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HomeMy WebLinkAbout042-1084-60-120 c o U y ~ I h a~ 4 o C o Clt I I Q I C N z° c m w c ~ .0 I 3 M I v (D w Z E LL ~ L O Z d m 0 C14 O O z v 'U ~ r O N d 2 C O N H C 7 N (D CU ~~V N a h ~ I c c O H Z Z z O z N C-4 '0 N E N C N 6 _ d fa IL M y w L V C. C co O ! 'd C G d zb~ vi O N ICI Lo E N> 0 0 0 a s Z O I m CL IL CL a~ a a N o N II 0 rn rn a~'i I > LO 00 0 0 M~~l Q p N 5 N IW_l O C) 00 00 E p L m c5) N tOp N Q) O ~ d Q } tf3 d y N N OO N N C LO C co 0) C) Y L N O w ~ c c o c" -q? co L O M W O N t!I -L N 2O N E2 co - "O co a) • v o `m a) ' N E U CU co o m ~ d o cn O ~ w I cl a d y r`Fv E c A vat o) u . FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SECTION- f o T N-R I W ADDRESS ST. CROIX COUNTY, WISCONSIN 4k-e SUBDIVISION LOT LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Ile E 6~6 SY INDICATE NORTH ARROW 7-0 O BENCHMARK:Elevation and description: `~feQ 0 f Alternate benchmark SEPTIC 'TANK: Manufacturer: 2~24<c ( Liquid Cap.-/W Rings used:,'LManhole cover elev: Final grade elev: Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front X , Side , Rear Ft. From nearest prop. line:Front Side, Rear Ft. No. of feet from: Well Building: (Include this information in the above plot 'plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE I' i 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: ~ 41 Width: Length Number of Lines:~Area Built Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top of pipe: No. feet from nearest prop. line:Front-g-, Side ~q ! Rear Ft. No. feet from well:_44 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: y LICENSE NUMBER:- 6/90:1 cj t Wiscoihsin.0epartmdntof Industry, PRIVATE SEWAGE SYSTEM County: Labor arad Human Relations INSPECTION REPORT St. Croix Safety and Buildings Division SW, SE, 30,29,18rAT~ACH TO PERMIT) Sanitary PermitNo.: GENERAL INFORMATION 70th St, Lot 149133 Permit Holder's Name: ❑ City ❑ Village W Town of: State Plan ID No.: James Peterson Warren CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: r 474A-20 I d 4~ %GC% c~~--~- TANK INFORMATION ELEVATION DATA Q a TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 3.1 5 103,95 /D d. D r Dosing Aeration Bldg. Sewer Holding St/Ht Inlet y,~13 q~,07- TANK SETBACK INFORMATION St/ Ht Outlet a~ ~q 5 TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic t30 NA Dt Bottom Dosing NA Header/ Man. 8 q 4x,66 Aeration NA Dist. Pipe obi q' q(,,q Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade (~,`?5 q o Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. Dist. To Well Fi SOIL ABSORPTION SYSTEM BED/TRENCH width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 0 DIMEN I N SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type O _m", Moe Number: System: 4,11 CHAMBER /olS~ /I/ ,t)fr 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 hh Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center rb O Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) C1 L1 Plan revision required? ❑ Yes ❑ No Use other side for additional information. a $ 6 SBD-6710 (R 05191) Date 1"nspector's Signature Cert. No. ILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY, / C12VIL4 • STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8'/z x 11 inches in size. ❑ Check i' t ~evislon o preZ, application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PRO ERT 'OWNER PROPERTY LOCATION '/a ' '/4, S 36 L20 , N, R E (Or)&V FTOPItR O ER 'S MAILING ADDRESS LOT # BLOCK # &-STA ZIP CODE PHONE NUMBER SUBDIVI ION NAME OR CSM NUMBER .4 444 0.1 es^ II. TYPE OF BUILDING: (Check one CITY NEAREST R9AD ❑ State Owned VILLAGE : [11 IOWN OF: ❑ Public ~ 1 or 2 Fam. Dwelling-# of bedrooms on PARCEI Ax N M O Q LO le0 ~'a III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 60 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 5 ❑ Hotel/Motel 9 ❑ Office/Factory 1130 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.E1 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 140 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 (s q. