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HomeMy WebLinkAbout042-1090-60-107 4; o 0) N O vy 'c 0 0 N 'R N dL I N N W N Z U ~ O 7 (D LL C r t3 O M V CD z E o d an M H U) li o I ~ I . O z v O U Lr r 0 N N F- N Z c Q 'a ~~V N Q j N N N N C •FV d U L O C C U O O Q w z H z N c LO 7; E N U) (D I ~ - w I a Cl) O N N d i O O O N G. 'C L t6 O N < 0 LO (n U) U) ~v Z> H~ M N Z ~i O O O z ° •wa ~ I ~ a a a *tv~ CL a ° ° N ° } N J U rn rn N Z ~ O L O O O C m d O N CD O O O O O H 00 (D 0) CC C O o L QC U (0 a) = n c (u i.i O CO Cn rl , R o a (L • a R d E- E E- o c 3 w o A U CL O W U FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT • OWNER /U TOWNSHIP SECTION T-P2 N-R ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISIONLOT ft ! `LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 14 . C y,I ~ f Ive k INDICATE NORTH ARROW BENCHMARK: Elevation and description: / ✓P ~i~-.c .*..~iG~it.~'. qq _.,.V _ Alternate benchmark' s rw SEPTIC TANK: Manu f acturer : , - /r ,Liquid Cap. 1 grade elev: j/3 Rings used: '"Manhole cover elev: Final Q Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front , Side Rear. Ft. From nearest prop, line:Front , Side Rear Ft. i No. of feet from: Well 1!z , Building: (Include this information in the above plot plan) (2 reference dimensions to septic tank) . 31 SEE REVERSE SIDE l 'a'S /D S: ,17 J, T'r v 4 9 3 77E 26, 9 , 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: 4'1" Seepage Pit: Width:Length Number of Lines: Area Built Ct t r I&ist. Grade Elev. Proposed Final Grade Elev. Fill depth to top of pipe: No. feet from nearest prop. line:Front , Side Lo,(jRear Ft. No. feet from well: No. feet from building HOLDING TANK e-°Y 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: -T J l DATE : PLUMBER ON JOB : LICENSE NUMBER:_ s S ~I 6/90:cj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR -SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 N-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION DISON Wj 53707 State Plan I.D. Number: W T4 , NW 4 ,Sec . 3 2 , T 2 9 - R18 CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Warren, Let 1 0 N IF Al Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PEROLD . LJ ER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Richard Meyers 313 Pleasant Roberts -/-/-g/ BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: /a!/C 2v 5 lJ v SU~ib~C i.1, G Name of Plumber: MP/ PRSW No. County: Sanitary Permit Number: Henry Nechville 3258 St. Croix 149046 SEPTIC TANK/HOLDING TANK: MANUFAC ER: LIQUID CAPAii:; TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. TUE C' CrES E:1 NO E:1 YES 2-10 BEDDING: VENT DIA.: VENT MATL.: HIGH WATEPROPERTY WELL: BUILDING: VENT TO FRESH FEET LINE: AIR INLET: ALARM: ❑ YES LINO ~ ❑ YES L 10 6 DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: M MOD PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER I PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: MP D NT S PERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: AER NLOT FRESH (DIFFERENCE BETWEEN FEET FROM LINE: PUMP ON AND OFF) I S NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moi ure a the d th of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction sh II cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID BED/TRENCH TRENCHES: I MATERIAL: F PIT DEPTH: DIMENSIONS r (o O'1~' !CF S / / GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. STR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABO COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AIR INLET: NEAREST~- C) ~2UO ISO J/ bS~ G,Y3U 2'1_1q MOUND SYSTEM: 7. if q Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: -VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST ~ c w / Retain in county file for audit. Sketch System on ~ J Reverse Side. SIG TURF: TIT r SBD-6710 (R. 06/88)) L. DI~HR SANITARY PERMIT APPLICATION P.