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HomeMy WebLinkAbout040-1157-90-000 eC o a~i °oC; M p 69 N o a o ti ~ ~ I ~ I 0 N I 1-4 I ~ I I ~ I 'y m I of ~ y CD € I 9 Z L I c IL c O '0 3 I > I I M (D I r Z N p I IL m N H O O Z :!t c a o o = N F c E Z m N O O C f00 N I N a ~i y c c ~ Q I 0 Z co z O N Z E M CI N H ~ I E O c LO i O 0 d N~ 0 N C G C m N Zco >°mmm albs _ Z 0 I •N ~aaa N N J V LL rn rn ~ I awl o o o ICI 3 O O D ^1 O N 00 to c a N N > ~ Q o i C C. y y ~j ,y N Y! c ` O _ C C N O 0 0 0 V EL OO p l CL M C C-4 O e0 ( ~ _ O O O N N L L +O•~ 'O n C~ I 00 N I fJ O .4+ ~ ~ ~ C L (D c L) N O Z 2 U) • O O O N 0 v~ m E a d EL IL 4-, t A c~a~ 0 v~t°~ ,IEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION Af SON YVI 53707 State Plan I.D. Number: Town Wk, Sec • 24, T28-R20 CONVENTIONAL ❑ ALTERATIVE (If assigned) Troy ❑ 1-1011 Xnag Tank ❑ In-Ground Pressure ❑ Mound Plainview NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: 0 /0., 4L/ BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT ROM PLAN: REF. PT. EV.: CST REF PT. ELEV.: ~Gti) ~ ~~ctitE~ Name of Plumber: MP/MPRSW No.: County: Sanitary P m Thomas Wang 3231 S f-. 3C 128r679 SEPTIC TANK/ MANUFACTURER: LIQUID CAPACITY: TANK INLET ftT17 TANK OUTL -BL WARNI LOCKING COVER PROVIDED: PROVIDED: O ; • I , t / ~t/ a z YES ❑ NO ❑ YES ❑ NO BEDDING: ViWi.DIA.: V&W MATL.: HIGH WATER 'NUMBER OF ROAD: PROPERTY WELL: BUILD . VENT TO FRESH t. tJ , ALARM: FEET FROM r LINE: AIR I/~L ❑ YES NO ❑ YES NO NEAREST 1 DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO [__1 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 ❑ YES E] NO NEAREST 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 int ire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM"("'. . ` fjp rr {c,-„_ = WIDTH: LE NO. OF ISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID BED/TRENCH / TRENCHES: MATERIAL,,;,, PIT DEPTH: DIMENSIONS 41,.F.~ f GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PE DISTR. PIPE MATERIAL: O. DISTR. NUMBER OF PROPERTY WELL: BUILD VENT TO FRESH BELOW PIPE`:: ABgyE CO~ ELEV. INLET ELEV. END: / PIPES,: FEET FROM LINE: a AIR INLET: ~1 .t r - NEAREST i 7Ce MOUN 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: 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 MBER OF PROPERTY WELL: BUILDING: PERMANENT MARKERS: OBSERVATION WELLS: 1AREST---- COMMENTS: FEET O LINE: 1F A. ~c.~ C , f1~ c c+ ❑ YES ❑ NO ❑ YES ❑ NO 1 AL 4i . 4.t, i, - r f _ E ,a r'i ' A ~ f ~'.0` n ~,r~- ~y-~ • ~ c'am' , L.t!"r'~ ~-h..... ~ ~~.G t ~ ~ 1'1 t„r l rL~ i : 'r..4;..! it!"C.~. ~'~,rw c . , ~ ~ f vv " ~ w' r r a . tain in county file for audit. Sketch System on Reverse Side. SIGNAT E: TITLE: SBD-6710 (R. 06/88) Yl SANITARY PERMIT APPLICATION 11191006 .S DILHR In accord with ILHR 83.05, Wis. Adm. Code COUN s ~a~r,tu~asw,w,~w,v~ STATE SANITARY PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ ~ 8% X 11 inches in size. Ch k rision to pre sous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPER OWNER PROPERTY LOCATION n ,OTY ~a % a S~/a, S d T N, R PROP RTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ` JZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM N MBER II. TYPE OF BUILDING: (Check one) El State Owned ❑ VILLLLAGE • fna NE ~OiD e~ jj= EL X NUMBER(S) /h O //l~J~. !~5 ❑ Public ❑ 1 or 2 Fam. Dwellings of bedro ms - 111. BUILDING USE: (If building tYPa is public, check all that y) lJ ! ✓ 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 40 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. ® New 2. ❑ Replacement 3. ❑ Replacement of 4.E1 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 Seepage Bed AR*W 21 ❑ Mound 30 ❑ Specity Type 41 ❑ Holding Tank 12 ❑ Seepage Trench Ji-"x 3 S 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 REQUI ED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) pELEVATION ~W 17,2 G 0 ~ Feet / 4 Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- TExper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastipp Tanks Tanks structed _TT Septic Tank or Holding Tank k;tt S 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. Plum er's Name (Print): Plum ignature: (No S mps) MP/MPRSW No.: Business Phone Number: a s 4~ PY ,7 Plumber's Address (Street, City, State, Zip Code • ' a Ccl A IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued ing Agent Signature (N mps) IP Approved ❑ Owner Given Initial / Surcharge Fee) _ Adverse Determination by 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 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, purnp/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'f x 11 inches must be submitted to the county. The plans