Loading...
HomeMy WebLinkAbout030-1083-40-300 C) O 6j. m (v O N 4 ~ C 1 O N b O ~ i d i y I y I 0 C Z LO L LL C O 3 Q M Z N E m C) IL Im o z Y m 2 ~ ~ aci (D N N O CL N c ~i y 0 0 0 C) c O w= N_ O O Q ICI O Z co z z z i d 00 N ! A E 0. co Q r O LO G IL £ N zN>I'3333 EL 000 •P oaaa N a o O) O o ° N 3 y (A J U O O O } O r r- M (n N 0 0 0 0 N O O - O r O O (\D (n L ~ ~ a N ~ N N Of 'D m N 6i n N 1- 1 N d Q } (A m O v O O C L N C r- R O M O O U Vl 7 a O V o pO~' Oa G7c a rn °0 0 0 0 N N N N co 'L" ' M d C y a 0 O N n r (D O OD ~ N ~ C N O C j N N r' N N H O d) O O a) n N n M L • O N (n 2 0 Z 0 U) cc y (n € V CL Sat ° ea • a m N r`IV E c c r A 0 a 2 I! O N U FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ~ j,.,c -:,Ja 1TOWNSHIP tzd SECTION a/ T30 N-R l! W ADDRESS cyfalov~ I~ e.~1 ST. CROIX COUNTY, WISCONSIN SUBDIVISION _LOT r2 LOT SIZE k PLAN VIEW SHOW EVERYTHING WI HIN 100 FEET OF SYSTEM - i floe 71 Al 1 t ~y CA- O T INDICATE NORTH ARROW BENCHMARK:Elevation and description: Alternate benchmark -~"a 5e 7C,, T SEPTIC TANK: Manufacturer: Y" s7 c, u Liquid Cap. I Rings used:lLManhole cover elev: Ivy( ?')Final grade elev: `l ;~L- Tank inlet ele .:'10 v ank outlet el v.: lJ t5 7 No. of feet from nearest road-Front 13V'Side , Rear Ft. From nearest prop. line:Front/-3() Side 7,i Rear Ft. No. of feet from: Well Building. rr __II (Include this information in the above plot p an Rl~S (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 Bed: Trench: Seepage Pit: Width: Length Number of Lines: Area Built Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top of pipe: go. 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: DATE: / PLUMBER ON JOB: LICENSE NUMBER: 6/90:cj ~ 9Io 0 . Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT St. Croix Safety and Buildings Division NW SW, 2t erg%, Z JT~S~ TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 4 g e 2 - Block 149191 Permit Holder's Name: ❑ City ❑ Village N Town of: 4 4 6 2 7 O State Plan ID No.: Keith Hildebranct St. Joseph CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: JD, UQ 030-1083-40-3000 TANK INFORMATION ELEVATION DATA r Z~ TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 407,8 ~-7 SS r /eo Go Dos' Aeration Bldg. Sewer G p~ a ~ Holding St/)Ot Inlet Go 70 TANK SETBACK INFORMATION V p(' f'j,5/' St/ let outlet fro?' e+ TANK TO P/ L WELL BLDG. Ventto ROAD t>t i~^.i.~ Air Intake Septic S ` NA ZZ-Betem tic. NA Header. 9.9s Aeration NA Dist. Pipe ' .8.3 Holding Bot. System 9y gy' PUMP/ SIPHON INFORMATION Final Grade 3,&' ZOO. 7$' mantil rer Demand Gd (I~r' 2, 9~ O5/ (p4 Model Number GPM 2,~r- pS y3 TDH Lift Friction Sys TDH Ft Loss mead V" o ' 0 ;Z6' Forcemain Length Dia. Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS .Z © DIMEN I N SYSTEM TO P/L BLDG WELL LAKE/STREAM LEAC Manufacturer: SETBACK CHAMBER INFORMATION Type O CCIt Moe er: System: 7 1(Q, I OR UNIT DISTRIBUTION SYSTEM Headert if+trFd Distribution Pipe(s) 9 x Hole Size x Hole Spacing Vent To Air Intake Length ( Dia q" Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over -i r, xx Depth Of xx Seeded/ Sodded xx Mulched Bed/ Trench Cen er _q +r Bed /Trench Edges '57 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) ~v ~ . ~ ~p.~~=moo Is~ - ~ . ~ Plan revision required. ❑ Yes ❑ No q / Use other side for additional information. 5 ic~, A SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code CoulNCOUNTY. STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than l y g l gl 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 OWNER PROPERTY LOCATION e. a c w d Y` Nov Y. Y., S cal 9 T 90, N, R 9 E (or) W PRO ER OWNER'§ MAILING ADDRESS ` ct_i LOT # BLOCK 0/270 J w E~ 11 1 C_ CITY STATE ZIP CODE PHONE NUMBER SUBjDIVISION NAME OR CS N MBER r.