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HomeMy WebLinkAbout020-1011-30-100 ~ ~ p °v3 I v o°o I ~ I e3 c ~ I N I a O i I I ° I I I ~i c I 0 3 m rn w E o Z ~ m m p cli w a m Q c C7 o z d c d Z v ° o N F- zz Cl) L4 a U ~r N `n N c ' N O d C O U O w Z F Z N ~ z I N N E N m E CL CL 0 20 .0 C, O O O z ° •"44 ~aCL a a c 7 O W U N -j C) rn rn } = m v o O o N O : O 0 00 0) O O E ~ N ~ d O O CO N N r- N i4 'a 4 } m I _LO O p O N C O E O gyp` C c O h W a- 0) c) SLrr ° 3 o ca o '0 a) w T C m C a CL N N N C o 0 C O N N N Z H O N -O _ 0 O E O I ~ ~ ~ w E I = # E a L L a w rr`iw~v ° INDU RMEN;TOF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS INDU~FRY, DIVISION ON LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 76 HUMAN RELATIONS N WI 3707 (H63.090) & Chapter 145.045) LOCATION: SECTION: TOWNS UNICIPALITY: OT NO.:BLK. NO.: SUBDIVISION NAME: x/436/ f 0 /T E (or so COUNTY:_ OWNER' ER'S NA MAILING ADDRES J S C ~ Q r CUSE DATES OBSERVATIONS MADE NO.BEDRMS : COMMERCIAL DESCRIPTION: PROFILE S IPTIONS: F ~XjResidence New ❑Replace /5 b 1) f!\ `Sfi• RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GFfOUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional) LA OU EIS EU If Percolation Tests are NOT required DESIGN RATE: y p ortion of the tested area is in the under s.H63.09(511b), indicate: indicate Floodplain elevation: [Floodplain, 7a, PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH T GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, OBSERVED E H TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- boo. Q ' . ' ' fad I/ ~t 5 sP Sd r, B- ~ o n ' b s' €l Doge S4 9r B- T; o. o > bfl 3 ~o o o a s~ S~ r TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. p l o -I p PERIOD PERIOD PER INCH P- 3 D I 3W L K 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. SY TEM ELEVATION _22 ' i r v'' t, i 100.0 , ! I_. e ! i 1 I . } I ~ 13 ~ i i i _ f) ! i I . I y 8 76 D , av I 1 4 Top f'l-aA N.E_4. 4rne r Nb {yha,t~ rL&0e to ~_c tk-f to, "cover l • . 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 (pri TESTS WERE OMP ETE ON: a s ZJ n ADDR SSV CERTI t TION UMBER: PHONE NUMBER Ioption al): Dry rT(y 9 s'~ CST SIGN E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) --OVER - L- ` FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SECTION-2jo_T_f2~ N-R_,Z W ADDRESS~I-IY ST. CROIX -COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~ , b ! "Tron DO.~ ~'x~on` ~4ev~CG, ~(eulod,n 'Vie 0 INDICATE NORTH ARROW BENCHMARK: Elevation and description: Alternate benchmark 9 SEPTIC TANK:Manufacturer: eSl w Cast Liquid Cap. / G Rings used: "3 Manhole cover elev: Final grade elev: Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front X , Side , Rear Ft. 35G~t From nearest prop. line:Front Side( , Rear Ft. No. o f feet from. Well ~ Building: (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE r ~ 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: Width: _Length C' Number of Lines:_ -Area Built Exist. Grade Elev. & 3►r Proposed Final Grade Elev. /el Fill depth to top of pipe: No. feet from nearest prop. line:Front Side, Rear Ft.~ No. feet from well: c-~ No. feet from building-,6t) V67 vr;/W 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 : J PLUMBER ON JOB : LICENSE NUMBER: 2j 6/90:cj i abor an Department of Industry, 4qlao -21a Labor and Human Relations PRIVATE SEWAGE SYSTEM Count : Safvtyaad.Buildings Division INSPECTION REPORT (ATTACH TO PERMIT) Lot 1 Sanitary Permit No.: GENERAL INFORMATION NE4,SE4,Sec.10,T29-R19, 67th St. Permit Holder's Name: ❑ City ❑ Village (a Town of: State Plan ID No.: CST B ev.: Insp. BM Elev.: BM Description: Parcel Tax No.: ~J' ),dD 47D TANK INFORMATION ELEVATION DATA o 5/ 3P , TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic r~ l Benchmark i ' i s 63 h3 Dosi r "r~G Aeration nIT- Bldg. Sewer 109.~~ yZ Holding St /t Inlet yeg /0 TANK SETBACK INFORMATION _ St/.Ire Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic > 140 4 / NA Dt Bottom NA Header4fin. 14 s,~3 4Ce Aeration-_-- NA Dist. Pipe o 79 Z ' Gv 0 11 Holding Bot. System -5- 70 92 2 3' PUMP/ SIPHON INFORMATION Final Grade /,gyp" Manufacturer Demand ' Mar La , 9 7 Model Number GPM TDH Lift I Loss Friction Syste TDH Ft Forcemain Length Dia. H Dist. To we SOIL ABSORPTION SYSTEM BED/TRENCH Width I Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 16d DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHI Manufacturer: SETBACK INFORMATION TypeO Cov,0% CHAMBER Mo ber. System: 1&_ OR UNIT DISTRIBUTION SYSTEM Header / Man f-old Distribution Pipe(s)! ` x Hole Size x Hole Spacing Vent To Air Intake Length ~ Dia. Length i-7- Dia. Spacing f SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges r-1 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, per ons present, etc.)_ f l.r Plan revision required? ❑ Yes [R'Ao Use other side for additional information. 9 D 7 9 SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. DILHR SANITARY PERMIT APPLICATION • COUNT In accord with ILHR 83.05, Wis. Adm. Code OU ~v STATE SANITARY PERMI # -Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 - 8% x 11 inches in size. .*fr won to pr sous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERE OWN R PROPERTY LOCATION cp e 0i It ~'a, S To `'7 , N, R /57 E (o PROPERTY OW ER' MAI INGID~RESS, LOT # BLOCK # CI TATE , ZIP CODE ~ PHONE NUMBER SUBDIVISION NAME OR CSM NUMR D So IA, E:I ~ II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD Jt ) ❑ State Owned VILLAGE : A4~6 6 2 D ❑ Public 1 or 2 Fam. Dwelling4of bedrooms 1 PAR~OWN OF: _j CEL TAX NU E O Lf7 0 III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 70 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 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. RNew 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 121 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ® Seepage Trench <W,00 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 V50 5 500 214 < Feet , !f Feet VII. TANK CAPACITY # of Prefab. Site Fiber- Exper. in gallons Total Manufacturer's Name Con- Steel Plastic INFORMATION New xistin Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Holdin Tank 60 Lift Pump Tank/Si hon Chamber ~ 60 1 F1 LJ 1 0 - El 0 Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plum r' ignature: (No Sta ps) MP/ RSW Business Phone Number: _/Z)n b '3 If " , q 6 1 Z Plumber's ddrgss ( rest ity, Sta ,Zip Code ~ &1' 5~~ n ~G,T ` d 3 IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued Issuing Agent Signature No raps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Det rmin ion 1 v 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 i INSTRUCTIONS 1. . y, A sanitary permit is va id 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 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 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-,insta~led. II. Type of building being served. Check only ohe 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 B% 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; (lose 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 (R.11/88) • a i ~ S T C - 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. -----------7-------------------------------------------------- Owner of property \a f l t L) Location of propertyD2L-1/4 !5E-_1/4, Section LQ_, T ;~JN-R_J~_W Township 14 L~i~ Mailing address t`-(-~( LEI Address of site Subdivision name Lot no. Other homes on property? yes_..