must include the following: A lot plan, drawn to scale or with complete dimensions location ) P P 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; (lose 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 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-6398 (R.11/88) I i i APPLICATION FOR SANITARY PERMIT 8TC-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 got tesale by ownst/conttectot,(spsc 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. ----------m-------------------------------------•------- Owner of property Ag"a Q_f1_2_L'e Location of property 216.L-1/4 'aj~j Section T P-It_9L_V Township Mallinq address - / k nX 4 Address of site subdivision name X7--t Lot numbet _ Previous owner of property Total size of parcel Date Patcel was created Ats all cornets and lot lines Identifiable? t -Yes o Is this property being developed for resale (,spec houseiT_Yes o Volume 7 ?6 and Page Number 3,&?, as tecotdad with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE POLLOWINCs A VARRANTY DIZtD which Includes a DOCUMENT NUMBER, VOLVMR AND PAOR muman, and the BRAL OF THE RROISTRR OF DRRDB. In addition, a certlfled survey, !f available, would be helpful so as to avoid delays of the reviewing process. it the deed description references to a Ceitlfled Survey Map, the certified survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(ve) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the ownet(s) of the property described In this Information form, by virtue of a warranty.d ed corded In the Office of the County Register of Deeds as Document No. 4s'`~• ; and that t (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to tun with the above described property, for the consttuctlon of sald system, and the same has bee 1 recorded in the office et h ounty Register of Deeds, as Document No. 1. Signatur of owner Signature of Co-owner ttf Applicable) ate of S gnatute Date of Signature J ~ r j m ..i , i _ ~R .a p,x~ R ~ i, ~ ~ mot. ~ ~ ~ , f: ~ ~ . ~ si ~ .,,~~~yy ~.1 Y • t \ ~ S ' STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER UYER `ROUTE/BOX NUMBER FIRE NO. CITY/STATE /c1 Pa(' A ZIP PROPERTY LOCATION: 1/4^1/4, Section 2_~_', T N, RZ;v_W, Town of St. Croix County, Subdivision t K , 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 DATE °t 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 IVISI SOIL BORINGS AND SAFETY & B DILDIN REPORT ON DV'S' t ~ 1 P.O. BOX 79, NO PERCOLATION TESTS (115) MADISON, WI 537 ,,IAN RELATIONS (H63.090) & Chapter 145.045) : S ~ UBDIVISION NAME: TOWNSHIP/M{~': LOT 11 LOCATION: SECTION: Croixrid ge SSW w' /4 24 /T28 N/~2o E Ior1 W mro Rt6 AME: MAILIN ADDRESS: BUYER'S N COUNTY: St. Croix Mike Getzie 1• Rt. 13ox 4 River Faller WI 4022 DATES OBSERVATIONS MADE USE PROFILE DESCRIPTIONS: E ATION TEST. NO. BEDRMS.: COMMER IAL DESCRIPTION: nNew Replace 4 5/82 [Residence ' ~2 r RATING: S- Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: -GROUND PRESSURE: SYSTEM-IN-FILLHOLDING TA NK: RECOMMENDED SYSTEM: (optional) S ❑U ❑ S EAT N S ❑U S ❑U ©S ❑U gravity, bed 2' 2' DESIGN RATE: ~If any portion of the tested area is in the If Percolation Tests are NOT required under s.H63.09(5) (b), indicate: Floodplain, indicate Floodplain elevation: nZa PROFILE DESCRIPTIONS BORING TOTAL WITH THICKNESS, COLOR, TEXTURE, AND DE PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL NUMBER DEPTH L ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) IN. B- 2 99, / B- 3 3 K 6 7cGn, s / B- , 92,2 9 J' lit/1 d',t•~9 t /8'ir:~H, y ~ . B- 1? 1, 7 B- PERCOLATION TESTS DROP IN WATER LEVEL•INCHES RATE MINU Of- DEPTH WATER IN HOLE TEST TIME PERIOD 2 R PER INCH NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD - t 1 s _ P. d P t s i P- 9 /1/ C 3 P_ P- s Indicate P_ itable soil Descr PLOT PLAN: Show locations eference points and showtheir location on' he plots plan uShow the surface elevat oncalt all toingseand the Idiir cti naa, zontal and vertical elevation of land slope. SYSTEM ELEVATION 89.8' 47 _ AV a-- _ I L1 t v } - SEE armom S S I , 1 , Fir cc ~e I I , I J _4 - - i i -i I j 1 i I I _ • { I, the undersigned, hereby terrify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. TESTS WERE COMPLETED ON:, NAME print CER I IFICAT!ON tvl6ER: r'IiONE NU p7il ADDRESs: 3233 749- Fogerty Hgts. Rd., Roberts, WI 54023 SIG TUBE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) -OVER - R/W f• f P ~M Y~ • f /d •E t 'rt. //1 AlIlle h jv/~fj kC. syy., i Al v 7 'PlIf j sel T•2 N5p ~ fro t ~le t«l93 ~3C ~ruAA ~~Zt I)A. 'vat YK-L Co m er W J to r 3' b' O r Pei (o rk Sys. ~fev, ~ ~nD bo g Irc~oO a~ p of ~t.d /vo . b 3o e~ vE a q GIs P P~ ~ gas-~~