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HomeMy WebLinkAbout042-1078-95-200 • t V Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER . c. t+ TOWNSHIP SEC. ' T i rN-R ~rT W r-- ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT ~ L LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IZI1R 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I ~ 5 Y's 1 1 I 1 ; L t4 llY1 ` 4,lkol,e INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used - eve Elevation of vertical reference point: Proposed slope at site: zC~J SEPTIC TANK: Manufacturer:Liquid Capacity: Number of rings used: C:,> Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: 7~ZC Number of feet from nearest Road: Front 10 Side, Rear, O ;2 feet From nearest property line Front,OSide10Rear, 0 feet Number of feet from: well_ ? building: '16 (Include this information of the above plot plan)( 2 reference dimensions to septic tank) i SEE REVERSE STnF. v 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, Q Side, O Rear, Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: Length: Number of Lines: ~ Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear, 0lit . Number of feet from well: ? Number of feet from building: L f (Include distances on plot plan). SEEPAGE PIT ~~//1~~~ Size: //oJT 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: License Number : 3/84:mj D LABOR EPART0MkNT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS P.O. BOX & HUMAN RELATIONS P 7969 PRIVATE SEWAGE SYSTEMS DIVISION MADISON, , WI WI 53707 BUREAU OF PLUMBING MA CONVENTIONAL ❑ALTERNATIVE State Plan LO. Numbnt 111 "$.a 11 Holding Tank El In-Ground Pressure 1:1 Mound NAME.OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPECTIO D E Dale Stewart Rt. 2 Roberts WI 54023 ~j o7 BENCH MARK (Permanent reference point! DESCRIBE IF DIFFERENT FROM PLAN REF. PT. E EV.~ CST NEi PI ELE V SE NE, Section 29, T29N-R18W, Town of Warren Na, M Plu,nlrer. 1P/MPHSW No.. County $anilary P"_., Number. Ro er Timm 3224 St. Croix 88393 SEPTIC TANK/HOLDING TANK: MANUFACTURER LIQUID CAPACITY TANK INLET ELEV. TANK OU7LETELEV WARNING LABEL LOCKING COVER )LO't _k'j" ] - 9 ~ PROVIDED PROVIlED 4' ~ 1.7 zn YES ❑NO DYES C )NO BEDDING VENT DIA. VENT MAT I. HIGH WA ER NUMBER OF ROAD: 1PROPERTY WELL BUILDING ITOfRFSH 1ALAHM FEET FROM LINE AIR INLET YES DNO DYES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER - BEDDING LIOUIDCAPACITY 1PUMP MODEL 1PLIMP. SIPHON MAN U/ ACTIMEH WARNING LABEL LOCKING COVER PROVIDED PROVIDED DYES DNO DYES ONO DYES EINO GALLONS PER CYCLE: PUMPANO CONTROLS OPERA710NA L. ENUMBER OF ""(1111'1r Wf Lt Holt DIN(. VE NT T() I HI SI/ (DIFFERENCE BETWEEN M LINt AIH INl f 1 PUMP ON A ND OFF) DYES ❑NO SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing n1AM1If 11 %IAil141,11ANOh+AHKINr, or excavation, (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: BED/TRENCH WIDTH LENGTH NQ of DISTH PIPE SVACINIV cnv H wslrnit-i E.N THE NL'FIM1InI' PIT DIMENSIONS LH AVF L MP 11 FILL )F H IrISIII 191'f DISH PIPE DISTR. PIQ~ MAT RIAL N( IH NR OF tH fV IIFI ELEV END P1"NI WILIHUILDING VHF L LOW PIPES AHOVECOV I , PIE FEET F UMBER,LIN ANEAREST_ Z MOUND SYSTEM: ~,7, Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- DYES ❑NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER Ti %Tl6iF Pt lihl(A~NI NI MAI/KI HS nll7:'VV'y" It INWI 1 I S `-]YES ONO ES LINO CENTER UE P111 gVIN TRENCH RED UE VTH qF TOPSOIL SODUF I, SF[UID E UGES M171J1 (,IU U DYES DNO DYES D NO DYES LINO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH TT NI, 111 NO.OF LATEI7AL SPtINA PT1/ HI LOW PII'1 f H L UFVI11 AHI W( CUVI H TRENCHES DIMENSIONS tLFMANIVF ULU POMP MANn OIU DISTR PIPE E HIAI N1 Inti DI InS