Loading...
HomeMy WebLinkAbout020-1136-20-000 I ~o O 6n, h 5 C O O ' N ~ N x O N O C N O v ~ O NN C ~ > O Ol 00 Q ~ 3 Cl) z H rn z o o z w a co ° z O z d c m N Z 'd fq f- ~ ~ I aD E (D co t! CL 0 0 in cn (D (D O O O N o_ U 6 N N c C7q, U O O p N Q ° N N N Q z I- z Z o o c c y N E N ~ CD m - L 0 NNO O f LL II o c a E > co ' p H H H 10 o 0 0 ~ • m a a a a 7 0 N O N N N fA U N -O rn m S 7 } N LO ~ O ~ ~ O O O ~ O _O N '6 m N M a N Q t0 cj U) ~1 7 ~I O ° O y C C C E to LO w O C GCC N O OLr N y U(L 0) 0 0 N N M c O O N N W\ 04 0 Q) 00 0 C L (n 'IT O O N E O N 2 O N O . a i tc a Q daw y E AS BUILT SANITARY SYSTEM REPORT OWNER ~u 8rddef.sa?j TOWNSHIP- SECTION--5 //TON-R~W ADDRESS CIS /Eon ST. CROIX COUNTY, WISCONSIN SUBDIVISION ~4 ,e ; jL- -LOT Z-3 LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM • 6014" e I p,:- J ~ t ! ,rm A4 Lot A i4s ~ la Sy 6 i i 39 25 , ~Q5 LDS G.w 6 INDICATE NORTH ARROW BENCHMARK:Elevation and description: .4a4. T Alternate benchmark SEPTIC TANK:Manufacturer: ~r Mks C.f Liquid Cap. /'004 Rings used: 3 Manhole cover elev: Final grade elev: Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front XC , Side , Rear Ft. From nearest prop. line:Front Side X , Rear Ft. 70.. No. of feet from: Well J` Building:s (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: /14 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: X Seepage Pit: Width: S Length 6o Number of Lines: 2 Area Built Exist. Grade Elev. 47 Proposed Final Grade Elev. Fill depth to top of pipe: yam No. feet from nearest prop. line:Front , Side X, Rear Ft. 76' No. feet from well: ~ No..feet from building Va HOLDING TANK ~ Manufacturer: / V/4 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: z der Ten #V- LICENSE NUMBER: 6/90:cj ~V,CAsc irlrRepart HUDOSt Y 9.29.18 6PRI~/AY&AGE SYSTEM RD A County: tabor and Human Relations INSPECTION REPORT Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary PermitNo.: Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.: BREDERSON VAN HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: f TANK INFORMATION j ELEVATION DATA A9200250 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 4VIrr: `s, p Benchmark job s ~p 0~ d Dosing Aeration Bldg. Sewer Holding St/ W Inlet 7, 96, 9810) `7 TANK SETBACK INFORMATION St/of Outlet 9~/~ /3 TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic '70 .1-S" NA Dt Bottom ~5~4 S3,7r s Dosing NA Header/ Man. 8e o q 1: -..-a 93•G Aeration NA Dis 46. by t. Pipe g,w "!3. I 10,04 Holding Bot. System It) pu ~t ! PUMP/ SIPHON INFORMATION Final Grade 5.$3 q6, ~Y Manufacturer Demand 3 A,, f;y, Model Number GPM TDH Lift Friction System TDH Ft Head 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 G Length DIMENSIONS LEACHING Manu acturer: SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM INFORMATION Type O CHAMBER Model Number: System: -YWf 4, OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. r_f F Spacing / SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over /1 Depth Over r f xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center, Bed /Trench Edges y Z Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) + 7 rc> Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH ` SANITARY PERMIT NUMBER: DILHR SANITARY PERMIT APPLICATION y In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITA Y PERMIT -Attach corrfplete plans (to the county copy only) for the system, on paper not less than 1:1 2~fr ~ itp 8% z 11 inches in size. Ch k wsi r evious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPTY OWNER PROPERTY LOCATION F-^ 6rdaz;SOA jVe_ Y. N E_ '/a, S I T , N, R 2-fl (or 18 PROPERTY OW ER'S MAILING ADDRESS LOT # BLOCK # e,4 Xa/ .4 6,4 1 CITY, STATE ' w ZIP CO E PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER Gv, 5 U .14 wea cv 6 II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD State Owned VILLAGE ❑ Public C51 or 2 Fam. Dwelling-# of bedrooms a PARCEL AX NUMB _X13 c1~t -COO III. BUILDING USE: (If building type is public, check all that apply) -F Cv✓ 1 ❑ Apt/Condo `D 2 ❑ Assembly Hall 60 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. Ix New 2.E] Replacement 3. ❑ Replacement of 4.0 Reconnection of 5. ❑ 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 14. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE J~ REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) D ELEVATION _16,K &&Z, • 5 7 or. ~ Feet f'2. v Feet VII. TANK CAPACITY Site in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New lExisting Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Holdin Tank oaep l ".415141T U Lift Pump Tank/Si hon Chamber 1:1 El 0 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' Signatur=Smps) MPAAR SW.No.: Business Phone Number: Jr ,s r/ i•~ 3 2Z- 77 2, 3z t Plum s Address (Street, City, State, Zip Code): 31_-2r as -1-4 ~v Z<,), l5au J ~ IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved S$y~itary Permit Fee (Includes Groundwater ate Issued Issuing Ag m Signature No Stam Approved ❑ Owner Given Initial 0t/ p/~/(( Surcharge Fee) Adverse Determination ` O V ~ G0 X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBDf398 (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 submytted 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: . 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) APPLICATION FOR SANITARY PERMIT 8TC- 100 This application form is to be completed 1n full and signed by the ovnet(a) of the property being developed. Any inadequacies will only result In delays of the permit issuance. -Should this development be intended got tesale by owner/conteactoc,(spec house)- than a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - "M - Owner at property U/Am A~-ee ee`5- n Location of property 1=c-1/4 /1/<,1/4, section Township 144 15oxi Malling address Address of site subdivision name Lot number od-~s ~'~l /Lrc1i Previous owner of property =f~ eel Total also of parcel Date parcel was created Are all corners and lot lines Identifiable? Yes ~_J1s is this property being developed tot resale Capec house)? as X 0 Volume q'0 e7and Page Number as recorded with the Register of Deeds. - - • - - - - - - • • - - - - - - - - - - - - - - - - - - - - - - - - - - • - - - - INCLUDE WITH THIS APPLICATION THE FOLLOWINCt A WARRANTY DEED which Includes a DOCUMENT NUMBER, VOLUME AND PAGE Numan, and the BEAL OF THE REGI8TER OF DEEDS. In addition, a cartlfled survey, It available, would be helpful so as to avoid delays of the reviewing process. it the deed description references to a CeitIlled Survey Map, the Cartl,led survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(Vs) cettlfy that all statements on this form are true to the best of, my (out) knowledge; that I (we) am (ate) the ownerts) of the ptoperty described In this lntotmatlon totm, b virtue of a warranty }a to ocded in the Office of the County Reglstet of Deeds as Document No. and that f (we) presently own the pzoposed site for the sawaga disposal system tot I two) have obtained an easement, to run with the above described property, tot the conettuctlon of sold system, and the same has been duly recorded in the Office of the Count Registst of Deeds, as Document No. Signature of owner signature of Co-Owner (if Applicable) Da of elgnatote Date of Signature M AV r .Yao.~ an and a'wrra u aan. V..-Qred"on" ailRt.lca bayrino': lson, ° and ~ri#~• ss ,~aicital. w' Mity, Mi Law s fojkp+Ri*g 4naib" Tom Mtate In J" I"Oix ..Count), Tax Parcel No: E x:44.63, Willow Ride 20. Addition to the TOW Of Hudson.ii not TTIAN hObws b-4 p"rt>. p f 'r"4 N#f °sny.. F . aap May UNI TCU WEE IIQD. C t1ilC~t OF for Uni 'td`+ieth©disL C k (4EAi.1 c. AQTU RN*10A?IOK ACKNOWLBDfi>ti!>lEisT `f 4s1 STATE OF WISCONSIN St. Croix County• awtianckst.d ths. a.3 of is Pr a ~nally Hermansen t y cklvin J."hrirai`i for United ' ithodist' Church bf' 'IME: 1(L*MBBR STATE,' BAR OV WISr.ONSI ti - artlwrieel by-~ -T+14A6. W i~ Stata.l to nt" krtnw n to he the rwr,nti who fare oinfi instrumf nt anYl acknowledge the, a y ,~i3TRy:JeE HT tN~t G}+4/SfG Rv ' ' William J. Radosevic~t{ ornej at law . " Karen J /any,).wren 502 Second St., *Wson, 5015.: Ss. Croix (signsu"" may •athentiraW or ne ngvrt.dapd, twr N±• t•nnivn erYnn i+ tKrmaw nf.0 Mot 't t' us not nerr a`ty.) date: Dete;.sber 22 ~q ~11.a+ r,fO1M[ pr 41H ~nR/MeiQr:..lin•r~A be tl"ltert ~T+~. Y,!4M1'!