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HomeMy WebLinkAbout020-1151-90-000 ~ o 3 0 y . O h d N ~ a O 1 V M N ~ I O i kr ~ I o I o Z c ~ m C LL a I' M R N Z tl! E 0 v 4) 0) rn o N W d m N F- V) o z v c r' o m z N a) 7 C a) n C I' w N O 0 0 N N O • I D. O V r O ) Z Z O _ N ur I Z Z C) V7 4) N N li N m I N W co as «E+ ° C R C 3'ooa a~ EI o 0HHH a~ O O O • =aCL a a~ M o N O rn rn a~'i to U rn rn } I~, C `O N 0 F\V d N O O O Ur O O N N N 3 Co P- 7 (U N ^ 0 0 N m N 0 2 0 I vN y Q CA m N p 0 s O O O O N C 'M+ p C ~ ~ ~ ~ ~7 O N N r`0 o n 3 ui (D c o a o oo 0 0 V i ? (D W(Z! C U) a, N 'p N N G of v a) v c d n o 0 0 • O Z Z ix O N= i O N fn r r \ V m A € no. CL z •2 0 r Sr- a~',Ov1U A U FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER Scz /r i ~~a-~ TOWNSHIP 9k ~~o H SECTION `i T 9 N-R W ADDRESS_~y~ r Q? g 7 ST. CROIX COUNTY, WISCONSIN, SUBDIVISION~fc s%J-,~ /•4.~ .-7~e f~> LOT l0 LOT SIZE V-42 PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM k .+.L y 67dGcSF C„"cym ~a Ar+lSD. .LV ~i 32" p,. S7" (o Z y2 F7 INDICATE NORTH ARROW i BENCMLkRK: Elevation and description: 7'o,2 .r ZV ~G Lor 5t c.. Alternate benchmark SEPTIC; TANK:Manufacturer: (,l/d~ a►r/ Liquid Cap. IDoc9 Rings used:-,/-Manhole cover elev:~.25---Final grade elev: y. > Tank inlet elev.: S Tank outlet elev.: 75 No. of feet from nearest road:Front , Side._, RearZ _Ft.-7& From nearest prop. line:Front , Side , Rear 7r Ft.- Co 6 No. of feet from: Well S7 ~ Building: I 'a (I'aclude this information in the above plot plan) (2.reference dimensions to septic tank) SEE REVERSE SIDE s 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: Oml-Trench : - Seepage Pit: i Width: /Z/ Length Ye _Number of Lines: 3 Area Built-7 Z4 s5 ';P Exist. Grade Elev. Y, 7 Lf Proposed Final Grade Elev. Fill depth to top of pipe: No. feet from nearest prop. line:Front Side), Rear Ft.3 7 No. feet from well: No. feet from building z 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: f 6/90:cj Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations St. Croix Sa~tyand~~guildings Division INSPECTION REPORT Lot 18 Sanitary Permit No.: (ATTACH TO PERMIT) GENERAL INFORMATIONSe,SW,Sec. 29,T29-R19,Glenna Dr. 149119 Permit Holder's Name: ❑ City ❑ Village R] Town of: State Plan ID No.: Sam Miller Hudson CST BM Elev.: Insp. BM Elev.: BM DParcel Tax No.: 827 /ev, L0 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 9 L ; Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet/ f TANKTO P/L WELL BLDG. VAientto lntake ROAD Dt Inlet r Septic ) NA Dt Bottom Dosing NA Header / Man. ~I ,c NA Dist. Pipe" Aeration Holding Bot. System g4 PUMP / SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM LFc Lift Lriction System TDH Ft mai n Length Dia. Fi Dist. TOweu SOIL ABSORPTION SYSTEM BED/TRENCH width MKW PIT EN IN No. Of Pits Inside Dia. Liquid Depth DIMENSIONS Manufacturer: SYSTEM LAKE/STREAM LEACHING SETBACK CHAMBER Moe Number. INFORMATION Type 0 OR UNIT System: DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only De th Over xx Depth Of L xx Seeded/Sodded xx Mulched Depth Over p Yes E3 No Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ C~MMENTS: (Include code discrepancies, persons present, etc.) U; Y i I , Plan revision required? ❑ Yes ❑ No m `p Use other side for additional information. NEE Ul~ ~ Date Inspector's Signature Cert. No. $BD-6710 (R 05/91) i SANITARY PERMIT APPLICATION ouN 7DILHR In accord with ILHR 83.05, Wis. Adm. Code cl STATE SANI ARY PERMI # -Attach complete plans (to the county copy only) for the system, on paper not less than 4 ` a 8% x 11 inches in size. ❑ Check if revision to p evious 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 //Or S C-- %t %&L--)1/4, S D,_j T1-1, N, R (7 E (o W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK# -.go jr -x'24 Z CI , ST TE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ` w a 71e : dam,. T:I NEAREST ROAD II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE : u~? a f f~ TOWN W, ❑ Public 91 or 2 Fam. Dwelling-# of bedrooms R EL AX NUMBER( ) Ill. BUILDING USE: (If building type is public, check all that apply) S IF a7 1 ❑ Apt/Condo 1p ❑ Outdoor Recreational Facility 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 1130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) of an A) 1. ~ New 2. ❑ Replacement 3. ❑ Tank Onlyent of 4. ❑ EReconnection of xisting System 5.E1 Exist ng System System System Date Issued B) ❑ A Sanitary Permit was previously issued. Permit # - V. TYPE OF SYSTEM: (Check only one) Other Non-Pressurized Distribution Pressurized Distribution Experimental 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 El Holding Tank 12 Seepage Trench 22 El In-Ground 42 1:1 PitPrivy 43 ❑ Vault Privy F 13 ❑ Seepage Pit Pressure 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PNRC. RATE 6. SYSTEM ELEV. 7. EFINAL LEVATION GRADE r REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (in ) 10 Feet Z. Sv Feet VII. TANK CAPACITY Prefab. Site Fiber- Exper. in allons Total # of :Man ufacturer's Name oncrete Con- Steel glass Plastic App INFORMATION New (stin Gallons Tanks structed Tanks Tanks Se tic Tank or Holdin Tank Q `S t t/ Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. MP/MPRSW No.: Business Phone Number: Plumber's Name (Print): Ilu is Sign re: (No mps) Ste r 2- Plumbs Address (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY Issuin Agent Signature o Stamps) Disapproved Sanitary Permit Fee (Includes Groundwater M ❑ Surcharge Fee) q Approved ❑ Owner Given Initial ^l Adverse Determination 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 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$ ~ 1/4 s W 1/4 , Section 1 y , T -may N-R Township Mailing address ~t~~CZ4l~ Address of site go-/ yC' e. Subdivision name -P6-M5 Lot no. / $r Other homes on property? yes X No Previous owner of property CQ/rc/ C. Total size of parcel 2.~/S Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? ,k'~Yes No Volume and Page Number &,O O 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. y (o,9S0 ( , and that I (we) presently own the proposed site for the 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. Y&9-25-0_6, 2~Lzcvx- :~itnature of applicant Co-applicant Date of Signature Date of Signature t►• rt SEPTIC TANK MAINTENANCE AGREEIIENT co St. Croix County c~ n OWNER/BUYER o • Fire Number.- J ROUTE/BOX NUMBER ZIP CITY/STATE Section:L • T N ► R ~ PROPERTY LOCATION 07 Town of St. Croix County, -n~-~ Subdivision.