OI PIP( lilti liuHU O(rN Vn'I Air.IinlAl gtN(K 1N(, ELEVATION AND ELEV Dln ELEV PIPES Dln DISTRIBUTION INFORMATION HALE SIIF HOLE SVACINO UIi1LLEU COIUIF CIIr FATE HIAL HItAt 1 I1 I(;tNIH F SV(INDS TO AVPIIOVI I, PL ANS DYES ❑DYES CJNO COMMENTS: PERMANENT MARKERS. OBSERVATION WELLS- 7'F' UMBER OF PROPERTY WELL BUILDING EET FROM LINE DYES DNO DYES DNO EAREST-_ Sketch System on Reverse Side. Retain in county file for audit. SO 'NATUR lli lE e DILHRSBD6710(R.01/82) C ' SANITARY PERMIT APPLICATION COUNTY L•DILHR In accord with ILHR 83.05, Wis. Adm. Code , STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8% x 11 inches in size. -See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES ❑ NO PROPERTY OWNER PROPERTY LOCATION /'P F '/a IrV %a, S T ?-I, N, R S! (or W PROPERTY OW R'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME -e, /?1114 /)~-7 CITY, ST E ` ZIP CODE PHONE NUMBER CITY NEAREST ROAD, LAKE OR LANDMARK 1~ 7 V ILLAGE : t414 I✓rM ~WfIJ r~~.s TQWN OR II. TYPE OF BUILDING OR USE SERVED: Q c"Q70 - ~S-lod Number of Bedrooms if 1 or 2 Family 2 OR Public (Specify): III. PURPOSE OF APPLICATION: (Check only one in ##1. Check 2,3 or 4, if applicable) 1. a. 0 New b.X00Replacement c. ❑ Replacement of d. ❑ Reconnection of e.0 Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in ##1 and only one in ##2) 1. a; Conventional b. ❑ Alternative c. ❑ Experimental 2. a. ❑ System- b. E1 Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a.XSee a e Bed b. ❑ Seepage Trench c. ❑ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): t 5 8 Feet Private ❑ Joint ❑ Public VI. TANK CAPACITY Site in gallons Total of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank MAO El F-1 ❑ ❑ ❑ Lift Pump Tank/Si hon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name (Print): Plumber' Signature: (No Sta s) V"MPRSW No.: Business Phone Number: 01 0 -e," 2 y / 77 2-5 7-1 Plumbe ' Addr s (Street, City, St e, ip Code): Name of Des' r: l/ s,gn z .n c VIII. SOIL TEST INFORMATION Certified Soil Tester (CST) Na a CST # T CST's ADD ESS (Street, City, St at Zip ) 11~ Phone Number: ~cGn~ Co S~ IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee Adverse Determination -,44 ~ X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, 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 Location of Property 1% It, Section 9 , T~N-R~ W Township 0 A A2 2 kM Mailing Address ,Q cyJ 534 2- Address of Site Subdivision Name Lot Number Previous Owner of Property Total Size of parcel (o - ,q L Date Parcel was Created /0 Are all corners and lot lines identifiable? x Yes No Is this property being developed for resale (spec house) ? Yes kLO No Volume J 3 and Page Number 70 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 refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTy OWNER CERTIFICATION 1 (We) cetti6y that a t Atatementh on this botm cute tAue to the best o6 my (out) hnowtedge; that I (we) am (ane) the ownet (,s) o6 the ptopehty da CA bed in thi.6 .inbotmation 6otm, by vi tue o6 a waAAanty yleed teco ded in the 066ice o6 the County RegiAtet oA Deedb ass Document No. "J'l d p and that I (We) ptaewt2y own the ptopo.a ed 6 to bot the sewage d is po.a d yb tem (ot I (we) have obtained an easement, to nun with the above deseAi,bed ptopenty, Got the conbttucti.on o6 said .sybtem, and the same has been duty tecotded in the 046ice o6 the County Regiztet o6 Deede, as Document No. 1 / J, ) SIGNATURE Old OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) TE SIGNED DATE SIGNED H r ST C- 105 9 H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County Z C d H OWNER/BUYER ROUTE/BOX NUMBER 2- 6x, X77 Fire Number CITY/STATE \0 R-✓' ZIP ~77~0 2-- PROPERTY