& HR In accord with ILHR 83.05, Wis. Adm. Code COON STATE SANITARY PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than 1496 8% x 11 inches in size. ❑ Cfeck f evision to revious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY WNER PROPERTY LOCATION 1"Claa Y0 x/4/1/142 t/4, S 3 T-22, N, R E (o W PROPERTY OWNER'S MAILING ADDRESS LOT # BL ZZ 71 3P~e4 Cg Y, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAM OR CSM NUMBER '3 / rrg-3Si C5 , - --42 7 11. TYPE OF BUILDING: (Check one) ❑ State Owned CITY~GE : NEAREST RO D ❑ Public LJ 1 or 2 Fam. Dwelling-# of bedrooms ~ PARCEL TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 7 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 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE 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 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 E - V . FINAL GRADE REQUIRED (sq. ft.) PROPOSED (s q. ft.) (Gals/day/sq. ft.) (Min./inch) a ac4 .~cy>~- ELEVATION VII. TANK CAPACITY ` Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New P-xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank '-j &2,- VT Lift Pump Tank/Si hon Chamber VIII. 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 Stam M p/ PRSW No • Business Phone Number: A/~~z ~ 1 ',1 1 _3~ S-F, Plumber' ddress (Str et, City, State, Zip Code): W je- t-1, 5_ U A01 IX. COUNTY/DEPAR ENT USE ONLY ❑ Disapproved S itary Permit Fee (Includes Groundwater Date Issued Issuin Agent Sign Sta Approved El Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/86) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber I • APPLICATION' F(" ,R SANITARY PERMIT 3TC- 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 Location of property N w 114, Section 3 .Z , T?2_N-R /FS W Township 11OA22~~/ Mailing address L/3 A~945-4-nj S/ Address of site fn~~ 7 57- Subdivision name Lot number I Q-ff4 lle~. $ A9 . X 17 +11c. -11 459250% Previous owner of property Ro~ Pf-jw ffi Total sixe of parcel. GSA Date parcel was created ~1-~- 90 7 ~~9d Are all corners and lot lines identifiable? Yes No is this property being developed for resale (spec house)? yes 0 Volume 32-2 _and i1age Number as recorded with the Register of Deeds. a.ACLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEND whi h includes a DOCUMRNT NUMBER, VOLUMB AND PACE NUMBER, and the ORAL OF THR REGISTER OF !DI(KDS, In addition, a certified survey, if available, would : helpful so as to avoid delays of the reviewing process. If the deed descripti.su references to a 1--ertified Survey Map, the Certified Survey Map shall also be l-,equired. PROPER a OWNER CERT I F I CATION I(We) certify that all statemento on th[s furor are true to the best of my (our) knowledge; that (we) am (nre) Lf,te owners; of the property described in this Information ,arm, by virtue of a wArranty deed recorded In the Office of the County Registe f heeds as Document No, and that I (We) pfesently awn the prePosed site for the sewage disposal system for I `(we) have obtained an e:x ~k•,f nt., to rkif, ujo.h !'he above described property, for the construction Of rf, ;,s ey 4er , wzkn vhr° 1"!Wnez h iE been duly recorded in the Office of the County Rms =.wr of Dw~ds,, as Documer,,., Signattilre of own :~sz eat Co Owner (If Applicable) Date o i M, «z. k" d iYA9n44ure STC 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County D _ v OWNER/BUYER d, I'C 4,yz, y Q,Z ROUTE/BOX NUMBER CCU 7 /00 Y-14 57' FIRE NO. CITY/STATE ROL2'dS ''U - S ZIP S--~"UZ3 PROPERTY LOCATION: :5U)114 d/ w 1/4, Section 3 2 , T~N, R W, Town of W Ae R,¢/V_ , St. Croix County, setbdTVZ ~ Csnc ✓o-~ • $ _ oa. -7071-7 , 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. SIGNED G DATE 2 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 p r, ' C ER T I F- I ED SURVEY MAP Located in the SW 1/4 of the NW 1/4 of Section 32, T29N, R 18W, Town of Warren, St. Croix County, Wisconsin. C.EfTIFI€D -SURVEY MAP (SO1°20'22"E 640.24') VOL.6,_ PG_ 1683 66 S 00'07'33"E 612.53' ' A 579.23' LEAST LINE OF THE SW 1/4 OF -r~ THE NW 1/4 OM zI QI LOT 2 JI 450,311 Sq. Ft. (10.33 Ac)' W 01 Including