Loading...
HomeMy WebLinkAbout040-1192-80-000 FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP 4 19 T SECTION~T_,gLN-R_,22 W ADDRESS _ ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT- LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM g~ ti 1 INDICATE NORTH ARROW i BENCHMARK:Elevation and description: a.~ Alternate benchmark SEPTIC TANK: Manufacturer: 4!~Ad<:~-e-C Liquid Cap. 04 Rings,used:~Manhole cover elev:~Final grade elev: 9~.D Tank inlet elev.: . Z _Tank outlet elev.: qS; P No. of feet from nearest road:Front Side , Rear V Ft. From nearest prop. line:Front , SideJ~, Rear -Ft. 7 SZ? No. of feet from: Well bve// , Building: 9 r} . (Include this information ~it~ 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: t..,I Trench: Seepage Pit: Width:_Ljlw Length Number,of Lines: Z Area Built Exist. Grade Elev. 9~•~Proposed Final Grade Elev. Fill depth to top-of pipe: t1145- go. feet from nearest prop. line:Front , Side, Rear Ft.- 40 No. feet from well : /;W r- No. feet from building Ss-1 i 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: / 6 PLUMBER ON JOB: LICENSE NUMBER: 6/90:cj Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Laborand'HtimanRelations INSPECTION REPORT Croix Ridge St Croix safety and Buildings Division (ATTACH TO PERMIT) Lot 18 Sanitary Permit No--. GENERAL INFORMATIONS E% SWa Sec.24 T28-R20 Plainview D .149102 Permit Holder's Name: ❑ City ❑ Village R1 Town o : State Plan ID No.: Matt Hu ert & Jodi LaBanc Troy CST BM Elev.: Insp. BM Elev.: BM description: Parcel Tax No.: TANK INFORMATION ELLVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Oil, Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet 94,2(/ TANK SETBACK INFORMATION St/Ht Outlet S d Vent TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet Air Septic NA Dt Bottom Dosing NA Header/ Man. Aeration NA Dist. Pie Holding Bot. Sy g PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM I Loss Friction System TDH Ft TDH Lift Forcemain Length Dia. H Dist. To well S ABSORPTION SYSTEM BENCH Width Len th No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN 1 N / ~ DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manuacturer: SETBACK INFORMATION Type O 7sO 2 ~ CHAMBER Model Number: System: ft)A 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 code discrepancies, persons present, etc.) Plan revision required? ❑ Yes ❑ No Use other side for additional information. 1671171 9 Rh(r" '`"t ~O SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. OIL HR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNIY/ 4 ~ awwms.n v MEMO _14941) - STATE SANITARY PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than El e D 8% X 11 inches in size. heck /Is ,icon to prev us 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 Ma Hu er & Jodi LaBlanc SE SW '/a, S 24 T 28 , N, R 20 [ or W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # 412 S. Div. St. Roberts WI 54023 18 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR C181=71 Roberts. WI 54023 7 V1 ) Y/ L Croix Rid e 1111. TYPE OF BUILDING: (Check one CITY NEAREST ROAD ❑ State Owned ❑ VILLAGE II~~II TROY Plainview Dr. ❑ Public L~ 1 or 2 Fam. Dwelling of bedrooms 3 PAR EL TAx NU ) 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 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 50 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. x❑ New 2. ❑ Replacement 3. ❑ Replacement of 4.E] Reconnection of 5.E] 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 nn 615 1 .73 .5 91.0 Feet 95.5 Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Se tic Tank or Holdin Tank 1U 0 xxxx 1000 1 Weeks Concrete x Lift Pump Tank/Si hon Chamber El I F1 [I I El F Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): ber' Si MP/MPRSW No.: Business Phone Number: 3289 749 3656 Plumber's Address (Street, City, State, Zip Code): Fne &XU Hats- Rd.- Roberts. WI 3 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued is 'ng Agent ture (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Pib-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 complntod In full and Signed by the ovnet(s) of the property being developed. Any lnadoquacles will only result In delays of the pttralt lssuance. -Should this development be lnttnded for resale by ovner/contractoc,(apac houae), then 4 sacond form should be tatalnad and c a x p I v I e d vhan Lila property Is sold and submitted to this otllca vlth the ■pptopciate deed recording. wow---------------------------------- Ovntc of property .'1A (t;;-',, Location of property 1/4 1/1, BectIon Township Kallln address ~LYn w~: z~ k Ad drIaI oL a I t a tubdtvlslon nar►i Lot number Ptevlous ovner of property Total also of parcel Date parcel vas created Ate all corners and lot lines ldsntlllablsl ~a to this pro patty being developed fog resale (spec house)?