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HomeMy WebLinkAbout020-1009-30-100 o o p ~ 0 d h c M i. O N ti O i L 65 LL ~ I 0 m o Z E C O L N _ C LL O N Q f6 Ili 3 M I v m awl', Z E i Z (D 4) rn CN IL o z d c v o w 0 Z C co H 91 S E v T N O O O Q • N a~ O d to V N 0 O 0 w O O N Q 'ar p N Z co z 0 Z O r C: 'o N _ ~ y _ co O R ~i o C 20 m G a m E Z N> O N N N U w 1 N I- F- H • T a a a a CL 0 ' 0 U) N U) _j I' 0 0) } o LO 00 0 N O _ O O 0 0 0 0 11~~ N N N co O 'O E O) L 7 0 C) N N N m N ^ O CO Q (n m D m U) N ~O _ C O N C E 'T O LlJ C y fOq C U d CO M O O O a) V N N N ~ Y C E C C N (O In O 0 j E co N 7 0 0 F' C N 1.. C14 a) N N O O N N t4 U • Al O r- 2 (n O Z N t (A r 4i E V pp ~ V1 ~ ' C as SL L: (L • c~ a. m 4) E c c t A 0 ~ a 2 O U)2 0 ~ FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP o R~ SECTION T N-R~~W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION (f, low LOT_~LOT SIZE -157 PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM n ~ INDICATE NORTH ARROW BENCHMARK:Elevation and description: S.~n~ Q4 /l S-' Alternate benchmark F✓r/ e_ SEPTIC TANK:Manufacturer: Liquid Cap. Rings used:_, _Manhole cover elev: Final grade elev: Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front , Side , Rear Ft. From nearest prop. line:Front , Side , RearXFt.,//4:-.) No. of feet from: Well S- , Building: .1 2 (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE f PUMP CHAFER 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: 2 Length Number of Lines: 2 Area Built Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top-of pipe: --Y~ 'r No. feet from nearest prop. line:Front , Side , Rear.~/ Ft._Z'-' No. feet from well: ~S 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 I III Vsconsin.Aepartmentof Industry, PRIVATE SEWAGE SYSTEM County: Lbbotand-4-IumanRelations INSPECTION REPORT Lot 2 St. Croix Safety and Buildings Division Sanitar Permit No.: GENERAL INFORMATION SE-4, NE4, JT/~l~H1T PE I~J% Cott Rd. 14098 Permit Holder's Name: ❑ City ❑ Village f] Town of: State Plan ID No.: Bill Schumaker Hudson CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: /19010 104. v 36E TANK INFORMATION ELEVATION DATA t ?06 9 -0 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ~'rZt~Lr- Benchmark 140,60 6110 Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet , q q TANK SETBACK INFORMATION St/ Ht Outlet 7, Vent TANKTO P/L WELL BLDG. Airito ntake ROAD Dt Inlet Ar Septic //.0/ 5-0, / ~L S / Z-„ NA Dt Bottom t Dosing NA Header / Man s i 97.9 9 Aeration NA Dist. Pipe °y, Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand, /,9 D, 5 Model Number GPM TDH Lift Friction System TDH Ft oss Head Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length I No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O 171t j CHAMBER Model Number: System: c~l 51 11~ <1 sr- OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake y Length Dia. Length' Dia. Spacing L SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over 22- xx Depth Of xx Seeded/ Sodded xx Mulched Bed/ Trench Center 3 ` Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons esent, etc.) I~ / c s ~ J 17 III _ _ ~ ~ 4 Plan revision required? ❑ Yes ❑ No Use other side for additional information. q 1 l/L~ a SBD-6710 (R 05/91) Date (inspector's Signature Cert. No. -11 SANITARY PERMIT APPLICATION 70ILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY/ STATE SANITAR PER IT -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ Q 8'fz x 11 inches in size. c/. evision t r ?0'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 l '/e,/:,:- %t, Sid T , N, R j E (o PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # _4~ ? 774-1 1k .v C;,vl CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 3916 /-At- - 5A42--r7o 417 11. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) ❑ State Owned 0 VILLAGE ❑ Public ~ 1 or 2 Fam. Dwelling-#~ of bedrooms ~ PARCEL TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) D - /00 "J~ Q `3 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) 1.0 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ 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 El Mound 30 [:1 Specify Type 41 El 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 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) CEELLrEVATION ~ r 73 3 ~s Feet 016 Feet VII. TANK CAPACITY Site in gallons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank !j Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system show on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY n G!/ ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing ent Si ature (No ) Approved El Owner Given Initial Surcharge Fee) ~SEG~,pj~ a Adverse Determination JJ 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 ' APPLICATION FOR SANITARY PERMIT • 9TC-100 Thlt sppllcstton form Is to be conplntod In full and tlgnad by the owner(s) of the property being developed, hny lnadoquacles will only result In delays of tilt pit rAIt Issuance. -Should thin development be intended for resale by owner/contrsctor,(spac houaa), then A second forin should be t I t a I n t d and completed vhan the property is sold and submitted to this a L I I c a v I t h the appropriate deed reeordlnq. Oynzr of property S.licz~~1? Location of property -f-e 114 .44_1/4# Section -/,I- T-.2-L_t-R /S' V T o w n s h i p Ha 1 1 1 n g a d d c• s s_ • Addrest of site IubdivIelon nacre- Yr!h~~f-4~`'? `,r ✓ _ Lot number _,Z r ptavlous owner Of Property Total slit of parcel ~Lcw~~ e Date parcel was croaked _ J Art all cornets and lot lines ldentlflablel Yen _ No It this pro patty being developed for resale (apes house)T__Yes No Volnr•e O6- and Page Humber 7 , as recorded with the Roglstac of Deeds. iNCLUD6 VIT11 THIS APPLICATION Tlla POLLOVINCt A VAA;IKXTT DY[D vhlch Includes a DOCUHXNT HV1{nRR, VoLlnta AND l'AOL HUxsLR and t}ie ©Y AL of TIM RR01 ©TRR OP DRRDtI ' In addition, a cectl avallsble would b Iltd survey, it be helpful so as to avoid doles o the deed deer y I the tovlavlnq process. l[ c! Lion tolerances rencea to a Cattllltd eurvty lisp, the Cettlllad lutvey Hap shall also be required, - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OV}lRR-CRRTIPICATIO}{------------------------- I(V•) rectl(y that ell statements on thle form are true to the best of my (out) knovledgti that 1 (we) am (ere) Lila owner(s) of the property described In LhII intotmatlon Corm, by virtue of a Knrranty deed recorded In the ottlee of Lh• county Freglstec of Deeds se Document )to. l C_S-7. Presently own the proposed alto Ior rho sewage dl eposal systen1(ordI [ vt)1 hx v` obtained an easement, to run w1L11 Lila above deaerlbad property, ter tha conatIuctlon of said system, and the same hoe been duly rtcordad In the otIIco of the covnty eglstor of Deoda, as Documank No. signature of owner`- elgnature of Co-owner (It Applleable) Dve i of elgnatute Date oL Signature DOCUMENT No. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1982 470258 PAGE,2 REGISTER'S OFFICE Dale G. Wucher and Sandra S. Wucher, husband ST. CROIX CO., W) and wife as..joint tenants,.. Recrd for Record su N 101 191 . . C. Schumaker and at 2:20 P. M conveys and warrants . to .-Wi . lliam . g Linda L. Schumaker, husband and wife as w Corn ` I urvivorship..marital-- property 0 - rr Register of Deeds . RETURN TO i; the following described real estate in ._.._..St. Croix .....................County, State of Wisconsin: Tax Parcel No: Part of the S 1/2 of NE 1/4 of Section 10-29-19 described as follows: Lot 2 of Certified Survey Map filed March 29, 1991 in Volume "8", Page 2342. AM -99 This is not homestead property. (is) (is not) Exception to warranties : Subject to easements, reservations and restrictions of record. 10th . 19.91.... Dated this day of Jun-------e--------•-•----/-'- - ~ • - - . . . . . . . . J • ---------••---.----•----.(SEAL) ................(SEAL) ••----------------------•------•-----------...------.......(SEAL) ~ L~b~.ffC'JL -4....._....(SEAL) * * . SANDRA..S,_..HI[? I~ R..---......._................... AUTHENTICATION ACKNOWLEDGMENT Signature(s) of Dale G. Wucher and STATE OF WISCONSIN Sandra S. Wucher ss. County. aut ticated is 10t June , 1991.. Personally came before me this ................daY of 19_....___ the above named r EPHEN : DUNLAP TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be the person who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY TEPHEN_J._.DUNLAP r Hudson, Wisconsin . Notary Public ..........................................County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) ) date: 19......... *Names of persons signing in any capacity should be typed or printed below their signatures, I{ WARRANTY T)TRFn FTATT: TSAR nF WT~,('ON°TN P: I,.;•,,I HI.,..i r„ i~~, SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER /i " ,1 -4 ADDRESS: aZ l1« ~f . ' FIRE NO: LOCATION: 5'4` 1/4, 1/4, SEC. r4 T.ti'fl N-R /5i W, TOWN OF: ST. CROIX COUNTY SUBDIVISION: ,f,l rid, yt~~ lc 5J'u.7`r LOT NO. C 5' iY1 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. .`'~c c SIGNED: DATE: i St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS I11DOSTgY, DIVISION P.O. BOX 76 LABOR AND PERCOLATION TESTS (115) MADISO N WI 3707 HUMAN RELATIONS (ILHR 83.0911) & Chapter 145) LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOTNO.:BLK.NO.:SUBDIVISIONNAME: Se~ 1/ 0EJ/a /O/T2gN/R/gE (or ,r IJ 3 Iv 2- 13 - S~f fn;0 COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: S +r_ R o IV L C_ v tr, eQ -7 Pr R Z +-h Z V USE DATES OBSERVATIONS MADE NO. BEDRI: COMMERCIAL DESCRIPTION: PROFILE DESCR PTIONS: ;~'Jvk OLATION TESTS: NResidence New ❑Replace I u h ~~1 G)e e& / RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) ®S ❑U ~S ❑U MS ❑U ~S ❑U ❑S NU C0 e tyq a r)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: C' Floodplain, indicate Floodplain elevation: PCC F*+ 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- 13,50 9*7t9O L 766(9 B-2 9,10 q~-10 A) QA) E 16 l3 5' 757 22." 0-PA) SL nJ j B- 44 -7 0 7, ~ A) e) A.) , '7 D 1 13 ~ T S /3 " tS n1 SL /7 ''c3rz4) B-5 1Y /6' 3/ZPJ SL?1"6RON 1; B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 _PER IOD2 PIZ PER INCH P 2 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/ - C~ t3 /A ITM ,Im , acs 31!q a E i [ F ~ . ..ate.. F , E 6,7 E 4~ -0 . . 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. ,print): TES S WERE COMPLETED ON: NAM 'J4we ply (.10 Ursa ~O 14 ►.i;sav.~ S k t v p./ AWESS:f 540 ^ CERT~I~~ IQN NUMBER: JP ~NUV`MBERloptional►: 1 rD Sofia I~/_V/ / 4 4 o C`J, CST SIG URE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) -OVER - ti. 'L f•~ 1 t ~ h r Y' 1 .r A i, 4N .41 t V~ .i i 3 R