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HomeMy WebLinkAbout026-1084-90-000 ~ O I O o ~ I I a c I I N I 0 ti ~ I C ~ I a L U .a 7 Li N N m I Q) w 0 a) Z 7 n3 N C U. O ~ »Y I :p U Q U Cl) Z w Z = o Z m m IL CO N F- U) I O 2 U m Z d O N to F- E i a N O O W U c N N a) 0 0 0 d N Q) - O •AJ a C N ~i O Z m z 15 Z o N ~ I O O N > m O N d! O 0 E a 'L' CJ L N d Q N N a Li G o a N 4) E N~ E 3 Imo- U) U) E Z) 0 Z 0 0 0 EL CL ~ ~ a a a I a M o N ' L a I U) J V p O 0 O W p a) qV M O O00 ~ 0 ^ T m r- `c ri O w co 06 0 o 06 7 U) O O C N O E j= 3 L c c t co O O LO H d N N . O OO O (T 4 .6 6 (n L. V c6 c - E E cq? 0) co o L N L L mU., W O o f > o N F F- c a) • y' O N > O N Cn M ,t O I CC I w w L d c0 4 d 3 at a a Z • c~ a m .2 m c FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER At 26'GS2 1,4_S" 'ex ' TOWNSHIP SECTION . f T2, N-R~ W ADDRESS ST. CROIX COUNTY, WISCONSIN L7 2 SUBDIVISION LOT.4/J,,~- SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i 77-7 ~ n_ 4 INDICATE NORTH ARROW 3 BENCHMARK: Elevation and description:, ')LJAL4 0~1wl Alternate benchmark / SEPTIC TANK:Manufacturer:,,n,.~=r Liquid cap. Iml? ; /A Rings used:-LManhole cover elev: 9ZW, Final grade elev--i-- Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front , Side, Rear Ft._,/_ From nearest prop. line:Front , Side , Rear-X-Ft. i No. of feet from: Well , Building: 2l (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 I SOIL ABSORPTION SYSTEM Bed:_~ Trench: Seepage Pit: Widtht2 -Length S' Number of Lines:-1,22 Area Built Exist. Grade Elev. 92 Proposed Final Grade Elev. Fill depth to top of pipe:,,? No. feet from nearest prop. line:Front , Side, Rear Ft.-~Z/ No. feet from well:- -.No. feet from building c'0 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: rQ- 9 - 2Z PLUMBER ON JOB : LICENSE NUMBER: < 3 6/90:cj 6EPARTNviENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969' ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MAQ4S.ONNy~4 5377 State Plan I.D. Number: ~5 WW 4 , W e c . 2 9 , T 3 0 - R 18 CONVENTIONAL El ALTERATIVE (If assigned) Town of Richmond Three Lakes Rd. ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: i John P. Wassber RPa er'ack #305 New Richmond WI - ~ ~ point) DESCRIBE IF DIFFERENT FROM LAN: REF. PT. ELEV. t CST T. ELE / t BENCHMARK (Permanentreferenc a4_ o 4 -cr MP/MPRSW No.: G County: Sanitary Permit Number: Name of Plumber: Calvin Powers Jr. 1563 St. Croix149012 SEPTIC TANK/HOLDING TAN . 3. MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: OUTLET ELEV.: WWINING BEL LOCKING PRPROVIDEDCOVER r97 78' L❑ ~BU ❑YES Jop~ BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELD IN~j: VENT TO I~RESH /t ALARM: FEET FROM LINrOt /A 1 / AIR IN ❑ YES 21TO ❑ YES 154- NEAREST--1111- DOSING CHAMBER: MANUFACTURER: BEDDING: ID CAPACITY: PUMP MOD UMP/SIPHON MANUFACTURER: WARM EDLABEL POCKING OVER PRO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: ER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET LINE: AIR INLET: PUMP ON AND OFF ❑ YES ❑ NO NEAREST LENGTH: DIAME MARKING: SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing =MAIN or excavation. (If soil can be rolled into a wire, construction shall cease until the so il is dry enough to continue.) CONVENTIONAL SYSTEM: ? & o 4_C WIDTH: LENGTH: NO. Oll: DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: - LIQUID BED/TRENCH TRENCHES: MAT AIL PIT DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. D STR. NUMBER OF PROPERTY WE BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVERT ELEV. INLE : ELEV. END: PIPES: FEET FROM LINE,:'`lt ! AIRINJ ,T,-00 ^~SC C]ltO q ~w 91.1. 