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HomeMy WebLinkAbout032-1081-30-000 C o ai ° I 0 o6q 00 ~ ~ a I 0 ° co I y w ~ I Q c o a o U a) a Z " C - (d L t4 a LL =O N C N a) I B Q co M CL O rn E U o 0 Z m m co z a m o I c O v v Z m tZ- N o c E -o ` N N C a) a) N O N = AJ i (o = CL O lrl m O O CD Q p Z co Z O Z N y ~ ~ I i c in A E = 041 :3 o ` - co a *~t N Lo a m 0 06 N d i N N ~ O 2~ D C CL a N E 0 0 a a a Z~ o N~ a ~ I ~ o v> > rn rn ►~i g co .r U aci rn rn } Q o N a" °o N `n O E N O O O O m CL :7 ^ N cD 'a N N a) a) C 0 c 2 c O O Q o °6 O N 3 0 0 Co . CC) l) V- v n c 0) o 04 o a> C E c a) M E f0 C:' C • O N (off O Z to w E m m a ' EL L: CL w • ~a a m .V m E 4' a N V `~1 A V O FORM - STC FO4 AS BUILT SANITARY SYSTEM REPORT OWNER LLX~ &aK S j,j TOWNSHIP SECTIONT_CI N-R_Z~'_W ADDRESS J~ ST. CROIX COUNTY, WISCONSIN SUBDIVISION A~Z LOTA~LLOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM L r~~ s t f = y0 .sc,~/,~ NDICATE NORTH ARROW BENCHMARK:Elevation and description: Alternate benchmark SEPTIC TANK: Manufacturer: ` Liquid Cap. Rings used: Manhole cover elev:- - inal grade elev: Tank inlet elev.: yI Tank outlet elev.: 7 No. of feet from nearest road:Front Side , Rear Ft.J,~Q From nearest prop. line:Front , Side A, Rear Ft.~ /S-0 No. of feet from: Well Building: (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE . PUMP CHAFER 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: x Trench: Seepage Pit: Width: Length X9 Number of Lines: Area Built Exist. Grade Elev. y~ Proposed Final Grade Elev. Fill depth to top of pipe: No. feet from nearest prop. line:Frontj/ , Side , Rear Ft. &fl No. feet from well:_J~No. feet from building 5'3 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: ? a Cs' LICENSE NUMBER: I621-~> 6/90:cj 9la a I DEPARTM4NT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR &.HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON WI 53727 State Plan I.D. Number: NE, SW, 8, 31, 19W MCONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Somerset ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Rita Erickson Rt. 2 Somerset. WI '9-r 'ql BENCH ARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF PT. ELEV.: Ye -c- AS a "I 7 ~Q., / Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Calvin Powers,jr. 1563 Ist, Croix 149036 SEPTIC TANK/HOLDING TANK: MANUFAC RER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER / -7 PROVIDED: PROVIDED: S b v 1 ~f e, ! lig YES ❑ NO ❑ YES Lf NO BEDDIN : VENT IA.: VHIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM /5- DOSING LINE:_~ J ~ AIR INLET: ❑ YES lX NO ❑ YES 0 NEAREST --1110- CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CER I NAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF E O NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the pth of p ng FORCE LENGTH: DIAMETER MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction all ceas 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 TR!t C ES: / M7ERIAL: PIT j DEPTH: DIMENSIONS 1`P GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DI TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE VER: LEV.j T: EL . ENIJv PIP FEET FROM LINE: c I QIR 11LET- y J Z I- NEAREST - , 5 ~.lJ MOUND SYSTEM: 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 FIEVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: 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 \ 111 Retain in county file for audit. Sketch System on Reverse Side. S ATU TITLE: ;.I~o 6~.J Zoning Administrator__] SBD-6710 (R. 06/88) T as Nelson DILHR SANITARY PERMIT APPLICATION couNTY , ` 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 /q 9,0 (p 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. PRO ERTY OW R PROPERTY LOCATION _ ~ . c ° ~/a _ ~/a, S T , N, R ~ 17 (Or PR P6~TYY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CO E PHONE NUMBER SUBDIVISION