~ flv (1' .i~ -qq^ ~ ~YS~- '7r~- •iif..r'~'i?;:., _~..ite~tb~...i~.'}ioiYi'i~i.~iVi..3` r+i4~Y'._"<r~. ,._r STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT w St. Croix County 'J r w OWNER/BUYER o ROUTE/BOX NUMBER Ct~rj~ Fire Number :3 CITY/ STATE AZL-Z0 2 ZIP v ro PROPERTY LOCATION:'.•OJE k, ~Ek, Section If T N, I-RW, Town of St. Croix County, Subdivision !Jowl ✓ ee Lot number. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed 's'ept'ic tank pumper. What you put into the system can affect the-function-of the septic tank as a treat- ment stage in the waste disposal system. St. Croix County residents may be eligible to recieve 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 sys't'ems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or.a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and .(2).after inspection and pumping (if nec- essary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. H I/WE, the undersigned have read the above requirements and agree 0 to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Depart- went of Natural Resources. Certification form must be completed •d and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED ll~z DATE 91 St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. SAFETY & BUILDINGS p~ARTMENT OF REPORT ON SOIL BORINGS AND DIVISION fADUSTRY, LAr R ^ P.O. BOX 7969 " (115) MADISON, WI 53707 HUMAN RELATIONS PERCOLATION TESTS (H63.09(1) & Chapter 145.045) LOCATION:, SECTION: TOWNSHIP LOT NO.: BLK. NO.: SUBDIVISION NAME: 1/ F~/ /T;? N/R'l E ( / . 1 ~~cx uCc f. e, 3 COUNTY:, 0 NER'S ff E: MA LIN ADDRESS: USE DAT O S RVATION MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFIL DESCRIPTIONS: A ION TESTS: I ©~esidence ®lglew ❑Replace ~S J RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MO~UN~`D: IN-GROUND-PRES'SIURE: SYST]EcM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) CAS oY E]J S ~V EIS El ~ El V r 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: '411491 1 4 PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 13- /m 'A B- 7 B r > / / l S / *13, 5 r is f9, 5" b B.e 9 PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 P RI D2 P R PER INCH P_ sir (arLr ? 7 P- P- L 3 > ? P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori• zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION. a»! s , . i I j I S~ I z ~ I I : t f CC, f r tN j e 1 i I 1 ' f ' 1 i AL_1 , i - I f , f ~ ' ; I I I i I 3 ( f I , I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods 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: WE FMM PLUMBING CERTIFICATION NUMBER: PHONE NUMBER (optional): Licensed Perk Tester &S Plumber #3233 #328 Fogerty Hei~i tS Oa T SIGNAJLIRF- RO_ ERTS WISf4vINSIm 54023 c~ D;Iil " DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - , 9 N i a vti u' . •,w. r ry IN" 1 i, ` y • O Y. WK- Vj Y ti pit RZI :a: ~ i JOB l/G~t 4~ r g a `c TIMM EXCAVATING SHEET NO. OF Route 1 Box 192 _ Z WILSON, WISCONSIN 54027 CALCULATED BY Y /J DATE (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE - < , . . . . . . _ i • _ > b. 6 W r 1' W o... _ jF7 T +o a ~ N . b . O A tt i r - a ry e, v r,_- ~r P • ~ O PRODUCT 205-1 Inc., Groton, Mass. 01471, To Order PHONE TOLL FREE 1-BOo-225-M Joe l~i. nre~c.-sue • TIMM EXCAVATING SHEET NO. 2 OF Z Route 1 Box 192 G _ _ 2 WILSON, WISCONSIN 54027 CALCULATED BY DATE (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE f e f.... 7..... < L..__. _ 4 . : a . = v. 61 qi2 2 < D PRODUCT 205-1 ~p Ina, Groton, Mau. 01471. To Order PHONE TOLL FREE 1-800.225-6380 REPT131 HUDSON ST. CROIX COUNTY ZONING PAGE 1 11/10,/92-10_45-_-REQUESTS -FOR_INSPECTION _WORK -SHEETS -FOR: 11/11/92AREA: _NJ-_ Activity: A9200250 11/11/92 Type: CONVSEPT Status: PENDING Constr. Address: HUDSON 19.29.18 672,NE,NE,LOT 63, CO. RD. A Use: Parcel: 002-1136-20-000 Occ: Description: 171482 Applicant: BREDERSON, VAN Phone: Owner: BREDERSON, VAN Phone: Contractor: TIMM, ROGER Phone: 772-3214 Inspection Request Information..... Requestor: TIMM, ROGER Phone: Req Time: 09:11 Comments: '7"36 Time Exp Items requested to be Inspected... Action Comments 00012 FINAL INSPECTION 6 711-0. Inspection History..... Item: OOPX2 FINAL INSPECTION