Loading...
HomeMy WebLinkAbout042-1090-60-110 -0 0 Y o w ° o p °v3 N 0. ~ I fN I N I ~o Q I I I ~ I z c LL c LL C O a I `Y' I Z E ° ~z = °o v ~ L Z a m rn M I- U) O O Z d C d Z c O to F- CD N z c E 'o O N Ch co 70 0) W u • Arl a L .c ° II C c U O Z H Z N z I 04 E N to E N R ~ O 41 = d N Q Q w J Ca °0 - m a~ o 0 (0 (n (n /ti T O Z N > N o 0 0 0 Z •rv a a a 00 M J U W m rn } r O CD a O N N N CD co to Go Q 0 O O U O N o m q Z Q O O O O N C C Q) ° co 3 m m c N a m ° ° r O Q N ° m ►C vi c c E a p O D) N O N . L: 6) 2 H N Cq O CN u) co E 04 0 O ~ r \ M d V ~ w m I'' y a Cr 7 ea?+ CL 0 rr~~ £ i C w 7 `~1 A vat IONV } y eL&sin Department of Industry, PRIVATE SEWAGE SYSTEM County: ciaborand Suman Relations INSPECTION REPORT St. Croix ` Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION SW, NW, Sec. 32 , T29-R18 , 149113 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: PatRoeings Warren CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 042109060110 ` TANK INFORMATION ELEVATION DATA A960t1I TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark U. SS /0,55- / J C 611 Dosin G CY>~ .r2 Aeration Bldg. Sewer Holding a St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Vent TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt..lnlet-•-- Ar ----"---:a Septic }yep NA Dt Bottom Do4i'ng _ NA Header/ ib4e 6,9 Aeration NA Dist. Pipe 00 y ~ Holding Bot. System PUMP / SIPHON INFORMATION Final Grade M u acturer Demand Model Number GPM TDH Lift Friction Syste TDH Ft Forcemain Length Dia. H Dist. To Well {1 SOIL ABSORPTION SYSTEM hep tom, a,,d z4 BED /TRENCH Width 5 Length f No. Of Trenches PI No. Of Pits Inside Dia. Liquid Depth DIMENSIONS S DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING =r: SETBACK INFORMATION Type O CHAMBER OR UNIT Model Numb System: DISTRIBUTION SYSTEM Header / Manif Distribution x Hole Size x Hole Spacing Vent To Air Intake Length Length ~ Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over r~ xx Depth Of xx Seeded / Sodded xx Mulched gaff/Trench Center O(9 ~ .9"/Trench Edges c~ --t Topsoil E] Yes ❑ No 7 ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) / l~ YI~Q~C..fJvt C ~/1~ P /L,~ t r~ k1 < ~ ter) r / .ICJ'' Plan revision required? ❑ Yes 2-14-0, Use other side for additional information. SBD-6710 (R 05191) "Date Inspector's Signature Cert. No. • DLHR SANITARY PERMIT APPLICATION c!2/, In accord with ILHR 83.05, Wis. Adm. Codey ` STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than El 8% x 11 inches in size. check i rewsio V,~ ous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER [t jj ZPROP~RTY LgC fTION '/a /l1 1 L'/a, S 3 TZ , N, R !~20 E (or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # Z 10 C C S /'►n CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISI N NAME OR CSM NUMBER B ' S C3 c /d G II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned 0 ,VILLAGE f ❑ Public 1 or 2 Fam. Dwelling-#~of bedroomS3 PAR ELT XNUv-+BE ( ) 111. BUILDING USE: (If building type is public, check all that apply) Q 4? ~l 1 ❑ Apt/Condo t.J 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 80 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) 1. XNew 2.E] Replacement 3. ❑ Replacement of 4.0 Reconnection of 5. ❑ 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 410 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/da /sq. ft.) (Min./inch) _ ELEVATION SG J Z) , Feet d~ 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 Septic Tank or Holdin Tank C-L~ Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Na a (Print/): Plumber' Signature: (N Stamps) MPRSW/ NNoo.: Business Phone Number: Plumber Address (Street, City, S fate, zip cod W A Z>_ -J'rz &6X V7.4 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater a e ssue Iss ng Agent Signature (No Stamps) Surcharge Fee) Approved ❑ Owner Given Initial 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 h APPLICATION FOR SANITARY PERMIT S TC - 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 PO r c=k 3 v S LA sa 4c" 1~ d 1 % n 5 Location of property a 1/4 l W /4, Section T.,ad~ _N-R~W Township A r rf P) Mailing address (3 P IBC, SCI YxT OL j-c . R o by rte Address of site 1 (3 Ca `34~` A be r•ts 4 cv Subdivision name Lot number Previous owner of property O 9 e r J e b-) T Total size of parcel i' 0 • 33 /ac Ye 5 Date parcel was created "7 /7 f Are all corners and lot lines identifiable? k Yes No Is this property being developed for resale (spec house)? Yes 7\ _No Volume and Page Number 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 references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. W„ 'UT V- ; and that 1 (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 system, and the same has been duly r corded in the Office of th County Register of Deeds, as Document No. P Signature f Owner Si ature of Co-Owner (If A icable) Date of Signature Date of Signature r - V4, ~ ~ r •.,T,..~:,., -'w' ..aye.. A S;, •~~L+- J A ~ 4 4f .s ~ y ! y W Mr T4 vamounts, rs ar"It' aay• t~ Of aCiilc+id, if f 41 ass M~Mod ~s+paty. r . E day of - . 1 . IRAL) f. By RDq r M ewett (SEAL) 17 ;t. ; i#!= A?l01t ACKNORLSl - STATE OF RiaCONBIN St. Croix 'M1r .:....-AWw a---. W----. P.ea...uy ea.. Mlh+a alit, J - , -*ri- E!A'!'t #A~ 4T w"t lgliBlN _ . .~........z"" Mlt 1. ~4a~.) tv afo kne" to be t►t ltetiN► : ~r1Y1 1 i/ss~te+iraal.~1~ • r v State of Wbconean comoy of St. Croix 1 hereby certify that this instrument is a full, true aid tarred copy of the document on file and of reoc>t'd in my office and has bees =mpared by me. r+~ July 15 91 James O'Connell O' Connell Register of D"rt CY Deputy STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/ BUYER fit r c1~ S w 5 t,. s a R o e -l" P\6 ROUTE/BOX NUMBER '10 a a ~P J ' f ' c • FIRE NO. 10-1 -1- CITY/STATE R o b.~ i- is W') `7 ZIP ~N6 Z3 PROPERTY LOCATION: 5 W1/4 X1/4, Section 5,2 , T R 9 N, R / g W, Town of (A)a rrf ,~7 , St. Croix County, Subdivision , Lot No. i 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. 1 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. SIGNS e 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 uEPARTMENT OF REPORT ON 501E BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN R-cLA7rio'WS ' l MADISON, WI 53707 (ILHR 83.090) & Chapter 145) (I J ATION: SECTION: TOWNSHIP/ fetf*4" OT N0.' LK NO.: SUBDIVISION NAME: [Bj PI14Jv1,110 6 P0/ 32- /TZyN/R/PE (o COUNTY: $vr&X ; AILING ADDRESS: 1,54 c.Roi ~ ?,VT- k0ir l l'NG s 3/0 (CIE~tssa; .a ~ / R 0 (3&'R TS 401S 6"VO 23 USE DATES OBSERVATIONS MADE NO. rOMMSR-CIAL DES RI TION: DESCRIPTIONS: PR?JFI LIE PCOLATION TIES PResidence 3 OR T y, 4New ❑Replace /I Pk• 30- I55o J`-I~}y ('I SSo RATING: S= Site suitable for system U= Site unsuitable for system SC's ~ 70 '`B 0 R K6t A P_ C) T-- CONVENTIONAL: MOUND: IN-GROUNDPREURE: STEM•IN-FILL OLDING TANK: RECOMMENDED SYSTEM:loptional) DS DU DS CDU DS ❑U rLis ~U OS EU r'Re'ic14 S - lal''~-k I Ad P "F-Ke't SiUE 5Z-0 S > /2 96, 1 E On! If Percolation Tests are NOT required DESIGN RATE: r`T!~ If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: C 4.11 S S Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS .50'.$ ~7 Bo R t-ti A /ZQ r BORING TOTAL QFP~H TO GROUNDWATER•INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED . FRM_R TO BEDROCK IF OBSERVED SEE ABBRV. ON BACK.) B. /02,50r 5 a' D.(~~,.,. /.o' Bro•S/ S ' o.P. s') G-o ~d u U C$ f-R . -Z S SDI 7 S / p` /9 /,f -'s Y: ! 1 .33 ' 3a-Sy. S"/ /0' OR-QN cS S.$ tJ CS B. 3 o ` to 5.3 ' 9to - > a2' 01c 5v • S/r ',P3 ' fi~ CS, 2. d • i?