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HomeMy WebLinkAbout030-2061-95-000 o C', a 0 6a y oo ~ 4 0 N ~ M o I N b O i C ~L J. d d y N C Z 7 (0 LL C O_ N ~ I' ~ Q I M r II a W E o Z O I N ~ a co N (n O Z c N H N N 7 0) C; CL c y O O O N a C I L N •*04 d I? C O 4- N o 4) O Z m z O N zz~ I 75 z L C a ~ w c I 0 O i 'I N H N L co a .0 Co II j m LO a 'm O O O •N CL CL IL ~i a o m 3 N U = rn rn (D 0) ~l N N O O O 0) 0 0 N N O O O ? M co c m (D a c6 v 0) w ayi O co to H N O p ~ C tl p h d O O N Lh w) Lo V cr -0 jD O - E a) C, C C C N N N CD 0 -It M W C 3 N _ 00 N o o C n Qy1 N H C O O p O O O p O E N .O L OVA O N fA r O Z yL:; (n • CE O r/~ ~ ~ 'Q I ~ a I v ~ 3 IL v c c A Ua2I',ONU FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER~'M a!n de TOWNSHIP -6A) S \10S~~r1 W^ SECTION_~_TN-Roy ) l ADDRESS 13 ~~n S ] - ST. CROIX COUNTY, WISCONSIN beg -7 OOftaop SUBDIVISION LOT LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM T 15 ,C y Q: 60 r o r J O S S ~PCi I NORTH ARROW INDICATE BENCBMARK:Elevation and description:/C> o o~SL Alternate benchmark ()©l1e- SEPTIC TANK:Manufacturer: _Liquid Cap. ooo ,A4 Rings used: Manhole cover elev:yFinal grade elev:~✓~-r Tank inlet elev.: Y~/`7! Tank outlet elev.: < No. of feet from nearest road: Front Side Rear Ft. From nearest prop. line:Front , Side X , Rear Ft. 0;~0 No. of feet from: Well Building: 7 (Include this information in the above plot plan) (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: Z Trench: Seepage Pit: Width: Length o'O Number of Lines: _Area Built Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top of pipe: !~6 No. feet from nearest prop. line:Front Side, Rear Ft. A. o-b No. feet from building No. feet from well: HOLDING TANK l ` 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 Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labof and Human Relations INSPECTION REPORT St. Croix Safety and Buildings Division (ATTACH TO PERMIT) Lot 2 Sanitary Permit No.: GENERAL INFORMATION SET, SE? Sec. 27 T30-R20 Hwy. 35 149173 Permit Holder's Name: ❑ City ❑ Village [R Town of: State Plan ID No.: St. Joseph CST BM Elev p. BM Elev.: BM Description. Parcel Tax No.: 030-2061 -95 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic )Ub v Benchmark / . G Dosi ng Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic )//;l-- NA Dt Bottom Dosing NA Header / Man./ Aeration NA Dist. Pipe 93~ Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft oss ead Forcemain Length JDia. H Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / LengNo. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS zo DIMEN I N SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER Model Number: INFORMATION Type O System: S S(11 OR UNIT DISTRIBUTION SYSTEM Header/Mani old Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length 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/ Tr nch Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include co a discrepancies, persons pr~e~ sen , etc.) V f Plan revision required? ❑ Yes ❑ Noj Use other side for additional information. SBD-6710 (R 05/91) Date inspector's Signature Cert. No. 4 Q ILHR SANITARY PERMIT APPLICATION COUNTY ~~,,In accord with ILHR 83.05, Wis. Adm. Code - STATE SANITARY PERMITA- -Attach complete plans (to the county copy only) for the system, on paper not less than I Q[ c/``~ 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 • 0/0 PROPERTY LOCATION ©n Y` '/a S T W, N, R E (o W PROPERTY OWNER'S MAILING ADDRE LOT # BLOCK # STA ZIP CODE PHONE NUMBER UBDIVISION NAME OR CSM NUMBER . TYPE OF BUILDING: (Check one) CITY osC NEAREST RO State Owned VILLAGE 4 4OWN OF: 11-7,3 ❑ Public or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMBER(S) ZA 111. BUILDING USE: (If building type is public, check all that apply) D3~ 1 El Apt/Condo 20 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 50 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. 