HomeMy WebLinkAbout032-1065-70-000
FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER , TOWNSHIP _ / 1 `rl moo., S Pf
SECTION_,Z_~(_T N-R=/, W
ADDRESS ~a 5 f ST. CROIX COUNTY, WISCONSIN
~~'~ntr ~ ~~r ~ ~d z5
SUBDIVISION LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
- s_
07w 55
°Cn T
INDICATE NORTH ARROW
BENCHMARK:Elevation and description: /off o ~o4~, c~ f~ s Cor,~
Alternate benchmark
SEPTIC TANK: Manufacturer:_ a Liquid Cap. LrJ~.c
Rings used: Manhole cover elev:
Final grade elev:
Tank inlet elev.: 41 Tank outlet elev.:
No. of feet from nearest road:Front
Side , Rearx Ft.':Z"2~-
From nearest prop. line:Front , Side, Rear Ft.
No. of feet from: Well o Building: 61?z ~
(Include this information in 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: Trench: Seepage Pit:
Width: Length -'5 Number of Lines Area Built ~~O
Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth to top of pipe: b;~"--? Z-5~-
No. feet from nearest prop. ine:Front Side, Rear Ft.a
No. feet from well: of No. feet from building
1-e
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:
INSPECTO
DATE : PLUMBER O JOB .
LICENSE NUMBER: Sr
6/90:cj
r AQW 18
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
LABOrd & HUMAN RELATIONS DIVISION
P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
MADISON, WI 53707
NE4iNW4,,Sec. ,T31-R19
0 CONVENTIONAL ALTERATIVE (ifasgned).Number:
❑
Town of N. Somers
Holding Tank ❑ In-Ground Pressure ❑ Mound
NAM F PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPE TION DA E:
Gerald Germain 738 205th Ave., Somerset, WI 8 a 9 a~- /Q ~v
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: / REF. PT. ELEV.: CST REF. PT. ELEV.:
Name Plumb : MP/MPRSW No.: County: Sanitary Permit Number:
Byron ird Jr. 3318 St. Croix 128760
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
S 000 24.91 PZ,d ES ❑NO P❑YES E4' 10
BEDDI G: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
~ l~ ALARM: FEET FROM LINE: AIR I LET:
❑ YES ~ f~ NO ❑ YES a No NEAREST d~ a / ~v N /a a 5 5
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: MP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL, BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF PU ❑ YES E] NO NEAREST POP-
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING:
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.) _
CONVENTIONAL SYSTEM: Q~ rij ~~cd~i = 4 3,
BED/TRENCH WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
TRENCHES: MATERIAL: PIT DEPTH:
DIMENSIONS 5
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DI R. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. EN PIPES: FEET LINE: AIR INLET:
FROM
ld'~ qt ~ NEAREST ~ N h O
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 ❑ 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
6 ~
t 'f S f Q G/LlT~ ~t o~z~ `V
\ AS 131e IL- 7-
f
a/i7
Sketch System on Retain in county file for audit.
Reverse Side. SIGNATURE: TITLE:
SBD-6710 (R. 06/88)
I
~SANITARY PERMIT APPLICATION
U 0N.HR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ ~j 7~~
8'/z x 11 inches in size. C ec if r vision to previous 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
erccI Pa^~ta~ r Y. S T,7/, N, R E (o
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
III. TYPE OF BUILDING: (Check one) El State Owned ❑ VILLAGE ; NEAREST R ~0
~i" G
WUN OF:
❑ Public ~ 1 or 2 Fam. Dwelling- # of bedrooms PARCEL Ax NUMBER(S)
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 80 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. R 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 300 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 (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
q Jrrp• 6o-4 0.Feet Feet
CAPACITY
VII. TANK Site
in allons Total IV of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New lExisting Gallons Tanks Concrete strutted glass App.
