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HomeMy WebLinkAbout032-1023-70-000 v o I ° o 4 o I 3 0 O v► y 0. 0 Mi g C II M i y O N O Cl O 0 C ° J T C ~ Q' f6 C O ° V N N 0.0 O. N 272 N O c Z V ° m to 0 LL c O N y N Q v°i c w I v cn Z ~ 0 I rn Z = ° ~ , ~ v € o ~ Z ° (D H a m °o ~ am F- N O z c H y ~ w v o r w c d 2 c i a c o N H O'O E c t:f m N N f0 = d CL N N N ` E I N N O V C C t0 1~ 01 a O O O N ' N d L L N m N C C O ° U tC N N Z H z z Z o E °Lo' - o e LO) O O a a E • i a a a a c°n n o m } rn rn J U N its rn - co L r N _ 0 V O OO E O) g m c d N 'C Q CA c0 ~l O O O Z' N C O p O E co ° Ui H a w c u d a CL jr F- N C~l O N C C E C C N co *0 N c! E ~ C N 1t,, M O O N a O of E U z O O U) 2 O Cn 10 t € a v a m 2 m a c A c°~ar 2 ;0 U)U WisFonsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT St. Croix Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATIONSW4,NW4,Sec. 9 T31-R19 40th S 149090 Permit Holder's Name: ❑ City ❑ Village ❑XTown of: State Plan ID No.: Mary Hildebrant Somerset CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 118 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 5 /,g Dosing Aeration Bldg. Sewer ' Holding St/Ht Inlet 7.g74 q(,~~'1 TANK SETBACK INFORMATION St/Ht Outlet Cj TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic >/60 7~ 3a NA Dt Bottom Dosing NA Header/Man. a, I ~i5 q'.4 L NA Dist. Pipe Aeration S•U Holding Bot. System I IU (o a 3 ~4 PUMP/ SIPHON INFORMATION Final Grade 6.0g gto.y a-- Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft oss Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length NO- Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM INFORMATION Type O CHAMBER Model Number: System:--l/&-ICIL, )100, 6~ 1 7lDU~ / OR UNIT DISTRIBUTION SYSTEM Header / Manifold 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 ~f 1 xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed / Trench V9 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discr ancie eirsons present, etc.) .t l l.\ Plan revision required`? ❑ Yes ❑ No f Use other side for additional information. /0 SBD-6710 (R 05/91) _ Date Inspector's Signature Cert. No. Y FORM - STC - 104 AS BUILT SANITARY SY PORT OWNER TOWNS VP i SECTION ___j~T- 3 ( N-RAW ST. CROIX COUNTY WISCONSIN ADDRESS SUBDIVISION LOT LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I I I rT v( i INDICATE NORTH ARROW BENCHMARK: Elevation and description: Alternate benchmark J~ SEPTIC TANK:Manufacturer; Liquid Cap. Rings used:-J-Manhole cover elev: Final grade elev: Tank inlet,,elev.: Tank outlet elev.: No. of feet from nearest road:Front , Side, Rear Ft. From nearest prop. line:Front__~_, Side , Rear Ft. No. of feet from: Well , Building: (Include this information in the above plot plan) (2 reference dimensions to septic tank) i SEE REVERSE SIDE n dovft P J ~~d 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: "Z Area Built J 4'~ Exist. Grade Elev. g7,5c, Proposed Final Grade Elev. "17,60P Fill depth to top-of pipe: No.'-44t-from nearest prop. line: Front Side , Rear ° Ft./x f No. f from well: No. feet from building CcZ HOLDIM AWM 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: cgs LICENSE NUMBER: 6/90:cj I SANITARY PERMIT APPLICATION 17EffILHR In accord with ILHR 83.05, Wis. Adm. Code couNTY STATE SANITARY PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 20p2evious 81A x 11 inches in size. application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY NER L PROPERTY LOCATION n ~s 55 !,J 1/4 %(1G~~ 1/4, S ~r T N, R ~ (Or) , 1 PROPERTY OWNE 'S MAILING ADDRE LOT # BLOCK t. 1-4 CITY, STATE ZIP CODE _ PHONE NUMBER /SUBDIVISION NAME OR CSM NUMBER 44* fo Ao,r CITY NEAR ST ROAD; II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE R( ) ❑ Public R1 or 2 Fam. Dwelling- # of bedrooms 3 PARGEL A NU Mill III. BUILDING USE: (If building type is public, check all that apply) ~1 X 1 ❑ Apt/Condo U 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 50 Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYIPPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. I, 9 New 2. ❑ Replacement 3. ❑ 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 ❑ 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 12. 