HomeMy WebLinkAbout030-2009-90-005
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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ~QC£// AA"g'S&A./ TOWNSHIP ST JOS~PN
SECTION .3"I T 30 N-R~W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
L1 5E,orlc ffi/L~1 I/Ne-
~u,cnrr
~pAfi4GE 1Q~~I~ES/~CN~r 'VINE
/
vEc.A`l iG " ~eE ~E/vlovs.0
I
}'/~nLbSc o •S~ ~ -
0 I ,
1 I
1 I ~Trj
1 r✓
I 1
I
Notes T~f w, rrl OLP.rttPY L4~✓./M~O.b9' I k2'~
tS~Jcv r .0:5.u/s N AAW'~cA z v. 100- 00' 30
'SaKr/► /Pv~PTt'l~iNF INDICATE NORTH ARR
Flo 56f
BENCHMARK: Elevation and description: VAIL /N
Alternate benchmark -~T LA4
SEPTIC TANK•Manufacturer: Liquid Cap. Sono are
Rings used: / Manhole cover elev: W. 30'Final grade elev: l• ~S
Tank inlet elev.: %Z-91/' Tank outlet elev.:
No. of feet from nearest road : Front , Side , Rear ,4 ~ t . o~
From nearest prop. line:Front , Side "Rear Ft. ~g
No. of feet from: Well 4i0 , Building: ~-s
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
* PER 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
SOIL ABSORPTION SYSTEM
Bed : 2'54e ✓-9S- s0Trench : Seepage Pit:
Area Built t1,34 Sq•~r
Width: /-Length S3 Number of Lines:
Exist. Grade Elev. AEG. Proposed Final Grade Elev. 9o' Av..
Fill depth to top of pipe: S-0
No. feet from nearest prop. line:Front , Side , Rear ----Ft.90'
No. feet from well: No. feet from building ~S-
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 : l 19Y PLUMBER ON JOB:
G7=
LICENSE NUMBER:
6/90:cj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
LE'BOR & HUMAN RELATIONS DIVISION
P.O. BOX 79969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
MADISON, Wl 53707 / State Plan I.D. Number:
SWQ, SFQ, Sec . 34 , T30 -R19 ~1/ (If assigned)
Town of St. Joe , ~ 2 L~/f CONVENTIONAL El ALTERATIVE
r) R (I Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Tracy Anderson c/o Zappa Bros., Hudson 9j
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. V. ST REF. PT. ELEV.:
~
Name of lumber: MP/MPRSW No.: County: Sanitary Permit Number:
Zappa Bros., Inc. 3300 St. 128889
SEPTIC TANK/HOLDING TA :5', •L.c Cevtrr 99-19"
MANUFACTURER: LIQUID CAPACITY: TANK INLET EL TANK OU WARNING LABEL LOCKING COV R
PROVIDED:/ PROVIDED:
J 7 07 6-Ay / S ❑ NO ❑ YES LINO
BEDDING: V NT DIA.: VENT MATL.: HIGH WA NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM: FEET FROM LINE: Q~ AIRI
EYES 0 YES NO NEAREST-~ 7
DOSING CHAMBER = S 3'
MANUFACTURER: BEDDI LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVDED:
0 ❑ YES ❑ NO ❑ YES ❑ NO
GALLO CYCLE: PUMP AND CONTROLS OPERATIONAL: OF PROPERTY WELL: BUILDING: VENT TO FRESH
G F ENCE BETWEEN FEET FR LINE: AIR INLET:
(ED) I
P ON AND OFF ❑ YES ❑ NO NEAREST -I
OIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAME AEor RIAL AND MARKING:
excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
BED/TRENCH / TRENCHES: / MAT RIAL:
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PI E DISTR. PIPE MATERIAL: N . ISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW.PIPIii$: ABOVE COVER: ELEV. INLETS E EV. END'y PIPES: FEET FROM LINE: O ~~I AIR IN LET
\/S~J 16. S3 ~01 ✓ a NEAREST -4111- 30 6 . ~ v
MOUND SYSTEM: .3 '
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 El NO ❑ YES ID NO
DEPTH OVER TRENCH/BED EPTH OVER TRENCH/BED DEPTHS OFT OIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YE ❑ NO
PRESSUR D DISTRIBUTION SYSTEM:
BED/T CH WIDTH: LENGTH: TRNO.OF ENCHES: LATERAL SPACING: G VEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COV
DIM SIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATER NO. DISTR. DISTR. PIPE DISTRIBUTION P E MATERIAL & MARKING:
ELEV.: ELEV.: DIA.: ELEV.: IPES: DIA.:
ELEVATION AND
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: V CAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑ YES ❑ NO ❑ YES ❑ NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
E] YES ❑ NO ❑ YES Ell NO NEAREST-►
e ain in county file for audit.