AME OR CSM NUMBER 11. TYPE OF BUILDING: (Check one CITY NEAREST ROAD ❑ State Owned O VILLAGE ❑ Public 5Q 1 or 2 Fam. Dwelling-# of bedrooms PARCEL AX NUM ER ) 111. BUILDING USE: (If building type is public, check all that apply) ?9., - e 1 ❑ Apt/Condo J 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 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. ❑ New 2. SJT 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 ~ rVI Seepage Bed 21 El Mound 30 El Specify Type 41 El 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 REO~UIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION Feet Feet CAPACITY Site VII. TANK in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank fI ^ Lift Pump Tank/Si hon Chamber I Li El 1:1 1 Ll 1:1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's ame (Prim Plumber's Signatu o Stamps) MP/MPRSW No.: Business Phone Number: - Plum1pr''s Address (Street, City State, Zip er- X S IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved S itary Permit Fee (Includes Groundwater a e Issued A ssuin gent Signature (No St s urcharge Fee) Approved ❑ Owner Given Initial 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 i£ Buildings Division, Owner, Plumber + APPLICATION FOR SANITARY PERMIT STC-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 r✓ 114-1. A Location of property _1/9 ,Sh) 1/9, Section, T~_N-RW Townships ii/ Mailing address 21 &M, e t Address of site j_s 4 dx Subdivision name „A ,L Lot number Previous owner of property Total size of parcel Date parcel was created Are all corners and lot lines Identifiable? es No Is this property being developed for resale (spec house)? Yes _ t No Volume 84 Z17 and Page Number ~ 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, and 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 dispos 1 system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office o County Register of D eds, as Document No. -V'- zoo t -IS gnature o Owner Signature of Co-Owner (If Applicable) Date of Signature Date of Signature DOCUMENT NO. ~rSTATE BAIL OF WISCONSIN FORM 1-1862 rHis sr ilESFlgw6pa F c DI DATA l WARRANTY DEEDi ' 467957 VOL 897 r'ACE..0S REGISTER'S ONCE ! I ST. CWIX t"X?..1~UI d- and- II This Deed, made between Ri __...t~_a R__ _ _iv_ a__r__ _ Reed for Record .Alice.. Rivard_,_-_as-_t_enant-s. _in_._common_,_...- - APR 0 51991 - Grantor, at 900 M ! and t-a._---ivar_dand_A1 icy Ri.vard_, . ! C~htiw _-.,_-_-as--,joint.-.tenants . - ' RptaW of Da~dt' _ Grantee, Witnesseth, That the said Grantor, for a valuable consideration...... ! - i RETURN TO conveys to Grantee the following described real estate in 1X_ County, State of Wisconsin: I! A parcel of land in the Northeast 1/4 of the Southwest 1/4 of Section 28, Township 31 North, Range 19 West, Tax Parcel No: EXCEPT the following described parcels: 1. Lot 1 of the Certified Survey Map recorded in Volume "2" of Certified Survey Maps on Page 578 as Document No. 347881. 2. The warranty deed to Wesley W. Halle and Thomas H. Roy recorded in Volume 514 of Records on Page 394 as Document No. 323327. j 3. The warranty deed to Wesley W. Halle and Thomas H. Roy recorded in Volume 514 j of Records on Page 395 as Document No. 323338. 4. The warranty deed to Wesley W. Halle and Linda R. Halle recorded in Volume 529 of Records on Page 370 as Document No. 329609. 5. The quit claim deed to Town of Somerset for roadway purposes recorded in Volume 512 of Records on Page 159 as Document No. 322342. I, Exempt No. 3. FEE ~ This __l.s---------------------- homestead property. (is) (is not) EALIVti'i' L Together with all and singular the hereditaments and appurtenances thereunto belonging; And Grantor • - - - warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except municipal zoning ordinances and easements of record ~j and will warrant and defend the same. i; Dated this day of Aprl.l....... 19..t~1-. - -----(SEAL) - - . . . - - (SEAL) _-Riga-.12 var-d ` -----•---------------------(SEAL) ..............................................