2a f) o~ NEAREST 111 MOUND SYSTEM•,~VV ) Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL-COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑YES ❑ NO ❑YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: TNO.OF RENCHES: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST---- 00- 'eG-r~'1(~ etain in county file for audit. Sketch System on Reverse Side. SIGNA RE: TITLE: SBD-6710 (R. 06/88) 17 ffILHR SANITARY PERMIT APPLICATION CouN In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than f q Q' d / .21 8% 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 OWNE PROPERTY LOCATION '/4, '/4, S_2 9 T , N, R (or PROPER MNER'"S MAILING A DRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME R CSM NUMBER II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD ❑ State Owned ❑ VILLAGE ❑ Public Vv 1 or 2 Fam. Dwelling- # of bedrooms ~L -PARCEL AX NUMBER(S) / 111. BUILDING USE: (If building type is public, check all that apply) - j 2,114 v~br-~ -QO- 1 ❑ Apt/Condo 2 ❑ Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 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 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. N New 2. ❑ Replacement 3.E1 Replacement of 4. ❑ Reconnection of 5.E] 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 ❑ 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/day/sq. ft.) (Min./inch) ELEVATION ""'Feet e 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 strutted Septic Tank or Holdin Tank 1600 FA n Lift Pump Tank/Si hon Chamber Li 7 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's /Name (Pri t): Plu er's Signatur (N Stamps) MP/MPRSW No.: Business Phone Number: _j JAI_ r~ ,eT 3 Plum is Address (Street City, State, 'p Code . IX. CO NTY/DEPARTMENT USE ONLY Disapproved itary Permit Fee (Includes Groundwater [Date Issued Issuing A ent Signature (No Stam Surcharge Fee) Approved ❑ Owner Given initial / Adverse Do rminat'on X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: s SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber APPLICATION FOR SANITARY PERMIT S T C - 100 of the This application form is to be completed in full and signed by the owner(s) permit ("'spec property being developed.' 'Any inadequacies will only result in delays of the issuance. Should this-development be intended for resale by owner/contractor, house"), then a second form should be retained and completed when the propertylis a - - - - - - - - sold and submitted-to this office with-the-app- priate - - - - deed - - - - - recording. - - - ca 'S` , vl o,'~ a Ir e Owner of Property . a 2 Q N - R , _ ~ W Location of Property SAN ' N,43 'x. Section T 3 l V,Unship '-k~v ~1~kw,.v w - ilt 1 r J -11 Mailing Address eW '2' i.w.vw WT s cri Subdivision Name . Lot Number • vr. t ~ a• ~ ~ vt~ l7 ' . Previous Owner of Property Total Size of Parcel 4-C) a (r e S Date Parcel was Created 10 -Ai -111(f Yes No Are all corners and lot lines identifiable? X Yes No Is this property being developed for resale (spec house) ? Volume and Page Number 2.S`t as-recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed • I 2. Land Contract 3. Other recordings filed with the Register of Deeds Office 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 the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION I (We) ceA.tiby that a.P.e atatementd on th,ib 6onm ane true to the beat oS my (oW!.) h.id knowledge; that I (we) am (ane) the owner (a) o6 the pnop?~y dedc~ci.bed in t .injonmati.on JoAm, by vi tue o6 a waxtanty deed neeonded in the 0jitee of the e) County Reg.idten o6 Deedb as Document No. and that 1 (w 1 aa (on Y (we) have 4 pnedentZy own the pnapoaed a.c to ion the aeivage po ya and that the. obtained an eaaement, to nun uz~:th the above dedeni,.bed pnope~.ty, 1Son co nd tcuc ti.o n o6. z aid a ya tem, and the name had been duty neeonded in the 0 6 j ice ob the County Reg.iatex o6 Deedd, as Document No. ) GNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED i DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 468191 r VOL 898 r'a~l ~a4 REC IaTER1 QFW a + + ~ o v ~ ST. CRotiX C.0.1 k w. IJQ 17 Reed for Reeord A n R 121991 P(. conveys and warrants to 4 5 S It ;10 Salo. ?