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HomeMy WebLinkAbout026-1056-90-000 FORM - STC - 104 f AS BUILT SANITARY SYSTEM REPORT OWNER/ / 'o-ce, /C OASHIP ► ?~?,~~?c~ SECTION l T 21^ N-R_ZfLW ADDRESS ~O j rf f' Cr ST. CROIX COUNTY, WISCONSIN _ SUBDIVISION - LOT --i~flT SIZE PLAN VIEW SHOW EVERYTHING WITHIP 100 FEET OF SYSTEM A, S _ t.. r / C; ~ G d~ _ .1 ~fj~C ry J, INDICATE NORTH ARROW BENCHMARK: Elevation and description: ,/1r. yS~~i/u Alternate benchmark - - - SEPTIC TANK:Manufacturer: Liquid Cap. Rings used : Manhole cover elev.~~- Final grade elev: ~j Tank inlet elev.: f"~-- Tank outlet elev.: No. of feet from nearest road:Front , Side Rear Ft. From nearest prop. line:Front Side , RearFt. No. of feet from: Well Building: (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE 1 - 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: ~l ! Length ~j Number of Li es: Area BuiltCi Exist. Grade Elev. ~1. Proposed Final Grade Elev. X Fill depth to top of pipe: No. feet from nearest prop. line:Front , Side Rear Ft. No. feet from well: 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: y DATE : PLUMBER ON JOB : LICENSE NUMBER: wjl 6/90:cj s Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: aand Humkn Relations S INSPECTION REPORT St. Croix Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION SW-L, SW4,Sec. 19,T30-R18,95th St. 149194 Permit Holder's Name: ❑ City ❑ Village IN Town of: State Plan ID No.: first Nat'l Bank/New Richmond Richmoni CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 026-1056-90 287E TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic octk Benchmark ,9 Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet 7~ ~S 0 / D TANK SETBACK INFORMATION St/ Ht Outlet , TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic 150 NA Dt Bottom Dosing NA Header / Man. oT 911 Aeration NA Dist. Pipe 9, 1~15 la 9 Holding Bot. System (IK j 9/. 9~7 PUMP/ SIPHON INFORMATION Final Grade / Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Len th No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN I N /a.U' DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM INFORMATION Type O CHAMBER Model Number: System: /00U OR UNIT DISTRIBUTION SYSTEM rLe er /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake th Di a. Length 76 Dia. Spacing 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 7 Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Y Plan revision requiredIr' ❑ Yes ❑ No - Use other side for additional information. 6 SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. FILHR SANITARY PERMIT APPLICATION - COUNTY ,77 In accord with ILHR 83.05, Wis. Adm. Code Cy, c:, / STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 19 8% x 11 inches in size. c k i e sion to previous application --See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATIOI%.S PROPERTY OWNE c P PERTY CATION e~Ct ~eox, ef* '/a S T Q, N, R E (or yl; PROPERTY OWNER'S MAILING ADDRESS L BLOCK # fp G ONE NUMBER SUBDIVISION NAME OR CSM NUMBER CITY, STAT ZIP CODE 2_1 c 1. 6V all ~ 1. TYPE OF BUILDING: (Check one) ❑ State Owned CITTLYAGE ' NEAREST ROB 1 R71 F: ❑ Public 160 1 or 2 Fam. Dwelling-# of bedrooms A L x N ER( Ill. BUILDING USE: (If building type is public, check all that apply) d '7 ~p~ 1 ❑ Apt/Condo Al 6 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 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. ❑ New 2. Replacement 3.0 Replacement of 4. ❑ Reconnection of 5. ❑ 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 L~F,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 O D REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION ~b ~(f V' Feet 01• ,2 Feet VII. TANK CAPACITY Site in allons 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 o ~4__ - - M_ n I F1 I El E] n Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber' i ature: (No Sta ) MP/MPRSW No.: Business Phone Number: Plum er' Address (Stre Pity, State, Zip Co e): A711- 1 0 a IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Lary Permit Fee (Includes Gro ndwater Date Issued Issuing Ag t Signatur No Stam Approved El Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11188) 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 - 60'k L, Location of Pro ert _do1/ P y /4 4, Section , T N-R JaW Township] ctrl Mailing address Address of site q~s f .r~J ,~+~/1^~ ~►i n~ Subdivision name Lot no. Other homes on property? yes V/ No Previous owner of property S G Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes V/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, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. _V7/_ 5Z , 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 recor ed in the office of County Register of deeds as