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HomeMy WebLinkAbout020-1185-60-000 Q ~ o © O o o tr ~ ~ °o N i N V 9 d ~ O x fV y O Fr C f9 ~ U O O C ~ y L r_ LL O 0) C) (D Q ~ 3 ch v o > z y O ~ r o 7 L Z d d 04 a m N F- U) O 2 d cC O Z d 7 CD C N O O (6 CU N y N N U L O N Q Q © Z co z N Q LO m N - dl ) a m w ~ O 0 a O N U) U) N O o d F- F• F- - 'O CL LL m OOO • ►v v a a a a „ g a) O p U1 N N N y i. 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CROIX COUNTY, WISCONSIN ller'u fa &&4 Gum SUBDIVISION 1;~~5 g`'* LOTjL-LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Ze #/o COX--;' , 2,4 fr~-c Yo' ` W/ ' r ~i elf 170 4 T pole ' INDICATE NORTH ARROW a BENCHMARK:Elevation and description: Alternate benchmark 1(6111 'e SEPTIC TANK: Manufacturer: Liquid Cap. Rings used: I Manhole cover elev: v. Final grade elev: 4g=, Tank inlet elev.: Tank outlet elev.: slow 9j, No. of feet from nearest road:Front , Side , Rear~Ft. l6b From nearest prop. line:Front7SDISide , Rear Ft. No. of feet from: Well > 3-©1 , 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 Type: Location Distance from nearest prop. line: Front-, Side_, Rear-Ft. Distance from: Well Building SOIL ABSORPTION SYSTEM Bed: Trench: Seepage Pit: Width:--Z--_?-Length 4if Number of Lines: ! Area Built 76, Exist. Grade Elev. /0 Proposed Final Grade Elev. /t.P Fill depth to top of pipe:- r No. feet from nearest prop. line:Front Side/ 31, , r Rear Ft . No. feet from well:}'. No. feet from building 5-S 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: / L PLUMBER ON JOB: LICENSE NUMBER: ?.t9' 6/90:cj LOCATION: HUDSON 21.29.19.1168,SW,SE,2I,WAGON WHEEL CIRCLE Wisconsin bepartmentof Industry, PRIVATE SEWAGE SYSTEM County: Libor and Human Relations INSPECTION REPORT Safety and Buildings Division ST. CROIX (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 149265 Permit Holder's Name: ❑ City ❑ Village -%F] Town of: State Plan ID No.: HANSON TOM HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: AD1 f"', d 020118560000 TANK INFORMATION ELEVATION DATA A9200111 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosi 0 7' D?.Cn Aeration Bldg. Sewer Inlet Holding St/ W TANK SETBACK INFORMATION St 1,V( Outlet y" 69 0,5-/ TANK TO P/ L WELL BLDG. vent to ROAD Dt Inlet Air Intake Septic I NA Dt Bottom Dosi NA Header. r 9 7 647 Aeration NA Dist. Pipe' ,s( Holding Bot. S~yste 9 7,5-, 9 ' PUMP/ SIPHON INFORMATION Final Grade 0.~ % es:< a ti 5fr(~ Man r Demand !a r S,C~~ Ud, g Model Number GPM /0 °F S•7. mn ue !S TDH Lift Friction System DH Ft mead Forcemain Length Dia. Dist. To Weil SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 2 DIMEN I SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHIN Manu acturer: SETBACK CHAMBER INFORMATION Type O C 1 L~ A Model Nu r. System: ~e~ A- OR UNIT DISTRIBUTION SYSTEM Header /44a Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length 4?.-' 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/ T*e"elt-Center 36 - Bed /Z4*weh Edges ~c~rjP Topsoil ❑ Yes ❑ No ❑ Yes ❑ No (Include code discrepancies, persons present, etc.) COMMENT ~a % r~ Plan revise required.) E] Yes o t~ Use other side for additional information. 14Z SBD-6710 (R 05191) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: I a r f RMIT APPLICATION HR SANITARY PE In accord with ILHR 83.05, Wis. Adm. Code COUNTY ,wnrnv~ , =Run STATE SANITARY PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than 1(41:?c~ (a S- 8% x 11 inches in size. ❑ Check 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 am f o~ W t/CS '/4, S T , N, R / 91 E (oryfD _XZ PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIV ION NAME OR CSM NUMBER X 'vt & 2.L II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned ❑ VILLAGE : 4V re -A Public L 71 or 2 Fam. Dwelling-# of bedrooms AR EL TAX NUMBER() 111. BUILDING USE: (If building type is public, check all that apply) e Z D / ja ir - 60 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ 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. g New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ 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 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE ,ryJ REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 7 72.0 Ar_,Z.2L , 4' Feet /AD.,s 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 Se tic Tank or Holdin Tank 4" d CG FRI F] Lift Pump Tank/Si hon Chamber + 0 0 Fj VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. PI ber's Name (Print): Plumb is Signature: ~drfMPRSW No.: Business Phone Number: C /f to/ e r ;0 4 E -365 lumber's Addr (Street, City, State, Z Code). r OUSE ONLY ❑ Disapproved Stary Permit Fee (includes Groundwater ~Eate Issued Mgent Signature (No S ps urcharge Fee) Approved El Owner Given Initial /z Adverse Determination 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. Onsite sewage systems must be ro erl maintained. The septic tanks 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 administr,itor 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 file' 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 poi its; C) complete specifications for pumps and controls; dose volume; elevation differences; fricJ-)n 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. Qrm; and F)_ alFIQng 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 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 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 Location of property A ;k) 1/4 -S E? 1/4, Section 'T261 N-R I'1 W Township A-) Mailing address S +J 1`LI L CI T l / ✓ m !1 S/W, 4 am, / l 4~, 4-1-d L Address of site Subdivision name ~ 2 r /(L C~~ •S / Lot number L Previous owner of property Total size of parcel ? S 7~dz. Date parcel was created Are all corners and lot lines identifiable? t Yes No Is this property being developed for resale (spec house)?Yes No Volume 9~3 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, and 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. ---------------------------------------------------------7--------------------- 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 r orded in the Office of the County Register of Deeds as Document No. 4/26 7 ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been d lv in the Office o "he Cou y Register of Deeds, as Document No. 7~ recorded D L Signs ure of Owner Signature of Co-Owner (If Applicable) /a- 5? 4//e ~ C - Date o ignature Date of ignature i II i I ~I DOCUMENT No. STATE BAR OF WISCONSIN FORM 1-1982 T.I. SPACE RESERVED FOR RECORDING DATA ~AIARRANTY DEED 478748 voL 933PAGE 246 - ~ This Deed, made between REGISTERST. 'CROIXS OFFICE CO. Verly_n-_E.-_-Benoy_"and Catherine A.- Benoy, , 1 husband--and - wife - - _ - . . - Recd for Record Grantor, FEB 0 3 1992 and.-_Thomas___W_.__.Ianson_" and Linda""L.- Hanson, - at4 ; 30 P. M b.usbai•i_d_..and- wi fe,--- as -survivorship- marital a propert~Z • Grantee, Register of Deeds Witnesseth, That the said Grantor, for a valuable consideration...... -----Seventeen,-Thous_and__DO lars--------------------------------------- • conveys to Grantee the following described real estate in St.- Cr`O lx RETURN TO County, State of Wisconsin: Tax Parcel No: _._020-1185-60 Lot 10, Prairie Vista First Addition to the Town of Hudson, St. Croix County, Wisconsin. I ~ II _O EA I I is not This homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And V.arly a E-'-- Benoy--.and " Catherine A. Benoy warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except recorded covenants, restrictions, and easements of record, if any and will warrant and defend the same. Dated this 3-4.& day of .{/ZJ 19__ 9.... - (SEAL) &='°tiQJ L7.r't lyn E. Beno Catherine A. Benoy - Ve y---------- ---•-----------------------(SEAL) (SEAL) * AUTHENTICATION ACKNOWLEDGMENT Signature(s)of Verlyn E. Benoy and STATE OF WISCONSIN Catherine A. Benoy ss. St. Croix - County - authenticated this ........day of. 19 9 2. P rsonally came before me this .3.Ad -----day of 19--9-2- the above named V. rly_ BenoY and Catherine A. n , tobert - F.!__.[nlall---------- B~nO1' TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) to me known tp be tKle pe son who who executed the foregoing instr~~rient a (La nowledge the same. THIS INSTRUMENT WAS DRAFTED BY-t,,/n/ - _ - -•-•-,l~ r E3.obest__ F_ Wall * -7-- y Larey'---- - ---------------------------I - - Notary Pn'1.