Tanks Tanks
Septic Tank or Holdin Tank
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 Si nature: (No Stamps) MP/MPRSW No.: Business Phone Number:
Plu A drea (Street, City, State, Zip Code):
C~ C!' at9
IX. COUNTY/DEPARTMENT USE ONLY
Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determin n
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
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 <i 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 a- tax number(s) of
where the system is to be installed.
II. Type of building being served. Check only one and complete # of t oily Dwelling.
III. Building use. If building type is Public, check all appropriate
IV. Type of permit. Check only one in line A. Complete line'" reconnection, or
repair.
V. Type of system. Check appropriate box depending on syst
VI. Absorption system information. Provide all information reg4
VII. Tank information. Fill in the capacity of every new and/or exi, er of
tanks and manufacturer's name. Indicate prefab or site constn all
septic, pump/siphon and holding tanks for this system. Check ea ~eived
experimental product approval from DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, liven, g.
MP, etc.), address and phone number. Plumber must sign applicatio.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8'% x 11 inches must , county. The
plans must include the following: A) plot plan, drawn to scale or with comps .,s, location of
molding tank(s), septic tank(s) or other treatment tanks; budding sewers; weh, mains/water service;
streams and lakes; pump or siphon. tanks; distribution boxes; soil absorption s,arems; 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) all sizing information.
- - - - - - - - - - - - - - -
GROUNDWATER SURCHARGE
1983 Wisconsin Act 414 included the creation of supercharges (fees) for a number of
regulated practices which can effect groundwater.
The nrcnies n1cllected through these surcharges are used for monitoring nrowidwater, graund-
water contamination investigations and establishment of standards.
I
SBD-6398 (R.11/88)
APPLICATION FOR SANITARY PERMIT
8TC-100
Thls appllcstlon Eotm is to be completed in full and signed ytheln delays of
the property being developed. Any Inadequacies Will Y tesult
the pitmit Issuance. Should this development be Intended got tesale by
ownered ateC operttold second should
thls officetawith the
completed when n th ticss property Is s .
appropriate deed recording.
Ownet of property ("C_v'OL~A G e V IM G n
Location of property ~_1/4 Section T.3 _1__P-1t1_'Lw
Township
S U
Malling address 3 g C)
Pr e i 6 S
Address of site
1041vision name
Lot number
Previous owner of property
Total size of parcel _qQ Ai--es.S
Date parcel was created
Are all corners and lot lines identifiable? an 0
Is this property being developed for resale tapec house)? as 0
Volume and Page Number as recorded With the Register of Deeds.
INCLUDE WITH THIS APPLICATION Tilt FOLLOWINGt
A WARRANTY DEED which Includes a DOCUMENT NUMBER, VOLUME AND PAGE NUNSlR, and
the 8EAL 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 Cestlfled 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 ptopetty described in
this intotmation totm, by virtue of a warranty deed recorded In the office of
the County Register of Deeds as Document No. Q't 7/7 ) and that i (We)
presently own the proposed alto for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, tog the
construction of sold system, and the same has been qul recorded In the Office
of the County Registeg of Deeds, as Document No. _~tS 6 1.
0)1 0_Q `
Signature of Owner Signature of co-Owner (if Applicable$
z I 9 v
Dat~S gnatuce Date of Signature
I
N
rt
• SEPTIC TANK MAINTENANCE AGREEHENT w
r
St. Croix County t-'
a
OWNER/ BUYER (2 - l in _ C
Fire Number d
ROUTE/BOX NUMBER 0
(,t)/'s , ZIP
CITY/ STATE m r~
PROPERTY LOCATION:. k' _ , Section T., 3 N R_LLW'
Town of 0M e hs St. Croix County,
Subdivision - Lot number_
Improper use and maintenance of sstmaintenanceem could
its premature failure to handle
sists of pumping out the septic tank every three years or sooner,
a l'icen's'ed' 's'e t'ic tank Dumper. What you put into
if needed, by
the system can a ect the, unct on o, t e 'septic tank as a treat-
ment-stage in the waste disposal system.