Sketch System on
Reverse Side. SIGN URE: TIT
SBD-6710 (R. 06/88)
QILHR SANITARY PERMIT APPLICATION
NTY
v_ COU
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 1:1 / 0
8% x 11 inches in size. Chec I n PoXious 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
h., Y. ,J`- S _7y T,?U, N, R / E (or W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
C
TY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
sl90 6
II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD
❑ State Owned ❑ VILLAGE
❑ Public ®1 or2 Fam. Dwelling-#of bedrooms PAR LTAXNUMB
111. BUILDING USE: (If building type is public, check all that apply) 34bK 6
1 ❑ Apt/Condo
20 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 80 Mobile Home Park 120 Service Station/Car Wash
50 Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ® New 2. ❑ Replacement 3.E] 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 9 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
130 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
S ~ S Feet d'_" f 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
Se tic Tank or Holdin Tank o ' o F1 -7 H F] I L1
Lift Pump Tank/Si hon Chamber I El F] L] El 0 1 1:1
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's Signature: (No Stamps) 4*WMPRSW No.: Business Phone Number:
Plumbers Address (Street, City, State, Zip Code):
i
'ry- All
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing ent Sig No Sta
XApproved El Owner Given Initial Surcharge Fee)
p
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
. APPLICATION FOR SANITARY PERMIT
8TC-100
This application fora is to tea co1rpletod In full and signed by the ownet(s) of
the pcopetty being developed. Any inadequacies will only result In delays of
the peimit Issuance. -Should this development be Intended Lot resale by
ovnec/contractor,topec house), tt:nn a second form should be retained and
completed when the property Is sold and submitted to this office with the
appropriate deed recording.
/yivnt ~.CT~n/
Ownec of property 7/1" CC, 1~
Location of property , 1/4 /4• Section
Township PT rt e'
Mailing address C' -
fTx_Tti S'. All /~i~n
Address of site T -
•ubdivision name
Lot number
Previous owner of property T
Total also of parcel 2 S`7 ~cn t1
Date parcel was created la/ ~dy"P7
Are all corners and lot lines Identifiable? _Yes
is this property being developed lot resale taper house)? as J40
VOIGee and Page Numbet as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THR FOLLOWING:
A WARRANTY DiitD which includes a DOCUHRNT NVMBRR, VOLVHX AND PAGR NUNDRR, and
the ORAL OF THR RBGtBTBR OF DRRD9. In addition, a certified survey, If
avallable, would be helpful so as to avoid delays of the reviewing process. If
the deed description references to a Caitlfled Survey Nap, the Certified Survey
Map shall also be requited.
-
PROPERTY OWNER CERTIFICATION
t(We) certify that all statements on this form are true to the best of my (out)
knovledgel that t (we) am (ate) the ownet(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. F6UVI2 • f and that I (We)
ptesently own the proposed site for the sewage disposal system (at I (we) have
obtained an easement, to tun with the above described property, fog the
construction of sold system, and the same has been duly recorded In the office
of ths' o~ Re Sat of Deeds, as Document No.
