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HomeMy WebLinkAbout020-1267-70-000 Q o o p °(0) ~ I - ~ I 0 o ~ I 4 C N z C LL C O Q I v I, 3 v i ~ 3 Z E I z = o z m rn N H vii LL m i o z v (D a) E N c C C co •►~i O o 0 I! d L R iv N O N Q O L- N 0 Z co z Q z o § rn ° N a 0 G D d 4 U) U) (A N :3 F H 7I 0o a o oa a s co • I a = O to = Q, N N J U o rn rnQ, IV 7 I~ N N co O O E N N O co c 04 O O oo N N C N Q cn In 'f0 0 Q z cn m C J W N ~j O o °2S _W C IV 'Z 0 I- C O E (m 9 0) O 3O J N U y N V d m O N V N a a= O) O O Qj ~ C C E E N O a c4 N OO y L L C 7 N N N I F- F- r t , N co u.) a) (D (D 0 1 0) -r- •Wei O N 2! d O z fn O v v~ d R a a L a ~ i • -7 FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER I~ U rte ( i J TOWNSHIP N U S 1, ) SECTION T l N-R 7 W ~j ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION lA Iy 1'rD q e LOT o~ u LOT SIZE N PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I d 2 T 3 5 a ep ~j IDICATE NORTH ARROW BENCHMARK: Elevation and description: Alternate benchmark SEPTIC TANK:Manufacturer: ~Liquid Cap. Rings used: Manhole cover elev: 10V'I SFinal grade elev: Tank inlet elev.: ~O .H Tank outlet elev.: No. of feet from nearest road:Front ~C Side , Rear Ft. Q0 From nearest prop. 1ine:Front , Side , Rear\< Ft. y No. of feet from: Well/)0 r> , Building: is, (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 1==` fir Bed: Trench: Seepage Pit: l Width: Length Number of Lines: Area Built Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top of pipe: . Q - 3 No. feet from nearest prop. line:Front , Side, Rear Ft.~ No. feet from well:NL 0 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 A(? I Wisconsin Department of Industr, Wborand Human Relations y PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT St, Croix GENERAL INFORMATION (ATTACH TO PERMIT) Lot 20 Sanitary Permit No-: 1 , 11 149115 Permit Holder's Name: I E] i y Village own of: tae Plan ID No.: LeRoy Peterson CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: (o ree f TANK INFORMATION ELEVATION DATA / TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark y U D Aeration Bldg. Sewer Co- 9 St/W Inlet TANK SETBACK INFORMATION St/.1ft Outlet 03. (o/ Vent TANK TO P/ L WELL BLDG. A ir Ito ntake ROAD l2 Septic NA Dt-BGROM D NA Headers. g Q 8 r Aeration NA Dist. Pipe Holding Bot. System a) PUMP/ SIPHON INFORMATION Final Grade Demand ' o>~w ►~~YKe ' Manufacturer I Mo GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width I Length i No. Of Trenches PIT. . , No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ;Z / / (0 DIMEN I SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHI Manufacturer: SETBACK CHAMBER INFORMATION Type O Cc^n1C. Mo um er: System: V~C,:~ ? 10' OR UNIT DISTRIBUTION SYSTEM Header gVmo4ekf- ~r Distribution Pipe(s) / x Hole Size x Hole Spacing Vent To Air Intake Length _12_~ Dia. Length Dia. --(L' Spacing sG' I~r D' SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over 1 r t / Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center °310 Bed/ Trench Edges 2~r)' 2Jko Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) a'6 &-:f Cc t Q( aJ Plan revision required? ❑ Yes ❑ No p Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ILHR SANITARY PERMIT APPLICATION Mac 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 /4911 8'f1 x 11 inches in size. ❑ 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. PROPERTY OWNER i PROPERTY LOCATION 4e r-b 0\ e IS b 0 k.Ji Y4 Y4, S;) T al, N, R 19 E (or PROPERTY OWN WA MAILING ADDRESS LOT # BLOCK # t (3 ' s oN NPA, CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NA MAP- CITY CSM NUMBER ~:a N 5iALS : T ROA II. PE OF BUILDING: (Check one) ❑ State Owned VILLAGE LLAGE k 424W RF ❑ Public X 1 or 2 Fam. Dwelling- # of bedrooms PARCEL TAX NUMBER(S) I!