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HomeMy WebLinkAbout020-1288-70-000 o w ° o O w c v Qo y o c I r, c I o N N i I a O N in i ! CO x h 6 ~J P N Y O r Z C 3 C ..i LL C ro _O O> O N ao M Z N O p C N Al: C d m O O Z :!t c I U a O d' d Z to t- ~ y '0 ll N O ~ }y N L',fJ N y N a) N O O N O O • 5 M N O w o O N °m z z 0~~o I o y ro a rn I O y 21 L ro O p, N O N 0 a ti cn ( o O O O C/) • +~•1 ro o a. n. IL a cn ~ I j N ! = O0'0') N J U a) °2 } CO N C) 2 o o = E cD ate. v IV m d c ro N 7 O U C O y O M C co ~ C C E~ O) 0 E CL CL O a00o ~ co c E E v i m 0 O N (n a) CD c4 +O k G> CL Q CL rr`Ir~~~i u E r c w' ~1 A U nom. 2 O in 00 AS BUILT SANITARY SYSTEM REPORT OWNER. 5%- .h A'h/ TOWNSHIP 11--ee "y n SECTION_a_,L-TPN-R ADDRESS Y' J10"~- ST. CROIX COUNTY, WISCONSIN SUBDIVISION LGtb/~< ~R.re ST~~iDro LOT_L7_LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Dr ; ,,d . „~r~tl wad N u5v gf•~ 3 y; 4~ 5 ?N I ZS~ ~I° 0 S3' i f . 45 i F I I i I ~SS, I .119. ToY°0;,o Is ~ stu lo~rrs 3 INDICATE NORTH ARROW BENCHMARK: Elevation and description: T° 1~ ( ~2 Alternate benchmark -r ©F -?09.LCe~1 /A2 = 87 SEPTIC TANK:Manufacturer: aw~s~v Liquid cap. OOO Rings used: i Manhole cover elev: B '.,-Final grade elev: Sad Tank inlet elev.: 300 %_Tank outlet elev.: No. of feet from nearest,road:Front L , Side , Rear Ft.1Vs From nearest prop. line:FrontT, Side, Rear Ft. S No. of feet from: Well d0 , Building: asp (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: (oit,L*-Trench : Seepage Pit: Width : f L , Length ? Number of Lines: ~ 51, 77-- _Area Built Z Exist. Grade Elev. 6,0-~ Proposed Final Grade Elev. , Fill depth to top of pipe: No. feet from nearest prop. line:Front , Side , Rear Ft.Lf No. feet from well:_~No. feet from building 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 LOT LOCO TIIeNertmeDSON4r21, 29.19,SPFAIVA`I'E SEWAGEYSTE4RAY CIRC oLabor and Human Relations INSPECTION REPORT Safety and Buildings Division ST- CROIX ' (ATTACH TO PERMIT) Sanitary Permit No.: GENEt+I~'AL INFORMATION a Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.: MILLER, SANE AUDSON CST BM Elev.: Insp. BM Elev.: 7~M Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9200299 91415-If 2 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 1 60, Dos Aeration Bldg. Sewer Holding St/I Inlet S7.0 03,66 TANK SETBACK INFORMATION St/ yK Outlet -63Y 163.36 Vent irito ntake ROAD Dt Inlet TANK TO P/ L WELL BLDG. A Ar Septic ~>Sci r "-3D .2Sr NA Dt Bottom Dosi rtg NA Header4-Hh n. X 0 ,95 3-04 Aeration NA Dist. Pipe S,,8 , /dZ,~SL ` Holding Bot. System 9 -;g 1A PUMP/ SIPHON INFORMATION Final Grade ,p~ rps,(o7 Manufacturer Demand -fop a 5 7- ' ` s,83 425:27 Model umber GPM /OS TDH Lift Friction Syst TDH Ft oss Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width I Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~g 07--> MEN I N SYSTEM TO P / L BLDG WELL LAKE/STREAM L CHING Manufacturer: SETBACK INFORMATION Type Of jig r CHA R Mode Number. -2- 1 JAL System: ,moo( " :5 OR UNIT DISTRIBUTION SYSTEM Header/M...4 fe - r, Distribution Pipe(s) e x Hole Size x Hole Spacing Vent To Air Intake Length jL" Dia Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over r, Depth Over 1' 4 xx Depth Of xx Seeded/ Sodded xx Mulched Bed/Tr nchCenter ~j Z' Bed /Trench Edges e32 - .3/ Topsoil El Yes E] No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) o - K1X coy/ Plan revision required? ❑ Yes Imo Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ` e r ' DILHR SANITARY PERMIT APPLICATION ~a In accord with ILHR 83.05, Wis. Adm. Code cod STATE SANITARY-PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than y,~j- 8% x 11 inches in size. ❑ Chalk I re lion to previo s 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, S E S 2 T Z , N, R / E (or PROPERTY OWNER'S MAILING ADDRESS LOT # / BLOCK # & Z Pi CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 