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HomeMy WebLinkAbout040-1206-80-000 N 00 oar i' p 6-s ao e ~ I o ICI I N ~ FF I N S e E I CL N m N Z N 3 c LL (D -_c I 'O C -0 0 Q U I 3 ~ d. y I z E z w °o z £ v` cD co w a co r Cn 0 c t9 m o z d c w O 7 N H r ~ "a 0) (D co hh O M _ a) v I wJ a 3 N C ~(A~3 a L L 0 C C O U O O Q w z I- z o N z I d c ~ N ~V co O y _ T. O) LO c z`!1 _ N N i N O ~ ~ ' 3 C C d .0 N I M fn fn _ E w N con N C 1- I- F- ~i 0 0 0 d H r` O shy = a a a i N O O N O N N U U rn rn ~ LO I O N O= O N C O O_ N D N N 553 N CD 0. d Q } ca a O S: U) U) U) O O N C 'v O M C U') co C3) 0 © O ~r p N O T C in CL a) a 00 r- ca E CL O 0 0 0 N _p N 04 0 try,) C 00 ~ O N O E O vi O E U y' O H Q O z N z Cn O hc~ .w V ~ ~ e d I d m d s a ` a w • c0 CL d ! d y c 44 c c `~1 A 0 aM~ 0 m 00 FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER Z _ r;;ikl TOWNSHIP 13 SECTION T_ZQ N-R A1 11W j ADDRESS_ 76 1I`1C CROIX COUNTY, WISCONSIN SUBDIVISION LOTLOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM yt I s f 7, ,q r z~ Gt t ~Y v INDICATE NORTH ARROW BENCHMARK:Elevation and description: ~L Alternate benchmark SEPTIC TANK:Manufacturer: d{r a , Liquid cap. /1<JrJ Rings used:- 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 , Sider, Rear Ft. t , Building: y No. of feet from: Well .419 (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: /y/9 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: -5 Length Number of Lines: Z Area Built Exist. Grade Elev. Proposed Final Grade Elev. "Poe Fill depth to top of pipe: 16 No. feet from nearest prop. line:Front / Side , Rear Ft. No. feet from well: f17 No. feet from building (O 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 : % J r''f ~jw LICENSE NUMBER: ! 6/90:cj Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT St. Croix Safety and Buildings Division Glover ATTACH TO PERMIT) t Sanitary Permit No.: GENERAL INFORMATION SE4,NW ,4ec.16,T28-R19, Lofa on 149198 Permit Holder's Name: ❑ City ❑ Village ® Town of: State Plan ID No.: R CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA p7 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic, Benchmark D 4 L oG, 9s' Aeration Bldg. Sewer Holding St/ Ht Inlet ~13~ 97,17 TANK SETBACK INFORMATION St/ Ht Outlet ie%!' 7 pj Ventto TANKTO P/L WELL BLDG. Airlntake ROAD Dt Inlet Septic > n ' 35 "tom NA Dt Bottom Do ' NA Header / M/kfr 95•c✓ 3 Aeration NA Dist. Pipe X• 1~ 1W ' 11 Holding Bot. System V 93,7 Z 38` PUMP/ SIPHON INFORMATION Final Grade 7S • 00' 1 Manufacturer Demand :5;7- 126~k, 60 d Model Number GPM TDH Lift Friction TDH Ft Forcemain Length Dia. Dist. To we SOIL ABSORPTION SYSTEM BED/TRENCH Width _ / Length ( No. Of Tenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN I N SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING anufacturer: SETBACK INFORMATION Type Of 0_01 ',A /f Mode Num System: c CHAMBER OR UNIT DISTRIBUTION SYSTEM Header/ Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length __X Dia Length ~ Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over 4PRt-~`~ ~(o"- 30 „ Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched -Bed-/Trench Center` ~ _ Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) , ~t r ley W y/ e J f~~~/ , r c,'z, cl-1 S.c~J, Cn~ ( of PlWre~isionrequired? ❑ 'Yef o Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. 