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HomeMy WebLinkAbout032-2001-10-000 741 /O . D 32 - 2av~- /moo AS BUILT SANITARY SYSTEM REPORT OWNER__.LA/,sir? TOWNSHIP_ SECTION~T__ N-R ? W ADDRESS ST. CROIX COUNTY, WISCONSIN { SUBDIVISION Z. LOTJLZLOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM _ y /7~ ccsr_" I INDI_CATE NORTH BENCHMARK: Elevation and description: Alternate benchmark SEPTIC TANK: Manufacturer: V Liquid Cap. Rings.used:,;;2-Manhole cover elev: a //Final grade elev: Tank inlet elev.: b --Tank outlet elev.: No. of feet from nearest road:Front , Side,, Rear Ft. From nearest prop. line:Front , Side , Rear_,~ Ft. No. of feet from: Well , Building: (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP DER 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:- A2 Length_ >'9 Number of Lines:--c;.,?, Area Built Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top of pipe: _ No. feet from neare:Y,-0_No- pline:Front Side Rear Ft.No. feet from well: 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:-4Z--/- PLUMBER ON JOB: LICENSE NUMBER:-_ ? c~ 6/90:cj y LOCATION: SOMERSET 36.31.19.468H,SE,SW,36, 180TH Wisconsin pepartmentof Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION GEN 149293 Permit Holder's Name: ❑ City ❑ Village % Town of: State Plan ID No.: CONSTANT DONALD R SOMERSET CST BM Elev.: Insp. B Elev.: BM Description: _ Parcel Tax No.: k- 4,64 032200110000 < r: TANK INFORMATION ELEVATION DATA A9200137 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 0 Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet ~5,-79 TANK TO P / L WELL BLDG- VentAir Ito ntake ROAD Dt Inlet Septic ® Z,/ ,e NA Dt Bottom Dosing NA Header /-i1. Aeration NA Dist. Pipe 1 Holding Bot. System v ~p PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand 77), 0~,, Zy~ 99 7 C-0 v Model Number GPM rd. 2 TDH Lift Friction System TDH Ft Forcemai n Length Dia. Dist. To Well Head SOIL ABSORPTION SYSTEM BED /TRENCH Width , Length Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS o~ DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manu acturer: SETBACK - CHAMBER OR UNIT Mode Number: INFORMATION Sysptem: C(~e 114- DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length -L Dia. -L Length y Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over << 11 Depth Over r xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center D - Cff3 Bed/ Trench Edges - Topsoil E] Yes C] No ❑ Yes C] No COMMENTS: (include code discrepancies, persons present, etc.) Plan revision required? ❑ Yes _P'fq-o- Use other side for additional information. (7 SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: s 3 1! HR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code CO E:z G: - ll~_ STATE SA ITA RMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than l R aC13 8% x 11 inches in size. El 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. PM14110 Y OWNER PROPERTY LOCATION %S '14,S36 T , N, R E (or PROP RTY OWNER'S MAILING ADDRESS LOT # BLOCK # CI , STATE ZIP C DE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) CITY NEAREST ROB y ❑ State Owned ❑ VILLAGE 151 =W RF: ARCEL TAX NUMBER(b) ❑ Public ®1 or 2 Fam. Dwelling- # of bedrooms E P III. BUILDING USE: (If building type is public, check all that apply) p3~ _ a~Q f - l® 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. © New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.E1 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 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xistin 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 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for install!!' n of the onsite sewage system shown on the attached plans. Plumber' Name (Print): Plumber' S' natur :(No rrp MP/MPRSW No.: Business Phone Number: 1 J /s - ~ q Plumb 's Address (Street, City, State, Zip Code : IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Isa itary Permit Fee (Includes Groundwater ate; rled~ Issuing Agent Signature Stamps) Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-8398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUC"TIONS 1. A sanitary per mlt is valid for two (2) years. ` 2.` Your sanitary permit may be renewed before the expiration date, and at the time of renewsi 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 (SB'_ 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be purrrped 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 admi~iistrator 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 systern. 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 thew) surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) 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,2_1/4 ,,3~jj 1/4, Section _j-Tj3/ N-R~W Township Mailing address _-X" f Address of site Subdivision name- 0R Lot no._ 41 other homes on property? yes--No Previous owner of property Total size of parcel Date parcel was created - 0n7- J,q /9X,5e Are all corners and lot lines identifiable?_ Yes No Is this property being developed for (spec house)? Yes 4-No Volume ~j and Page Number 33,21- 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. 