LOCATION:Section T~N, R a W, Town of St. Croix County, Subdivision 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 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 stems 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 E z I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with 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 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. DEPARTMENT OF REPORT ON IL BORINGS AND SAFETY & 43uIL04N INDUSTRY, DIVISION ~ABOR AND PERCOLATION TESTS (115) MADISON, I 537077969 HUMAN RELATIONS __j"(1) & Chapter 145.045) LOCATION: SECTION: OWNS Y: O. NO.: SUBDIVISIO NAME: 1%►J% Tz9N RieVo w F= ,J [OT - - - COUNTY: OW~N!ER BUYER'S NAME' MAI LINO ADDRESS: OJT Gear lX t_E "fL W*4? - 1/0/1 TW ffJ LA r-" Xtr. P -oiaal 7 S ,W I. USE DATE$ OBSERVATIONS MADE Residence ❑New XRapisp Q E PIM m F L A W w~ l Or 1-t>: RATING: 8•- She sukeWe for system Um Sks unsuitable for system N - 2 1 NK: RECOMMENDED SYSTEM:(optional) ros 11 10-isOul SOU S U IDS U C am V. iz ' G- Z3 c C~ If Percolation Tests are NOT required D S GI ATE: If any portion of the totted area is in the under s.H63.09(5)(b), indicate: N, A, rr L s s iFloodplain, indicate Floodpiain elevation: f v .4., ' Z> Ee- /MA L. PROFILE DESCRIPTIONS r- MILT BORING TOTAL L WITH S, COLOR, T R AND DEPTH SELEVATION BSERVEQ EST, Hi TO BEORQ2K IF OBSERVED EE ABBRV. ON BACK.) B- p8 7, z t. J~J6 > '7.a81 osa' L L ' R R 2.00 4 S B- 3.so MEt,s B-7 7, 757, S19 Nl > 7S o.~s gi 5,L 3's 7.757 W is t.., late aC Lr M&, B- B-~ Jfl 50 ~ i:~ 0 L' >1©,sa i i.'7 LSw &.rsNr rtii oS~. B- D fMA L PERCOLATION TESTS FEtT TEST DEPTH WA R IN HOLE TES IM RATE PER INCH E NUMBER TOC31MS AFTER SWELLING INTERVAL-MIN. P. 311 rJON11- -V.41 It ;-P > (0 P. 4.00 C42me 1. Z >6 P- S ` L .L } P- P L.ev Tl P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate sale 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 rcent of land slope. , rt:f Lc 0~ *It SYSTEM ELEVATION . t r " 'rT Lm I t , i ~i,44, Y TCj', I • 3 L" Le AT110N'a t~ t7 ~ : 4V s dQ ,ant t _ i TZ H/,Je/ud7 os r • ~ 1 ~iL i 4 C64 6 c ZD~ j Y ogp/.of~' ! i rorir,oe Dayd ~ ~ i ~ i ~ s ~ i IV-he IT 1 i 14 1, the undersi~Inod, 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 am correct to the boat of my knowledge and belief. NAM print : TESTS COMPLETED ON. &AEs C. ~'vsc1~ ODRESS: CERTIFICATION NUMBER: PHONE N MBER(optional): ` ~7 S~co~ r<; ST /vbsonl Wi 5401 568 386.-40an CS NATURE: j: Original and one copy to Loaf Authority, Property Owner and Soil Teter. .r 43395 (R. 02/82) - OVER - Timm JOB lea ~P ro Lsk/~~ _ l SHEET NO. OF Excavating Co. ~r DATES ' - RO CALCULATED BY R 1, BOX 192, Wilson, Wl 54027 CHECKED BY n rrf~'~(`u ZA/ SCALE we X~r f oI'D err, _ I I I , ~ I l/2~L 1 d- rns~tc~rori~TM ~ZG--~B qq r` vN(nnr' '&1 v A: nr.. 0Mw M.. 01471 PAGE OF Z- ~ CroSS Seel'lon O~ A eS Se-0 ys tern Fresh Mr 1111016 And Observation pips Approved Vent Cap Minimum 12" Above Final Grade 20- 42" Above Pipe _ 4" Cast Iron To Final Grad• Vent Plpe Mash Flay Or Synthetic Covering win. 2" Aggregate Over Plpe Oletrlbullon Plp• 0 0 0 0 0 -Too 6" Agora2ole Beneath Pipo Perforated Pipe Below o -'Coupling Terminating At BOtlam Of System j PruPOseD P1nrj ``qr;%A-c SOIL FILL DISTRIBUT10k] PIPE APPROVED S4W1ETIC COVER !`-'MAT~RI^t- OR 9" OF STRAW OF AGOREGAIE OR MARSU HAIJ 1tLEV. OF Q3vf FEET-.. OF 12-21/2 AGGREGATE e8\\` DISTRIFSUTIOU PIPE TO BE AT LEAST IUCHES BELOW ORIGIMAL GRADE AUU AT LEASTP-0 IMCHES BUT 1.10 MORE THAiJ 42 INCHES BELOW FMAL GRADE MAXIMUM ®EQT1♦ OF E-ACAVATIOP FROM OKI&VAL 6KApF- WILL BE MINIMUM ®EPrh of EXCAVATION FROM 01KIGIbqL C394D€ WILL BE SIGMEO: ~jb G' ~ Q Gc~Qy LICEMSE AJUMBER: M~"(S , 225 O f DATE: