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HomeMy WebLinkAbout040-1187-95-000 j K e k > \ 0 cc k 04 .f � . D \ cc (k $ f\0 / ] a) o k§o ( a22R � L } i § » § -r ) 2acE 23 g \//\ � § 2 & D.Q § � m / \ IL m E ) § / ] / CD k f \ D ) r ± E 2 I (D m 3 [ } . 9 / I § ) Q } cok / , k I K R )) 2 § $ 0 E \ § o a CD 6 S / LO ■ ■ ■ _2 § } - k � 2 a a 2 j S ± k k 2 kto \ ) k § _ / E � o c £ 2 � 2 $ � < » m R � ed 00 a k 2 ( LO® t : 0 8 = r = � a § 2 e c § / ( / @ £ R - \ 0 / / \ \ D / f ] 5 � e k e / 3 2 0 2 $ } ] 2 $ « ( : 2 $ k ( 0 2 C 2 % f / \ 0.) k k C.) . L " ` ` Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER re 1 �D `e TOWNSHIP SEC. T N-R_Zl W J ) ADDRESS MST. CROIX COUNTY, WISCONSIN 1 SUBDIVISION LOT LOT SIZE �` PLAN VIEW Distances and dimensions to meet requirements of ILHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Q u�pleX ` 0,11 ran u0je o'' 0. 4a ar INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: 16 6.0 Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: ,0?00 0 Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: t Number of feet from nearest Road.: Front,QC Side,O Rear, O, feet From nearest, property line ' Front 0 Side,O Rear,O �G feet Number of feet from: well � D , building: _�� (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE r • 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: t(ll Trench• Width: d Length: Number of Lines: Area Built: /!� Fill depth to top of pipe: Number of feet from nearest property line: Front, 0 Side, O Rear,0 ht .1j�, Number of feet from well: ! Number of feet from building: l (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, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: 4L/�� License Number:` 3/84:mj DEPARTMEW OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING 1 LA40R&HUMAN RELATIONS DIVISION P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION W.I ,,18'70Y8, 19W XXX-REPLACEMENT State Plan I.D.Number: ToW1 of Troy ❑ CONVENTIONAL ❑ ALTERATIVE (If assigned) Lot 50 CTY MM ❑ Holding Tank El In-Ground Pressure ❑ Mound IrIf NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION D Greg Lone R 5 Dry Run Rd River Falls BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.: o� -_ _ j 0 Name coPlumberb MP/MP SW No.: County: Sanitary Permit Number: Thomas Wang 3231 St . Croix 128617 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: [:]YES ❑NO ❑YES ❑NO BEDDING: VENT DIA.: VENT MATL.: UGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM Q D LIN AIR INLET: ❑YES ❑NO F-1 YES El NO NEAREST-- I U 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: PUMP A CON RO S OPERA NAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ❑ E ❑ NEAREST—� SOIL ABSORPTION SYSTEM. Check the soil moisture th d th o plowi FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire,cons all cease u I MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED/TRENCH WIDTH: LENGTH: NO.OF /// DISTR.PIPE SPACING: COVER INSIDE DIA.: #PITS: LIQUID / /y TRENC ATERIAL- PIT % DEPTH: DIMENSIONS f/ III GRAVEL DEPTH FILL DEPTH DISTR.PIPE rDISTR.PIPE I DISTR.PIPE.ffATERIAL: NO TR. NUMBER OF PROPERTY WELL: BUILDINCp: VENT TO FRESH BELOW P ES: A VE CO ER: ELEV INL ELEV END: PIP S: LINE i D I AIR INLET: FEET FROM / Cj NEAR EST�+► ( U 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 I ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM ❑YES ❑NO ❑YES ❑NO NEAREST—� v Y )� i v J 1 Sketch System on Retain in county file for audit. Reverse Side. SIG ATURE: TITLE: o Zoning Administrator SBD-6710(R.06/88) :EDILHA SANITARY PERMIT APPLICATION In accord with ILHR 83.05,Wis.Adm.Code CouN� • STATE SANITARY PERM # –Attach complete plans(to the county copy only)for the system,on paper not less than ((/y�-� 7 8'/z x 11 inches in size. ❑ cnecrevislon fo previous application -See reverse Side for instructions for completing this application. STATE PLAN I.D.NUMBER I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. PROP // d E� OWNER R �Tb Y, �4, S .3(D T N, R E(Ot� PROP FP O ER's M ILING AD R SS t LOT# BLOCK# F�� � %TY,STATE ! ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 0 II. TYPE OF BUILDING: (Check one) CITY �d NEA ESZ OAD ❑State Owned O VILLAGE� 'r ❑ Public ©1 or 2 Fam. Dwelling-#of bedrooms jr— PARCECTAX NI IMBERI PARCEL III. BUILDING USE: (If building type is public,check all that apply) 1 ❑ Apt/Condo V 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 OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. E1 New 2. © Replacement 3. ❑Replacement of 4. F] Reconnection of 5.El 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 ia'X 69 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 ELEV. 7. FINAL GRADE REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) n QQELEVATION DD 2'aQ a$ 4)b 3 d40 Feet 77 aD Feet VII. TANK CAPACITY Site in s ons Total #of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete strr cted Steel glass Plastic App_ Tanks I Tanks Septic Tank or Holding Tank VDU r►PA h to A Lift Pump Tank/Siphon Chamber VIII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. Plu ber's Name(Print): II PIu s Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: WQ � 7..?0 Plumber'?Address(Street,City,S e,Zip Code): ! IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved itary Permit Fee(includes Groundwater a si Imssued Issui g A ent Signature(No Stamps) Surcharge Fee) pproved ❑ Owner Given Initial Adverse termin t' n X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber 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 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 6 Location of property 1/9 0 1/4, Section 3 , T_jZ_J�_N-R W Township Q /� ,7✓,-/Mailing address Fa� Gl ly �U Zv;- • �` a -9 Address of site P,o e- m Subdivision name Lot number Previous owner of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? es No Is this property being developed for resale (spec house)? Yes No 4 Volume and Page Number as recorded with the Register of Deeds. k 4 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. ---------------------------------------------------------7--------------------- 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 de� rq 2ld in the Office of the County Register of Deeds as Document No. ; 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 bee�1, 1 racprded in the Office o he County Re q' ter of Deeds, as Document No. S ) . I Signs ure Of Owner Signature of Co-Owner (If Applicable) KI �2 Date o )Si ature Date of Signature t STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER e 1\6he� ROUTE/BOX NUMBER rC FIRE NO. CITY/STATE kt\(Ay- �411r— G(l/ J �Drrl ZIP PROPERTY LOCATION: -9 4 1/4 /4, Section , T_2k N, R 119 W, Town of _rD , St. Croix County, Subdivision tlY�/tot No. 0 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 $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE , St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (1151 P.O. BOX 3707 HUM/.11y IfiELATIONS 1 / MADISON,WI 53707 (ILHR 83.09(1)&Chapter 145) LOCATION: SECTI OWNSHIP/A46%N4G"kA"TY: LOT NO.:BLK.NO.: SUBDIVISION NAME: s W 1/ N�/ 3CP /T z N/R�9 E( ►W T R o CO N O UY M ADDRESS: �; X 6W6- L0AA y +.-5 b Ry PU.-) pp. Ft U_&. f� /& USE 1 -- ps'qLe DATES OBSERVATIONS MADE NO.B MS:'COMMERCIAL DESCRI TION: PROFILE S:IP OLATION TESTS: Residence yf. ❑New AR eplace" RATING:S=Site suitable for system U=Site unsuitable for system RYS NVENTIONAL: MOUND: IN-GROUND•PRESSURE: SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional 0U�ecfZ�� ❑U �$ ❑U ©$ ❑� ❑$ ©U ❑$ ®U TPf_X�4 s - w 1D RO �OX If Percolation Tests are NOT required DESIGN RATE: q If any portion of the tested area is in the under s.ILHR 83.09(5)(b),indicate: P'S S --r— Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS 0 BORING TOTAL r— PTH T GR U", DWATER-INCHES CHARACTER OF SOIL WITH THICKNESS:,COLOR,TEXTURE,AND DEPTH p NUMBER DEPTH IN. ELEVATION OBSERVED GHE TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) B- / go y zo' > o , I l k•S i t) 1. 4 ' r4A1 X"/) -S'e ' TAB `AY c rb A 6-Z Se 4 1 1 P 0cKt f 1.33 k it L I G a Si l IS' B-3 7&(p c C 3- B- B- I PERCOLATION TESTS USP-( C$ 5-rk v�S' I EST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INGWrog. AFTERSWELLING INTERVAL-MIN. PERIOD RI D 2 PERIOD 3 PER INCH j Of P- 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- 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. SYSTEM ELEVATION R 3 .2 0 `"" /61 n x''4 V"1 ro F1 i � I I 1 l I I i I I I i ) Ll 1- L Ctrs fief Sjte � T -T- I . I _� o�`a C e 11421 '71C t w' TIE- 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:SEPTIC PLUMBING CO. n, 656 O'NEIL RD.,HUDSON,WIS.54016 Z 7 `T ADDRESS: ROBW ULBRIGHT CERTIFItATION NUMBER: PHONE NUMBER(optional)-: WIS.MASTER PLUMBER LIC.N0.3307 M.P.R.S. ;. y 3 6 /?5 .00663 T SIGNATURE: DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBDS395(R.10/83) —OVER — i i 33 �I l 5P 33 -dp p NQ � f{1- i i � 3 � C kot 30 ��pl gb � hZai , P. 0 S ; $► 1�0 4491- toT' P61-k- PR*4- B - 6kf)At1a= /010:0 PtYG pLUM'tAIvU p16 A N 1ESIE pD NUDE'Wks..4 T c aP4TAP� °F g55 0' rt ULLIC- NO 330?M.P l cr�. 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