sc,dn TOWNSHIP Ya d So r1 SECTION T ADDRESS ~~y2~j Z ST. CROIX COUNTY, WISCONSIN SUBDIVISIONL,~ t ~SfQf 5 2: LOT / y/LOT SIZE PLAN VIEW I SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM -r 830. 7- e ^ I PC- IE Im 00 Sc~~E_ ~Y . /D a a \I ~ 3n 1 ~ ~ /a/o Scaly r ~ lv ~8 qo ~ ~ N G4 ~a ~ c. Jaous a... 3yxsy ,oaQxSO~ well r INDICATE NORTH ARROW i BENCHMARK: Elevation and description: %T e F / ',aa EA dv Alternate benchmark ~o P 6 SEPTIC TANK:Manufacturer: W4r-z'~4v-1/ _Liquid Cap. ddz9 ;o1 Rings used:? Manhole cover elev: 3.77 Final grade elev: a Tank inlet elev.: ?,0 Z_.- Tank outlet elev.: 7.3 7 No. of feet from nearest road:Front , Side , Rear7Ft./~ - 5-From nearest prop. line:Front , Side)c , Rear Ft. S"2 No. of feet from: Well ?D Building: (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE r r ~ PUMP CHAMBER y~ 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 Type: Location Distance from nearest prop. line: Front-, Side, Rear_Ft. Distance from: Well Building SOIL ABSORPTION SYSTEM Bed: Trench: Seepage Pit: - Width: / Length '7& Number of Lines:-3 Area Built72,0S,*-?-'"- Exist. Grade Elev. C2 Proposed Final Grade Elev. ~Z, .~-C7 Fill depth to top of pipe: 1/0"' No. feet from nearest prop. line:Front , Side , RearAFt.z&' No. feet from well: ~',O • No. feet from building 3 $ 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: INSPECTOR: DATE: PLUMBER ON JOB: LICENSE NUMBER: 6/90:cj , +WJM, -trrklTJI?gPAtr~7.29.19 - lM~A.jISTVk '1 %,r&NSON LA ounty: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division GENERPtL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Permit H01 er's Name: ❑ City ❑ Village ❑XTown of: State Plan ID No.: Elev.: Insp. BM Elev.: BM Description: n Parcel Tax No.: 4~/ - - _Q00 A TANK INFORMATION ELEVATION DATA A9200370 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic e ~ r Benchmark ea Dosin /053 Aeration Bldg. Sewer Holding St/0 Inlet 7 pZ~ TANK SETBACK INFORMATION St/ ILK Outlet 37 TANK TO P/ L WELL BLDG. ventto ROAD Dt Inlet Air Intake Septic a ' NA Dt Bottom Dosin NA Header /±6ok. Aeration NA Dist. Pipe Holding Bot. System ,52' PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand 110 M Number GPM rd, ay S T 2 y' TDH Lift Friction etem TDH Ft oss Forcemain Length Dia. SOIL ABSORPTION SYSTEM BED /TRENCH Width Length / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN I N /e 9V D SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHI Manufacturer: SETBACK del N umber: INFORMATION TypeO C A~ CHAMBER System: ZD e DISTRIBUTION SYSTEM Header /-Maff4e4 Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake LengthtllL Dia. T r Length AV Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Ifft ) Depth Over O , xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center 27 ' Bed /Trench Edges G'f ' 7l~ Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 17.219.19.1220,SW,SE,LOT121, JENS/Or~N LANE l". Uv nn ' Plan revision required? ❑ Yes E~.Pkr'- Use other side for additional information. F SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. a' ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 0 SANITARY PERMIT APPLICATION DILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY PER T#_ -Attach conlplete plans (to the county copy only) for the system, on paper not less than ir,8th x 11 inches in size. ❑ Checkk