~ ,rt,;. S ~ s S.s ' T U CS B- g' 0 10/x, 10 `hc> > C~ 33 ' D/l .G7 U CS 13- PERCOLATION TESTS /,v C S STR"tTrt-s DEPTH WATER IN HOLE TEST TIME DR IN WATER LEVEL-INCHES RATE MINUTES 'NUMBER INCHES AFTER SWELLING INTERVAL-MIN. R 01) 1 P 190 2 PER INCH P- '/'0' 2- P_ ~ y.o G P- L 2_ 60 1 P_ P- LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- intal 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 ,I land slope. YSTEM ELEVATION. 14 (6-t.._ T Pea r,6, = /v 14 z 7"rEti cf" 3 S' i sk PLOT L,~ TN `r his test site APPROVED converit'orat septic 50- for a 1.__4_._.:..1..-_._l_ ..1 ..1-- ~L... _..._.L__1_._1 the undersigned, herbby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin ministrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. ME (print : HOMESITE SEPTIC PLUMOING e6- TESTS WERE COMPLETED ON: 655 O'NEIL RD., HUDSON, 4't'IS. 54016 A~q -T GB6 T t tI F1Rlf`FIT ODRESS. _ - 1"ISTAI NUMBER: PHONE NUMBER (optional): tIIS. MASTER PLUMBER LIC. N0.3307 M.P.R.S. CER I9)-- L FR R DESIGNER LiC. NO. 00663 • CST SIGNATUR STRIBUTION: Original and one copy to Local Authority. Property Owner and Soil Tester. R•S813.6395 (R. 10/83) OVER - /.OEST GaT t `iiv,~ a zm a m O \ M O oen a 0~ °v LP a` A ,z 8r P -4 a N J V ~''n n ~ 1,► ~~u,s0 ~ v1 ~ 5d ti N 1 ~ 1 p o_ CoCI 1 \ TJ o O ` \ 1 ~ N 1 ^ , ~pp v m o v ~ ~n O CO) CO) y D I C) N ~ J V i C4 4;h, ~ Q DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDIJSTA Y, DIVISION LABOR HU AN REDLATIONS PERCOLATION TESTS 115) MADISOP.O. BOX 7969 N WI 53707 (ILHR $3.0911) & Chapter 145) LOCATION: SECTION: goWNSHIP/ OT NO.:BLK. NO.: SUBDIVISION NAME: yc~ 1/ ~v0/ 3 z /T zy N/R/,?E (o Gv ~P~PE~ es,., PE1Vo% 0 61- COUNTY: Bv~r MAILING ADDRESS: 54 C Roi k ~hT Qd0, 1 1' Aj S 310 (~IE~sst ~ i , (Z o f3~ IQ TS ~O/ S 6'41o 23 USE DATES OBSERVATIONS MADE NO. B DRMS.: 1COMMERCIAL DES RI TION: PROFILE DESCRIPTIONS: [PERCOLATION MM-1 cc Residence 3 L) ¢ N, &New ❑Replace IAPPI 3Q- ~5s0 M?j~~ RATING: S= Site suitable for system U= Site unsuitable for system SCS Z 0 R Kti 0- 0 T-- CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) ©s ❑u 11:1 s au as ❑u ❑s ou ❑s au r P-eA-)ct4S - wl If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: G L~ S s Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS SC•-$ 4,'7 . By f? t-~t A aD T-- BORING TOTAL P H TO R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERV D HIGHEST- EST. TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- ~.S ! 102,50 /<a' oK3~. ; i o ' BN-S/1 , 5 s1 o , 7'1c~ S U C S (r- . B-2- S $D' alt S"/) G7'~'(3~-sy. S. 1 ,33 3N-Sy. /O' OR-QN c.S S.S ` 1'fi~ V C3 . 3 r ~O r 67 ' OK B • S,1',P3 ' ~fi~ c's~ LS r 21 v ' jet,.. cv { B- 9,~ ~,3s >S o s S" (5, ' T B_ g, Q /0 % 20 > 3 3 '0/l ~ S i / /'d S'r'/ B- s %D ~r D r Tca' > GAR t CS B- PERCOLATION TESTS /,v C S STR7tT~FS TEST DEPTH WATER IN HOLE TEST TIME DR I WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. P IOD 1 P RI D2 P PER INCH p' < 2 1 P_ z y O 1 2 , P- 2. 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- !ontal 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. 14T Peace- /014 za GDLc' T_eEtie4L 35 LOT- TN This t Jt s to APPSOVED sy efor a Cortyentiona $ 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): .'OMESITE FLUMbING Co. TESTS WERE COMPLETED ON: 655 O'NEIL RD., HUDSON, WIS. 54016 ADDRESS: -iOBEFiT 1~413RIrHT f4S. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. CER ~ 1 UMBER: PH3INE NUMBBE (optional): DESIGNER LIC. NO. 00663 ~~JJ S CST SIGNATUR 'DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. JILHR-SBD-6395 (R. 10/83) - OVER - BEST Go7- ~ i.v_: v'im zm a ~ a M rr- m R1 :a a a) :D pp tti M a C n m~z N r , lot -Aar o o 1 ° J - G _ M ~ r' O j y _ CO) i ~ K ~ I