77 m SANITARY PERMIT APPLICATION COUN In accord with ILHR 83.05, Wis. Adm. Code . RILHR -OMMENOMEN STATE SANITARY PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than c 8% x 11 inches in size. ❑ cMeCk if revision to evious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROP TY OWNER PROPERTY LOCATION S' Y4 !'IJ4jY4, S T Z8, N, R 12 X(or) PROPER OWNER'S MAILING ADDRESS LOT # BLOCK # 3-7 5 Saw W~W pt, / C17, ,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR C M DUMBER Pu 4 Clo rJ II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD ) State Owned VILLAGE ❑ Public M 1 or 2 Fam. Dwelling-* of bedrooms ~ PAR AX NU BER( III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 1o ❑ 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 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. ❑ 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 A 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) T/ 93, W ELEVATION 4~ Loo ~ --Apo eOG 75` T Z 5'1.4'oFeet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION Manufacturer's Name Con- Steel Plastic New xistin Gallons Tanks Concrete glass App. Tanks Tanks structed Septic Tank or Holdin Tank /7bb . 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): Plumber's Signature: (No Stamps) MP/MPRSXbkL: Business Phone Number: 7,n.►-•~ 3z 2 -7 7 7 7- 3 2i Plumbs s Ad ress (Street, City, State, Zip Code): Z f 7-7 IX. COUNTY/DEPARTMENT USE ONLY Includes Groundwater Date Issued Issuin9 Agent Sign at o Stamps) ❑ Disapproved Sanitary Permit Fee Surcharge Fee) Approved ❑ Owner Given Initial $ -ql r,, Adverse Determination / ! S 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 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 use intended for resale by owner/contractor, ("spec house"), then a second form should Ise retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property, - r, i, Location of Property Section T O N-R__LL- W Township Mailing Address AL, Address of Site S {mac ? 1C3 rt Subdivision Nana Irc { r-'°y .Lot Number Previous Owner of Property Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? L'' Yes No is this property being developed for resale (spec house) ? Yes No Volume and Page Number /C 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 refer- ences to a Certified Survey Nap, the Certified Survey Hap shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION i JWV J CV_Ati.6y that a.Ct s.tateme.nt~s oil ,tltivs ohm she tlcue to tjte best o6 my (ouh) hncwtedge; that I (we) am (ahei tile CW"e .(~s¢ o6 the phopen.ty dezuti.bed in .thiA y .in6onmation 6okirr, by v.iA-tue 06 a waAAan.ty deed heeohded in the 066ice 06 the Corrn.tyy Reg.usten o6 Deeds ah Voerrment No. ; and that t (We) pheAentty sun t' lie ooposed site 6oh tile sewage diApos s ys em (oh 1 (we) have obtained an eaAcmcnt, to Run With .the above deAcAtbed ph.opehty, 6oh the eon.sthuction o6 said Oysten+, and the dame ha.e been duty neeonded in the. 066tce 06 the County RegiAteA 06 Deeds, as Voem nt No. ) . SIGNAT 01? OWNER SIGNATURE OF CO-OWNER (IF APPLIqa CABLE) ~-3 91 . DATE SIGNED - DATE SIGNED STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT P3 St. Croix County N ro OWNER/BUYER aLrn000( 4- IDCfll5E P, A -nl-50n 0 ROUTE/BOX NUMBER l C, ~ ti < 'ire Number CITY/STATE ZIP Y / M PROPERTY LOCATION:'.' L. k, ' Lk, Section 1C. . T N, RAW, Town of- St. Croix County, Subdivision &-~QJy-e4- S".-A , Lot number. Improper use and v ainteYLance 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 licensed 'septic tank pumper. What you put into the system can a"E£act the function othe septic tank as a treat- ment stage in the waste disposal system. St. Croix County residents m~ 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 ystems 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 5 the standards set forth, herein, as set by the Wisconsin Depart- ment of Natural Resources. Certification form must be completed .d and returned to the St. Croix County Zoning Office,within 30 days of the three year expiration date. (L.LL,vL't~~ SIGNED DATE " a 3 "~I J St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. q R^ r ~v g A n } te, Qlo"r = SobdivisOa, located iw t " _ t tot . atpi ttort# 4 •rtp ~ ~ .yF IV K I W,4 . STATE OP Y , sot War* M , this 1 the above named r. x t', 1 •w~ xrxy' FiAseis to ~Cl1e ivos ....A„ " left xt? i pA A', 4 DEPARTMENT OF ~ REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS DIVISION L 3707 7969 LABO LABOR T AND PERCOLATION TESTS (115) P.O. BOX HUMAN RE.I ATIONS MADISON, WI 53707 h (ILHR.83.090) & Chapter 145) LOCATION E TION: TOWNSHIP/Id4tifd+E+PA+1TY: OT NO.:BLK NO.: SUBDIVISION NAME: -5'67 1/4 Nw 1/4 Ice /T~ N/R l5 E(o W ->^RbY E-AG-r `P,AR-,T I GIouC R -STET,IOAJ COUNTY: MAILING ADDRESS: S,, ~ A,4)/' Mi Ijrso,_J 13337y /5:2F"i5- ~P~~ ~/~/~Ey .