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HomeMy WebLinkAbout020-1123-50-000 ' FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SECTION ADDRESS- ST. CROIX COUNTY, WISCONSIN 1~7'L~ LL''-- w S~Y7 s`rS 34r"r SUBDIVISION -~~p ,j~~~• LOT LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM t\ 1e fi\- INDICATE NORTH ARROW BENCHMARK:Elevation and description: Alternate benchmark SEPTIC TANK:Manufacturer: Ve_ej L. , Liquid Cap. /2-00 Rings used: -Z- Manhole cover elev: Final grade elev: Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front , Side, Rear Ft. let 71- From nearest prop. line:Front , Side X, Rear Ft. /:~d No. of feet from: Well & , Building: (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE f~ r' N.A F PUMP CHAMBER f Manufacturer: /~4 Liquid Capacity: Pump Model: p/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: Length 6D Number of Lines: Area Built Ri,O~ 1~u Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top of pipe: No. feet from nearest prop. line:Front Side Rear( Ft. No. feet from well: 1AV t No. feet from building ldo,4 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: 0 PLUMBER ON JOB: LICENSE NUMBER: 6 90: / c J b Wiscortsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT St. Croix Swafety anSLBuildings Division Eagle Rid (ATTACH TO PERMIT) anitaryPermit No.: GENERALINFORMATIONNE-,NE-1, -Rl9,Kratley°~n23 149167 Permit Holder's Name: ❑ City E] Village ® Town of: State Plan ID No.: Ronald Jenke Hudson CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 020-1123-50-000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ~Qe Benchmark of /0 i „ i Dosing ° 0 r-oi 6S y. Bldg. Sewer Holding St/ Inlet a` TANK SETBACK INFORMATION St/ Outlet 2" i g6; z3~ TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake s /~i✓L, ' gS, 0~ l Septic y/' r ro NA Dt Bottom Dosing '7/ f ~r NA Header / Man. 2 3so' ' ,r G~3 " NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade 3 cf r Manufacturer ®cr Demand 5'T. y6'1"1~~ Model Number F "1 GP vv S 1 z y~ 8g~ 9,121 1 System A TDH Ft , TDH Lift L H wtna o e ~E .,o .T 66 OSS Forcemain Length f Dia. 2 ` Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT Inside Dia. Liquid Depth DIMENSIONS S DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufactu SETBACK CHAMBER INFORMATION Type O a,,,~. Mode NuTer-: System: ~iedK~Ce E /cc > /Cu OR UNIT DISTRIBUTION SYSTEM Header M6"+fQW Distribution Pipe(s) r i7 Ix Hole Size x Hole Spacing Vent To Air Intake Length ~z Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over n 2 xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center 30 -3Bed/ Trench Edges aG Topsoil ❑ Yes ❑ No ❑ Yes ❑ No i COMMENTS: (Include code disscrepancies, persons present etc.) C}` / ~ 1i7) G'7/~ >*j 50 i Plan revision required? ❑ Yes Qkwo Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's ignature Cert. No. qLHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUN Elr - .4~ STATE SANITAR pT -Attach complete plans (to the county copy only) for the system, on paper not less than / ' 8'/z x 11 inches in size. ❑ Check if revision to prev us application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPE OWNER _ PROPERTY LOCATION yr , ~ nrL r` %4 It %4, S -7 T 2 l4 N, R / ~j E (or) W PROPERTY OWNE ' MAID ING ADDRESS LOT # BLOCK # r) CITY, STATE ZIP CODE. PHONE NUMBER SUBDIVISION NAME 7CSM/ NUMBER II. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) ❑ State Owned VILLAGE 1 1 ~sl ❑ Public 131 or 2 Fam. Dwelling-# of bedrooms PARCEL M 111. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo z 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. TYPPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. 