~?b-la~7-76 -006 III. BUILDING USE: (If building type is public, check all that apply) i 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. JR 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 11~1Seepage 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/da /sq. ft.) (Min./inch) ELEVATION LeOO 8 ;t V a (0 UT C Feet 169, Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Hold! n Tank Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT 1, 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/MPRSW No.: Business Phone Number: ,er eeS 3.0 1,"- 3& -900 Plumber's Address (Street City, State, Zip Code):. , / 1108 rA. C~ e S ON S1 N 60, 1 kDi 1 J• - JW10 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date issued I g Agent Signature (No Stam s) Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination / / l X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s Buildings Division, Owner, Plumber yy ~j~~ max:. Pr . I APPLICATION FOR SANITARY PERMIT 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 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property Location of Property 51, Section Al' , T_S j N-Rt_ W Township A Hailing Address Address of Site Subdivision Name _14 Lot Number Previous Owner of Property r Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume Gq--~ and Page Number as recorded with.the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: i A Warranty Deed which includes a Document number, volume and page number, and 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 refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION 1 ((ve) Ce t16y that atQ. 6tatemen;6 on thi.6 on.m ahe thue to the befit 06 my (oun) know.tedg e; that I (we) am (ah.e) the owner (e f o6 the pnopent y deA cA i.bed in thiA in6o4mati,on 6onm, by viAtue o6 a waAAantLeed neconded in the 066ice o6 the County RegiAteA o6 Deedd ab Document No. and that I (we) phebentey own the phoposed site bon the sewage dc,6pod dYZ em (oh I (we) have obtained an eaa ement, to nun with the above deb cxi.bed pnopen ty, bo& the con.6.tAuc tc:on o6 aaid .sy6.tem, and the same ha6 been duty neconded in the 066.ice o6 the County Regi6ten o6 Deeds, ab Document No. r ' SIGNA OP OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED ` DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED __-6802 _►il----_vOL_ This Deed, made between Greenwood Enterprises, Inc_.,__ REGISTER'S OFFICE a Wisconsin Corporation ST. CROIX C©.+ WI Recd for Record Grantor, g 199 -.eterson. and __Lillian__O Peterson.,--------------------- A --.P and___LeRoy-L Cf 10:4 ~ M - husband--and wife, as survivorship maxi-tal_-prgper-ty_._.._-_... + .1 CivY Grantee, f RegisterdDeeds Witnesseth, That the said Grantor, for a valuable consideration.-_..- i conveys to Grantee the following described real estate in ..............St..-_Graix__ RErURrrTO County, State of Wisconsin: I Lot 20 of the Plat of Sunridge filed in the office Tax Parcel No: of the Register of Deeds for St. Croix County, Wisconsin, on September 22, 1989 in Volume 5 of Plats at Page 71, as Document No. 451750 This Deed given in satisfaction of Land Contract dated October 29, 1990 and recorded in the St. Croix County Register of Deeds Office on October 30, 1990, Volume 884, Page 629, Document No. 463652. TRAN-OrTR !N ~ a t`V This i.s. not._.__...___ homestead property. (W (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And...... Greenwood Enterprises-----Inc.---• - warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except and will warrant and defend the same. Dated this ..Z B day of March--••---------- 1991 EENWOOD ENTE ISES I GREEN OOD TF IS S INC. (SEAL) ~:C------ (SEAL) James E. Rusch, President Mar Rusch, _ _etary__ ---------------(SEAL) ------1= . (SEAL) * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) James E. Rusch, President and STATE; OF WISCONSIN Mar R. Rusch Secretary of Greenwood SS. v Enterprises, Inc -----------------------County. authenticated this .2a Y-day of.-March y 19-9 1 Personally came before me this ................day of , 19........ the above named Z ,j i-- Walter__ Hodynsky0 TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) to me known to be the person who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY __HQYWQQd_-&..({ar -.P_D-..Box-.223-,.-HudfiQn.,.