19 Replacement 3. ❑ Replacement of 4.E:1 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 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 2 REQUIRED (sq. ft.) PROPOSE (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION O 2~ /~~~Feet Feet VII. TANK CAPACITY Site in alions 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 Holding Tank 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 ame (Print): Plumber' 'gnature: (No Stamps) MP/MPRSW No.: Business Phone Number: 6 RI Plumber.' d as (Street, ity, te, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sa itary Permit Fee (Includes Groundwater ate Issued Issuing ent Signature No a Approved ❑ Owner Given Initial Surcharge Fee) 9 /v Adverse Determination 22 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 j Q, yvt S C . 0 N L~ 0 Location of property ~Wl/4 1/4, Section J,7, T ? 0 _N-R,2 09 W Township 2 Mailing address AK Y 1A, Address of site 1,~Y- km e (C Subdivision name Lot no. Other homes on property? yes.- 1,7 No (14 Previous owner of property (2 "~7`7` v Fr1 ~2 h e F,- Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is thig property being developed for (spec house)? Yes VNo 0 .2 Cl 11 Volume and Page Numbed 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 of ice of the County Register of Deeds as Document No.9 '7 , 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. 4 Z S' nature of applicant Co-applicant - p Date f Signature Date of Signature No. 13.10. Warranty Deed-Hy corporation. l8'!A72 or W1won/ix1 pebmw by w OWN Oak & suer" 016 -Short Form. (Sea 285.16. W(a Statats) 1M0 MO- 0 jut) r144'20 VOL t ~'hi:L~ ( 4TD lute tore made by AMERICAN CANCER SOCIETY, INC., a New York . Corporation, Grantor, of the City of New York, State pf New York, NNP.~w Yor • a Corporation duly organised and existing under and by virtue of the laws of the State of Wt hereby conveys and warrants to JAMES C. MONDOR and JOYCE Y. MONDOR, Husband. and Wife, ' • grantees , of County, Wisconsin, for the sum of One Dollar ($1.00) and other good and valuable consideration, the following tract of land in St. Croix County, State of Wisconsin: ofthe Lot Two Section eTwSouthwest enty-seven (27),• Town- Northeast2Quarterk(SW e - (9), being ship Thirty (30) North, Range Twenty 20) West in Village of Houlton, and Lot One (1), Block Nine (9) in Section Twenty-seven (27), Township Thirty (30) North, Range Twenty (20) West, being in *Village of Houlton, according to recorded Plat and all that parcel of land described as follows, to-wit: Commencing in Southeast corner of lands conveyed by Mary Ann Sullivan to one Daniel Sullivan, as shown by deed recorded in book "70" on page 4746 in office of Register of Deeds of St. Croix County; thence South Two (2) rods; to South line of Southwest Quarter of the Northeast Quarter (SW-41 - NE) of Section Twenty-seven (27), Township Thirty (30) North, Range Twenty (20) West; thence West to Hudson and Houlton road; thence Northwesterly along the East line of said road to a point West of the place of beginning; thence East to the place of beginning. This deed is pursuant to the terms of a certain land contract recorded in the office of the Register of Deeds, Volume 396 RECORDS, p. 127-128, and the warranties,contained herein do not include any acts-or transactions of the grantees after July 10, 1963. Sin UM MOO Mbtttot, the said grantor has caused these presents to be signed by Mendell G. Scott , its President and countersigned by Charles R. Ebersol , its Secretary,a► at New York, New York , JUdo nsiw, and its cdrporate seal to be hereto affixed, this 12th day of November , A. D., 1963 Signed and Sealed in Presence of A 1"ICAN CAUL? R SOC Y, RC. vim. rrti~n. . Wendell G. Scott,,M. D. c: . er ed: -VicW ite~klient for,:..