3 New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.0 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) T1 95, 2-0 ELEVATION 5, 7' '7Z 87,T:3 Feet 9 3"0 Feet VII. TANK CAPACITY Site in allons 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 Tiv~r-c` v Lift Pump Tank/Si hon Chamber 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's Signature: (No Stamps) MP/MPRS o.: Business Phone Number: e✓ /~ti 7/4 7 Plum r s dress (Street, City, State, Zip Code): L/ t IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (includes Groundwater a Issued Issui gent Signature (No Stamps) #Approved ❑ Owner Given Initial / L(9- X. Surcharge Fee) V-) I Adverse De ermina ion ( 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 S A ~ APPLICATION FOR 9ANITAA Y PSRHIT • 9TC-100 This oppllcatlon form is to be complntod In full and signed by the omit(s) of the property beinq developed, luny lnadoquaclea will only result in delays of the pit rAlt Iaiuanca. -Should th15 development be intended for resale by owner/contrsctot,(spec house), thon a socond form should be retained and aompIttad when tits property Is mold and submitted to t h I a o f f I c a v I t h the ■pptoprlate deed recordinq. Owntr of property Location of property Yi-< 1/4 r 1/4r Bectlon -7 T 22--)1-R V Township Kalling address Address of site / /ubdlvlaIon naM_ Lot nuebet 17;2 1 Ptevlous ovntr of propetty d1.c -t r i~~ Total size of parcel t Date parcel war created At• ■ll corners and lot llnsr ldentlflable? "„Yes _ Ho Is this pro potty being developed for resale (spec house)? Yas .,No YolnrK and Page Number -?-t as recorded with the Register of Deeds. INCLUD9 VIT11 T14I9 APPLICATION 7112 FOLLOVIHCI A VKARANTT D¢ID whlch Includes a DOcuHRHT H"n¢R, VOL"K "D PAOt MUM1IR, and tilt 9IkL OT TII[ RROI9TRR OF DRRD9. In addition, a certlfled sutvay, if available, would be helpful so as to avold delays of the tevlevlnq process, if the deed deecrlptlon references to a Cattllled survey Hap, the Cattilled survey Hap shall also be required, ------------------7--------------------- PROPERTY MMR CERTIFICATION I(ve) ctrtlfy that all statements on this form are true to the bast of my (out) )tnovltdgtf that I (we) am (ere) the owner(s) of the property descrlbed In I. h I x Infotmatlon form, by virtue of a warranty deed recorded In the office of iht County Rtglster of Deeds as Document Ha./JG7 I and that I (v.) pttetntly own the proposed mite for tho newags dleposal syaten (or I (we) have obtained an easement, to ru with the above described property, I o r t.ha consttuctlon of Mid nye m, ;'n the Name has been duly recorded In the of lice of the ht a star oaa r am Document )4o. a na uce of wne fllgnatutr o ©e0wner (11 Applleable) Date of~l9n uc Dat pt n u r a ,tea Y+ S i ' 8T kTE BAR'ti . tea . . a. single ma Gratd i r • tv d. w ift Y*-. i mband and wift m.fxrvivovWhip marital p~oplo r a, . .fit. . ntruan 7O. ,:~gt Gimbwt 71w- MA St. Croix ~t i e tc i.c~ n Tax Pared We ~ IDt 23 Engle Ridge in the Town of Hudson .s Kk y~ ONOWNWAS ~c`jsP.~,.fC? : W I Z~ Fn Paul Opmeth " e41TT igt~' ICAaTYOIti AcKN0w1.&D(b~f ? ' ;LAT? ,,F .lit„'f7:CSI F r j~f s! St. clodix C, tuber , z Pawl Opswuh + ~s Lys ~py G~yy Fyt iTATE RAR OF E. ~ S r; i7 Rs; ~s~!si7 •.y , ^ i~#.~'~ ° „ j t~~' ti hky:.at, N. iem L 4 *'i k -4 tAXII$SM ^L6 .4 & t SEPTIC TANK MAINTENANCE AGREEIIENT w St. Croix County OWNER/BUYER o ROUTE/BOX NUMBER' Fire Number- 0 CITY/,STATE ZIP `:~~5 rv PROPERTY LOCATION:'.` is', (L Section T_N► R= , Town of Y`lc _~=>tc-~ a St. Croix County, Subdivision ~~4~~ 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 licens'ed' 's'e t'ic tank um er. What you put into the system can a ect the .unct on o. ERs-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 607. of the cost.of replacement of a failing system, whi.c 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), t•he 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 the standards set forth, herein, as.set by the Wisconsin Depart- s ment of Natural Resources. Certification form must be completed b• and returned to the St. Croix County Zoning Office within 0 days of the three year expiration.date. 12 SIGNED DATE T _ St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. DEPAJFTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS LNDUSTRYRY, _ _C_ _ DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 53707 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP/ LOTNO.:BLK.NO.: SUBDIVISIONAp~~ ME: Nt V44 S' 1/ -7 /T24 N/R j9 E (or ulsoy Z3 - E144LE VIIIGC COUNTY: OWER'S/BUYER'S NAME: MAILING ADDRESS: SsG2o, USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFIL~i DE RIPTIONS: PERCgLATI N TESTS: Residence uN~ XINew ❑Replace t~/(_ ~I~.s ox 9 ~ d& - j-rC►1t-/ RATING: S= Site suitable for system U= Site unsuitable for system I'll 01t7 CO EN S EM I❑ULHO❑LDING -TANK:IRECO N I STI❑u ONAL: MQ, IN-GROUND PD URE: SYI" S KU D SYSTE ~tional) Cuts If Percolation Tests are NOT required DESIGy, RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: CLASS f Floodplain, indicate Floodplain elevation: NA L PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH MIII ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- B 33 9 .~9 a > 8,33 7 $c.1a's a Q.ZiL i SC xv ,east. _VC ab $,<tr<. AS !rG a cab B- Z 8.4? 93.30 r4aNr > g,ki 8"ecsc m 13"IuleU MS 860190 " MS-Fete B- 3 -6 ,1-7 9 /.Z-1 nlov mr > 6.17 711-S,01-s i4 "$Q>jS, t leiebgRw MS ~G2 0"8k,r'h546A, B- 4 rLoo 9,78 dom& a. 9"$c~n ie''Be>.,s►~ 41"I e~s~c,$L>~u ~4"~R,DSQ~~hS~s~ B- 9~ •~S 4.0,#,j ? ~,~g3 ~~"Scs~c~s !Z"$2uS~~33"3euS~t$E~Y 5a"$~~~ts~~,~ B- PERCOLATION TESTS TEST DEPTFI~{ WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER YIV6bl AFTER SWELLING INTERVAL-MIN. PE I D 1 PER D 2 P R D PER INCH P_ 1 3.06 o 119070 /O 114 /74 4 P- Z .OD c>w►IE 93.jo 3 > >,:Z- > Z < P- 3.60 f- .36 3 > 2L >'2- > < P- P- lkVd1+ JAT t_ 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 _hkE~W 1 84-~ i~~~cu Z - ~7 76 NEr 7 , , , ~,1'Ly a L+tJ _ LOT , I i Op fin,., *26 pAK: Qb bc~ ~a E E 1 ~A A3 zE a - L4 3 _ - C )l 3 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. III NAME (print): TESTS WERE OMPLETE D ON: ~e ley INNsoU ~644NSe_)q So PI - UST /3 /W/ ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): go~S4-► l sw14--l0 . 344 ~t 4o1s6 CST SIG URE: R STRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. iRSBD-6395 (R. 10/83) - OVER - ~v 4 d ~e v~ K P JOB r TIMM EXCAVATING 3 SHEET NO. of Route 1 Box 192 WILSON, WISCONSIN 54027 CALCULATED BY DATE (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE rY !f . r l ; . fir...... a O . # J ~i - J: r Ire L DS tD \ p X, 64 . nn.. _ } . i5 D~~d ; - F - _l~, . , c W p Q Uc~ A GL,^r f ..7 rep !iS__ rL j G~ •~~t~~~ 1. ( J~,. ZI........... J - PRODUCT 205-1 Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE 1-800-225-M z°~'~' JOB { • TIMM EXCAVATING Route 1 Box 192 SHEET NO. OF WILSON, WISCONSIN 54027 CALCULATED BY ' " DATE - C' JJ l (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA 0696 MN CHECKED BY DATE SCALE LrY v 115 A L. V 46 5 Z 2 ' t r 1 ?Z. i zz p 5 (L r. 8 ~0 _ PRODUCT 205-1 ~ Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE 1-800225-6380 ~~JG ~d ~Eit KP PAGE OF 3 w - PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS VENT CAP "C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING JUNCTION BOX MAWHOLE COVER . 25' FROM DOOR, 12'Mlll. oQcOW OR FRESH I iiR INTAKE I GRADE i y' MItJ , IV' MI AI. CONDUIT IB"MIN,\ 7'z .50 PROVIDE ( I~JI-F_~ AIRTIGHT SEAL I III V I -7 PPP.O`JEC JOINT A I III APPROVED JOINTS W/C.I. PIPE ~ I III EXTENDING 3' jC,I. F. XTENDINf 3' ALARM ONTO SOLID SOIL i~JTO SOLID SO':. ~ I I I I I I ON c I I I rte'"P > OFF ~ V D CONCRETE 5LOCK RISER EXIT PERMITTED GQLy IF TANK MANUFACTURER HAS SUCH APPROVAL 5PEC. IFICAT IOPJS TAN D MANUFACTURER: ~~pe t cC~/lC/f/ [°o NUMBER OF DOSES: 3 PER DAy ~ TAWK ;,IZE : Rf)o GALLONS DOSE VOLUME iSo /~00 INCLUDING BAGKFLOW~ GALLONS ALARM MANUFACTUFRGR: L ~Jf' I~/cam c., MODEL NUMBER: 10L1/ CAPACITIES: A= INCHES OR GALLONS SWITCH TYPE.' f1l e i B= z- INCHES OR d GALLONS PUMP MANUFACTURER: •ZDP C INCHES OR11660_ GALLON5 MODEL NUMBER: 5;-7- g ~i P /)S.cJol~~ D- 16,' INCHES OR -.fit- GALLONS SWITCH TYPE' ~1t14i ' p1d~S NOTE: PUMP AND ALARM ARE TO BE • INSTALLED ON SEPARATE CIRCUITS PUMP DISCHA.R`E RATE GPM VERTICAL DIFFEREWCE I6J'Y1WrFU PUMP OFF AND DISTRIBUTION PIPE.. FEET + MINIMUM NETWORK SUPPLY PRESSURE , , , . . 1!91;;-- FEE; _L0_ FEET OF FORCE MAIN X J'j F oFT.FR►CTION FACTO! ' -Z-2----F "-T--' TOTAL OtWAMIL HEAP = FEET INTERNAL DIMEWSIOWS OF TANK: L-eio-fi MF- ;WIDTH -;LIQUID DEPTH T T I%-At"S 32Z~4 SIGNED:` LICENSE NUMBER: DATE: -117- _