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HomeMy WebLinkAbout020-1119-50-000 R~ O O O h ti Q dO4 d 4 O ti tl O N ti 3 C z C LL C O 3 ;o I I Cl) r z E o H Z a m I _o I O z a=i Z ° o fA F- r' ~ N ~ ~ N ~ a) I J N _a .o a 0-1 (CD O z H z o N = N E Y t0 m O. m co'cOa` a E a) CD U) U) u _ aLL O O •N ~aaa o W J V 7 O O N = O O Cl) LO O O O O O O E 0, ~ c d - ~ I 0 9 d Q~ (n Q ~r m 7 v O 0 C y C 1V 0 Cl) O = E O N V U O y d> N O co M O N C V n. 0 0 0 0 L? iA O N a Y I-- CD N V W _ _ N C O O C 7 y m' c w n rn o o l a m N 'o 4) r- 0 ' O 2 Z O Z 'n =5 Cl) r a ~ ~ = E v a r EL • CL d•~ ma +r E u O R c t v A c~a~ m Form -STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER f' e, TOWNSHIP SEC. T N-R~W ~y ,S1Z ADDRESS ST. CROIX COUNTY, WISCONSIN ~rao 1~w 00 SUBDIVISION o!tOT LOT SIZE U~ ~ ~ ~ ~ - SO-C10D PLAN VIEW Distances and dimensions to meet requirements of I1HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM /Y 18~ ri. 10 3 e- f`` 1f G/ ~•"L'JZ T7 IK r r • ~y r~`s~ f(c # lc~ +4tL _ .~~rq2. Yo,~6 f INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point usec /?•f~. Elevation of vertical reference point: ©C~:~7/ Proposed slope at site: _ SEPTIC TANK: Manufacturer: &P4l-ets Liquid Capacity: /~L®G' Number of rings used: e)Tank manhole cover elevation: /°Ocrr0 ~ Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road.: Front 10 Side,(D Rear, O > 5-0 feet -From nearest property line ' Front 10 Side 10 Rear,0 ? ;-o feet Number of feet from: well 6&e/l, building: 3--,- (Include this information of the above plot plan)( 2 reference dimensions to septic tank) RRE RPVRRSR RTnV • PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, © Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: _ 5-.e4,-e-A f ao? xas7e /-z c Width: S Length: .:Ea- Number of Lines: Area Built:Sx 0 Fill depth to top of pipe: 3 Number of feet from nearest property line: Front, O Side, O Rear, 0 It 40 Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector:- If~a Plumber on job: e~ Dated: p X" Al~/ -1j-1 License Number: 3 2- 3/84:mj 4D1~PARTU&T OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION M4, ISION. 15707 4f ec.17,T29-R19 State Plan l.D.Number: 1:1 CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Hudson Lot? Brookwood Dr. Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: David Neeck 804 8th St. Hudson WI /O -/°-70 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: David Fogerty 3289 St. Croix 128742 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: K~ 6D t 14 DES ❑NO ❑YES O BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: ❑ YES FzrNO 1 ❑ YES E~Kci NEAREST S > s o ,>J 3 DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES [__1 NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: PUMP ON AND OFF YE NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture t th d pth f pl wing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, constr io sh II c ase 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: MATERIAL: PIT DEPTH: DIMENSIONS Z yL GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DI TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOV COVER: ELEV. INLET- I EL V. END: ~J PIPES: FEET FROM LINE: ~ AIR INLET: 0 4, 7 Z 17- ( NEAREST / Sti I S MOUND SYSTEM: 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 El NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND 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 WCOMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST I► Sketch System on Retain in county file for audit. TLE Reverse Side. SIGNATURE: TI: /t SBD-6710 (R. 06/88) DI SANITARY PERMIT APPLICATION COON _ffILHR In accord with ILHR 83.05, Wis. Adm. Code .e....,...v,.,..,..,,~,.,o . STATE SANITARY PERMI # -Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 ~ 8% x 11 inches in size. ch k f e E7in to revtou application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PRO TY OWI`ffiR PROPERTY LOCATION C Y4 Y4, S 7 T , N, R E (or PROPERTY OWtJJgR'S t7ILING ADDRESS LOT # BLOCK # Gn 1~ CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR R - 91 L II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD I ~ I~ State OWIt@d ❑ ILLAGE ; S f 6r/ ~ ❑ Public E41 or 2 Fam. Dwelling-# of bedrooms- PAR EL TAX NUMBER(b) 111. 