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HomeMy WebLinkAbout026-1111-40-000 -6 0 c,~ (lll O 'S O N ~ C -a c N Y -p C O O U N _ 0 a'X (D Q) N E N E m C p r Y m O O_ U C w O d _ Ll 7 O U 6 Z O d c o y N 7 76 p LL CpNO O _ C C W C ~ ~ fn ~ x U d N E N U ~ M a ~ o ~ N p O o 0 N w a m a Z o z d c 'U o N m z d a, IE! m c E 2 aN N N O 'M~IY~~ O w O~I O • py _p a U) .C U N T 0 a) Q a p~ 4 © z m z N Cll w > r E o L w C Y LO a w a A i T 2 D d a m ) M 'D N N N O VdfJ d co ~►i~ E O O O w".6 R 4i I-- m IL U g rp ~ c N ) z rn a) 0) rn } co -It (.0 m p O rs E iz: (O O "1 N O O _'i A N N O N N m w ~:;J U O O a r ml `N Cl) m c O O C N C 0 3 E o c E~ r- rn O ce 0 o m U o c 0) 0 0 0 cMO F _ u c a rn o o N v c E 0 0 .~Or Co: N °-3 .co ^ N N L', p E N00 O o t`y ~ O M U Co E U O O a. O N cr O ~ w c3 w d f d m a x* ° L (L w ~~ww• a d .2 m ) c `01 o c 3 m A a2 0 N U AS BUILT SANITARY SYSTEM REPORT OWNER l ~ ~ l/arc e G ~ TOWNSHIP SECTION 44 T43') N-R l `75 W ADDRESS z%/2 ,0'jOO e7 3l'_ ST. CROIX COUNTY, WISCONSIN to/ -1 ,c SUBDIVISION 4n,OT--,&LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I ae.1l i I r I i~ NDICATE NORTH ARROW critic ~ BENCHMARK:Elevation and description:_ Alternate benchmark SEPTIC TANK:Manufacturer: Liquid Cap. Rings used: 1!57 Manhole cover elev: - Final grade elev: Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front Side, Rear Ft. ~O From nearest prop. line:Front Side, Rear Ft. No. of feet from: Well l9e Building: /J (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: i p Width:- Length ~ Number of Lines: Area Built Exist. Grade Elev. ©v~ Proposed Final Grade Elev. Fill depth to top of pipe: t~ No. feet from nearest prop. line:Front , Side Rear Ft. 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. 2- /^Z PLUMBER ON JOB LICENSE NUMBER: 3 7 l 6/90:cj LOCATION: RICHMOND 4.30.18.631 NE SE LO 4TH AVE•Count Wisconsin Department of Industry, PRIV'ATE'&AG S`TE'IN County: Labor and Heiman Relations INSPECTION REPORT Safety andguildings Division (ATTACH TO PERMIT) sanitary ermit o.: GENERAL INFORMATION 1714 Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan I o.: PREECE, DONNA M RICHMOND CST BM Elev.: , Insp. BM Elev.: r BM Description: Parcel Tax No.: ,,I'v, 6D /L -)p Q ~S /-tYd A_~r - - - - > 71g TANK INFORMATION ELEVATION DATA A9200248 TYPE MANUFACTURER CAPACITY STATION BS H ELEV. Septic Benchmarks d,Gt~ Dos' Aeration Bldg. Sewer St/ APE Inlet Holding TANK SETBACK INFORMATION St/ I IC Outlet TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet Ar I Septic ?~Or NA Dt Bottom Dosin NA Header / Pdtn. 5'0 /0,/S Aeration NA Dist. Pipe 7, OD- 02-Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade p~ /0Z.~r Manufacturer Demand Model Number GPM TDH Lift Fr' Ion System TDH Ft rss OSS Forcemai ength Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED / T4*N@H Width /C r Length yo r No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS / N LEACHING Manufacturer: SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM INFORMATION CHAMBER TypeO r r r Mode Number: S OR UNIT DISTRIBUTION SYSTEM Headers--- Distribution Pipe(s) ~r x Hole Size x Hole Spacing Vent To Air Intake Length -L2_ Dia. Lenqth7A or Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over „ Depth Over „ 2 / xx Depth Of xx Seeded/ Sodded xx Mulched Bed /1&eac -Center Bed /~rerrek Edges 1p _0S Topsoil C] Yes E] No EE] Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) 0 Plan revision required? ❑ Yes 0 Use other side for additional information. [~LOF qv2 r SBD-6710 (R 05191) Date Inspector's Signature Cert. No. t ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: a DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 11-7 8% x 11 inches in size. ❑ Check i revision o 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 P-Y,, T Q,N,R J E(or PROPERTY OWNER'S MAILING ADDRESS OT BLOCK # D 41 I - S. r c, A)M E OR CSM NUM ER 1ji 'Olt 141 IP CODE PHONE NUMBER SUBDIVISION N CITY STATFt II. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) State Owned . VILLAGE : 4)%W OF ❑ Public 4 or 2 Fam. Dwelling-# of bedrooms PARCEL AX . UMB ( ) III. BUILDING USE: (If building type is public, check all that apply) 67 aZ 4~~ 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 40 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) 1.0 New 2. NRystern eplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an 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 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION Feet Feet CAPACITY VII. TANK Site in gallons Total #of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank Z F1 1 11 Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's ame (Print): / Plumber' nature: (No Stamps) MP/MPRSW No.: Business Phone Number: Plum er' AZ7 (Street, City, State, Zip Code): 1~~1~f-.+ ~2h A IX. OUNTY/DEPART ENT SE ONLY ❑ Disapproved Sanitary Permi ee (Includes Groundwater a e s e issuing Agent Signature (No Stamps) A ro Surcharge Fee) ved v pp El Owner Given Initial C-A Adverse Determination r*1 0 V X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: / 7 (x`12 l~`~~~ , y 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 properly maintained. The septic tank(s) must be pumpe:i 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. f I SBD-6398 (R.11/88) STC-100 This application form is to be completed in full and signed b the 0"cr(s) Of the property being developed. Any inadequacies will only result in delays of the issuance. S this development be intended for resale byt owner/contr ctor,i(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 J P-6 CCC Location of property _1/4 SE 1/4, Section ey' r / ► T J°_N-R c~ W Township ' e.hmr cl Hailing address l 3 Al Address of site Subdivision name 0;e-Cra~4 &61?'Ur-r d zl _Lot no. 32- ,?3 Other homes on property? es `C Y No Previous owner of property Total size of parcel • S 4~-e- Date parcel was created Are all corners and lot lines identifiable? of Yes No Is this property being developed for (spec house)? Yes 6,,/ No volume 66 /and page Number Z S" as recorded. with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: - A WARRAtITY DEED which includes a DOCUMENT NUMBER, VOLUHE 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 owe am the property described in this information ) (Are) the owner(s) of w arranty deed recorded in the office of the by virtue of a Deed ~ e C Documen Count Re is t Ito .~8 S 2 Y g ter of and t hat I (we) presently oun the proposed site for the sewage disposal obtaine d an s ste easement, m Y or I we) 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. signature of ap li.cant Co-appl cant r Z D°`-e of Signature Date of signature f ~ . - ••r + y ' ' Y1. n l% . a ` t ~ r v ~ , - sit. ` _ 't r~ 0 v x ~ ..t ~ i.l ~ ~ n .S ~ , • 9. r~. k 3 ~ d , a 1' FF~ ~T~ >k 4i `I 1} y 1 -1 MALI A s~ i6k Y • Net st~^ 13. 1 ~i zi • MIS jai 5$ R fa~EtY~ TeX 1 ~ j jk- • ~ 1\ CY fa` aJ y J i i YSAa. t t C 3• i ~ „ I.i j j tf (t st Y •t 11rSYi = J+ I t M ~ ~ 7 WI OD i= f- 1 19 a i1 aa • fit ; t t I ,t tN( j f = ti _ s j E~., •*.it:... ~1j I Ica : j 9 1 , r ~ it's ~ . i 3, IS'. N jrt~lrt. =a Y,, w l0 A x %fy jY t~ I" 1, = 1=• • r 8 WAN Y S~ ' • %'j ~I- ~t~ '•a' h~ ~t,~•1r'~. i -u p }f~pyp'=~~ ~ ~ -hr is Ai- a, ' , i•• ' :cam'!" - of J° T • sit 144 i i it ,~t t4f~ •f~, t ~ , ; ~ ~ ~ /:J~~ i ~ ~ ~ ~ ':j Mr~ %~I rat i A -1'. Pi yr ~•d s'~ V t SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County L) L' E OWNER/BUYER I,-,(iQ 4C rr, a ~ ~A ADDRESS: ~7 ~3 ~Ia r~ 4', e FIRE NO: _ Zz S` 3 LOCATION: 1/41 _ J 1/4, SEC.- TJe N-R__W, TOWN OF: COIMV-r.4 ST.•CROIX COUNTY eS SUBDIVISION: dice broCQs LOT NO. 3Z.~Ar4- oP, 33 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 systems St. Croix County residents may be eligible to receive a grant to help with the cost of the 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 the St. Croix County Zoning a certification form, signed by the owner and by a master 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 sludg-e'and scum. Certification from will be sent approximately 30 days prior to three year expiration-. I/WE, the undersigned have read the above regt1irements and agree to maintain the private sewage disposal system-in accordance with the standards set forth, herein, as set by the '"WI-sconsin DNR. Certification form "must be completed and"'r4turned ..td the St. Croix County Zoning officer within 30 days 'of the three year expiration date. SIGNED: G~5(~-~ - , ~~1/~R DATE:, 14, St. Croix County Zoning Office 911 4th-St. ' Hudso•h, 'WI 54016 • DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION 7969 LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 3707 HUMAN RELATIONS 63.09(1) & Chapter 145.045) LOC TION: SECTION: OWNSHI MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: /T oN/R E (oo O C NT : OWNER' B YER'S NAM AILING ADDRESS: DOV Sf l"') o~ r M5=lo USE p tilt tti ' DATES OBSERVATIONS MADE p? 116 - 41 0 ..