-Sul at I TZ, . R later o~F Oet' RETURN TO the following described real estate in b'. C Yb 1 X County, State of Wisconsin: ~ Tax Parcel No: 0 L(,, toH -I 7kawl" ck T 1 ~4 vo,`T~ WeS~' o4' M o y--t tN \iJi y~ , 'Tu w h S k ~ ~ 3 tJ v`~" , `i?a~g~ We- S`~' IY;V,S 0,C" eV y c~' ~tiP w l Row d ~Z C>4' \j0. tUk 30.0 This S nUt homestead property. (is) (is not) Exception to Warranties: Dated this/ day of 119 (SEAL) /l-7 ~_rZ~C EAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT, trj ~\1 til n ~Jj Signature(s) STATE OF WISCONSIN ss Y ^ `J \J 1 C La-c,, Cla lee County. ~h. authenticated this day of , 19 Pers nally came before me this QC 0 19 the above.named I,cI. /nee on TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the person , who executed the authorized by § 706.06, Wis. Stats.) foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY V O~^ Y. W 0.SSb i' Notary Public County, Wis. (Signatures may be authenticated acknowledged. Both My Commissl n is permanent. (If not, state expiration are not necessary.) date: 119-2 19 ) 'Names of persons signing in any capacity should be typed or printed below their signatures. SB2 NTF 0021 WARRANTY DEED STATE BAR OF WISCONSIN Nelco Tax Forms, P.O. Box 10208, Green Bay, WI 54307-0208 Form No 2 - 19$2 cn ST C- 105 r . a SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County z c7 a OWNER/BUYER d(,~h ~a ; 'ROUTE/BOX NUMBER Fire Number CITY/ STATE e W R,0-. -U,,, j W' ZIP x;_401 7 PROPERTY LOCATION: j\AJ Z, NW k, Section 2-1 T SO N, R W, Town of I~~C w•ay, St. Croix County, Subdivision Lot number 1 Improper use and maintenance of your septic system could result in its premature failure•to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you ptit into I the system can affect the function of the septic tank as a treat- ment stage in the-waste disposal system. St. Croix.County residents may be eligible to receive 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 systems agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master.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 • E I/WE, the undersigned, have read the above requirements and agree N to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- v ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of.the three year expiration date. SICNED \.J + - l~= DATE St. Croix County Zoning Office P.O. Box 98. Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. -DEPARTIMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS ` DUSYRYRY DIVISION IN LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 7969 HUMAN RELATIONS N WI 53707 (ILHR 83.0911) & Chapter 145) LOCATION: SECTION: TOWN IP/MUPd+eW-XMY: LOT N ]BLR.-N0.:1SUBDIVI ION NAME: Alk) ~ 4 /T o N/R (or ,I' COUN OWNER'S/BUYER'S NAME: MAILING ADDRESS. USE ATES OBSERVATIONS MADE NO. BEDRMS.: ICOMMERCI L DESCRIPTION: PROFILE DESCRIPTIONS: 1PERCOLATION TESTS: Residence New ❑Replace / Z Z - ~"Z RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) ZS ❑U ©S EA ®S ❑U ❑S ®U ❑S IM I/ 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: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SO L WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGHEST- TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- r~ AIA B- ,E B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD .1 PERT 2 P R PER INCH P- / P- P-7 S'S 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 r~ ri-~ ' ~y/~Y i✓iMf'f. P~.. J 4~ /-1 s/.Clrfl4 ~~G~/.C/ / _ € j l ~ € ~ r r r , I f r , s ' ) € a r , N E { r a r r r = r r € r ~r r ` r € r r r r r ~ I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and me ods 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 (pri TESTS WE E COMPLETED ON: / ADDR CERTIFICATION NUM ER: PHONE NUMBER (optional): f - / M/NATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - -70 I oil I PAGE OF C r U S S J t 1 O 11 p 1 A U r 17 ~ Y's T C 0-) fts►A Alt InI►I► And Obtaivollon pipe A4, n ie,1 ,,,w I f~01 7 ^ ApproYiO Vonl Cop ►IInITUT 12' Aeoro flnol Geode 20- ♦2' Above Plpr 4- Cost lion T° fled Grooo V4A1 Pies - Mwsh liar Or SrnlMllt Co.ulny Wn 2' AYOrspolo Orst Plpo OIa1110Y0on - ' o -Tao s Pipo LAggisjols `ps 6 po ParlorOlod Pips bdov ° o -Cc*-41no TorTlnollno At 94119T 01 316140 Pru o P, D Fins-1 rf. < -~-rte---' ~~tJw t Io~1 / SOIL FILL DISTRIBUTIOM PIPE • APPROVED S4N'pETIC COVER 2"0F /,GGR£GATE OR 9" OF STRAW OIl M11RSN HA`.! AGGREGATE J:LEV, oF6 -~FUT--.. 3- DIS-1-11II5UTIrOW PIPE TO BC AT LEAST r~V INCHES BELOW ORIGINAL GRADE AUU AT LEASTLO INCHES BUT 1.10 MORC THAW 42 IAICI{ES BELOW FINAL GRADE. MAXIMUM DEPTH OF F-XC/IVATIOIJ FROM OR16V AL 69ADF WILL BE INCHES MIamm orp 1i OF EACAVATION rAOA 0tr161WAL (3RAP . WILL BE INCHES 00 SIGIJCO: LICEUSC NUMBER: DATE: 110 •