-x_No Previous owner of property Total size of parcel , 5i S Date parcel was created 61 -1 - Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes ~No Volume and Page Number 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 b virtue Y of a warranty deed recorded in the office of the County Register of Deeds as Document No. and that I (we) presently own the proposed for t site he sewage disposal system or I (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. Signatures applicant Co-applicant Da<t:ye% of Signature Date of Signature a - r v. . II. is$ •.nasital•--•-• ; ;.Ii-•~*~±! r wnvww n 1 O a =rf 'cS~in t~t37,~4 c,...:., „},.•.:+riww .3t....Crroix............c..as~. - w 02014 Tax Psaad ltos 020 f"t SOSSA Sec. 10-T29N-R19W, described as v'. follows. Lot 1 of Certified Survey Map filed t. t t j"* , l"l in yol. "8" , page 2371. t+r.` 4 '.r ~ gyp. ~n y ✓ ~ / r ~ ' ~bo~aasgad proportlr. -Y~s ; 4 ~ t .**w*t*_ ` tzisting highways, easements and rights of way i of x4cord rt • t 6 . , day of ALt$31llC. 49~.- 'r - ,n x ir►t 4'._ t c/,.~1 cap... (SEAL) . . : r •.Ranald..L...... ill.i.e... e MiU!lx4~!!!! :..........(SEAL) iReO~i,R~.. .~..L.cr... ~ . . Naomi,R.. Wi-llie.. 4911112 VICATION ACKNOWLsDGKIBUT t, its) STATE OF WISCONSIN K ~ ° - ..SM.•...cza ...Coaaty. qpefttle-ad ok . ..day of 119 Pa sowd)y tame before m this ....Alw4t.~$ 1~11$I1RL . 1itg1. twr arCe► SS_ • ' ' - .ii11.].ie,...huabAnd ..ank.sif t= **P sM 6TATa BAR OF WISCONSIN - - to me known to be the person & whf i~elllsd tis foregoing instrument and aetnowledge the eaoe~a M1V44&TMH&MT WAS SMAPT90 ar ~Ll\Q_... ~r~ u et ..:5? . :.40 6...._.. Not.T~ PuMie u s ; .Z Rd-ftA 4:. isay be aatLentieated or admowbi"i. Both Z<p Conuni~ab is }etsnaneat. ad. l~Idlt ,My> date. . , • M/ I. W WP" ANW 1 OW rr PftW blow Uwk Ww`mrw. , SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 1 ADDRESS: [0(E - "4 enk) FIRE NO: lot LOCATION:- 1/4, x_1/4, SEC. T,,Z~N-R~W, TOWN OF: ST. CROIX COUNTY SUBDIVISION: LOT NO.- 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 SIGNED: I. DATE: St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 DEP^TMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS A"IDUS INDUSTRYRY, , DIVISION LABOR AND, PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS MADISON, WI 53707 (H63.090) & Chapter 145.045) 10 LOCATION: J~~ SECTION: TOWNS UNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: /~L~/a JD 1T E (or so ^ EWS NA MAILING ADDRES COUNTY OWNER' iWYW. r ~C-~► F 294 1A) USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE ES IPTIONS: TION ESTS: Residence New ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IIN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) NS 0U 0S❑U CIS❑U ❑S©U ❑SQU n ~r100` If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGH-EST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- I >oo. lad S i Pq B- /o o bb s ' s o $ oosC 349r, B- /o3, D bbD o g' S' b b oo S r, L OD s i r'l easy S 1 C B- Z60. D ~~D 3510 S 1, o 'm 605e B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH l 9l 6 P_ © O 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 pergen+ of land slope. SY TEM ELEVATION /oo,o F ; s j ~ l E F 3 • ? r i , noi. 2;07 t N o S tt t i t k i ~ ~l { ( l i .~_10.? o ~_ra►~~~~_ peg - 1 4=►~__~ - w ' i 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. NAME (pri TESTS WERE OMP ETE ON: 7 ~s n 14-71 ADDR SS CERTI I ATION UMBER: JPHONE NUMBER (optional): CST SIGN E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - 3~~1 914 ~jh-~4, oer Wl Per~~ ~ ~,h 7a r e,:K160' S s. bleu, 9~ 3oa' J `Xioo1 fTene~ Qrb~bs~ ~o + B 1, ovo ai I 39~ • ~ (fie r F~pq 7 I ll~o I60.0 %oP j'`1rov~ l~l.. Corned'