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HomeMy WebLinkAbout040-1205-90-000 Q c o ° ro p Ge ti c 4. o 0 0 N d' N w Q I C I N (U CS 9 2 C LL c C O a I w z = °o L CO co > - 1 m z c 0 0 U O Z c 0 - CUi 2 d' ~ ~ O fA F- c- O O Z c o E o ~ M 4) co CL O O N U) • O O N Q. L L i C C O U O z z z N CO O E N o 1,5 10 N N m y- d N cn O. ( o i5 D 0 j > d O_ N U) U) U) E CL p O m d N O i O O O Z ° •rv i = a a a N~ a o ~i C V) : w y U co rn n L 0 E N - p rn o E I o ~ M m a- LO N a) .2 m 4 co ~i 3 4) O o 06 a c i. o Y o c E O M O Co y : U d 0 1 L+ O O~ y _ F-r O6 O (D Q c O. c 12 V O C O O N O N ` O w N h- m O U1 -n H N a C N r C N o a m E m v • O H O z y to eOe ~ i I V v~ m ~o I a EL L: 0. CL Q •E C r Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER /YIAl~K©~ic~5 r oAl TOWNSHIP ~c, S/ SEC._ T o,~~,N-RW -T ADDRESS ST. CROIX COUNTY, WISCONSIN ~ 7~~ So/V G✓i . S~v/G SUBDIVISION ~Ln V&~T/v.cJ LOTS LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM IJoTE SO~OTon/ As st To ~I~A0-6 To 1Y7t,F T /YIA X . /JT l~ Rte` t~ a .r~ 1e1T ~o r /0 Aeo LJEL~. SAP slw~,~ ~ (JES 7 TANK w , T,! 15 N y0 61' A7" ZA'v 0,4 "4Z4a 7S Q NOTE 5 DrP 3 S Svc t cvr 4 /,vr. oeop is ox Too ~.I VcuTS 0,5r?f I ACA 72-_ L ~Q ~t ~Lc To A607W ~,Po v OPT GfT ~5 W. < f~07 COe/0 62 L_/,t /c~C7. 00 ~PvoE~y~ivE INDICATE NORTH ARROW On A//A -f o ~Io ~c1tL ~ BENCHMARK: Describe the vertical reference point used ,~~oc> ~p~ hT 5.c_J • 1,-7-Coll .P Elevation of vertical reference point: /00.6' Proposed slope at site: i o SEPTIC TANK: Manufacturer: Liquid Capacity: /-;~Sca GAS . Number of rings used: Tank manhole cover elevation: /p V Tank Inlet Elevation: 1o/. S31 Tank Outlet Elevation: a4/' ' Number of feet from nearest Road: Front 10 Side0 Rear, feet .From nearest-property line Front 10Side,aRear,0 feet Number of feet from: well 4~a' , building: 9&V (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE war PUMP CHAMBER Manufacturer: Liquid Capacity: .::'Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: -`Number of feet from nearest property linef. • Front, O Side, O Rear, © Ft. 'Number of feet from well: Number of feet from building:,. (Include distances on plot plan). SOIL ABSORFTIONSYSTEM Bed:- • Trench: t3 3-cao Width: 6' Length: g .-Number of Lines: / Area Built: Fill depth to tj of pipe: 3 Number of feet f m nearest property line: Front, O Side, O Rear, Tt ;Number of feet from well: N tuber of feet from building: /3 Y (Include di "lances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box or distribution box O been used on any of the above soil r• absorbtion sytems? (C eck one). HOLDING TANK Manufacturer: Capacity: Number of".rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: y r Inspector:. Dated: //,-.7 Plumber on job: Zfe-114-1 License Number : s Y39.9- 3/84:mj ! k 4 Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM Lot 9 County: Labor and Human Relations Sal'f@ty and.Buildings Division INSPECTION REPORT Glover St. Croix (ATTACH TO PERMIT) Station Sanitary Permit No.: GENERAL INFORMATIONNW4,NE4,Sec.16,T28-R19,Omaha Rd. 144P201 Permit Holder's Name: ❑ City ❑ Village [2 Town of: State Plan ID No.: Mark Johnston Troy CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 0401 963 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic / - / Benchmark I0S,_6q i00, Dosing q, ! 