`. . Administration Charles R. Eb&,.,,~.. $~tett OJ~~iiA!'aMl~lt, ss. COUNTY CE N. Y. County. . Personally came before me this 12th day of November , A. D., 1963 Wendell G.- Scott President, and Charles R. Ebersol Secretary. of the above named Corporation, to me known to be the persons who executed the foregoing instrument, and to me known to be such President and Secretary of said Corporation, and acknowledged that they executed the foregoing instrument as such officers as the deed of said Corporation, by its authority. rv C.l. ;l S 1'S Cwt ` Il.~ ~.Uj r "AWIX co.. WIS. Zsr~Q ~~,°r 1P_th RE '(i for IZrco?~i this Cur . sUGLISI m ,5x, r-,w r •ry Yub if Star A t 4w Y&6 " ~ R7 QQ '~Tj do of. Ngyemher r,.u.l9 No. (y X145.4195 :aiif-ed r, r;,roc County Notary Public, Y.."5 Y at ;34P/ N Cut. filed in Naw Y~rt Coun~r ~ ~Iprd~lion ExAiret March 30, Ifs'? My Commission expires ; ,~~~y Drat ~ - Provides en . re ff fiiii-F~UIB as .gsaa at the rrentatg grantees, wttnea.em and notary.) . ` . SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ~ a l,,,, e _S C , Mo M/I/ O J~ ADDRESS: ,5/ 1~,Iz"L/ S4 FIRE NO: 3S_1 LOCATION: 1/4, 1/4, SEC. ~-7 T 30 N-R ` e9 W, TOWN OF: I ~ 2 ST. CROIX COUNTY, /Z 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: r DATE : St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDk1STRY, C DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N W 53707 HUMAN RELATIONS HR 83.09(1) & Chapter 145) LOCATION: , SECTION: WNS /MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: t/a, 4 7 /T vN/ (o Ll/. 1, 0 -4 , COUNTY: ~ IMAILINGAIDDRES : 3s / 74, /foh Gr1~ 5 S/r f Oror X ~i p n c/o Y' 17 /7,17t "I'l, USE DATES OBSERVATIONS MADE - 6G NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTION PER OL ON TESTS: Residence ? ❑ New eplace RATING: S= Site suitable for system U= Site unsuitable for system ky A rctl0.3 .0 aO6 A ,.S'-• CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) o E/ S ❑U ®S ❑U ®S ❑U ❑S U ❑S 21U I Z;9 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: G/~J _Z Floodplain, indicate Floodplain elevation: 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.) B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER I JI1111 ft AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERT D3 PER INCH P_ G 41- P_ ~ P- 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 ELEV TION • All 5--: 15 r n L/' o~ 12 , 1 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures 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 (print): 1 TESTS WERE COMPLETED ON: / 14. DDRESS: , CERTIFICATION NUMBER: PHONE NUMBER (optional): //r Ali' 7 l CST GN A low' ION: Original and one copy to Local Authority, Property Owner and Soil Tester. 95 (R. 10/83) - OVER - PL T PLAN //?77 P.RO EST S/,'1 A V617 or ADDRESS ~✓l/i. o ~4'S t/41/4/SGN/(~W TOWN Byron Bird Jr. 3318 DATE - -igz BEDROOM CLASS PERC__/_ CONVENTIONAL~klN-GROUND P SURE CONVENTIONAL LIFT_ MOUND_ HOLDI TANK SEPTIC TANK SIZE e-e*- P LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA PERC RATE BED SIZE 1 116 Benchmark V.R.P. Assume Elevation 100' Location of Benchmark * H.R.P._ Cl Borehole Well Scale Feet 0 Perc Hole System Elevation Uent 12" Gradp TYPAR COVERING • ~ 2- 12- 3- O 6' O 3- 6- Sewer Rock 12' ry 14 L ~s ~v