_ Ix -4~1 N0 Volume ;-ALand page Humber as recorded with the Re91ster of Deeds. IUCLUD9 A vAARAYTi DVID whlcltInncludes l a }1DOCU?iINT CH"DIII TIIZ I R, VOLV It "DPA02 )IU1(IIA, and tt~e BIAL Or TIM R8010THR OF DHRD©. In addition, a certified au Ive It available, y, would be helptul so an to avoid delays of the tavlawing process. It the deed descclptlon references to a CettiLled survey Nap, the Cattltled Survey Nap shall also be required. PROPERTY OV11tR CERTIFICATION - - - 11va) cettity that all statements on this form are true to the best of ■y (our) xnov"09ti that I (we) am (tire) Lila owner(s) of the property dercrlbed In this Infot- Lion form, by virtue of a warranty deed recorded In the Oltlce o f the county Regiatet of Deeds ae Document No. y. and that I (vet PteeentIy own the proposed elks for thD news die oral s atenI (or I t) ave obtalncd ■n easement, to run with Lilo abova daaccIbad (v ti cvnatruclton of sold nyrtem, property, lor t he and the same has bean duly recorded In the ol11ca of the Coynty Reglater of De an, as Document No. _4/7//.2,0 slgnatvice of owner 8lgnatute oL Co-owner (IL Applicable) Date of Al natuve Data of signature DOCUMENT No. STATE BAR OF WISCONSIN FORM 1-1982 Ii THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED - 47 1 90_?A~t_J87---=- REGISTER'S OFFICE ' 1N1 This Deed, made between .....A~..e x_..5....-KQ83 ST. CROIX M ~ Rec~ d for Record Grantor Gt JUL h 1991 4:40 1 and....------Matthew._J __Huppert_ and.... ...-•---------.Jodi---L_....la.aSlan-c ,IQint..T.qnA>} s...---------------....... II Regiaterof0eeds Grantee, j Witnesseth, That the said Grantor, for a valuable consideration..... ~i - - - ' -N O roix ET~`t t . Cro ix conveys to Grantee the following described real estate in anU County, State of Wisconsin: ij 2212 Crestview Dr. ;;Hudson, WI 54016 Lot 18, Plat of CROIXRIDGE Addition located 'lax Parcel No: in the Southwest Quarter of Section 24, T28N, R20W, in the Town of Troy. Acceptance of this deed shall be indicated by its recording with the Register of Deeds and shall automatically and irrevocably make the Grantees, their successors and assigns a member of a non-profit, non stock corporation known as CROIXRIDGE ASSOCIATION and entitle them to the benefits and privileges of said association and bind them to the terms, conditions and obligations of said association. 10.. ~ ~C This is not homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And....... A1ex...S-.Kosa.... warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances.e+xoelbbt and will warrant and defend the same. Dated this -•-•------•---------19--- day of JPn- 19.91.... ..............(SEAL) .....(SEAL) ex S. Kosa (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN St. Croix ss. _ County. authenticated this day of 19 Personally came before me this 19th -day of ..June 19 91... the above named Alex S. Kosa TITLE: MEMBER STATE BAR OF WISCONSIN (If not- authorized by § 706.06, Wis. Stats.) to me known to be the person who executed the foregoi nstrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Alex S. Koss, Attorney ~-,#Apj „ Edry L. Kosa 325 Vine St., Hudson WI 54016 No Commission is not Notary Public .---..5t....-C.r, - _91-X X County, Wis. (Signatures may be authenticated or acknowledged. Both permanent. ( not, state expiration are not necessary.) 19.2....) j date: June ...14 *Names of persons signing in any capacity should be typed or printed below their signatures. I. WARRANTY DEFT) ST.ATF1 nATR OF NVTcZCON:-N T,--n! i31❑nk Co. T- STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County M I ~ OWNER/BUYER I r , 1~ )LcC'L ROUTE/BOX NUMBERti - s - FIRE NO. CITY/STATE ZIP PROPERTY LOCATION: l/4 ~ w 1/4, Section T~~N, R ~u W, Town of `U~ , St. Croix County, Subdivision 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 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 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. / S I GNErk'1- [ L~< i lz r 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 DU'S D~PARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS I N NDUSTRY,` DIVISION P.O. BOX 76 LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP/TTY: LOT NO=BLKNO.j SUBDIVISION NAME: SE ~ SW ~ 24 /T 28N/R 20E for Tro 18 Croix Ridge COUNTY: OWNER'S E: MAILING ADD ESS: St. Croix Matt Hu ert & Jodi LaBlanc 412 S. Div. S R r,.t USE Phone' 7 DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFI E DESCRIPT ONS: ER OLATION TESTS: Residence 3 New ❑Replace xxxxxxxxxxxxxx 6-3-91 6-28-91 RATING: S= Site suitable for system U= Site unsuitable for system MSEIUTis[~Ul ENTIONAL: ND: IN-GROUND-PRESSURE: Z?Mu ILL HOLDING TANK: RECOMMENDED SYSTEM:(optional) ®S ❑U ®S ❑U conventional 12' X 53' 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: n/a I Floodplain, indicate Floodplain elevation: Nang PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) NUMBER DEPTH IN, EA B- 1 85 2 nl2ne > 85 ' I'Rnlq J-11"Rnsal ' B-2 80 96.4 none >80 .3B11s 1.4'Bnol 4 9'Bncs B-3 80 94.4 none >80 1' Blls . 5' Rdls 4.1' Bncs . B-4 80 95.9 none >80 .3B11s 2.7' Bnsl w/gr. 3.4' Rdcs w/gr. B-5 95 97.4 none >95 'Blls 1.75'Bnsl 2.1Rdcs 3.1Bncs B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER PER INCH P 5 P- P n P- 41 3 -.0 5 P- P-I - I I I -d 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 g 1 _ o _ - E - T_7~_ . 4e l w ~o s~y E 3 - 4 ~ r jurlf ' T0.. ~ Are d = d""rBd~% ~xo. c< f.flYlwt l~+A 47 I Gv~ti OAIl:Tre • 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 t is onsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of /my/knowlleedg nd belief. 6. 4P NAME (print : DAVE FpGERTY PLUMBING TESTS W RE MPLETE ON: -n--A PA ster L Plumber ADDRESS: #3,233 #3289 CERTIFICATION NUMBER: PHONE NUMBER (optional): F e Heights Road ROBERTS, CST A R E Phone 749-3656 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - , . - v Al V `I ~ a ►1 o cal -f.. e 'Q M 2 d ~ o~ ~ ~ r . 1 • • ~ ' Q ~ ~ : M i ,.I . ~ ~ ` r, l ~ \ ~ ~ _ _ ~ ' a ~ ~ , , ~ I ~ ~I ,.Q. , ~ I , I~C ~ •