0 1,~L / D 0 , p Aeration Bldg. Sewer Holding St/ Ht Inlet i L/~ v TANK SETBACK INFORMATION St/ Ht Outlet poi „ Vent TANK TO P/ L WELL BLDG. Airito ntake ROAD Dt Inlet ir Septic 7 NA Dt Bottom Dosing NA Header / Man. lo' ~O g 9 Aeration NA Dist. Pipe - 83 Holding Bot. System y3 L4 0 PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No.Of Tr ches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS / 8 DIMENSIONS Manufacturer: SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING INFORMATION Type O CHAMBER Mode Number: System: 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 xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include codetoiscrepancies, persons present, etc.) I t Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. SANITARY PERMIT APPLICATION . DLHR In accord with ILHR 83.05, Wis. Adm. Code COUNYV/ STATE SANITARY PERMI # -Attach complete plans (to the.county copy only) for the system, on paper not less than Q 8% x 11 inches in size. Ch k if ev s!on o previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPE OWNER PROPERTY LOCATION T /V J Y.A16'Y4, S / Tag, N, R E (0 PROPER OWNER'S MAILING ADDRESS LOT # BLOCK # 7 c CITY, TATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) ❑ State Owned vILTMLAGE NEAREST ROAD ❑ Public g1or2Fam.Dwelling4of bedrooms PARCEL x NUMBER(b) III. BUILDING USE: (If building type is public, check all that apply) UJJ 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 50 Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 114 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ 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 300 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) q 9 as - EL VATION 00 -r0Sat ~ Wo Se?.~ 3 Q . &o' Feet '~9~ Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank a / 50 G. , E Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumbe ' igna ure: (No Stamps) MP/MPRSW No.: Business Phone Number: 5 S39S rJi~ 3zS,o `~FrS'o ~iA os .it.c. A(~e Plumber's Address (Street, City, State, Zip Code : / s -7A- 57- AJ /yko SON W r 'S4~O1 ~ IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sa ary Permit Fee (Includes Groundwater a e Issued Issuing gent Signat o Sta s Approved ❑ Owner Given Initial Surcharge Fee) z Adverse Determination Z922 7~r j X. CONDITIONS OF,APPROVAL/REAS S FORMSAPPROVAL1 17 10,4~1 0,U4 MV q,z'aA" 4,10 ~1gCao SBD-6398 (formerly Plb-67) (R. 11188) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber ti . APPLICATION FOR SANITARY PERMIT 8TC-100 This application form is to be completed in full and signed by the ornet(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= recordin9--------------------------------------------------•-- Owner of property ,.