/ 1.1
g at to of Ovnet Signature at co-owner (11 Applicable)
3 S
Date of Ign Lute D ! of Bignatute
MAR 08 '91 10:03 RIV VAL ABSTRACT 3867664AARRAAAR P.2i2
DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
STATE EAR OF WISCONSIN FORM 2-1962
„STEVEN W, HENNING and NORMA J. HENNING,
..1?usband and.wife., ...gramots ~ )
conveys and warrants to ....~'RACY.,I,,• ANT~F~R~SON„A? ,.k
.........VERONLCA.. A.....ANDERSQN. hushaz`td...an.d..W.3.fa
as. s.urvivorahip.. m=it.a1..prop.srty
..Gxante,es.
RETURN TO
the fallowing described real estate in t ....r~.~ ...........County,
State of Wisconsin:
Tax Parcel No:
Part of the SWk of SEk of Section 34, Township 30 North,
Range 19 West, St. Croix County,. Wisconsin described as follows-,
Lot 2 of Certified Survey Map filed June'24, 1988 in Volume 'T',
page 1989, Document No. 438728,
Together With and Subject To a 66 foot Private Road Easement as shown
on said Certified Survey Map.-
TOGETHER WITH and SUBJECT TO reservations, restrictions, easements
and rights-of-way of record, if any.
i
14 1S not
This
. homestead property.
(XX (is not)
Exception to . warranties:
~I
Dated this 30 th of px:.
.
.............(SEAL) ..(SLAT,)
• i iH..
(SEAT) (SEAT,)
NORMA J
......RENNIN..
AUTHENTICATION AC$NOWLEDOMENT
Signature (a) S'T'ATE OF' WISCONSIN
sa
St. Croi................... .
County.
authenticated this ........day of 19...... personally came before me thin ...30. h... day of
April
, 19..90., the above namod
} ..Steven W. Henning••and....•:.
TITLE: MEMBER STATE RAR OF WISCONSIN Norma J. Henning.
(If not,
.
.
authorized by 746.06, Wis. Stat$.) to me known to be the persons.......,... who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WA$ DRAFTED BY
Attorney Harry C. . .
Lundeen
I` 110 Second St -reason , WI -54016 1r.'!''"'..............
Notary Public t. ~ro R X County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent, (If not, state expiration
are not necessary.) date: 19.........)
~Nxmas of PCno" signing in sny eBDkity 41w414 bo VRod or prIAW laulow their mignuturm.
WAUANTY DF.ZD STAT~_iEIAH na tUYannnraru
D INDUSEPAR+T RY, MENT OF REPORT ON SOIL BORINGS SAFETY & BUILDINGS
DIVISION
LABOR AND PERCOLATION TESTS (115) nnAOlso wl 7969
HUMAN RELATIONS 53707
(1-163.090) & Chapter 145.045) t
LOCATION: SE TON: TOWNSHIP/MUNICIPALITY: OT NO.: BLK, NO.: SUBDIVISION NAME:
w )/:e-)/ 3 /Tso N/R/9 E (0 1 a '
COUNTY: U R'S NAM : D
r-
USE 1-612 t DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAl DESCRIPTION: S S:
®Residence ®'New ❑Repiace
RATING: S- Site suitable for system U- Site unsuitable for system
rONVENTIINAI; MOUND: IN-GROUND-PR N-FILL HOLDING TANK: RECOMMENDED SYSTEM: ptional)
OS If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the j •I
under s.H63.09(5)(b), indicate: , I Floodplain, Indicate Floodplain elevation:
PROFILE DESCRIPTIONS I j
RIN NUMBER DEPTH IN. ELEVATION P H T R UNDWATER•INCHES CHARACTER SOIL IT THICKNESS. COLOR. TEXTURE, AND DEPTH
BSERVED TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
t:5 I. HIGHEST
r '
d, "n Xr et /C J -
B' ( o, ' 9j
B- Z- 1 >
B- ,7 a'KTI
,Pk ~ L Oi .r
B- ire Al >/e V 3 'R
I
B- s ~T. > 9S . 4' At S/
B-
PERCOLATION TESTS i
TEST DEPTH WATER IN HOLE TEST TIME DROP WATER LEVEL-INCHES 'RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PER INCH
P. -
P-
P v~ S 1 7 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 hors.