St. Croix Countyy residentssmal!fbYeeiacementtofracfailinggsystem~
a maximum of 60% of the co rep lac,
1978, St. Croix County
wh c was in operation prior to-July , with accepted this program in Aagree to 6keep their systhe that
owners of all new 's•~►stems g
maintained.
The property owner agrees to s~heiownerSandCbyia materypltmnber,a
certification form, signed by veri journeyman plumber, restrcWagtewaterplumber disposallicensed
systempi~spin proper
Eying that (1) the on-site if nec-
operating condition and(is'lessrthanpl/3ifullnofpsluindge and scum.
essary), the septic-.tank 30 days prior to
Certification form will be sent approximately
three year•expiration. H
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 Depart- :r
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix Co y Zoning Office within of the three year expiration.date.
SIGNED
DATE
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
DEPARTMENT fF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUST'RY,, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 7969
N W 53707
HUMAN RELATIONS I 3.09(1) & Chapter 145)
LOCATION: SECTION: OW SH UNICIPALITY: NO.:BLK-NO.: SUBDIVISION NAME:
r:T
- -
/T N/R/ (r► W a e~v
COUNTY' MAILING ADDRESS:
5 as
Zff
DATES OBSERVATIONS MADE 7
USE
NO. BEDRMS.: COMMER IAL DES RIPTION: ROFILE DESCRIPTIONS: OLATION TEST
Residence r- oNew ❑Replace
(7 G ra, v
RATING: S= Site suitable for system U= Site unsuitable for system
ONVENTIONAL: MOUND: 1N-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional)
9S CU ES E111 ES ou DS HU ❑S U
loor
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: II Floodplain indicate Floodplain elevation: ~Q
PROFILE DESCRIPTIONS
AB RV ~ON BAC TEXTURE, AND DEPTH
BORING TOTAL COLOR NUM ER DEPTH N. ELEVATION DEPTH OBSERTO G VED UND WATER -I HE ES TCHARXCTER O BEDROCK IF -(SEETHICKNESS
I B- o-~
IT/d-`-c
B-
El-
B-
101V !~Pw
B-
El-
PERCOLATION TESTS
is
T DEPTH , WATER IN HOLE TEST TIME DR I WATER L V -IN H RATER (INCH NUTES
f NUMBER INCHES AFTERSWELLING INTERVAL-MIN. p RI D t P RI D
P-
Ple;
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-
lontal Ulld veltical illavnllun lolliluncn lluiull 11111) ahuw 1111111 1uc111iu11 oil 11141 111111 1111111. Show the suflaco elevation at all boring%and the direction and perant
of land slope. 17- lev G~
SYSTEM ELEVATION.
Ire
(J~
I
l 4 { ( ! l ~
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 : TESTS WERE COMPLETED ON:
r - -
ADDRESS: - CERTIFICATION NUMBER: PHONE NUMBER optional
ry~ 2
CS SIG AT E:
L DiSTRIBUTiON: Original and one copy to Local Authority, Property Owner and Soil Tester.
PLOT PLAN
PRpdECT err ~~Ger;0,7a.gADDRESS 73-6 1/4 A,1/4/S,;z~lT3/ N/V-11W TOWN /1/. 5o-•~,crs-~~ COUNTY >`G•~~~5`/~~`S'
MPRS Byron Bird Jr. 3318 DA E o 712'0o
BEDROOM. CLASS PERC CONVENTIONALA IN-GROUND ESSURE
CONVENTIONAL LIFT_ MOUN_ HOLDING TANK
SEPTIC TANK SIZE a-~ LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA z PERC RATE BED SIZE
1111L Benchmark V.R.P. Assume Elevation 100'
Location of Benchmark 4&,::F e-
* H. R. P. Al c - C~ cr o 5- GQG • ~/0 1~6i
E3 Borehole Q Well Scale Feet
O Perc Hole System Elevation
Uent
12'
Grade
1
TYPAR COVERING
2"
12" 31 4 6' O 3-
1 6 Sewer Rock
1.2'
I
b
3d•
7o