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~ If ~jp l~ 0 Feet y0 Feet VII. TANK CAPACITY Prefab. Site Fiber- Exper. in allons Total # of Manufacturer's Name Pref abe Con- Steel glass Plastic App INFORMATION New istin Gallons Tanks structed Tanks Tanks Se tic Tank or Holdin Tank COGt: j ~a_ k `s Lift Pump Tank/Si hon Chamber F1 [I 1 0- F F] VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plu~"'s Name (Print): Plumber's Signature: (No tamps) 4FP/1~APBSIK No•: Business Phone Number: 75 _ fij V/1 if if k ° L ,1 7 Plumber' Address (Street, City, State, Zip Gode): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sa ' ry Permit Fee (Includes Groundwater a e ssue Issuing A ent Signature (No Sta Surcharge Fee) Approved ❑ owner Given initial Adverse Determination w X. CONDITIONS OF APPROVAL/REASONS F 6R DISAPPROVAL: -6398 (formerly Pib-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber APPLICATION FOR SANITARY PERMIT STC-100 This application form Is to be completed In full and signed by the Ovnet(s) of the property being developed. Any Inadequacies will only result In delays of the permit Issuance. Should this development be Intended tot tesali by owner/contcactocr(spec house)# then a second form should be tetalned and completed when the property Is sold and submitted to this office with the appropriate deed recording. Owner of property Location of property 2' .-1/4 .1/41 Section ` T 2-1-N- R.L V Township Mailing address Address of site -_,62e Subdivision name Lot number Previous owner of property Total size of parcel Date parcel was created - Are all cognacs and lot lines identifiable? , as o / Is this property being developed tog resale Capac house)T_Yes =~M0 Volume and Page Number` r~ as recorded with the Register of Deeds. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - • - - INCLUDE WITH THIS APPLICATION THE FOLLOWINCt A VARRAXTY DRZD which Includes a DOCUMENT NVM813Rr VOLVMZ AND PAOR NVNa1;Rr and the SEAL OF THE REOtBTER OF DEEDS. In addltlon, a cegtltled sutvay, It available, would be helpful so as to avoid delays of the reviewing process. it the deed description references to a Ceitltled Survey Map, the Certified Survey Nap shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - • - - PROPERTY OWNER CERTIFICATION t(ve) cQttity that all statements on this form ace true to the best of my (out) knowledge= that t (we) am (ate) the owner(s) of the property described In this lntotmatlon tocm, by vlctue of a warranty oSp tdad In the office of the County Reglstec of Deeds as Document No. tt~f .f~# t and that i (we) presently own the ptoposed site for the sewage disposal system (or i (we) have obtained an easement, to tun with the above descrlbed pcopetty, tot the consttuctlon of said system, and the same has been duly recorded In the office of the County )teglstec of Deader as Document No. I 8 q of owner Signature of Co-owner III Appllcab el Date of elgnatute Data of Signature 7W i, , M-1 E 1 ~u~ ~ •F may. •TFl A' - Y 1 Oki tv'm vQ n Tat P" Nr: A ~iarter',of art r st gliarter of Section to R u Y t Q lifft Mmestcwd property. Ai~ day of October it a. 'ALO Robert E. Schi ~1R FAI 1 te2bsin ~ (SEAL) 10 wClZNOwLaDdli«Ix ♦..RIb!!.~T... STATE OF WISCONSIN . s ..$Jilw e G r _ ss Pane Coetot)E. S~ber_..:. , is 90. r.