~ Lot numb er._Lj~_• ` Improper use and maintenance of your septic system could r esult in con- its premature failure to handle waste sists of pumping out the septic tank every three years or sooner, if needed, by a licen•s•ed' 's'e t1c tank um er. What you put into the system can a ect the .unct on o, t ho septic tank as a treat- ment-stage in the waste disposal system. St. Croix Count elilagibleementtoofraecifailingeve a maximum of 60% of the co 1► 1978. St. Croix County whi.c was in operation prior to.July with the requirement accepted this program in August ree to keep►their system properly that owners of all new sYs~ g- g maintained. a The property owner agrees to.submit to St. Croix County Zoning certification form, signed by the owner and by a mater plumber, vjourneyman plumber, n-sitecwastewaterrdisposalcsystempisper in proper fying that (1) the o if nec operating condition and •(2s• less inspectionfullanofd and scum. essary), the septic'•tank is 30 days prior to Certification form will be sent approximately three year expiration. ►4 0 to.mthe undersigned addithe sposalvsystemiinmaccordancegwith to .maintain n the the private sewage Wis the standards set orces. Certifiicationyform mustobeicompleted a ment of Natural Resou and returned to theSt. Croix County Zoning Office within 30 days of the three year exp r SIGNE DATE ? 2 Z_- 4 St. Croix County Zoning Office 911 4th St. Hudson, WI 54016. 386-4680 Sign, date and return to the above address. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY; DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O.~FOX 769 N, WI 537 HUMAN RELATIONS 07 (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHI /A4r}Pd+21LifiY: LOT NO.: BLK. NO.: BDIVISION NAME: 1 Sw 1/ zg /Tz9 N/Rl9 E (or) cs1soN 18 a E5~ ai-F /a MAILING ADD ESS: C '?~NTY: OWNER'S/BUYER'S NAME: 'SAM /~u~sa~ , Soo~6 CRo, ~M I4,UF,e To%T ~cax USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: I FI DESCRIPTIONS: N ESTS: 1 -1 New ❑ Replace Il VLy /d 11/ 99/ 131-y 47• 94 Residence 1~I~lt 66 ms- RATING: S= Site suitable for system U= Site unsuitable for system r ON ENTIONAL: IMOUP S. ❑U IN G~ S P[--u RESSIRE]SYSTEM-IN-FILLHOLDING TANK:: RECOMMENDED ON4&Tthk..'4:` ptigpal) SSa UU S U Q S S U 8-1 If Percolation Tests are NOT required DESIGN RATE: n I I If any portion of the tested area is in the A under s. ILHR 83.09(5) (b), indicate: 1..L1~~ Floodplain, indicate Floodplain elevation: C PROFILE DESCRIPTIONS r BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESSt/COLOR, TEXTURE, AND.DEPTH NUMBER DEPTH LA, ELEVATION OBSERVED EST. HIGHEST- TO BEDROCK IF OBSERVED (SEE ABBR .O SACK.) B- ~ yr« ~ .5% Q3.8Z X948 3 2''$e MFS-G 3 ~>Ru 5,S C ,r~'h 5 B- Z 4.06 94.-LZ 9.0LA" 84-50S '~8~$t2t-f B- 7.75 9Lq-7 D ? 9•79 4-~ LJLTS 17'9•yt4S 514 B- QUZ .15 6'~$c~s~Ts /2- hms b Ru } >~IaMS~~i B- I I asa 9 o ,E > b.sb cs -s !2"$q~~hs 60 qS S ,~,WjS~+G~ B- G~f PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERI PER INCH P_ I .oo NaNE .'%6 > Z > >Z < P- Z AO rjeW F. 4 .-Jo >Z >2 le 3 P- • D N O > > P- P_ - A'T► ►u AT ~ 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 84.80' -Alp I € c I j i ~ 4 l;.r . A A, ' ~-1 I € aa_ _ Qu .01 I E I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the pygoedures 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 not : TESTS WERE COMPLETED ON: A&V J6NN U AGNNSnjm 'SC.I IN4 J k` 1,7 /94 j ~I NUpABER1optionall: ADF~S. x / U~Sa>✓ 5401 CERTIFJLATION_NUMBER: IP384-4680 CST SIG URE: w 60 ISTRIBUTION: Original and one copy to'Local Authority, Property Owner and Soil Tester. D DILHR-SBD-6395 (R. 10/R"i -OVER - - I o o Z~ 1 ~ -i- R 2-. Ilk: Ul\ 75 I P o l o w r, C 1 i w S ~ ~ i ~ 1 z U) I rri ' z I I 1 1 I < 1~ I 11 rn I I .p {I I ~ 2 I I ~ II G? i j O h I III ~ II < I +li O 1~ z I I! I I ca X m I © I 1 ~~*t; I O 7 1 I! j 1 I ! 1 I I 1 I -0 I b I ~ I i m ! m I I I 1 ~ I II I . I W I I _ O I I I ! { < ! 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