('la-i' Al ~~h^~s Location of property ~~1/4 A) /4, Section T_4-L-N-R-= V Township ~ro Melling address Lod ~r/~,,er S`~"7,0`~ ~w v, s,"o✓ Address of site So- -C, lubdlvlslon name C,~ `d v--e-,- 7'a-"~-J s, ""f . Lot number .41 5? Previous owner of property Total also of parcel o? 33 ~C r Date parcel was created ,Z/.;~qh9- Are all cornets and lot lines Identifiable? _Yes No is this property being developed for resale (spec house)? as 0 V019M Viand Page Number C&°' as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which Includes a DOCUMENT NUMBER, VOLUMB AND PACE 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. It the deed description references to a Cestified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(We) cettlfy that all statements on this form are true to the best of my (out) knowledge= that t (we) am (ate) the owner(s) of the property described In this infotmatlon form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. IS_(o6(ola0 • j 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, for the construction of said pystem, and the same has been duly recorded In the office of the Coun a later of Deeds, as Document No. gig atuc of Owner Signature of Co-owner (If Applicable) f15 /7 D a o Signature Date of Signature SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER !~q l ~O ,a S Ta -J ADDRESS: L, T * / G~ ro ve ,r _54,_A-o -J FIRE NO: LOCATION : /A)4) 1/4, 1/4, SEC. h/a T,~gN-R_Z2_W, TOWN OF: / o ST. CROIX COUNTY SUBDIVISION: yi ~o v e r Sl~ti 5L L J v s o.✓ 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. I SIGNED: DATE: St. Croix County Zoning Office f 911 4th St. Hudson, WI 54016 WEST ONE E 112 Or NW 114 . IRIZATTEO 4p~ N•S!'Or.E 1x100' ^ ei.C ~auvi----- -~l40oo'_-I f_-Zia oo_- A40 Tx 146 711 VOL 619 o' E t I G b r t ~ I.~.r I a. ~ o N r]]'a"E s:] 27' = N l,1 j yip` 4 "I Sr R a G aG• G ~ I Ilyii Y ~ C tr oco . I R t ° i L 8 iii l]' I no oo oo' q 3s •'N ~1 • L']]O••'w !1911 !lSOi MI•x•M,14•S O' ar a------- € s \ ~ 'qr SNER PACIFIC -1- eon ROAD Nrx'oi [ w.oi fP so 6 .000d R 1~~ • x $,o % 300 'ti+~ gg aa Y y 4~ ~ $ SI NNSSOi'[ 40003 R pe Q~,~ 4 I~ S~ NI „ ~y~~~1e ~A Q1 . 4 ~t]I NI, ~ w y IEyx^` i ~ • i w 4y la. u' I b [ow ' bt Jo ' /'f l I . •oooo' 40002' ~ q A R A 9,r ,b• M" ~b ~ I 8. r 3 •i 4•r. I .oouo IJ- j ~S .oo i I I ° ~ ° ~ lux IIE.x Rt br" ..I 1r 6 I 171 ~YF44~ AS' 1 8 gg. 1 8. 8 66 4i sccnoN ~9.E a a 8^ q 8. ~Mt d I z rwl r SeJ• R~ 'I 1 E' s]wm m Is", 'y N + NI•]i0•"E 4WW N1•!!06°[n F. \ p V "n Z I N ~ ~ ~Y / Ku Z. 8 c B p p II b •S R N $ w 8~+•+'' 4+J. M N •a• I 6 °I 8I . i 9 \ rn~ r o"' w y ^ x m a, R" 8. H 3 .,'b't la° 1. "••...1• 1+ I n i s: (n Z' iAi''].'•8• i o . Ncv]il'E 406 of I G "j DIY,°g-.~ f •.yf i t~ :U= n ,1', ] a C R .:'a'se"E [e] 9s 8 G Qy ( ^4a 0 m .x Y 8 R $ L. nS 9 n IX ~ 4 ~ ~ ~ J J' 9r ti. R a I n ~ 'i 2 6 D y ONN .l,i•~ J, i +.O •J~f t~ 0 N S I s, b i I I', 'w ar s J I i 2 Y> e si 5 a l ► 8 18 Q J, 0 j t K w i.~;aN a s\ r k ~ a Z ro sea ( R » ,JJO•Q. a• rr. Joror 1 Z N A A' /O8 4JJ• ~i \ / / q n F yl' 0 4 " 'to J R A U • ~ 1 ~ X '~P Aft` FI , •J• 'r ~ •a•"° •Fp ."