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 5 ❑ 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. E New 2. ❑ 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 El ySeepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 `''Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 430 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 y . P " Feet . e "Feet VII. TANK CAPACITY Site in allons Total It of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Se tic Tank or Holdin Tank O Lift Pump Tank/Si hon Chamber ~-L1 I El F1 FJ El 1 1:1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Number: : Plu ber's Name (Print): Plumber's Signature: (No Stamps) TM PRSW No.: Business Phone umber's Addre (Street, City, te, Zip de): wr IX. N /DEPARTMENT US NLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuin Agent Signature (No Sta Approved ❑ Owner Given Initial Surcharge Fee) ~i 10 Adverse Determination ` w 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 INSTRUCTIONS Y 1 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) alrbizing information. - - - - - - - - - - - - GROUNDWATER SURCHARGE I 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-8398 (R.11188) T 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 petmit Issuance. Should this development be intended Lot resale by owner/contractoc,(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 "Coin-x AIA00 k._ t~9Od1clS Location of property G` 1/4 /4• Section 7 T -R-L.9-V Township Melling address Address of site subdivision name„ ro"- t vae. fL ' , o " Lot number _ Previous owner of property .k e C-~ ~"A.,eZ ` Total sise of parcel t ,r O 4 Date parcel was created 1q'1 9 Ate all cornets and lot lines identifiable? _Yes o ' If this property being developed for ressie (spec house)?_ __Yes No Volume Viand Page Number =97 as recorded with the Register of Deeds. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - INCLUDE WITH THIS APPLICATION THE FOLLOWING A WARRANTY DEED which Includes a DOCUMENT NUMBERp VOLUME AMD 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 Ceitified 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 (out) knowledge; that I (we) am (ate) the owner(s) of the property described In this information form, by virtue of a warranty dead recorded In the Office of the County Register of Deeds as Document No. r?.za •-///f'- 57); and that I (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 recorded in the office of the Co y Register of Deeds, as Document No. y-2v -iii S~ 1• signature of Owner Signature of Co-Owner (If Applicable) Date of 819etut Date of Signature DOCUMENT NO. WARRANTY DEED I THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1982 Clyde E. Eklund and___Marilyn__W. Eklund husband and wife .as marital survivors...................... property conveys and warrants to ....David M. Neeck and Laurie A. Nee-ck-,_-husband.. and..wife.-as-•ms.rital•-.survivorship property-----•... I . . II RETURN TO II I; . I' the following described real estate in ........St."... Cr...oi.x County, State of Wisconsin: Tax Parcel No: Lot 9, Trout Brook Woods in the Town of Hudson, St. Croix County, Wisconsin. R: This 1S not . homestead property. (is) (is not) Exception to warranties: easements, restrictions and rights-of-way of record, if any. Dated this ....__.31 ay of July-----....---...._....------..•-•.