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. i
SYSTEM ELEVATION
_,7 P 7 ; I I ! f I i is e It 1
fJy
/ J'r, f' L
- -
•
r<Iolsti poop . ->s~ I I I i
do"
RLY
I_ } I i I 41
, d iT 1 I
,
r
vrr k ' i t?0 C ia/ J ~r l I rji✓~~~ / i' _ i
doi~ tl y ~H 3nt if 7
n the W nsin
i
specified h the procedures and methods
~ r
1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with P
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. I
1
D N TESTS WER COMPLETED ON:
NAME print): K11 P ~
FOGE
Ucensed Perk Tester & Plumber
ADDRESS: ~Hg f►8R08 CERTIFI ATI NNUMBER: PHONE NUMBER (optional):
Fo ertY N 5~23
W IS CONSI
S' CST SI N TU E:
one
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. „ Rdz
DILHR•SBD-6395 (R. 02/82) - OVER -
1
N
SEPTIC TANK MAINTENANCE AGREEIIENT
St. Croix County
a
OWNER/ BUYER ~111 o
0
ROUTE/BOX NUMBER ' :~1 X ti i Fire Ntmnber~_ , d
CITY/STATE
PROPERTY LOCATION:s( Section TAN, R.,~Z_W,
Town of-, rT St. Croix County,
Subdivision Lot number
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes.--P-rover maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed by a licens'ed' *s'ept'ic tank pumper . What you put into
the system can affect the-function o, t e -septic .tank as a treat-
ment'stage in the waste disposal system. •
St. Croix County residents-MV 'be eligible to recieve a grant for
a maximum of 60% of the cost-of replacement of a failing system,
wh a 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 hew 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 less than 1/3
Ce
rtification
three year•expiration. H
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 Depart- µ
ment of Natural Resources. Certification form must be completed •d
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration-date
SIGNED
DATE 3 Z7 ~q /
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
1
l
P, -,,o PLB 67
Cu L vsaT ~l PLOT & CROSS SECTION PLANS
ZAPPA BROS. EXCAVATING INC
/'/eoPosE~ ,`Z ~J >u /VO/<TN /A100t*127Y J-X"E PLUMBING UNIT
DruVEwAY
PROJECT
h/!U/o3E0 .~~ARAGE
/~i2oPosEO /~estoEniGE
/~RaoolEO
AdA snot
~,/~1 ss ivvs~ '-'i✓ /6 0 oK >itEE
/OOV GAL. S'~PTSG TAn!k Q Q;t FLE✓. = 100, o? ,,07
PnvPos.o wfLC Ali fi /"Loo/z or' rje,zy
SO, ,D/2Y /1N KzivB
3
d3'6-~OT~ E
5~' .fLcPG
?o 1n/F_sr AA0AVZTY Zx v--
VENTSTiocR ~3STo E.vs> /%iapE27Y L7N6
o/0 Q
a 5
131
30
.SU[.fTN /~2oPEZ7Y Lsrvt TMj
SCALE
I,
FRESH AIR INLET AND OBSERVATION PIPE
APPROVED VENT CAP
MAXIMUM 12'
ABOVE FINAL GRADE
4' CAST IRON VENT PIPE
MAXIMUM OF 42' ABOVE
PIPE TO FINAL GRADE
SIGNED:
MARSH HAY OR SYNTHETIC COVERING LICENSE: /"J PAf .2?00
MINIMUM 2' AGGREGATE DATE:
OVER PIPE
DISTRIBUTION PIPE
TEE SOIL TESTING BY:
DA v~ ~CJ GEicT;(
ELEVATION BED 6' AGGREGATE •
BOTTOM PER SOIL BENEATH PIPE PERFORATED PIPE BELOW
TEST IS • COUPLING TERMINATING
S's.~S" FT. AT BOTTOM OF SYSTEM