•r~:~it~• ~.n,~ eery October Robert E...Schliefek~ J!'1'ATS'8~1ROF wrsco:vst'\ Ql[<.9it. W stats.) to nee IMOWU is be the psr fo:c~SwK ;nan:a~at ar+i x, 1hIA~,DItAS-•t0 ev _ ~ R.. flaw r _ ...a fib' STC - 105 w SEPTIC TANK MAINTENANCE AGREE11ENT w St. Croix County w OWNER/BUYER w 0 ROUTE/BOX NUMBER Fire Number o d S ZIP Do2 CITY/STATE i 1,/_N, R _W, PROPERTY LOCATION:'.'',W k, N, k, Section T9 Town ofd .^SP~ St. Croix County, Subdivision Lot number 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, b a licensed 'septic tank Pum er. What you put into the system can affect the .unction o he-septic tank as a treat- ment-stage in the waste disposal system. St. Croix County residents may be eligible to recieve a grant for a maximum of 60% of the cost-of replacement of a failing system, whit 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 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 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 I/WE, the undersigned have read the above requirements and agree 0 to maintain the private sewage disposal system in accordance with the standards set forth, herein, asset by the Wisconsin Depart- o+ 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. SIGNED ` DATE St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY,* DIVISION LABOR AND PERCOLATION TESTS (115)~X 7969 HUMAN REJEATiONS MADISON, WI 53707 (ILHR 83.09(1) & Chapter 145) ION NAME: LOCATION: SECTION: TOWNSHIP/ LOT NO.:BLK. NO.r7 SW '/4 1`40/4 /T~ ► N/R19 E (o) W "S0M kS&--1- - - - COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: '57 C-_POI k MM~y USE DATES OBSERVATIONS MADE NO. BEDRMS.: 1COMMERCIAL DESCRIPTION: IPR FILEDESCRIPTIONS: E OLATION TESTS: Residence Uri N<, JrNew ❑Replace ~C)N r 'ZZ, /94 C) I`V Z3 /991) '~.LS ak C Z ~e>~S P IC ` i 114111 FIF-LA RATING: S= Site suitable for system U= Site unsuitable for system CO _U_ I ENTIO❑N~ . M~~. [:]U IN-GROUNDS P❑U RE: SYSTEM-INQFILLHO❑LDING TANK: RECOMQMENDED SYSTEM: (optio~ C11 D~EJSIlGN RATE: If any portion of the tested area is in the If Percolation Tests are NOT required under s. ILHR 83.09(5)(b), indicate: LIQSS ` Floodplain, indicate Floodplain elevation: ry 4 vit- PROFILE DESCRIPTIONS D c BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTFr=, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 7.56 TA Lf- > 8.S$ 14'8 s s 94`8Q,~j ms B- _Z Aj > 647 B- .Og 9%./U IVd~I ~•U~ 1~~I3~sL_~ 86"iepNMS ~L~t1yCt dt2d9S4n~J BA 1.25 9711 t4c) N ? 7.f(5 "'A i sLT-S aoNIr > g 9 Z ~b CsLn 3r MS cob 60~LT9Q,, A7 B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER ICES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R PER INCH P_ 3-26 N 1E 9-1.52 3 ?'Z . >Z > 2 < 3 ~ Z > ~ 3 P- Z .30 0 9%./0 '3j >'Z < P- 3 -2-co ONZ 99.4o J > P- P- T_ L-l:V A71 N AT nRC_ 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. 4~Qt+ i p SYSM EVATION l l ~ -Nc►1►h~d~.l -S~P~ KlC NLdKe~s; I C~ bK i ~va~►n>. - loo.~d . t i . I ~s 4 t <_~r_ 04 L.r ~1 ~Tt? i~►.l T s' a6-' 460 t To - 40T -77 'S E - r i a I, 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 : TESTS WERE COMPLETED ON: 1EI1AQJ&Y 3014NSO-sJ 1 u SoNSu1eJaY NL 30N& Z3 /990 ADDRESS: CERTIFICATIO NUMBER: PHONE NU BER(optional): o7 coN+~ S; 14U As~~ Wi 5-o 14 ~4g~ 3~C- ono CST SIGN .94- DU 60- DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) -OVER - JOB Ala r vi ~d t~r~_~1 r:., w TIMM EXCAVATING SHEET NO. OF Z Route 1 Box 192 WILSON, WISCONSIN 54027 CALCULATED BY DATE (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE . f 1 i:.. , f . + i y, . s - c:._.... Z . . . -a- 1 z~_ s a 7 ~ C L ~o PRODUCT 205.1 ~ Inc.,Groton,Mass,01471. To Order PHONE TOLL FREE 1.800-225-6380 i °Ci JOB LL TIMM EXCAVATING SHEET NO. rJ OF Route 1 Box 192 WILSON, WISCONSIN 54027 CALCULATED BY DATE - (715) 772-3214 (715) 386.5443 ' MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE . I . ' a J ...r.'. I. 4 .....1~. t.....__ r y , e 1 PRODUCT 205-1 Inc., Groton, Mess, 01471. To Order PHONE TOLL FREE I-800-225-6180