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION Feet Feet 07 VII. TANK CAPACITY Site in allons 7Gallons of Prefab. Fiber - Exper. INFORMATION New istin nks Manufacturer's Name Concret Con- Steel glass Plastic App Tanks Tanks structed r Se tic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber L1 I F1 Ej F1 1 11 Vlll. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for install ' f the onsite sewage system shown on the attached plans. Plumber' Name (Pri Q: P ber's gnat : (No Stamps) MP/MPRSW No.: Business Phone Number: 4 --A- le u is Addre (Street, C' ,State, Zip Code): -11.- COON /DEPARTME USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater [Date Issue ing Agent Signature (N S mps) Approved ❑ Owner Given Initial Surcharge Fee) / P 1 Adverse Determination 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 S T C - 100 This application form is to be completed in full and signed by the owner(s)~of their property being developed. 'Any inadequacies will only result in delays of the perm issuapce. Should this-development be intended for resale by owner/contractor,("•spec house"), then a second form should be retained and completed when the propertyiis sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property Location of Property Section 6 T N - R ? W unship Mailing Address - Subdivision Name C Lot Number Previous Owner of Property i Cl {j Total Size of Parcel o Gy e r I, Date Parcel was Created y 9 Yes No Are all corners and lot lines identifiable? ` Is this property being developed for resale (spec house) ? Yes No p r Volume S' and Page Number as-recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed s 2. Land Contract 3. Other recordings filed with the Register of Deeds Office 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 the Certified Survey Map shall also be required. _ _ _ ~ - - - - - - - - - - - - - - - - - - - - T - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION I (We) cvLti6y that aQ,e btatement6 on thiA 6onm are tnueto hbc At of to ) ` knowPedge; that I (we) am (axe) the owner(s) o6 the p'~ p y ea thiA { .in6onmatcon 6onm, by vi tue o6 a waAAan ty deed neeonded in the 066.~ee o6 the County Regi6teA o6 eed6 a6 Document No. ; and that I (We) pne6 enttey own .the pro pob ed eito bon the b ewag a 'A pow-d ybtem (on I lwe) hav e ' obtained an eet6ement, to nun ukith the above d"c ibed pnopenty, bon the. eon6tnucti.on o6. 6aid bystem, and the atone ha6 been duty tecoxdid in the 066.iee o Reg•c.6ten o Deedb, a6 Document No. 6 County GNATUR F OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) .'s • I- ~ 1 ~ DATE SIGNED DATE SIGNED ,s 3 45 7 FPM ( r ~a _ ..li_.. REGISTER'S OFFICE This Deed, made between W.c...S.•...C.1a.p,_ : ST. CRON CO., W1 Recd for Record ' HPR061990 Grantor, Q1 9:00 A. M :Intl James ..W.. .Pete.rso.n..and Dea.nna..M. Peter.son,.. a 0A nM husband and .wif.e..as...sur.vi.vorship. ilari.ta.l............ ^C property- Regislor of Deeds I' Witnesseth, That the said Grantor, for a valua+,i:.: consideration...... 