~lic {1 a= 61.E-CrDiX County, Wis. (Signatures may be authenticated or acknowledged. Both My Coml ssion Imo= (Tf not, state expiration are not necessary.) p it date: 19..l.... ) •Names of persons signing in any capacity should be typed or printed below their signatures. ~ I WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc. FORM No. 1 - 1982 Milwaukee, Wis. J STC - 105 m SEPTIC TANK MAINTENANCE AGREEMENT w St. Croix County r OWNER/BUYER w o ROUTE/BOX NUMBER l.~Jl2 US U,f ut-~ Fire Number o CITY/STATE (.U ZIP0 Z Z r PROPERTY LOCATION:'.' Section 2 / T 2 N. R Town of NZ~LSG St. Croix County, Subdivision Lot number Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Prover maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed 'septic tank um er. What you put into the system can aTTect Me,function o 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- ::r ment of Natural Resources. Certification form must be completed and returned to the St. Croix Coun Zoni g Office within 30 days of the three year expiration date SIGNED DATE St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. DEPARTMENT RY, OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, DIVISION BOX 7969 LABOR AND PERCOLATION TESTS (115) MADISON, WI 3707 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP/mk+eH,~+ : LOT NO.: BLK. NO.: SUB VISION NAME: 'e ' jd14 2 /T~q N/R E (o - ' 01 14r k COUNTY: 'S/BUYER'S A ME: MA LING ADDRESS: v /Yt o USE DATES OBSERVATIONS MADE No.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: ER OLATION TESTS: Residence 3 ItAew ❑ Replace 7 2 0 RATING: S= Site suitable for system U= Site unsuitable for system ~ynn - CONVENTIONAL: MOUND: IN-GROUND-N~`D-PRESSURE: SYSTEcM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) CC'S 0U11;1-soul U J EA EIJ O IU If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate Floodplain, indicate Floodplain elevation: 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.) B 1011-7 7 . ' "9 / ' n 3 ' 8n nrt uL K ~ 8" J cs B- /o/. c ' z v, B- 3 /o /o/.o C /0 9 /3 s/ / G ' s > 13n ~s w OpE ~!O` n rrr s B- S' Zr mt. B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PER PER INCH P- O P- P- P- P- 3 3 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. 13°° V w SYSTEM ELEVATION Q6. ' E E / i E , 4 _ f ht RSSHkr~ _G+° Q . t,7, 60 7 E 3 O - - - - l /NC 7 Sys/em S 5 o . - m _ _ Ai r / yi s yf I r,k t 7f+ t a~~ i ~ Stcvc Ml!%, ~f~ f0~'Uv NS _ Lfilw N { f~C 01-C& Ile, f 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): DAVE FOGERTY PLUMBING TESTS WERE COMPLETED ON: Licensed Park Tester & Plum-h-er d., 7 '14P Z ADDRESS: 13233 #3289 CERTIFICATIO NUM ER: PHONE NUMBER (optional): log" He' hts hoed "WERIS, WISCONSIN 54023 CST SI NATURE:" Phone 749-3656 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - i. O THE 1 I ~.o wNw Dave Fogerty Plumbing SEWER SYSTEMS & PERK TESTING f FOGERTY HEIGHTS ROAD ROBERTS, WISCONSIN 54023 (715) 749-3656 r I 3s' , X--1 - z flLT 0 Yet ~ s ys~~~ •'s ~s. , > yl w" se t {rout txi$4-- /ZxLo) 1, ,•y *,Ft. ads well privl, /3~ f Sca~c ~ yo ' 1749 e pre ~ DG' '4 n -e, ' . Get r T' d~tfj tcoar Tr re well NSP ~o~ Gvheel ~ 1~ IM L O } O REPT131 HUDSON ST. CROIX COUNTY ZONING PAGE 1 02/18/92 08:13 REQUESTS FOR INSPECTION WORK SHEETS FOR: 2/18/92 AREA: JT Activity: A9200111 2/18/92 Type: CONVSEPT Status: PENDING Constr: Address: HUDSON 21.29.19.1168,SW,SE,2I,WAGON WHEEL CIRCLE Parcel: 020-1185-60-000 Occ: Use: Description: 149265 Applicant: HANSON, TOM Phone: 425-8355 Owner: HANSON, TOM Phone: 425-8355 Contractor: FOGERTY, DAVID B. Phone: 749-3656 Inspection Request Information..... Requestor: DAVID FOGERTY Phone: Req Time: 15:12~-Comments: Items requested to be Inspected... Action Comments Time Exp 00012 FINAL INSPECTION 3•"/~-.' cz;? Inspection History..... Item: 00012 FINAL INSPECTION REPT131 HUDSON ST. CROIX COUNTY ZONING PAGE 1 02/18/92 08:13 REQUESTS FOR INSPECTION WORK SHEETS FOR: 2/18/92 AREA: JT * * * * INSPECTION REQUEST SUMMARY Address Time Activity Type HUDSON 21.29.19.1168,SW,SE,2I,WAGON WHEEL CIRCLE 15:02 A9200111 CONVSEP Item: 00012 FINAL INSPECTION