Document No. /S7v l~ lye U~f. ~p li an 5~j'/~/,fctnc~ Co-applicant Date ignature Date of signature 4 71570 VQL 9a{4 PAGE 240 SHERIFF'S DEED ON FORECLOSURE WHEREAS, pursuant to a Judgment of Foreclosure and Sale rendered in the Circuit Court of St. Croix County, Wisconsin, on December 26, 1990, in an action between: FIRST NATIONAL BANK OF NEW RI HMM IONDD, PLA, CASE NO. 90 CV 449 VS. DENNIS KINNEY and KAREN A. KOPRAS, DEFENDANTS, and, after due advertisement, the subject premises hereinafter described were sold on July 2, 1991, to First National Bank of New Richmond for the sum of $36,930.02. And, WHEREAS, the said First National Bank of New Richmond is now entitled to a conveyance according to law, NOW, THEREFORE, the undersigned in consideration of the payment to him of $36,930.02, receipt of which is hereby acknowledged, conveys to the First National Bank of New Richmond, a Wisconsin corporation, the following tract of land in St. Croix County, Wisconsin: Part of SW 1/4 of Section 19-30-18 described as follows: commencing on the E and W 1/4 section line of said Section 19 in centerline of Town Road (said point being 2143.0 feet E of W 1/4 of said Section 19); thence S29 ° 18'W 1067.0 feet to a point on said centerline and Place of Beginning; thence S 29 ° 41'W on said centerline 503.4 feet; thence N68 ° 49'W 89.8 feet; thence N9 ° 21'W 198.5 feet; thence N10 ° 54'E 214.5 feet; thence S87 ° 4TE 325.00 feet to the Place of Beginning. DATED this day of July, 1991. REGISTERS OFFICE Rat Sheriff, Baader r ntY ~ St. Cro* D SRecdfor Reco d 1?FC&vE2 ,1111:40 61991 A. M # ILI r.... JUL 0199, s at 1 /n~n F,iCE ) 1 ~1c Register of Deeds VOL 909. ?AGE 241 STATE OF WISCONSIN } } ss. COUNTY OF ST. CROIX } On this~~day of July, 1991, before me came Sheriff Ralph Bader, known to be the individual and officer described in, and who executed, the above conveyance, and acknowledged that he executed the same as such Sheriff, for the uses and purposes therein set forth. ~G22 G- i-rnv`L~.-- ' . Nota ublic,t4: fro Cjoi#pty State of Wisconsin; My Commission- - THIS INSTRUMENT DRAFTED BY: BAKKE, NORMAN, SCHUMACHER, SKINNER & WALTER, S.C. 900 Main Street P.O. Box 54 Baldwin, WI 54002 (715) 6844545 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ffa Z FIRE NO: ADDRESS: LOCATION : _,dleg/4 , 1/4, SEC. IV T JD N-R__L~LW, TOWN OF: ~Cb~'jofid 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. SIGNED., ~~X BCD ~ ti5 cht U eu) ~ ; DATE : 9 / St. Croix County Zoning office 911 4th St. Hudson, WI 54016 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY,. DIVISION LABOR ANTI PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN, ELAT S 1 / MADISON, WI 53707 LHR 83.0911) & Chapter 145) A49L "-V LOCATION: SECTION: OWNSHI UNICIPALITY: OT NO.: BLK. NO.: SUBDIVISION NAME: OUNT : * / MAILI G ADDRE S: ' t '0040e'~~ U 9'E (C DATES OBSERVATIONS MADE G P NO.BEDRMS.: COMMER IALDESCRIPTION: PROFILE DESCRIPITIONS: A E TS: A Residence ~ - ❑ New Replace ~ ~ ~ _ RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) IMS EU S❑U ©s DU ES U Os [A If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.0915)(b), indicate: Floodplain, indicate Floodplain elevation: ROFILE DESCRIPTIONS BORING TOTAL DEPTH TO ROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HET TO BEDROCK IF OBSERVED (SEE ABBRV. ON B 02K.) d -ra of j/d-~6 ` 3 lop ~i B- ~ i? ~ q7 5/0~ B- B- B- PERCOLATION TESTS c TEST } DEPTH. WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES t NUMBER AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERI D2 P R PER INCH P- O~ P_ L P- P . P- P- P OT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate seal sw antes. Describe wh re he hori- z ntal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation rings alwi he j ction rcent land slope. r~ C~SS t^~ z O G .r M ELEVATION. - to inn E i I I E , f i t the undersigned, hereby certify that his form were made by me in accord with the procedu s an methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correc NAME (print): TESTS WERE COMlMPVETED ON: ADDRESS: CERTIFICATION NUMBER: IPHONE UMBER(optional): 41 -7,5;f CST SIGN E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - PLOT PLAN PROJECT ~ - ~hfADDRESS b Su) 1/d 1/4/S/f /T,,Io N/R / W TOWN COUNTY Gra t',< MPRS Byron Bird Jr. 3318 DATE BEDROOM CLASS PERC_~ CONVENTIONAL/( IN-GROUN PRESSURE CONVENTI0 AL LIFT MOUND- HOLDING TANK SEPTIC TANK SIZE 1/12-er~ LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA PERC RATE ABED SIZE 1,;2 4 0 111116 Benchmark V.R.P. Assume Elevation 100' Location of Benchmark 51 eI, At Y * H. R. P L Borehole Q Well Scale = Feet 0 Perc Hole System Elevation Uent 12" Grade TYPAR COVERING 2" 12" 3• 4 6' O 3' I 6 " Sewer Rock ~r 12' J t11I PL PL L