1 7 RETURN TO com'a's to Grantee the following described real estate in . ~....Cr.Oi.x..... County, State of Wisconsin: II ~ i ~ I vt?r ~R. I ~S Lot Two (2) of Certified Survey Mai, 1.n l~f S~IGZ Z Volume 8 of Certified Survey Maps, ;..lge 2192, Tax Parcel No: as document number 456664, filed in St. Croix County Register of Deeds of'fic.- on March 15, 1990, beinf located in the Southwes Quarter of the Southeast Quarter (SW4 of SEJ) of Section Thirty (30), Township Twenty-nine (29) North, Range Eighteen (18) West, Town of W..,rren. 'IRAN. r h Ep, This ...is...no.t.......... homestead property. (is) (is not) Together with all and singular the hereclitamcnts tug.. appurtenances thereunto belonging; And ...W•... S.......Clapp ~~:u runts that the title is good, indefeasible in fee simple a free and clear of encumbrances except easements and rights of way of - 2cord, if any, and .vill warrant and defend the stone. [Dated this .....2./ day of , 19...9.0. . . . . . . (SEAL) voo.( . (SEAL) I • . S app W. l. . . ..(SEAL) . . (SEAL) ' ' ! I AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ss. ......................................County. f"- rJ authenticated this ........day of 19...... P rsonaljY came before me this ....~1........day of 4 ]9..9.0. the above named ................W..,....S .....Ua pP • TITLE: MEiIBER STATE BAR OF WISCONSIN (If not . authorized by 706.06............................................ , Wis. Stats.) to me known to be the person ivffQic(chcyted the foregoing instrument and acknowl le, same. .31 ns~ THIS INSTRUMENT WAS DRAFTED BY Y+ W r• C. L. Caylord.,_Attorney.. `A 1, River Calls, WI 54022 •...,.o`~aat.t~.t~ to Notary Public ..a ~,,.........Counl.p, wk, nab i (Signatures mny he authenticated or acknowledged. Both b1y Commission is permanent. state cxpiratiom nre not necessary.) date: t..~~• ]J../.3..) 'Names of persons signing in any capacity should be typed or printed hcl- tf,eir signatures. Ij 7 7.7, STATr BAR 01 VISCONSIN Maltnt Na 1 -1981. Stock No. 13001 ' rfIGTGIRI1TIr1N..O.laiaa.D7. N ` H a STC - 105 r' r a ' H SEPTIC TANK MAIN•rENANCE AGREEMENT r. St. Croix County z . v a OWNER/BUYER Z5 - Q6AJ H M ROUTE/BOX NUMBER 2 M~, Fire Number .CITY/STATE ~/l 1 PROPERTY LOCATION:~ti, ' Section_?© TN, R_,Z.& _W, Town of_J St. Croix County, Subdivision , Lot number 10 Improper use and maintenance of your septic system could result in its premature failure,to handle wastes. Proper maintenance eori - sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you ptit into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive 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 acdepted 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 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 wil'1 be sent approximately.30 days prior to three year expiration. H 0 E I/WE, the undersigned, have read the above requirements and agree N to maintain the private sewage disposal system in accordance with x the s'titdards set forth, herein, as set by the Wisconsin Depart- o r ment of Natural Resources. Certification orm mu4t be completed and returned to the St. Croix County Zo n; Offic' Chin 30 days of the three year expiration date. SIGNED ` DAT f -ter I/- St. Croix County Zoning Office P.O. Box 98. Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. 3 Vy_-,e : T 'm Dr ~F~A ICE?£ ~5 DEPARTMENTOF REPORT,ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND P.O. BOX 7969 HUMAN RELATIONS PERCOLATION TESTS (115) MADISON, WI 53707 (ILHR 83.09(1) & Chapter 145) Lo-~ -2--- LOCATION: SECTION: OWNS HIP/ OT NO.:BLK. NO.: SUBDIVISI N NAM : Sw 11 SE 1/ 3a /T2-T N/R TE (o ►W xx?