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HomeMy WebLinkAbout032-1082-10-000 ~ y N a ~ I O N n O C C N C Z 7 f6 LL O 3 I Q Z H II z €d I N H a m o z a c d z ° C-D Q~111 Of O. C C CO N O O 00 •N 2) N N (mil O V O 0 (D O Z co Z Z Z o N LO N ~ l0 y A Y LO CL - = +g ~j a 20) 4) v c ~ G G C ~ ~ ~ l Z H3H; H3 a O E 000 U) CL (L CL FL 45 7 o U N~ N c fA J U a CD rn v rn ii o 0 N r C N_ N 0 0 p p L 0 N m C C a 00 C) N CA p Fn lc~ p -e ' N 00 O C O C C E < CO -q 0) C-4 O rO O6 O d d d O C) M ' i1C M E E 0 N m N N V O co O y p N O p Y 7 N N 3~. N O H CD F- H C co co O a N M E t d E c4 U Cl) w p 7 O U) Al O N U) M O Z c U) O d v a) ~a C a EL L: CL 4- c P: tt`i~v •r E c ~1 A c) a 0 ; vii ti FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SECTION_,Z?_T N-R W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE e k PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM J8p ~~o vs, G,h.11 75 ~ . bt f 0 Su/ INDICATE NORTH ARROW srsc t art -L ~1 BENCHMARK: Elevation and description: Alternate benchmark SEPTIC TANK:Manufacturer: ~~~=mss Liquid Cap. Rings used: Manhole cover elev:-/~-Final grade elev: Tank inlet elev.: Tank outlet elev.: 166'1111 No. of feet from nearest road:Front-/-, Side , Rear Ft.~ From nearest prop. line:Front , Side( , Rear Ft. /S0 No. of feet from: Well l0Building: o?/ (Include this information in the above plot plan) (2 reference dimensions td septic tank) SEE REVERSE SIDE f 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: Trench: Seepage Pit: Width: Length Number of Lines:_,-_2_Area Built Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top-of pipe: 6~24/-- CIO. feet from nearest prop. line:Front , Side , Rear Ft.,X No. feet from well:Ze No. feet from building S-c 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 Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County- Labor and Himan Relations INSPECTION REPORT j,Ot 1 St. Croix 'lafety and Buildings 4fvision Sanitary Permit No.: '°`TTACgT9PI 1T192nd St. GENERAL INFORMATIONSW4, Sti1~4 Sc • 149092 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: Mark & Barb Putz Somerset CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 700a oq TANK INFORMATION ELEVATION DATA g/ TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing y 0 d S Aeration Bldg. Sewer Holding St/44 Inlet /p/,pa TANK SETBACK INFORMATION St/ 1 Outlet % ,:o, 79 ' TANK TO P/ L WELL BLDG- AirI to ntake ROAD Dt Inlet Air I Septic NA Dt Bottom Dosi ng- NA Header / Man. 7 Aeration NA Dist. Pipe q - S Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade / Manufacturer Demand 5.T ^I`C y h/" er GPM TDH Lift Lrictl System TDH Ft oss Fi Forcemain Length Dia. wen SOIL ABSORPTION SYSTEM BED/TRENCH Width Length / No.Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS /a p? DIMEN I N SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING faaurer: INFORMATION Type O CHAMBER !l Mode Number: System: ~ J`~Cn d V OR UNIT DISTRIBUTION SYSTEM Header/ Manifold Distribution Pipe(s) r x Hole Size x Hole Spacing Vent To Air Intake Length Dia. ~ Length -49- Dia. AL Spacing i SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over / it Depth Over I / xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center 3 (0 Bed /Trench Edges Topsoil rrTes ❑ No ❑ Yes No COMMENTS: (Include code discrepancies, persons present, etc.) Plan revision required? ❑ Yes M No Use other side for additional information. 