v or previ m 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 S~ li(fc s~ S LtJ'/4SE '/a, S T o2 N, R E (o PROPERTY OWNER'S AILING ADDRESS LOT # BLOCK # 4'Z,f Z__ Z CITY, STE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ~d Gv.r o ~a'~ a~ e3 Q~~ ~;ss ,Oo II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD ) ❑ State Owned ❑ VILLAGE: Ta,,,,s en ~ti ~ 52 =N QF: ❑ Public 1 or 2 Fam. Dwelling-# of bedroom PARCEL TAX NUMBER() © a0 _ Z ZU go III. BUILDING USE: (If building type is public, check Z11 that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 1o ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ 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. ❑ 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 NSeepage 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 / 10 2,0 720 ' yS 00 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 Holdin Tank 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 Stamps) MP/MPRSW No.: Business Phone Number: PouglG< S roA6ctl /('fly' 3z J)32 Plumber's Address (Street, City, State, Zip Code): 8,~ f ~z .NO lm A 04mo f J w. s 1017 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sa ' ry Permit Fee (Includes Groundwater Date Issued issuing ent Sign lure (No S mps) Approved ❑ Owner G iv en Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to county, One Copy To: Safety s Buildings Division, Owner, Plumber s INSTRUCTIONS 1.:_ _ A sanitary.permit invalid 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 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 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 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 in delays of the pormit issuance. ,Should this development be intended for resale b owner/co by ntractor,(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 Sa ,m /yi; /~at~rZZ4e &,111 w,-, - Location of•property5_40-1/4 S~E 1/4, Section J 2 TAN-R_ZFR Township so r._. Mailing address &4,K W-1 Address of site Subdivision name-4-4/4 Lot no. Other homes on property? yes- X No Previous owner of property _ VJO ✓1 Total size of parcel _1.X1c m✓ g Date parcel -was created I ?f c/ Are all corners and lot lines identifiable? Z _Yes No Is this property being developed for (spec house)?Yes No Volume %o Sand. Page Number S to S 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 . _ 9 4o4,2 , 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. 39' LQ G 3 . gnature of applicant Co-applicant r. Date of Signature Date of Signature Yi l ~1 Y:r ~ ~.F i~ f ~e y~ M YM,~1I Y .ya'~ n ~ ;.ti air ~`;F [ • _ x ' ~ ~ ~ .3► ~"s {yam • H .~I~~iE k' a •sd` ~~1>f ~ ~ p y`.F~`, ' Q ~ ~ I .A ~ S 'i Im', I•'~ t: M f V r 1 ^7 a.~'7'~.' .,i}"~:~"•'',• :,:tray` wp} 444 tv; t'+ti'' '4S M'~y loft y' 1 411 ' 1`rp' rs'a I S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ADDRESS L3 ©X # 2" 8 L FIRE NUMBER CITY/STATE__14r,PSa yV~ ZIP PROPERTY LOCATION :5 O 1/41S 1/4, SECTION__-7-1 T-:L2_N-R_LeL& TOWN OF S a v~ , St. Croix County, SUBDIVISIONT" ~ Vi LW ta~~5 , LOT NUMBER Z . 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. J SIGNED: DATE: . 