+ar " It IZ ~ ° R = a A t L 'b. ~ ~ ye • ~ ,/gyp ! ~ j ~ Ii ► • I 1 I ~ Y ~ w1• ~ I~ 8~ ~,:•4' ~ ~ i A f s, 3 ~ ~ M~ Y 1 f. Is ~I 11 ~ ~ 1, 1\\ • ~I k, 1 1 _ 1. • INDUSTRY, OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS IhiDUS7RY DIVISION LABOR AND PERCOLATION TESTS (115) MADISP.O. BOX 7969 ON WI 3707 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SE TION: TOWNSHIP/ LO NO.: BLK. NO.: SUBDIVISION NAME: NE 1/ NW'/ /T zgN/R 1gE (or 1+~Q` ~t a✓e~2 ST4rIO ~J COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: Cho ~x MA )I ws-r6 1 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PRIG I DE RI TIONS: PER Z TESTS: ❑Replace il 9~ Z Residence V'6N ~E Ll 3 Z . RKl1~~'t' RATING: S= Site suitable for system U=~1unssuitab a or system ~4 d at► ra! O NTIO~NAL: MQ~N~. ❑U IN-GROWND S FP URE: NS 1❑uLHO❑LDING TA K: RE MEND 7/~SU~M:(opti-o n") - 41 XS I S X1U I ortion of the tested area is in the A If Percolation Tests are NOT required DE N RATE: If any P N ~ under s. ILHR 83.09(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 DEPTHJiI~, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 2o'Qz'SL'rS t2" BaaSc 2d''I~~~.~5, Z4' e ~ 1'►'tS jpbzj B- I1.`a3 hl~ > l~.~3 4z~ LT$R~► S 74'L-r9A&j ,~,S~G►2 B- Z 9.56 z;?? ~a 6 > 9.Sb ~~&~z s lo$~~~~L(e 17"8d&4e,+i li-6 BQ,gMs-~G /Q" ~SLTS 2ti► L. ice" R N , C IO" 880>i V-15 eUVs L-r B>2u !'hS C►2 A WBCLTS IC~ Rw 5~l /l v,3a,l , 1 y B- /0,-b3 J.<-t IL ,rg /41'9&F6 1Z" R&M-sGR S9'19 Qn► 14SLIe ~~$CSLlt~ /L)r k k~St / >2N i B- j x,33 i $.33 i5"VAa.N VRIB. P jFS 40'' B~,n-►s~L n B- PERCOLATION TESTS C TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER N.AL04B"9 AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P- s~ e%Qb~ 19'610 3 > > 2. > < 4Ab tdaut~ (9) A6 'S P > > > < P- P_ -T Q 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 point and show their to ation/ion the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. N " `74 .2-5' SYSTEM ELEVATION R NON " 93.c`e 3 E E 6, AT ~t-ZV4 low /Q~,C . 3 F All, 5~ A P-JJ ATE rs E 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. NAM (print): A6 e TESTS WERE COMPLETED ON: I&NIZIA/ J(aso M pal ►.1 ~j _-~o 1P6 Pr . -,76 / g1 ADDRE S: CERTIFICATION NUMBER: PHEJV~~(optional): '9% P 1 4 6 0 b CST ATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - i"LD Of PLOT & CROSS SECTION PLANS ZAPPA BROS. EXCAVATING INC PLUMBING UNIT P~~Y PROJECT 1,/N ~yGSIPE'`~c~~ I J ,~NSTO,tJ J'~OR~~SEO lve-4,-, cx~ ✓c N Lv~4 e S mAA ~C~ SGwc'P L.~ n/E I S i C ~c~1X ~GY~(NT /0 0 T g J /fox a J~'nrrs ~ ~I A 3 t l nT. ~A ~ 77•'MYr• g~ uc,/MAPFZ'_ ~v~ "o"96- hr S w- NO ~0-T SCALE FRESH AIR INLET AND OBSERVATION PIPE _ ~2'` - APPROVED VENT CAP MAXIMUM 12' ABOVE FINAL GRADE 4' CAST IRON VENT PIPE MAXIMUM OF 42' ABOVE PIPE TO FINAL GRADE SIGNED: MARSH HAY OR SYNTHETIC COVERING LICENSE: doiPs .T95 MINIMUM 2' AGGREGATE DATE. OVER PIPE J DISTRIBUTION PIPE _J I TEE SOIL TESTING BY: ELEVATION BED 6' AGGREGATE • BOTTOM PER.SOIL, BENEATH PIPE PERFORATED PIPE BELOW TESTIS COUPLING TERMINATING A. FT. 4L AT BOTTOM OFSYSTEM B,~3.o0"