0 SBD-6710 (R 05/91) Date Inspector's Signature Cert. No 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 ❑ Ll 77f~ 8% x 11 inches in size. C 4k if revision to previou 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 s '/a_ '/a, S T , N, R (or)(v PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SM NUMBER / 7 g~ /7- AO 11. TYPE OF BUILDING: (Check one) El State Owned O VILLAGE : EAREST ROAU_ N~ ❑ Public V 1 or 2 Fam. Dwelling-# of bedrooms R PACEL NUMBER(b) a - 0 of Obi 7 q A 111. BUILDING USE: (If building tYPa is public, check all that apply) (3 d 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranVBar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ 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. N New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.0 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 1 h:;1 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/da /sq. ft.) (Min./inch) ELEVATION . 7 Feet J1W, /5 Feet VII. TANK CAPACITY Site in gallons Total #of Prefab. Fiber- Exper. INFORMATION New lExisting 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 insta tion of the onsite sewage system shown on the attached plans. Plum is Name (Print): Plum er' ignat e: (N S ) MP/MPRSW No.: Business Phone Number: ,4, W 0 57 lumber's Address Street, City, State, Zip Code IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sa 'tary Permit Fee (Includes Groundwater Date Issued Issuing gent Signal re (No S Approved ❑ Owner Given Initial / Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVALIREASONS 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 9TC-100 This application form Is to be complated in full and signed by the owner(s) of the property being developed. Any 1nadequacles will only result in delays of the patmlt issuance. -Should this development be intended for resale by ownet/contractot,(spec house), then a second form should be retained and completed when tha property Is sold and submitted to this office with the appropriate deed recording. Ovnec of property . ~ al'k a r) Bar b 7Z Location of property _i/~ SQL-_,1/4, Section T 3! li-R„L_~_V Township S0Vn0'/S&17 Mailing address y 0-) S- 0, f'X T I C Address of site A/v h^ r-d 5_ Subdivision naves, .N~ Lot number 1-074- Q C7 69 er l ~ie~l►~ai.v Previous owner of property EdlJ(~( Total size of parcel _ L- yy a&V2o Date parcel was created vl Cc190 Are all corners and lot lines idsntltlable? on Ao Is this property being developed for resale ('spec house)? Yas A No Volume and Page Humber ' an recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWINCt A WARRANTY DYED which Includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER Of DEEDS. In addition, a cert~llad survey, it available, would be helpful so as to avoid delays of the reviewing process. it the dead description references to a Cet:tifled 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 Intolmatlon form, by virtue of a warranty ,deaadrecords ~I the Office of the County Register of Deeds as Document No. !--'rF6g447_4(, and that t (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, tot the conattuctton of sold system, and the same has been duly recorded In the office of the County { atec of Deeds, as Document N . signature of Owner signature of Co-ownac (I !cable) Date of signature bate of signature .or 4 ; ' W ,rye.. L.~ T • tip' mow, _ V SM~i~ aild a+e wi ds~ sE 0"-of-may of May d . Gerald W. Susan L. Dermaix t s ar ACIN STATE OF W1900 r St Croix ~iL 1l.._. peisonaiky air bwww I". Gera1Q;~ B" Or VISMNSiN . Alice Jo t . Na~«v PUN* a. .R SEPTIC TANK MAINTENANCE AGREEMENT w St. Croix County OWNER/BUYER d r~_' arJ 6 Qca r L Pori r?Fl. ROUTE/SOX NUMBER Fire Number a d Or~ CITY/ STATE ~~~1tIf7 _ C:~ISG ' ZIP PROPERTY LOCATION: L' k, 5,5- k Sections q T_I_N, R /9 W, Town of `ne1j-CT St. Croix County, Subdivision Lot number Improper use and maintenance of your septic system could result in its premature failure to handle wastes.- Prover 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, unct on o• tt e-sepaie.tank as a treat- ment'stage in the waste disposal system. St. Croix Counter residents'-may.be eligible to recieve 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 's'sy tams 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 to maintain the private sewage disposal system in accordance with Jr the standards set forth, herein, as..set by the Wisconsin Depart- ar ment of Natural Resources. Certification form must be completed .U' and returned to the St. Croix County Zoning Office within 30 days of the three year expiration.date. SIGNED DATE Z- St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. (yo DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, G DIVISION P.O. BOX 76 LABOR AND PERCOLATION TESTS (115) MADISO N WI 53707 -HUMAN RELATIONS (H63.0911) & Chapter 145.045) LOCATION: SECTION: TOWNS UNICIPALIT LOT NO.:BLK. NO.: SUBDIVISION NAME: 1% /a /1 1 N/Rl~' E ( ) a- 000 COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: ~ 01 ~c Fmg G rs e GPi s, USE DATES OBSERVATIONS MADE NO. BE RMS.: COMMERCIAL DESCRIPTION: PROFIL DES R PTIONS,,ER L O ESTS: 02Residence FRNew ❑Replace / ~Q / 7 ga RATING: S= Site suitable for system U= Site unsuitable for system y!~ a © Role 60l S ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: IS YSTEM-IN-FILLHOLDING TANK: RECOMMENDED SY TEM:(optional) D S DU DD S DU O S LU O S M ❑ S ©U V. d oh na~roW t or tree s ~xiou 1a 501, If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: 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.) /I~ s~ Y~~ o6se S4~ B- J ebb Do.~ ~.Ud a5 ls4~ ~6o EllW-A B- a Od 71,0 .~a~ls~ ~.a bhmcd~/~' 5~~5ob~osP Svc, B- IV ` 6 koo 6Is" I Poo 1.4 /h e l s' -6o,d Aoge St' B- ~ 766 /60, d' 4~o f s; .SU & Jo, S gr B- ~~06 ?7, 0 , ~0 61 i ~o ra in eg ilk st 1_740,& ease- 5'9 t, B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P PER INCH P_ ! 10 1 ?h P_ /G? 3 P- 3 L ! P A4, a P-_ P_ LP- 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 ELEVATION r ` E e : E , , i _ y 1 ~ ~ de- F y p 1 ~l. rrf^ , 1 E ~,D I , I ~ 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 COMPLETFA 11,2 ADDT* LI CERTIFICATtO UMB R: PHONE NUM~~Io ionaFl: -tri_oel- T ~Vlq 0,* CST SIGNAT DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - ~e7 ,860 s~~~ - la 4!rpz " A 4-Ja / g~'2~ ~j~sz s~~ r ~osf R~dRrl - ,~l ~cD.4 tg o~ ,ZG /eve ~ '~d7 S~ip1.J~ S7` PAGE OF . /.1K~csk f LJ ~ C. r v S S S~ c~ l u 1, o~~ V r l~ S y s ~ r fiekh All Inlaib And Obob/vollon Plpa Approved Veal Cop Mlnlmum 12-Above ' flnol Cede 20- 42' Above Pip' - 4- Ceet lion ye final Gru• Vent Pipe - _"Wsh 1191 Of Syno Lila 2' AY0/4001• 0.e/ Plpe 01e1rib vlton a Tea tip u c + 6' AOy.epala o perlorelea PIP$ below 13eneelb Plpe o ~CG%OIAo Twonlnellny Al Balloon 01 $,►lem _lID©Q SOIL FILL DISTKIBUTIO►.! PIPE APPROVED $IA per-TIC COVCR ` ""-'N►AT~1t1/~t- OR q'017 STRAW 2"OFAG6 RE6A1E OR MARSW FtAy Io' 0FAGGRCGATE ELEV. OFffe-fEEY- DIS-I-RIB~JTIOIJ PIPE TV BE AT LEAST WCHES BELOW ORIGIIJAL GRADE A1,IU AT. LEASTZ0 IMCHES BUT 1,10 MORC THAN tit IAICHES BELOW FINAL GRADE M MMUM DEQTFI OF F-Y-CA ATIOP F4011 OK16WAL 6XA0F- WILL BE IMCHES M 41M1VM QCFTIi of EACAVATIOW r-f\OJM Col?,141WAL C3RAPF- WILL BE INCHES SIGHED: LICC►JSC IJUMBER: DATE: 110 _ r i s v t•J~4 S