7 -1 Z, St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 Wisconsin, Department of Industry, SOIL AND SITE EVALUATION REPORT Page i of 'S • 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 ► Clx 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 Q 5A lot M I Lj,L (Z• GOVT. LOT -5tn)1/4 5 L 1/4,S T z N,R ` E (or) W PROPERTY OWNER':S %LING ADDRES,~) LOT # BLOCK # SD. NAME OR CSM # `rQ6 ,-r 2~>< K b JZ I f 'ap2k- I EW LA'S; S CITY} ~TATE ZIP CODE PHONE NUMBER ❑CITY ❑VIL GE MOWN NEAREST ROAD NUS W) s46 16 ( ) u~so New Construction Use Residential / Number of bedrooms [ j Addition to existing building j J Replacement [ J Public or commercial describe Code derived daily flow A~6 gpd Recommended design loading rate 0•7 bed, gpd/ft2 b,I trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate 0.7 bed, gpolft2 0.% trench, gpd/ft2 Recommended infiltration surface elevation(s) 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 Ir~ROUND PRESSURE T GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem MS ❑ U 0S ❑ U WS ❑ U S E] U g~ S❑ U ❑ S 96 SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends t w« CZ., _ I b~ n, r Z 0. L a Ground 39'' / p 3 4 •7 elev. !oo Xft. $ sa,. /oY~ 4 4 fts O n,1 ? i0.g Depth to limiting f ct~ or Remarks: Boring # ! D Y 3/ b r G 4 le) B) -7, 16R, 63 SL La~~-nnl t-11 r I O O.S~ Ground -L 4/ /d 3 4 _ AIS4 Ik 0 9r) r1i ,7 : 1 elev. S'?'' Q d MS 1 6.7 • X jd,3Lft. Depth to limiting 7 If tor67 Remarks: 6_ CST Name: Please Print Phone: 1'~r ~.,J( /Sam Address: /,v~~ w, S`to1 b 3oi4&Zd~J7&j luty k'x Signature: N Date: ~,c CSTNumber3~~~ PROPERTYMNER SOIL DESCRIPTION REPORT Page Z of 3 PARCEL I.D. # Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon Texture Consistence Bourbary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends ~;xA;: /o` 3 3 I 4bk r~r 1 o.4 S Ground Z" 10 XP, 3 `t S e: yL~' C, 0 -7 O elev. „ l .Lat. 13 Sg /a ',e4 3 5 0; U rh l I G.7 O$ Depth to limiting ~ f ct 3 Remarks: Boring # :;:;i '•4:•tiiti , S /d rK 3 L, J 4 b K rv! 0'4 o. r:::< 1 g ! k V3 L l (oK r C .S Ground1 -7 7a 16/k 4 Q -X4 rh 1 4.7 6 Z elev. IQL pzft. Depth to limiting f ctor ? Remarks: Boring # OZ. k, .4 -Z6 th OL 16 yp 0-4: Ground 76 /o YP-4 4 5f4g i'h + O o.$ elev. I" ft. Depth to limiting ~ f ct~ or Remarks: Boring # aLi~A svi~~: Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) I Q( ~ A Lor Catij&-k - FL4J -100 ad" , , 1 -'C 1 4 ~1 ~Di NG 7055 !fir ~ 1 _ f ~ 1 •Z Ski KRf ~ 36 ' M Aky i i v' ~ J ~ 'SUQ LL 36* Q ZG' ale ;Z /40 • 'R. M. To r o{ l f.4, NF a r E AlG 5 32 lv/7-/ ~L SENsoiy L~rVf_ A. 7ve t( 1- loot, ~ I-ago, I'A lzl i 0\0 r A F T A 54, a F35 ~h(oa s'c 50 b1 Geiafa ~S'Xr/y 10 3s40 z4 n t . rat;ham ~L-tB,oa i "t ~sw {ui _a r t I ^ i~ i! rn p i i O t! i m }I' i 1 m j I r., li I I zl i y I lj p {i t -Az ~y m ~ 1 t I 1 70 © t ( I o 1 i ! w ! 1 "t7 ~ i ! ,A I W f ,L .11. I~ 1 pX Q i ~ do--. i -C{ ~ ~ ~ t x~7 i ~U X ~ ~ \w T` z m -p A c n c j I # J REPT131 HUDSON ST. CROIX COUNTY ZONING PAGE 1 ,21/05/92 14:38 REQUESTS FOR INSPECTION WORK SHEETS FOR: 11/ 6/92 AREA: JT Activity: A9200370 11/ 6/92 Type: CONVSEPT Status: PENDING Constr: Address: HUDSON 17.29.19.1220,SW,SE,LOT121, JENSON LANE Parcel: 020-1220-80-000 Occ: Use: Description: 180289 Applicant: WERT, DARREL & BEVERLY Phone: Owner: WERT, DARREL &tBEVERLY Phone: Contractor: STROHBEEN, DOUG Phone: Inspection Request Information..... Requestor: STROHBEEN, DOUG Phone: Req Time: 11:11 Comments: 11!66 Items requested to be Inspected... Action Comments Time Exp 00012 FINAL INSPECTION Inspection History..... Item: 00012 FINAL INSPECTION i