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. Cu ~nt L Sre of applicaCo-applicant Ga gnature Date of i Date of Signature ~I i DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA II WARRANTY DEED ~I 44242 BOOK 825 PAU'E 382 REGISTER'S OFFICE ST. CROIX CO., WI This Deed made between Recd for Record James R. Moe OCT 11988 . Grantor, at 8.30 A. M and Donald R. Constant C~'c Regi»te►of Leeds Grantee, Witnesseth, That the said Grantor, for a valuable consideration...... James _R Moe conveys to Grantee the following described real estate in S.t Cr'01X RETURN TO County, State of Wisconsin: Tax Parcel No: East 503.2 feet of the West 1100.2 feet of that part of the SE4 of the SW4 of Section 36-31-19 lying Sly of State Trunk Highway 64. I N VNISr 'Eh 2_2" FT E) This ls not homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And James. R . Moe warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and rights-of-way of record, if any. and will warrant and defend the (same. Dated this V day of _---October 1988 (SEAL) - --~i'i~►?!?? ~ q'n-47f.-------•--•------•-•-------(SEAL) i * * ames R. Moe ---(SEAL) ------•------------•------------------------------------------------(SEAL) * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ss. St. Croix ..............County. authenticated this day of--------•-------------- 19 Personally O came before me 6? October day of , 19........ the above named * James R. IJio e TITLE: MEMBER STATE BAR OF WISCONSIN (If not- authorized by § 706.06, Wis. Stats.) to me known to be the person who executed the f r o' _0g, in tru en and p owledge the same. THIS INSTRUMENT WAS DRAFTED BY Kristina Ogland Lundeen ttorrili~7y. at- Law----------------------------------- * Alice J. Fleisch - J,FLE;uCHAl1ER__ St . Croix No,*, Notary Public r rjay, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If8ftdt; r§tate qjq ion are not necessary.) date: ~ ) •Names o4 persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc. -FARM V- f _/.a. SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER- ADDRESS: FIRE NO: LOCATION: 1/4, 5&t) 1/4, SEC. T J / N-RAW, TOWN OF: ST. CROIX COUNTY SUBDIVISION: , LOT NO._ 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 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 sludge and scum. Certification from will be sent approximately 30 days prior to three year expiration. 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 form must be completed and returned to the St. Croix County Zoning officer within 30 days of the three year expiration date. SIGNED: I. DATE:- St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 r j y~ i 427.40' _ - w ~1) w (D$ -P Oj 'p OD OD 0 0 279.8o' 100 75 75 75 225 yy CD N p N 8 rya r 8 m - Oo 0o OD o _ z L Rrl h ' w ° 0) OD • th o • h' y 178, o' ) OD t G) rna N w o 450' rnPD ..1 / CU I I T!TLE:SEAACHES - - 'r:SCA0wS TtTL_FJN5URA?4CE ct:o5tNGS A$:.__ = nncra_n _r.... W _ _HUDSON:,- SC kE I&TM' OF rITIsE: - - DESCRIPTION. E 503.2 feet 'of _W_ 1400.2 feef 6f 'that part of SE4_ of..SWc: of Section 36-31-19 lying Southerly of State- Tnmk-ffiCtMY_N___~ _ "64" GRAI+?I'EE OF- DEID . . a>. 4a. CONVEYING ABC7VE DJ:SCRI$a) PROPE-IC f: William F. Beseau and Grace M. Beseau subject-.to-Land C.ontr'act.- to James R. Moe,' single Man, dated January 4, 1988' recorded January 5,-1988 at 8:30 o'clock in the A.M. in Volume "800 `rage' 358, Doc. No. 433492. TC.'U: = GEE: .3one. Paid thru 1987. JUDGMENTS & LIENS: None. DATED AT Hudson, Wisconsin this 18th day of October, 1988 at 2:00 o'clock in the P.M. RIVER VALLEY ABSTRACT & TITLE, INC. BY: Kathie M. VandermVorst i N I mo`` (115) MADISON, JWl 53 tiU' A', f,t L•AT!U'~ . ~.t U LF.TiO ULHR 83.0911) & Chapter 145) LOCATIQN: SECTION: OWNSHIP UNICWALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: N/R/, co Qr c ~y .177 f/ 6 /4 COUNTY: OWNER'S UYER'S NAME: MAILIN ADDRESS: 64 G6,roa< 3-#m o e_ Sa .z '13o h~& USE DATES OBSERVATIONS MADE NO.BEDRMS: romMER IA DESCRIPTION: ! I DESCRIPTIONS: PERCOLATION T Residence 1ANew ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system ^ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILL OLDING T NK: RECOMMENDED SYSTEM:(option 1) ® S ❑U S ❑U DJS ❑U ❑ $ [Z' 'I U I ❑ S U JDESIGN RATE: If Percolation Tests are NOT required y / If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: ` Q Floodplain, indicate Floodplain elevation: V4 0' PROFILE DESCRIPTIONS BORING TOTAL DEPTH T R UND ATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH LIMBER DEPTH IN, ELE ATION OBSERVED EST. HIGHEST TO BEDROCK IF BSERVED (SEE ABBRV. ON BACK.) B- a '1- G p 01 _5'^100 B-3 A q Olt o Ar...~► ~ r~.s~'' o'er B- it L o B- 11'V ~'V A U B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEV L-IN HE RATE MINUTES NUMBER I AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD PER INCH P- P- P- P- 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 y~ 6 kill Ar e" to O L G1c 1 To vd''.(cvc~ L7 Qa _ ~ ~.SS f-~v loo ' ' '6_Sr T H f .4 fro A, 6'r, 64 174, /a>tL6- fro 16 ~ 5s' ;50 If , 5^0 ~ / 1, 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 lvr'nti TESTS WERE COMPLETED O : On i rd/ 7 ADDRESS _ CERTIFICATION NUMBER: PHONE NUMBER (optional): t o C m ~--v o/ Y-// CST SIGN URE: L Lo-_.- 79 y' s i -30 r 6 / f C/ .y, y aso' S~3 /so REPT131 SOMERSET ST. CROIX COUNTY ZONING PAGE 1 04/08/92 10:46 REQUESTS FOR INSPECTION WORK SHEETS FOR: 4/ 8/92 AREA: JT Activity: A9200137 4/ 8/92 Type: CONVSEPT Status: PENDING Constr: 'Addfess: SOMERSET 36.31.19.468H,SE,SW,36, 180TH Parcel: 032-2001-10-000 Occ: Use: Description: 149293 Applicant: CONSTANT, DONALD R Phone: Owner: CONSTANT, DONALD R Phone: Contractor: O'CONNELL, KIM A. Phone: Inspection Request Information..... Requestor: KIM O'CONNELL Phone: (715)248-321 Req Time: 09:04 Comments: Items requested to be Inspected... Action Comments Time Exp 00012 FINAL INSPECTION Inspection History..... Item: 00012 FINAL INSPECTION jffxjz~