11 ,$C h s oi~ 3 a) t: 5 VY411/6 aa,= O sY~ 71,oh 11. TYPE OF BUILDING: (Check one CITY NEAREST ROAD ) ❑ State Owned ❑ VILLAGE : re t'a C ; 6 soY% 167ot11.. ❑ Public ®1 or 2 Fam. Dwelling~# of bedrooms - Da TOWN OF: 4 3 PARCEL NUMBER(S) 111. BUILDING USE: (If building type is public, check all that apply) D - 1 ❑ Apt/Condo I 20 Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 1120 Service Station/Car Wash ❑ Office/Facto 130 Other: Specify 5 ❑ Hotel/Motel 9 Office/Factory IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. VM New 2. ❑ 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 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE u REQUIRED (sq. ft.) PROPOSED (s q. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 1 SO Zo 7 Z O • . to 3 ~O 2 , do Feet / 0 S S Feet VII. TANK CAPACITY Site in gallons Total #of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncret 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,,@ssume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No S mps) MP/MPRSW No.: Business Phone Number: - '932 rs 2 2 3 s 6 G 3 33 Vaufk~ Plumber's Address (Street, City, St~at/e' Zip Code): / 90 ~l/(-7 IX. C UNTY/DEPARTMENT USE ONLY ❑ Disapproved Sa ' ary Permit Fee (Includes Groundwater ate Issued issuing gent Sign g Approved El Owner Given initial fLg6,9&1 S urchargeFee) Adverse D rmination 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. a 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 admnistrator 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. Cornp ete for all septic, pump/siphon and holding tanks for this system. Chuck experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropria°e 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 13% 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 (6.11/88) S T C - 100 This application form is to be completed in full and signed b 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 r//a r Location of property. L N~1/4, Section Tel`' N-R 19® Township Mailing address &©X /4'+' Address of site `tea roc 6~~N Subdivision name S-f~)Oc;'Lot no. j/ 7 . Other homes on property? yes X _No Previous owner of property jt_l ; e_ Total size of parcel Date parcel was created, tf /9qZ Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)?Yes No Volume 9(and Page Number 3 as recorded. with the Register of Deed&. 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. Vvc Z Fj~ , and that I (we) own the proposed site for the sewage disposal system orr I e (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._ 4ia tur e of ap~l cant Co-applicant Date of signature _ Date of Signature s, a 4E T 7 rT y, Ylk M ~ 4 k'J } f e hA ~ • nil, SEPTIC TANK MAINTENANCE AGREE11ENT St. Croix County w OWNER/BUYER 0 ROUTE/BOX MIME Fire Number 0 R 'G~O}C ~ d CITY/STATE ZIP Section _Z/ TgIL N, R l~ PROPERTY LOCATION : ~I~, Town of c.c ~t'S 6 vt St. Croix County, SubdivisionW9l(s ~4 TD 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 licen's'ed' 's'ept'ic tank pumper. What you put into the system can affect the .unct on of the septic tank as a treat- ment-stage in the waste disposal system. St. Croix County residents'•mn be eligible to recieve a grant for a maximum of 60% of the cost.of replacement of a failing system, whic 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 rew '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. y 0 I/WE, the undersigned have read the above requirements and agree 0 to maintain the private sewage disposal system in accordance with y the standards set forth, herein, a s set by the Wisconsin Depart- L ment of Natural Resources. Certification form must be completed .o and returned to the St. Croix County Zoning Office within 30 days of the three year expiration.date. ~y rI ~;,,yr~ /IZ~k~R SIGNED DATE " t 7- i _ St. Croix County Zoning Office 911 4th St. Hudson, WI 54016. 