R -O -W LuI 427,631 Sq. Ft. (9:82 Ac) o aI Excluding R -O -W (11 to a N W to ZI m m v ID to tD .l 1t Q1 ----I Q co m m t01 t91 Z cn V I e-1 ~ W LL I co O I W w U. Jol N O S 00'05'36"E 711.051I s >1 677.71 33.34' .94 01 a I In 3 3 ,Q W 1 !0 CD V-1 IL 1 • W OV 1 ~ ` CD X H 481,387 Sq. Ft. (11,05 Ac.) o z' wI >I Z o LL co Including R -O -W (n NI M W 434,855 Sq. Ft. ( 9.98 Ac.) Excluding R -O -W _ N . ~1 3 0 - 0 V N Z I ' J~ tY WM W 0 O Z N Z o 2 O Z a WEST LINE OF THE SW I/4 OF THE NWI/4' v 0 er F- Z V) F- 'r' 764.99' ` tW 1295.53' °D W 100TH STREET 9' 43 S00003'38"E c° _ N 00003'38"W 803.10' LEGEND UNPLATTED LAND$ 6•' 1 Section Corner, St. Croix - Co. cap found ° 1"XZ4" Iron pipe weigh Bearings referenced to!,the es ing 1.68 lbs/lin ft t e of the NW 1 /4 of SectionW32, set . assumed N00 03'3811W • 1" Iron pipe found Previously recorded information. This instrument drafted by: 490-1714 R ~ i I y I . I i i ~~ans ONyy o*t- e> Llb . 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OTA VZ•Z 1 N Y u - O.~a SLL 0 O tNJ r~ d Ion / n ,o1 ;L. 04 F to AM- - 0 d 40f -N O to M N - 113 ul yA 1 / J o \ Q d~^J y / yN ~ o v : - M 'Ovd o 00 N 3 J' iz S 1 1 I I /1~ I ~d LL / d LY c a N a 9 5 ~e9 ~~ns " L 9 'o 9 '1 I I v > r4 I /x Q tin q O FW u\~ I o I \ " N 0 N ? I .r+~ ~N I N O I _r 0 0 Y I 0 ~ I dvD ~~Iq ,dy 0 ?v ~T 5 r4 s O i o T Y NZ o l ' k h Y * Z~ 5 N/ > .N 9 O w W 4 -p i ZE T '21Q.'1'J31S oO~,d i. p t3, DEPARTM,ENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, , DIVISION LABOR HUMAN RELATIONS PERCOLATION TESTS (115) MADISOP.O. BOX 7969 N WI 53707 (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP/M`014tetPAttrY: OT NO.: BLK. NO.: SUBDIVISION NAME: yy yrv 1/ AM 1/ 3 Z /T 29 N/R 1e E to Wlj,eop A-l ~srt COUNTY: MAILING ADDRESS: S-f.C1?OI~ (2~~(~t1RD /LIEYcRS 9/3 jJ/E~sna( R0IS ER7S 4jtS SV62.3 USE DATES OBSERVATIONS MADE NO.B DRMS.: COMMER IAL DESCRIPTION: DESCRIPTIONS: PROFILE PERCOLATION TEST971 Residence 3 e y ¢ ,P T New ❑Replace P/0'o;1 3O I170 hht 9 S RATING: S= Site suitable for system U- Site unsuitable for system SC S 9 '9 u?_ k(,^ T ONVENTI NAL: MOUND: JIOLDING TANK: RECOMMENDED SYSTEM: (optional) ©s [:]U DS au ®s au EIS ®u DS au Tee S - w, arzo P o K E/ce:sS;oc SLO&5 > (Z % 'DIST Ri 13 v Ttc.J If Percolation Tests are NOT required DESIGN RATE: C744S S ~ If any portion of the tested area is in the o under s. ILHR 83.0915)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOAL P H T GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHTIN, ELEVATION OBSERVED EST. HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- o' ao.c6' .33' ~k3a. SI 33 '3.15 1,33 OR- S 1.0' 2 8. v c s B-2, 0 /00, ylo ! > !5 /.o ' `1 Sy S/ , I S ' Teti v tom, cs D , 8,o SI 1.33 & >0ust!A cS 4- 1 16'131e- Sid o /E'- Q.~ S1 B_ y5 , Am I FT• Rule APPIlE17 , /.5'3(K. Sr/ 1.U' $y. Sr• 2.y S B-S s /~2,(p(y > 12" hottitD fRw I t~iST 0 IP-rcnf5 5 '0 8,~ - cS B- PERCOLATION TESTS /V C S 5-1'R t l~r} 5- TEST DEPTH WATER IN HOLE TEST TIME DR I WATER LEVEL-INCHES RATE MINUTES- NUMBER INCHES' AFTERSWELLING INTERVAL-MIN. PERIOD 1 P RI D PER INCH P- / '4 ')L- P P-2 2' < k 13 1 P- 3 .t re 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. , ELEVATION. (6- C` ? P E 76' So 16w 3.5''0 ' SYSTEM LOT PG~~ ~pEVsE s~~E TN This test site APPROVED for a conventional sleptic syst i 1, 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): HOMESITE SEPTIC PLUMBING CO. TESTS WERE COMPLETED ON: 655 O'NEIL RD., HUDSON, WIS. 54016 ;k4 y / - if s e2 ADDRESS: ROBERTI R~`aFFr CERTIFICATION NUMBER: PHONE NUMBER (optional): WiS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. )-'/,P 2. CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. OILHR•SBD-6395 IR. 10183) - OVER - ' ST. ~PP~dx o - L -d o Qt o~ ° N i -v ~ UN 1-- 1 m a~ a 1 Vh ~ I L i ► 1 1 ~ x 'o t~ ~n n p N 0 140 - N O m i N •p N z N Cp fi a i 70 n F5 o N ORJ 1 , I IP a n -v I ! ~ Sw° f 1 \ Oq ro I 0 jEj I 's r T P CO N o > .fl. O U~ N7~,r o a~ -L L c~ i o s As. ~ ff C= V3 `SY