Loading...
HomeMy WebLinkAbout036-2006-50-000 1 _ FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP C2fe~,/ SECTION__Z/ _T_,T L_N-R_17 W ADDRESS~4//,,/ ' ,~4 ST. CROIX COUNTY, WISCONSIN SUBDIVISION 1` LOT LOT SIZE 4'c ~ PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM f O r r ~ GI `1 a~ INDICATE NORTH ARROW BENCHMARK: Elevation and description:, Alternate benchmark SEPTIC TANK:Manufactur r:,Liquid cap. Rings used: Manho e ci er 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,~LFt. y No. of feet from: Well Building: d (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: Trench: Seepage Pit: Width: Length Number of Lines:_..2Area Built Exist. Grade-Elev. Proposed Final Grade Elev. Fill depth to top of pipe: No. feet from nearest prop. line:Front , Side , Rear-Ft.~ No. feet from well: No. feet from building 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: 021 LICENSE NUMBER: 6/90:cj ,Wistoinsin 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 INFORMATION NW,SE,31,31-17W Oak Ridge l (185th Ave.)149086 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: Bruce Knutson Stanton CST BM Elev.: Insp. BM Elev.: Description: Parcel Tax No.: a.60 60,607 657 ELEVATION DATA -2-" n Co t TANK INFORMATION TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark A &V~ Dosi Aeration Bldg. Sewer ..A i Holding St/, rd Inlet 9( TANK SETBACK INFORMATION St/ Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake oZ ' NA Dt Bottom Septic 'yJ0 I Dosin NA' Header/ NPIK Aeration NA Dist. Pipe j/" Holding Bot. System /0,90 , 0 f PUMP/ SIPHON INFORMATION Final Grade . Y's s Manufat ur Demand Model Number GPM TDH Lift Friction stem TDH Ft Forcemain Length Dia. Dis . e SOIL ABSORPTION SYSTEM BED/TRENCH width Lent No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth 7, DIMENSIONS DIMENSIONS /.A LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM INFORMATION Type Of , 7 CHAMBER Mode Number: v. OR UNIT System: DISTRIBUTION SYSTEM Header- Distribution Pipe(s) „ x Hole Size x Hole Spacing Vent To Air Intake r l Length JDia. ~ Length ~ Dia. ~ Spacing /0 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 /Trench Center o) Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No I COMMENTS: (Inclu a Coyle dis~,yepancies, persons present, etc.) Plan revision required? ❑ Yes No Use other side for additional information. 91 SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. A ti ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ► ! 1 ftlt '3 ~ppv Co 1 ' Q ; SANITARY PERMIT APPLICATION cTY D LHR In accord with ILHR 83.05, Wis. Adm. Code ouN STATE SANITARY PE I # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ ~ / 8% x 11 inches in size. c r is n p evious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROP RTY OWNER PROPERTY LOCATION ac Z- fi) S"r % S,_ T3 , N, R (or , Z04) PROPERTY OWNER'S MAC VG DDRESS LOT # BLOCK # C h Cl , STAT ZIP CODE PHONE NUMBER SUBDIVISION NA E OR CSM NUMBER Il. TYPE OF BUILDING: (Check one) CITY NEAREST RO~q ❑ State Owned VILLAGE ❑ Public 1 or 2 Fam. Dwelling-# of bedrooms A PARCEL AX N BE III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 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. ® 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 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION Feet / Feet VII. TANK CAPACITY Site in allons 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 Holdin Tank S Lift Pump Tank/SI hon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for insta tion of the onsite sewage system shown on the attached plans. Plum is Name (Print): Plumb is gnatu : (No S MP/MPRSW No.: Business Phone Number: • ~s S ~lS 9 lu r s Addr (Street CIhtate, Zip Co e IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater at I e su Issuing Agent Sig ture (N Stfimps) Approved ❑ Owner Given Initial Surcharge Fee) Av Determination / E 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 F INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to :3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. If. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in #1-7. VII. Tank information. Fill in the capacity of every new ;and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8'% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. - GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-8398 (R.11/88) 10 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 lA ^ 0hj Location of property _ VY 1/4 5 t 1/4, Section 3 , T 3,_L_N-R I ]W Township jlCi, 9" Mailing address Peckvriooc(,A' 5 C,O n 5 1 k"l Address of site ' SO1 W\-e. ciS A ~OU Subdivision name 0G Li e 54a4e S Lot number J 5 Previous owner of property Day i D ~J \/o 0, V\[X CkP-CL I VO 14 Total size of parcel -L2 el Date parcel was created Are all corners and lot lines identifiable? es No Is this property being developed for resale (spec house)? Yes X No Volume -75-0 and Page Number r 3 / 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. ---------------------------------------------------------7--------------------- 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. / ,~I A ; and that I (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, for the constr tion of said sy em and the same has been duly recorded in the Office _4V X of t County Re ' to o eds, as Document No. ti nature of wner 91anature of Co-Owner (Ifpplicable) Da of Signature ate of Signature. I r i ~ Icy •4t. ~.tn .l u INA antom r ~}I611~M4+41~p~ri s, aft mom +r.