386-4680 Sign, date and return to the above address. Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page ~ of 3 Lab4 ar-4 Human Relations D*visionafety a 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 CRo IX not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. If dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION S.4)w M ILLC- 5 E 114f4W 1/4,S'Zf T 29 N,R 19 E (or) W PROPERTY OWNERS MAILING ADWESS n LOT # BLOCK # SUBD.~N9ME OR CSM # -1 IEedaV_RDA-1 /7 W~ACS 1714&,6 CITY STATE ZIP COD PHONE NUMBER [3CITY ❑VIL~ GE OWN NEAREST ROAD ~So*~ Wt 54-6 I ( ) hIUDSo r.6 svCfecl-c New Construction Use PO Residential / Number of bedrooms3 N (J Addition to existing building j j Replacement [ j Public or commercial describe Code derived daily flow gpd Recommended design loading rate O.7 bed, gpd/ft20X trench, gpd/112 Absorption area required Za bed, ft2 trench, ft2 Maxim m design loading rate O•-7 bed, gpd/ft2 0.g trench, gpd/ft2 Recommended infiltration surface elevation(s) /07 . IOR MaR 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 MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING T NK U=Unsuitable fors stem 4S ❑U QS oU JIS ❑U S ❑U MS 0U ❑S 10-u SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouxkvy Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tiench P.,-1i J6 16 yR,3 Z L_ i n, s6 C Z 0.4 6.-15 /3 Jog 4 4 L I n~ Sb rh i C 2 0.4 o.< Ground 4 ¢ `JL r 1 0.7 0.'& elev. 7-7 10 Yk 6A S r Yh I 0:1 10 Depth to limiting factor > 9•o& Remarks: Boring # _ .e 4 I m sbk ~ ► a.4a D .S 7 'O$ Ground g 7' -S Yoe 4 0 elev. $ p" /O Yoe S 2 O r rh ( 0.7 10.%1 to5-1) S ft. Depth to limiting factor > 9.00 Remarks: Phone: CST Name:-P ~e Print 614 A40N Address: Signature: N Date: 84 Z Z CST Numb[ PROPERTYOWNER S4M M 1UXP. SOIL DESCRIPTION REPORT Page? of 3 PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots jqPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tb9ch 3 16 16yk I L I m Sb9, ,v► r C Z a.4 0.5 $ 4 l 1 rn SWO mFr C. Z 6A O. S Ground g ! 2'' /O Y+2 ' g- 5rL M-E C) .5 b K I 65 0.6 elev. ~ ft $ 7i' y.e 6 S~ 0--7 08 Depth to limiting factor > 8.Sf3 Remarks: Borin qmq A /7" .516K 0A g # :0.'5 _ 16 7 es" JOYR,3~4 L OA lo-5 &Z 1/8 " 5 YA, 4 SL C ( O? Ground OAS elev. eq> 3 516 Ye Z 5 r ~ O.7 s0~5 z I67.Z ft. Depth to limiting factor > cl.ZS' Remarks: Boring # z s o.4 oS Ls /9 o ,2 5 3 - L 1 S k Z .4 O.S /3 -z lb" 1 4/4 5- 0. air ;11 C -0--7 ::0.% Ground elev. B -76" 16YA 5 AZ S O G r r►, 1 !6?•OZ ft O.~ s 0 g Depth to limiting factor > 9.13 Remarks: Boring # F: r Ground elev. ft. Depth to limiting factor ~ . t- -T- Remarks: SBD-8330(8.05/92) g o a ~ D Q r- f r' `Z El I 6 ~ ~ i / (70 i , P1 n r~ lw (w saw ~~~~a,r well s ~aryo S1-eTio~ ~ot'~17 Z. 60 ~t.aM''c• /v /0 • 3.M. I~~ P;p~ a"~ sW ~plNdv EI ~OD.oOt~ 1~ f1 / l~~ yy MGR` Ct CL D rt I V E Jos A Y v~Et~ ' SS ~s'rsn c0.,. ~y ~Jl 3 t' u Lot 1 -1 U; zl ~ O 103 0 SO'~ ~a+ I~ 8.ytl, ,h a-r R Sg' W I 1 d E h y ~ B-I 17 --~-=~3De 5S - ' a II I V IyZ i $ N1. T-lp d. E1=100.00 u/e s? /•t N 6 3/~ aa' r , Z CK?. z 1 _ ~ } 1 ran 1 1 " r~ j O ~ I j l+ ~ f j p l rrl ~ I ~ 11I ~ it r ,if I li CD ij O 1 III JI) ~i ! M jl rrl C.4 C4 s ~ rid i ; II O j I 41. O ; l 1 j { -V m i o ! LAI +!J CA J ~.1~ o 90 F'r 0 O 17] x o m O , b _ -a m c o n 00 3 V 1 N ~ o ~ o ~ V REPT131 HUDSON ST. CROIX COUNTY ZONING PAGE 1 09/25/92 07:57 REQUESTS FOR INSPECTION WORK SHEETS FOR: 9/25/92 AREA: JT Activity: A9200299 9/25/92 Type: CONVSEPT Status: PENDING Constr: Address: HUDSON,21.29.19,SE,NW, LOT 17, ZANE GRAY CIRCLE Parcel: - - - Occ: Use: Description: 175640 Applicant: MILLER, SAM Phone: Owner: MILLER, SAM Phone: Contractor: STROHBEEN, DOUG Phone: Inspection Request Information..... Requestor: STROHBEEN, DOUG Phone: Req Time: 13:09 Comments: 1100 Items requested to be Inspected... Action Comments Time Exp 00012 FINAL INSPECTION Inspection History..... Item: 00012 FINAL INSPECTION