--....(SEAL) . Alice Rivard i AUTHENTICATION ACKNOWLEDGMENT Signature (s) STATE OF WISCONSIN I t ss. St. Croix authenticated this ........day of 19 Personally came before me this ...r IGZ.AaY of ' At? r i 1------------------ , 19..9. the above named Rta..Rivard...and_.Ali•ce__- Rivard......... TITLE: MEMBER STATE BAR OF WISCONSIN j I (If not, authorized by § 706.06, Wis. Stats.) to me known to be the persons--_____--.- who executed the i foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY i BAKKE, NORMAN' SCHUMACHER SKINNER S4AZTER; .S_~C.:" S ephanie A. Desin-- - - _-New.. FachmQnd.,_._W.)_..... 54.6.x_7............. Notary Public t.. _CTO1X__...--...............County, Wis. (Signatures may be authenticated or ,acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: -_...------_L-- -3 ..................XXXXXXX *Names of persons signing in any capacity should be typed or printed below their s,gnawres' Sll+rf7AhNE A.1)ESiF10 I~ Notary Pupiio" State of Wisconsin bTATE BAR OF WISCONSIN FORM No. I - 1982 Stock No. 13001 ST C- 105 r r . 9 SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z OWNER/BUYER ai~T~,~~~s~w1 ch ROUTE/BOX NUMBER _A,2 Fire Number CITY/STATE ZIP PROPERTY LOCATION:Section,-2,f_, T21 N, R_ _W, Town of 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, by a licensed septic tank pumper. What you put into 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 to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- u 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. SIGNE 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. DEPARTMENT OF REPORT ON SOIL BORINGS AND' SAFETY & BUILDINGS INDUS~TkiY, DIVISION LABOA AND PERCOLATION TESTS (115) MADISOP. BOX 76 N .O, 3707 HUMAN RELATIONS- HUMAN ' (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOW OW S JP/MUIdt£tf'fXtTTY: LOT O.:BLK. SUBDIV SION NAME: E Al, e /T) N/R,~ , (or r COUNTY: ER'S/BUYER'S NAME: AILING ADDRESS: USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCI L DESCRIPTION: X Replace DESCRIPTIONS : PER O ATION TESTS: Residence ❑New I,a,iReplace _ 7 / L1L9 ?Z 2 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) ©S ❑U 2S ❑U 0 S DU EIS OU OS 1AU 7 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: ZI/ PROFILE DESCRIPTIONS j'' - _ / 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.) r ~141 A/ B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD PERIOD2 PERIOD 3 PER INCH P-2 /V A4~ /e P- S, 7 r% .41 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. i SYSTEM ELEVATION E . E e e 3 E ea a E m 'G F 3 E 3 E 3 F F I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the proced nd 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 (pri TESTS WERE COMPLETED ON: 10, ADD SS: CERTIFICATION NUMBER: PHONE NUMBER (optiTal): J GS RIG TUR DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R• 10/83) - OVER - C 1- ~a %f0 ~ /e I 1 xk, i I ~ I i l PAGE OF CrvSS S~c~101, 01 A 4)Q1~ Systeft-) flogh All Inlol6 And OD66rvallon Plpa r J Approald Vaal Cop 19- ~C final Grodo 20. 42• Above Plpp 4• Cool lion To final OrSSS Vent Pipe Ma+n liar Or S/nlMlk Coraiing "in 2•Ay9180416 Oval PIPS 0161114a11on . Pip; o o --TaS + A Pipe PStloralSd PIPS 6410r ' Beneath Pipe ° o -Coypllno Tawadnaling At 6aumn 01 SfNaw SOIL FILL DISTRIBUTIO1.1 PIPE APPROVED S49'j11ETIC COVER OR 40 O 2"OFAG6R£GAlE OK MAR'SN mA i F STRAW r OPAGGREGATE ALE V. OF'FEE-(', S DISTRIBUTIOW PIPE TO 8E AT LEAST INCHES BELOW ORIGIQAL GRADE AQU AT LEAST LO WCHES BUT LIO MORC THAW tit ILICVIES BELOW FINAL CKAOC MAXIMUM WN OF EXCAVATIOP FK011 OWWAL 6WF- WILL BE / _ IIJCHES MilmvM 9EP1"H of EACAVATION rA0Y\ 0~14INAL GRADF- WILL eC INCHES StGIJCO' ~ I LICCUSC LJUMBER: DAT C > > o _