_RE',Aj PAP-r Or 40 )4C4c,s- END)A)~ c's COUNTY: MAILING ADDR SS: St.GRD(X R+ Z ~Uo>< I13--C otitRTS Gals, .402 USE DATES OBSERVATIONS MADE NO. B DR : COMMERCIAL D S RIPTION: q TESTS: Residence aR I N r - XNew ❑Replace :j o- L4 [ y'd f91 ~1, y - I /mod RATING: S= Site suitable for system U= Site unsuitable for system dCJ~ 4 7 B U R i< t1 i4•'RD T ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: YSTEM-IN-FILL DING TANK: RECOMMENDED SYSTEM: (optional) ®S ❑U ©S ❑U EIS EA ISEISEUT] S © U CovvE•uTioAvAC -TR&•vG1(4f9 w/ 0 ox CST i 0 T/O-J 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: CLASS 57- Floodplain, indicate Floodplain elevation: Wiv7T4R Teir 64uD1TIOOS: SUuNY 3 - PROFILE DESCRIPTIONS .2y° osr BORING TOTAL DEPTH T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. EST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B. / Or 7• y~ f > mot, 0 ' 'ACS 61 6-851, ►.33 T~~ s~~, 7,6 • 01~, u6 Ry ( t ' 6V 'Dk--6~. S/ I,G7' x,10 s d) (p, 7 ' 012. VEAy B-2- D R7.Sz 7~1r0 es3 GR 3 Idyl, ~Z' • s' ~~.13 If Al s,'i) - OR . B- v c p CS <r B-T ~'~t / > r 47'Pk- R4 .51! I.~?3'SI'I. T-~~ O(? . _A- CS 3 BIZ l p' bk,80. S(, 2.0'T'lAJ S<< G.o' op CS B-5 7, 0" /00. 17' > ' L . B- PERCOLATION TESTS IN LJ&Q Y C S G'~ 57-p7om s ~s EST DEPTH WATER IN HOLE TEST TIME DROP 1 WATER LEVEL-INCHES RATS TER INCH NUMBER INCHES' AFTERSWELLING INTERVAL-MIN. PERIOD 1 P I D '5, P-1 , s -,w < 2 Y P- 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. I+ l t T ► Cf; N 1 l~ e0 r L r~ W ~iLl ~i+~ a ! / o t SYSTEM ELEVATION. r ! ; APPROVE - - This test ,ate 4ern a conventional s~,p~rr ~y ~ I__ for t , 2 p LO r P L h tJ __.t ~2sE s ID>~` H ii i ~ } I LidA 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 SMESITE SEPTIC PtUMBIN TESTS WERE COMPLETED N: 655 O'NEIL RD., HUDSON, WIS. 54016 j A k) 5_ q 0 ROB.ERI_ULBRIGIHT _ ADDRESS: VIS. MASTER PLUMBER LIC. NO.3307M.P.R.3 C TI;~~TION NUMBER: IPHONE NUMBER (optional): ' `ANN. INSTALLER & DESIGNER LIC. NO.00663 g `e CST SIGNATURE: 1 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester, Oll HR-Sall-6395 LR_10/83L - OVER - HOMESITE SEPTIC PLUMBING CO. 1-0 T Z 655 O'NEIL RD., HUDSON, WIS. 5401 # y ROBERT ULBRIGHT C-5 r WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. MINN. INSTALLER 6 DESIGNER LIC. NO. 00663 ( t2 c S I t F$ 30 r , 3 Asti -Tle~e.* Ue-RT. REV-. PT. f s sprk~ la rleEE . 167VA-rio'i r r 11S By a~ 3 , r M r E (oS s 6s tu 3s t ' & lo~ 10, _ so --p . f~ .3 3 z 3 ~vsE Mvsr ~:E- r .z 5 ~ ~~o~ T" 'r h I~e.1 . Ao~ E/l M s r L i~ S d "~QO h T e"Sr ffeE, S/J sf~~ Sj-c ..its, s'x = s Old 'sewn oZ ! _ PAGE OF . CroSS S~cEll)1, p~ A fie 11% All Idols And Obi,ervallon Pipe SS'6 / 411cokJN ✓ ^ i,. Appiovld Venl Cop U111101-0 12*Abo,o final Cvede i 20. 42' Above Pip' _ 4" Cast lion To final 014de Veal Pipe WvaD hor Or no Mfie Co.ulny Y111 2' Ayplepolo O.ev Pipe ' OIU/Ibr110n - • ee pip. ° glpo 0 0 - Too 1 0 A elk opipe P.rlovolod PIVa below o Covpilnll Tanctneling Al solloan Of $16140% v . + t o n SOIL FILL DISTKIBUT101.1 PIPE APPROVED S`)JTHETIC COVER ~'-14ATERIN- OR 9" OF STRAW 2" OF 11GGR£GAlE af! OR ARSW HAy 0 M" C., 0r -21/2 AGGREGA7 OF~4 FFEET~ DIS-I-R115OUTIOW PIPE TU BE AT LEAST ;;-26 INCHES BELOW ORIGIWAL GRADE AWU AT LEAST t0 IWCHES BUT 1.10 MORC THAW 42 IAICHES 13ELOW FINAL GRADE M MILIM DEPTH OF EXCAVATIOP ROM OWMAL 6RADF- WILL BE ~ IWCHEs milrwM ocrrt Of EACAVATIO" rA01A 0,161NAL. rjRAPF- WILL Bc INCHES SIGI ICD: LIGCWSC LJUMBEIZ: DATE: - i , o _