~ v,ay ~A~ ,Qq ,J S'Y P~ y. ~73i e,,.a,A t 4 / I (o P/ _A1 7 11. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) State Owned ❑ VILLAGE J--/ F'4,41 (gj ❑ Public 6~1 or 2 Fam. Dwelling-# of bedrooms.] A EL TAX NUMBER( S) III. BUILDING USE: (If building type is public, check all that apply) 03 -lo 8 3 _ Yo -3a GD d 1 ❑ Apt/Condo 2 ❑ Assembly Hall 60 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 i IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) ~ A) 1. 9,New 2. El Replacement 3. ❑ Replacement of 4.1 Reconnection of 5. El 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 M 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.) (Minn../inch) ELEVATION Y o z, o .3 `x ba" = zva • 6 O ~v Feet 1-63.C6_ Feet VII. TANK CAPACITY Site INFORMATION in allons Total of Manufacturer's Prefab. Fiber- Exper. New istin Gallons Tanks Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank 00C w Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): P mber's Si natu (No Sta *f 4MPRSW No.: Business Phone Number: Plumber's A ress (Street, City, State, Zip Code): 13a I /V L y L-3 IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sjnitary Permit Fee (includes roeej water a e ea -1 Iss ing Agent Signatur No Stamps) Approved ❑ Owner Given Initial J9 -00 Surcharge Adverse Determinati n /5/s. 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 .r 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 C~ -Z"? e-C Location of property 1/4 1/4, Section , T N-R W Township Maili g address Address of-site subdivision name eY'~ e Lot no.- Other homes on property? yes ' No Previous owner of property l,-7 1 7JTI i `~t~ 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 ~---No Volume 3l and Page Number as recorde d. with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER 6 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. and that I (we) presently own the proposed site for the sewage disposal system or I (we) I;>',, obtained an easement, to run the above described property, for the construction of said system, and the same has een duly recorded in the office of County Register of deeds as Document No. gnatu a of apPl cant /Co-aPP1 ~~hnt Date of Signature Dat of S gnature rcd~r,,~ DATA ~ c WARRAN'T'S DEED THIS S►AG[ R[SERV[O O RECORDING 4///"73382 . ISTATE BAR OF W~CONfSIN FOR,11~ 2--1982 VOL. 9A jAt GE:45Z i/ REGISTERS OFFICE i ....Danie.....smith,~ a single person ST. CROIX CO., WI Recd for Record j ct SEP091991 11. .15 A. M conveys and warrants to e3_ h_..R.,..-H ~l~br )1d-•. n~l , nn Jacklyn K.. Hildebrand, husband and wife ....a..s........ ~~n+ ii survivorship. marital property ee older of D"(13 t . . -.!X'J... RETULBox NorFederal i~ P 0 60 i the following described real estate in ........St.,...Cr.0iX ..................County, __aw ond w- r__,--_S4 017 State of Wisconsin: 0p, Tax Parcel No: it Part of Southwest Quarter of Northwest Qu~rter of Section 29-30-19 described as follows: Lot 2 of Certified Survey Map filed March 21, 1989 in Volume 'T', Page 2081. j TOGETHER WITH AND SUBJECT TO 66 foot private road easement as describedil in Volume 1181611, Page 362. I: li ~I I li i l This i5 not . homestead property. (is) (is not) Exception to warranties: easements, restrictions and rights-of-way of record, if any. Dated t i day of Septem.................................................. er 1. . , 10...... is . (SEAL) (SEAL) Daniel Smit (SEAL) (SEAL) * * i i AUTHENTICATION ACKNOWLEDGMENT ' Signature(s) STATE OF WISCONSIN St . Croix as. County. authenticated this ........day of 19...... Per naPy came before me 'e . .._-.day of September , 19........ the above named • Daniel...Smith TITLE: MEMBER STATE BAR OF WISCONSIN (If not . 0 authorized by § 706.06, Wis. Stats.) to to me known to be n . o executed the going inst c d ~k ame. THIS INSTRUMENT WAS DRAFTED BY y Kristina Oland Lundeen Alice Jo n r: a~,.. Attorney at Law 4Q' --•-r............ Notary Public S. County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is ~3e ;fit. 09 state expiration ~I are not necessary.) date: July 12 19 93 •Names of persons 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. 2 - 1982 Milwaukee, Wisconsin ; SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County i ' OWNER/BUYER J ,r ADDRESS: FIRE NO: LOCATION: 1/4, 1/4, SEC. T N-R W, TOWN OF: ``57___. lye ST. CROIX COUNTY . j 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 day of the t e year expiration date. SIGNED- DATE': , St. Croix County Zoning Office`' 911 4th St. N Hudson WI 54016 4 I ' SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County -OWNER BUYER l CLIr ~/G C~~C~C G L' t G`~` C~ w ADDRESS : FIRE NO: LOCATION: 1/4, 1/4p SEC. T N-R W, TON OF: ST. CROIX COUNTY SUBDIVISION: LOT NO. 2 F` Itproper use and maintenance of your septic system could result in its premature failure' to handle wastes. Proper maintenance - onsists of pumping out the septic tank every three years or soon', if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as z a,treatment stage in the waste disposal system: St. Croix County residents may be eligible to receive d 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 id. 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 3,0 day of the t e year expiration date. L FA IGN DAT St Croix County Zoning Offic 911 4th St. Hudson, WI 54016 9 t q ` NDUSRY OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, , DIVISION LABOR AND PERCOLATION TESTS (115) VY62 70 7969 MADP.O.ISON, WI BOX 53707 HUMAN RELATIONS 3707 (ILHR 83.09(1) & Chapter 145) rd p,.yip /Vo t I LOCATION: SECTION: TOWNSHIP/ G+PRtfiT'Y: LOT NO.: BLK. NO.: SU DIVISION NAME: AtLIJ1/S /T.3o N/RR(or)W - / 2 - r~ •o~ COUNTY: l J MAIILIN ADDRES%S: / 1 e r c o. C NV Q ` A cd. / AI W f + USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PR~QFILE DESCRIPTIONS: 1PERCOLATION TESTS: ®Residence New ❑ Replace (J•- O J _ 2/ RATING: S= Site suitable for system U= Site unsuitable for system rgs ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) ❑U xS ❑u KS ❑u EIS ZU EIS RU eU.JV1lz.Al7;a,Vo.i If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the ~r under s. ILHR 83.09(5)(b), indicate: t 4a j T / Floodplain, indicate Floodplain elevation: AJ1 PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 0 - 9 v t~.BA~ r 9 -d3 X, fO.F .73 - 3rP fBw m r _ a Ax- -'l r 4, B- Z /Q Z. ~O /ll yr RT ,F U Y- .?S !1 et '.C - PG B- 3 `t 10?-,VO A aeAt - g ( f • • ~ B- Qe 6~ InX q -;7V Sy A- of S', 6e NO N'S _~rl• g- B- 7 7 o/. 90 Noju #4- 7T > (0,0K4, s4, B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERT D PER INCH p- C> y.v $ y L 7 P. A-;- F_ ff_i 3 &;;,P 3& is P- ~L+ 8 3i 8 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. Sho the surface elevation at all borings and,t.,h% direction and percent of land slope. SYSTEM ELEVATION 1C, 40. 1 60 TN /00.'7 LQ a 1, .1 _r 8bi't.ICS.._.__ Nd fn 1. M' V + z I, the undersigned, hereby certify that the soil tests reported on this form were made by mein accord with the procedures and methods specified in the Wisco'cia Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TES S WERE COMPLETED ON: 014 J- 7C ,;,r e r I Th d 9 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): CST SI NA RE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) -OVER - I -4 t~ 3 a ~ J h 41 ® 4 -a cli ~ o 4 j O h ~ s a 0ll< ON, a d i C-A. d L9f V ` f 1% 14, 4 4