*nwr &vim 'Oor -All C, k a .Te x e,. STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County 9~ T OWNER/BUYER ~su e e, ni e s i l ~7Ld50o ROUTE/BOX NUMBER H& AU2 FIRE NO. Iy~~O CITY/STATE tileLd I~ IC'k "0V1 CP ~ kscoV15; r') ZIP PROPERTY LOCATION: LL\~(_1/4 S ~E 111/4, Section T 3~_N, W, Town of V\ ~0V-\ , St. Croix County, Subdivision C , Lot No. 3 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 for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Nat Resources. C rt' cation form must be completed and returned to the St.Cr County Zo f e within 30 days of the three year expiration date. SIGNED DATE St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR P.O. BOX 76 HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707 (H63.090) & Chapter 145.045) LOCATION: / SECT ~ N p~ H/R L (or TOWNSHIP/MUNtet'P""TY: LOT NO.: BLK- O.: SUBDIVISION NAME: /T ~t OU TY: OWNER'S/BUY ER'S ME: A LING ADDR SS: ~h USE DATES OBSERVATIONS MADE S RIPTIONS: 1PERCOLATION TESTS: NO. BEDRMS.: COMMERCI L DESCRIPTION: O Replace Residence ❑New 14iReplace I RATING: S= Site suitable for system U= Site unsuitable for system r ONVENTIONAL: MOUND: S-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTE :(optional) ~$❑U 2 $❑U ©$OU ❑$ZU cAJ~1 ' If Percolation Tests are NOT require DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5) (b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH HIC ESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- • /J y B- > IAJ? al - B-,3 y - / - ,-2-1 AUC B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD ,1 PERT D2 P R I Y, PER INCH P- / / P- 3 s, / P- 1 lid* ::J P P_ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 4 1✓_" CP { - - - 7 _ _~5$ r 41 f ~_s E 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 Wisc nsin 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 t): I TESTS WERE COMPLETED ON: AD ~S: CERTIFICATION NUMBER: PHONE NUMBER (optional): zo~ CST S TUR I DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - INSTRUCTIONS FOR COMPLETING FORM 116 - SBD - 6396 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 1 MAXIMU I umber of bedrooms or commercial use planned; 4. Is this a - ~)r °nplacement systern; 5. Comply tability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHERS' FEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; B. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 1 1 . Sign the form and place your current address and your certification number; 12. Male legible copies and distribute as required, ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures ~r Symbols st Stone (over 10") BR - Bedrock cob Cobble (3 - 10") SS Sandstone gr Gravel (under 3") LS - Limestone *s - Sand HGW - High Groundwater cs Coarse Sand Perc Percolation Rate med s - Mediu n Sand W - Well fs F_ Bldg - Building Is - Lo, r 7d > - Greater Than 'sl Sand,, 1m < Less Than *1 - Lo.rrn Bn - Brown *sil - Silt L.;:. BI Black si - Silt Gy - Gray -1 - Clay Loarn Y Yellow Sandy Clay Loam R - Red - Silty Clay Loam mot N° ttles - Sandy Clay wr' r sic - Silty Clay fff few, fine, faint *.c Clay cc common, coarse pt - Peat rsrm Many, medium m - Duck d - distinct p - prominent HWL - High way, , 1, Six general soil textures surface v for liquid waste disposal BM Bench Mar' VRP Vertical F TO THE OWNER: is the fir ~ irrct a sanitary 7w cou❑'y _ +t may request s soil test for to permit: A r + nn' E, the private -1 1 permit apt r s't be submitted n order to TI-ie sanitary permit st be obtained and pos >rr. ~s- =ate-9i yon fi ~f /IC -1 epr 1 ~ PAGE OF C.rvSS S~c~IVI, o~ ~ ~e17 S~sTc:n-, 1 •~Glct ,tso . froth All IM►1► And Obteirvellon pips L ApproriA Va°I Cup N~F t Minimum 12'Aeora Syr 7 final Grad. 20- 42' Abora PIYr _ 4' Coal Iron To final 0811410 Vaal PIPS uaran Ilor Or SrnIMIk Corarlny On 2-Aypragala Oran PIPS ' OIOrlOallon ~ ' 9 9 0 0 0 Too + PIpS AOprSpola Parlaolaa PI a 4a10v ' Banaal► PIPa ° Y o -Cowling T.rnJnallat Al 6olloim O/ Slalom Pit) p o 1 e D ~l a-~ 9 SOIL FILL DISTRlBUT101.1 PIPE • APPROVED .SIA pr-TIC COVCR OR 9" OF STRAW 2w OFAGG9EGAIE OR MARSH HAS f.••O F lL-21/2 AGGREGAT E. -K 'm ELEV. OF9 ZEET_--... DIST•RIBUTIOW PIPE TO INC AT LEAST INCHES BELOW ORIGIWAL GRADE AQU AT LENS-1740 INCHES BUT 1.10 MORC THP%W tit IMCHES BELOW FINAL GRADE ,t M IMUM DEPrN OF FXCAVATI00 FXc)M 0R16VJA.L 6~ADF- WILL BE _ INCHES YUNIMVM BEPrH OF EACAVATIOW F Ot\ C!A~1611JgL GRAPE WILL BE, INCHES SIGIJEO: LICEMSC LJUMBER: ~.;a~!r2l DATE. r~ 110 _ ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that have inspected the septic tank presently C.ic _'x/~') residence located at: serving the A,hZ 1/4, St 1/4, Sec. , T2~-N, R_zz-W, Town of _SlA,,l Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced Did flow back occur from absorption system? Yes,No (if no, skip next line) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete---A -Steel Other Manufacurer (if known) : Age of Tank (if nown (Signature) (Name) Please Print - ~LI&s14✓ - e(i S-2 (Title) (License Number) 5--X29 -!Z./ (Date) Form to be completed by licensed plumber (x.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR-83, Wis. Adm. Code (except for inspecti n opening over outlet baffle). Name , A/ AWRZZ Signature MP/MPRSS~ 5/88