-BIZ.... 54016 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 persona signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc. FORM No. 1 -1982 Milwaukee, Wis. SEPTIC TANK MAINTENANCE AGREEMENT ~ St. Croix County r r' OWNER/ BUYER 0 ROUTE/BOX NUMBER Fire Number :J d CITY/STATE ZIP M PROPERTY LOCATION: * ~ti/ k,ALL34, Section 4J•, • TAN. W, Town of St. Croix County, Subdivision Lot number 4r, Improper use and maintenance of your septic system could result in its premature failure to handle wastes.- Prover maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed* 's•e tic tank pumper. What you put into the system can affect the tunct on o. t e 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 60% of the cost.of 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 .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), the 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. H 0 I/WE, the undersigned have read the above requirements and agree 0 to maintain the private sewage disposal system in accordance with N the standards set forth, herein, as set by the Wisconsin Depart- ment of Natural Resources. Certification form must be completed a and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED, DATE St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. D~PAIiTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, _ DIVISION P.O. BOX 76 LABOR AND PERCOLATION TESTS (115) MADISO N WI 53707 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNS I P/tPfit1TY: LOT NO.:BLK. NO.: NAME: Sw1/ wwV4 z4 /Tz9 N/R)9 E (or pso z0 4S COUNTY: OWNER'S/BU R'S NAME: MAILING ADDRESS: Ce I Po . `LR so USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROnFIL DE R C) PTIONS: PER LAT ON TESTS: Residence (A W < - ew ❑Replace / 3 -9 /4 90 L A N 6 l ~S S ~p 1t~ &C RATING: S= Site suitable for system U= Site unsuitable for system COVKN)JENTIONA IS ❑U M&NS.OU ING S P SYZS IEULH0SG P~~.RCQOMMENDrED"*LT,EI g~onal) If Percolation Tests are NOT required DESIGN RATE: 1~ I If any portion of the tested area is in the under s. ILHR 83.09(5) (b), indicate: Cl, dss I Floodplain, indicate Floodplain elevation: NQ I~IEC_~ PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHJ"% ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE A'BBRV.OQN~BACK.) y~ ~p B- ' 6'S 02. f~ L~ 7slc1S p~IXA1 iC ~DCV~ 7C O • 'J'I B- Z 7.72S 02.0 ,V y Z ' Cl5 2 ~$u S! G~ IGe R 2ti~ B- 3 66 ,oZ 146,N E ? -7. . 7S I Pa S! 3o CS ~66 22'' t A y B= 4 C , 7 0 6, C Sic /K`P_,eS,c 31K &.uAS44# S CTS k 4S' aNP9il6 B- S6 oS,Z > ISO 9'' s c ~~'Ba,,,S,C{G d D CS zs''84~~Sd~, B- PERCOLATION TESTS Y TEST DEPT WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER I AFTER SWELLING INTERVAL-MIN. PERIOD 1 PER OD 2 P D PER INCH P- 3.10 a. P_ Z, E30, 163,60. i 4 M Y-4 P- 3 ,ZO o oS.Zo A 174 P- P- L1. AT I O~, 6'iF Ptec- P- PLOT PLAN: how locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and ver 'cal elevation refyrence pojpt~ ndi how3_thheir_location on ! e plot plan. Show the surface elevation at all borings and the direction and percent of land slope. a D SYSTE ELEVATION o E paz E 'A A, ■ &3 o ' A~- Ire S ~►J 6'r C.c a&j, it P_ - - N 41 _ r E a E E E cki `LI r o I, the undemig ed, 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. NAM (print): TESTS WERE COMP TE ON: l~ 'eN(&, 14 50,ONN SG S A v /NK '9//4/9b ADDRESS: CERTIFICATION rAiMBLPR: PHONE ( optional): AUMBER SEcemrl S7 du 4's WI 14 ~MIKA o~ CST SI ATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - `.P Q.L . 67 PLOT A141 i,' 0S5 5 EC~~I ~I 1'-'OJ EC r~ :~s►u m~;,~s ~e N A M E Um o' ...NAME 11 L 0 C A T I ON y. . L IC ENS E=//- _ 3 ~c~ - A....._....~....... l.J-----~.---- Not? p,(Ut3i I,JQ iI s A(C{ ~pP l IU T l,J e l s rr~rt: a~, ~nnr, 75 ffi 4 ~ ` `Y fir ~3 0 i<7- os P3 l~ }k* 6ep r 8s ~--j a Bo, B3 ° 0 -1 boo qA ! V ccs Sc~ se n, I7 Borce~olt s as Lw,a s~ a ►F-t qfi lot C Elw. = ~oap QN -7)1) FRESH AI12 INLETS AND OBSERVATION PI-PE C1;O~S SECTION ..Approved Vent Cap Minimum 12" Above ~~S•30 Final Grady \ 1%►hJw~ aAnt 4" Cast Iron Above Pipe Vent Pipe To Final Grade Marsh flay Or Synthetic Covering Min. 2" Aggreg'd over Pipe \V _ Distribution Tee Pipe i _........._.I.t Aggregate lD Perforated Pipe Below ~Q) 00 Beneath Pipe le Coupling Terminating T Bottom of System