*'a L 7DRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence 3 ❑ New Replace 6-- o~ RATING: S= Site suitable for system U= Site unsuitable for system f71" p?~r+ 3a y~ C VENTIONAL: MOUND: IN-GROUND•PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (option a S ❑U S ❑U S ❑U S U D S U 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: ~a Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS dab '^~~~/-~fp BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST- IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- B- a '7 2 /0-A B off-aa- B- /evil B Qr c Le~ f B- PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER tORM& AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER I 0_D3 PER INCH P_ G P- L 12 P (e Ilk P r►~- L FPE~:_l 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 9> i E I - E . i 'A 3 F a E f ~ 4 E I 4- -i { i a i!! J Me Irv ad I, the undersigned, ~e ~Yt44 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, a at 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: '9' J~_ J, _1e'9A' - ADDRESS: • CERTIFICATION NUM ER: PHONE NUMBER (optional): V 7f CST 011 AT E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. D I LH R-SB D-6395 (R. 02/82) - OVER - INSTRUCTIONS FOR COMPLETING FORM 115 - SBO - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXI_ 'M numi. >r of bedrooms or commercial use planned; 4. Is th' or - --ement system; b. Cor cr, ity rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTI-' _ ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEA tions shown here for writing profile descriptions a rd cor, the plot plan; 7. L diagram accu-.tely locating your test locations. C i , scale is preferred. A y b , used if des;, 8. nc rmark and if elevation referer point are clearly shown, and are permanent; 9. Cc r -fate boxes ; a dates, names, a flood plain data, percolation test exemp- 10, s flood plain, elevation) does i )ply, pla4 I`, k riate box; 1 1 . your current address and yo,.-. cation 11L- 12. distribute as required. ALL " 1lL TESTS N.JST BE . ILED WITH THE L_ UTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIES} SOIL TESTERS Soil Separates and Textures Other Symbols st Stone (over 10") BR Bedrock cola Cobble (3 - 10") SS - Sandstone gr Gravel (under 3") LS - Limestone - Sand HGW - High Grounri - Coarse Sand Pr- Percolation - Medium Saari - well - Fine Sand - Building Is Loamy Sand Greater Than sl `?s:,dy Loarn ( - Less Than *I - Lon Bn - Brown *'0 Loarn Bl Black Gy - Gray Clay Loam Y ow Sandy Clay L~ R- _ ~I Silty Clay L.;. mot rr1y Clay wl Clay fff c t>t. - r ;rim - -`3y, in _ _ck d - t, stinr ' p prornine HWL _ L th .:I texturesI waste disposal BM VRP t Tt R Th' eport is " ring a sanitary rin The t ~3unty r "Ire Department may request ro pr,.-. ~f plan- th,- private be sr,: ~n, au in order to Thy [ obtaiierl a t f. ~d«+ v -may PLAT PLAN PROJECT !G-e- ADDRESS O`7 .~o►f n-eT,~- ~.✓~G''~~*d*-f~ C~1. ~ ~ 1/4 !;5---1/4/Sl~ /T 3,q N/R/4W TOWN- COU TY o, MPRS Byron Bird r. 3318 DATE fa BEDROOM CLASS PERC _ CONVENTIONALdIN-GR D PRESSURE CONVENTI NAL LIFT _ MOUND- HOLDING ANK SEPTIC TANK SIZE ' T TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA _,:4~ PERC RATE BED SIZE Benchmark V.R.P. Assume Elevation 100' gyp/ Location of Benchmark ~ Cp * H.R.P.~,p ~y Q Borehole Q Well Scale = Feet 0 Perc Hole System Elevation Uent 12" Gradp_ TYPAR COVERING 2" 12" 3' 44 6' O 3' 1 6" Sewer Rock 12' 4~"I r f Ulf 1 lay i 0 6~ REPT131 HUDSON ST. CROIX COUNTY ZONING PAGE 1 07/02/92 13:09 REQUESTS FOR INSPECTION WORK SHEETS FOR: 7/ 2/92 AREA: SELECTION CRITERIA INSPECTION DATE - 7/ 2/92 INSPECTOR AREA - TN REQUESTS SELECTED - 0 ll~ 414a~~