--......., 19.90... - (SEAL) ....C EAL) Cly.d~.-•E EXJ.and •i!'~~x a W_.... .....................•--•-•-----••----.......(SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature (s) ..Clyde---E_....Eklund STATE OF WISCONSIN Marilyn W. Eklund $g, County. authenticated this ..31-day of-.JU-IY ...............1 190-- Personally came before me this day of 19 the above named •..Krl.2tAna._9_gl and..&uadean--------------------- TITLE: MEMBER STATE BAR OF WISCONSIN (If not, - authorized by § 706.06, Wis. Stats.) to me known to be the person who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Kristina Ogland Lundeen R rrie--- t_..Law Notary Public . -•-•-----------County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: "Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATH DAR OF WISCONSIN wisronvin LeRnl lllank I'... live FORM P7n, P - 1982 a -1. 1 -A- H z cn " H a STC - 105 r a H SEPTIC TANK MAINTENANCE AGREEMENT 0 St. Croix County z d a H OWNER/BUYER K.~ ROUTE/BOX NUMBER 'qbc-t Fire Number .CITY/STATE z ZIP Y6 PROPERTY LOCATION: Section T_-7 je N, R W, Town of 4~~a&~ St. Croix County, Subdivision, t,9a,,/ ~ Lot number. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper 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 II 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 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 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 0 I/WE, the undersigned, have read the above requirements and agree N to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- ro ment 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 DATE 13' 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. TRY, PERCOLATION TESTS (115) wry (M8 SON, AND N RELATIONS' i IO BLK NO.: 57,CoU~IVAM WO w9/ 5 - E TON : TOWN IP/MUNICIPALITY: /4 /4 TON N/R E (orlW v~SMA DOR TYn OWNER'S BUYER'S NAME: CKO~~ r DATES OBSERVATIONS MADE sidence NO. B DRMS : -0 [XNe•N ❑Replace 13 57 G: S- Site suitable for system U- Site unsuitable system -SVg FILL OLOING TANK: RFFVMytENDED SYSTEM:Io~%~al) E N 7 11 NAL: MOUND: IN- G ROU~- S ❑U C~~ [IS ©U a ((.VT/ONnL- DESIGN RATE: 11 any portion of the lot is In the colation Tests are NOT requirod Floodplain, indicate Floodplain elevation: r s.H63.091511b1, indicate: PROFILE OE~;C;R rlICJIgS ING TOTAL P HT R UNDWATER-INCHES CH AEDROE K IOF OOIERVED 7 EIABBRV.OOBAR, TEXTURE, AND DEPTH O , BER DEPTH IN. ELEVATION E TO 8BS.(5,F A'1 ~ IS A), SL, 13 L o H s,L , 7 'll w R 93.5 f 7 ~Z ;3 -1S/J vc .s C_ -3 5,, y~,^' -~N s I X80 17 8U y y° e 5. ~y3 >76 PERCOLATION TESTS r€ ;',Ol'4 F~ r~~ vcrin UMBER~ IN HES AFT RSWELLING INTERVAL-MIN. G G P. N VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what-aro thw-hw ntal and vertical elevation reference points and show their to/tion on the Blot plan, SIpw the s !6 elevation at all b~l and the direction and perca EX fJt1 r CAUA7, land slop. ~JIa`r Of D Q / T' SA'uL Lie- EXnl7Ly y /o fr. 3e io w o YSTEM ELEVATION rt LE 5 o fll~`iE O ~ " F'7q), g 3 Q f tt A _ l U l~v S e the undersigned, hereby certify that the soil tests reported on this form were made by awgrd with the procedures methods specltial in the Wiscc dmimistrative Code, and Cher he data recorded and the location of the tesu are correct to the ba;tpf;rrtY'k"owledge and belief. 'IdArvi" 'P-10: TESdL~EMPLEj7 0 NI / Uv> U v l l il' ~p C E3 tj1p t ER P H..l~ ON U ~ :on ADDRESS:. i,~ ~C / - A CST 8)QU f~T 1 )151U~BUTION: Original-Local Authority, r zrv -Bureau of Plumbing, 3rd page-Property Owner. 4th oage$oii Tester, QlhHfi,S90~(ioot.ltr_~af~t) - w ^ f DAVE FOGERTY PLUMBING Ucensed Pork Teste3289 & Plumber 03233 # Fogerty Heights Road ROBERTS, WISCONSIN 54023 Phone 749.3656 "elf Xe, ll)eiff 3r 70` / " 3!1 ~ 1 i `t Scales ~ 3d ` ri Y° 1^ i3C f° j e~ lug v~.7~ # 2 0 ~ prwk ~G~ a 4c s r= Lille