~iti, SY/2 y USE "e/2 -:'73 2 r 7 DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: TESTS] ®Residence 1-3 o,e ;/(,f New ❑Replace I i % ,y 21 f f ~ Al9 yL Z ) r f _5'e,5 02- Bv~Kti~eor 0A.,A f/;4 RATING: S= Site suitable for system U= Site unsuitable for system • COA AE T ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) ®S ❑u ❑ S ❑u a S ❑u ❑ S au ❑ S ou S/,0-4- If ~.v ~e~ -r T~srF o DESIGN RAT Percolation Tests are NOT required If any portion of the tested area is in the under s. ILHR 83.09(5)lbl, indicate: GLS S- Floodplain, indicate Floodplain elevation: l~ ;to- PROFILE DESCRIPTIONS BORING TOTAL PTH T GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED E TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) b'/D'lOy~ ~/2 S okK yR r„2 /O /J"iaYX 3/1 S 40 a.. fx. B-3 /0 9~. ~y > rod s~; /P-3o /off 4/lv 51 C7 S.-e,jo'~-/oye S/¢ 7 v"( G t yo SR • 0,? - /ono /c~ s i R B- lbg 1~. 4q -AV /off rR r~s~yCs, '01~,,.„-r. 0_/11 /V B- to y/? 4I'n s' oa /2-t ; 3>y~ /o~"Sio~yip S/y CS //7 c S6-A%,C . B- Cy /~Q Ala /d yR Z/2 5 Ow~9k nhQ 12-30° ioJiP s/ 24 5bK, ~LO 49 yR~6 cs, o c s , e /oy 212 S, i s ; y-2y'. /o Y b 4 51, Y b*,, 7 //S 8V Ao /!5 ^~f R ; z~- yp /o vk ¢/G r~ yes/y C -S P"W",P o-/2 rl~ NdtEP/k S ' /z-3 o Y n.. y,~~ w, R 3o-y6' A7_ B- 610 / 3C, oyR V4 s// '*A j Yo-Gp Ao s,/ 2- = DE.OT I'CAL To 2 o Per PERCOLATION TESTS 3 S K, v w~eLt ~D t S { TEST DEPTH WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES f NUMBER INCHES' AFTER SWELLING INTERVAL-MIN. PERIOD t P RI D PERIOD3 PER INCH P- Z P- 2 Cv Z P_ 2 G 2 Y 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. /1/J 7~ 'V`im = / 3• y I-Ocokle SYSTEM ELEVATION. 1 3; _71 *-017 t cu"eve - Ilk f 1 i P. tH Y I , ' 5 . Aso ?ice sc i' _ I _J t74 "IP LO 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 COMPLETED ON: HOMESITE SEPTIC PLL)MBING CO. Mlf 2-S 655 O'NEIL RD..AWDSOAIryYl ,54Aa6-- ADDRESS: ROBERT ULBRIGHT CERTIFICATION NUMBER: PHONE NUMBER (optional): 'CIS. MASTER PLUMBER LIC. NO. Z- ~JP 2- F/J'S 3307 M.PA-g- MINN. INSTALLER & DESIGNER LIC. N0.00663 CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. rill HR.CRr).R39r, IR if)/R3) -.OVFR. - - s ~nT P~AAj . P y f Scjt / - 30 r i r ~ x PI f ' t ! (cv I F ~ 5 P3 ~ I IU 1 G 1)o i S Io 12 , i l e7 f i 5 $Z $ I B~ s e= r a2 ors t 11 / _ i ~n~a~cr~ rGbrtr "LUM!lING'Cp. ~w y ;v ',u., iitJl)Sf3N, VYIS. 540'16 7ti ROSEAT ULWHT C-V 7 2 y~n2-. WIS. MASTER PLAMER LIC. NO. *7 M.P.R.S. \ MI*rN. iw►,,)TALLER 6 DESIGNER LIC. NO, OO 63 (OVAL 0 JOB /LQ 1/ A rf1 k5d A TIMM EXCAVATING SHEET NO. OF 2 Route 1 Box 192 1 _ n - WILSON, WISCONSIN 54027 CALCULATED BY DATE - (715) 5 (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE C'r - f w ; ~ i l U GP _ t P efY I Y J - ! t p ;.0 ` I I i.......... , tE mac' I' I I r r : . _ 1 I 1 . , k f 1 `''r~„ 1,,° . i f o t~ w UZ Ot t t c r ti _ - x.. 00 p . . II PRODUCT 205-1 Inc, Groton, Mass. 01471. To Order PHONE TOLL FREE 1-000-2256380 l JOB ~I C. G ~F/I ~SdYI TIMM EXCAVATING SHEET NO. z- OF z Route 1 Box 192 25- WILSON, WISCONSIN 54027 CALCULATED BY DATE (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE s i................... . . . _i... i. i... i........................ , ..i 1 . , ...J i 7 4 _ e. . , E 5. ?.o. " I:... 2. . J l~ , ~ ._'L' a _ .~,,C ~ ~ C..... ~ y, Z/d_._~ - _ . - ? i PRODUCT 205-1 Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE 1-600-225-6360