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HomeMy WebLinkAbout016-1077-10-000 n CA O 3 v n ID O o C I C O rD ID d CD n fD -a Ss~ • w # 'G CD m m ^ I CD A7 o y o ° CO CD - CWn - f ' • . = e). 0 y Cn y U~ ~i~ \ I (7 Grp ( 3 o in g o CO CD C4 4' 0.0 girl a N. 4.. F . F.. m tt O V N CD ° W cq I i 1 N CD Z° to ° m m o m rt. w c`n m c=i m m Q. L' m m n o o CD y a m 2 -1 o O n Q, Cl, i I ~1 O OD N 0000 3 m ° ° o A~ 1.0 n tr tr I I n co N J o ,cu 'C ''C N N m k N o rt. O \ 0 I O CD Co- y N C co co rt Jp G 3 Q I o o w -4 w 'a lot O M O rt y n y 'ij rrt q o CD ° ® IV IV t 1 rfi a O tr O c°n (co w m m m co W O n Cl) o c !i En :7r ti•,D ~O~i I y Ul Ln~Mv c1, b b ti C1, a a c 't7 m rt h O o a IV -0 0 cq rt o + rt I C~ C) o ti m tp ~ (n ti I a a m -t 0 n _ n ` z: m I o a v 0 ~ v. y Q O C1, rt rt Ln Ln w m v cn Q° 1 a O a• w p m a m D, " 0 0 n ID (D CL ~m iI z ° z-IZ l~ v o > CD 0 O ti 3 a w n I s 0 `r . Z5, CD 0 o m H (n ►r m I y p rt rot w n O q, CD CD i•i :r m (n N m (n o a a I w D m O CD Q w I z to A Z m n k w. O C0 rt ` _ A d C rt I 0. y m rt o rip C" I W m o cn co I a z m 0 3 A (n Ln I °o z cn 'a 01 ,tr I z m m m N 0 0- H• CD ° Q_ o S I o ° rt. k I o N a T 'Y a ~ m z a (n lei CD O _ O I = N WN n ,I m a ►ti, R7 rt I I a c rt. w. c wn w it A CD 3 I fi C7~ I x Cn v q I 0 :3 cz CD q I N ~ R I 0 b (D dv o C) O r e I ° Q Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT N-R W OWNER ,48 I/ ;)V l eq e& TOWNSHIP gaeN w d 0 d SEC. , T3 ADDRESS ` ST. CROIX COUNTY, WISCONSIN G,4 eNWe®d 6 1PZ~ /I T SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I11iR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 14 Sc~P~/C tANk oaa yh P t W L , N Ilk at Nw y ld~p X . INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used +eROtS Hwi)e 1.2e Elevation of vertical reference point: ld d Proposed slope at site: SEPTIC TANK: Manufacturer: Cn,/eet:K X Liquid Capacity: Number of rings used:_ Tank manhole cover elevation: ~Q;E' fQ2. Tank Inlet Elevation: 6 Tank Outlet Elevation: Number of feet from nearest Road: Front Side o Rear, O 1064, feet From nearest property line Front 10 Side 10 Rear, O 1,0'a feet Number of feet from: well , building: Z7- (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE M PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Mode Pump/Siphon Manufacturer: _ Pump Size Elevation of inlet: Bottom of tank el tion: Pump off switch elevation: Gal s per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest perty line: t, O Side, O Rear, Q Ft. Nu of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: i Width: Leng+th:_ .~j D . Number of Lines: Area Built: ~da Fill depth to top of pipe: Number of feet from nearest property line: Front, ® Side, O Rear, 0irt. g Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT t Size: Number of pits: Diameter: 4 Liquid depth: Bottom of seepage pit elevat Area Built: Has either a drop box O or distri on 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 to Elevation of inlet: Number of feet from nearest property line Front, O Side, O Rear, 0Ft. Number of feet om well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: License Number : 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. 60X 7969 BUREAU OF PLUMBING MADISON, WI 53707 ~ ONVENTIONAL ❑ALTERNATIVE State Plal.D.Number: (If -ignL ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE: Marvin Tei en R. R. 1, Glenwood City, Wr 54013 1-95-9S 0.30 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: SW NW, Section 35, T30N-R15W, Town of Glenwood Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Gale Smith I5690 St. Croix 69607 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET EL V. WWDED. NG LABEL LOCKING COVER 1012, P PROVIDED: z`4 56 ES ❑NO ❑YES ❑NO BEDDING: VENT DIA.: VENT MATLL. HIGH WATER NUMBER : PROPERT WELL: BUILDING: JVENTTOFRESH ET / n ALARM: FEET FRO(''Z LIN} A ❑YES NO \ ❑YES ❑NO N~lv jl DO SING CHAMBER: MANUFACTURER: 71`YNGS LIQ UID CAPACITY PUMP MODELPU / IPHON MNUFACTURERWARNING LABEL LOCKING COVER PROVIDED: PROVIDEDE❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OP ER ToNA NUMBER OF PROPERTY WELL. BUILDING: JVENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) ❑YES O NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of pl wing EMATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until F ACE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH: L G NO. OF DISTR. PIPE SPACING. COVER INSIDE DIA.-. *PITS. LIQUID BED/TRENCH TRENCHE MATERIAL: PIT DEPTH: DIMENSIONS J GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MAT RIAL: NO. DISTR. NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH BELOW PIPES. ABOVE COVER. ELEV. INLEJ7~. ELEV. END PIPES FEET FROM , LINE _ AIR INLET: 7 l) Sal UI' ~ 7 ~ NEAREST-w- MOUND SYSTEM: 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- meets the criteria for medium sand. TIONS MEAS ED. ❑YES ❑NO SOIL COVER TEXTURE JPERMANENT MAi(KEEI$ OBS RVATION WELLS ❑Y ❑NO ❑YES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED = F TOPSOIL. SODDED. AEMULCHEDCENTEREDGES❑YES NO ❑No ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH: TRENCHES: LATERAL SPACING: GRAVEL DEPT BE W PIPE FILL DEPTH ABOVE COVER. DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MNO. DISTR. 1-:51 R. PIPE DISTRIBUTION PIPE MATERIAL & MARKINGELEVELEVDIA.ELEV.PIPEDA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: ❑YES ❑NO _ ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: j ( ❑YES ❑NO ❑YES ❑NO NEAREST 4L 00 s~ 6, A, 0 /L J 0 OM Sketch System on ain in county file ar audit. Reverse Side. - SIGNATURE- ~ ~ TITLE:' DILHR S B D 6710 (R. 01/82) mllli- (~rR Wisconsin APPLICATION FOR SANITARY PERMIT c DILH , . ` /C? f X COUNTY (PLB 67) UNIFORM SANITARY PERMIT # ol=paaTfnenr of ~ inousTav,LasoasnumancLFanons 9/d -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8%x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS D e ri/il PROPERTY LOCATION CITY: VILLAGE: Sk1/4 /4, S :S _j , T S11, N, Rf' ,lor W o ,n' LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER r C 16P - 1V77- TYPE OF BUILDING OR USE SERVED `~-LLD 1 .1 or 2 Family Number of Bedrooms: ❑ Public (Specify): THIS PERMIT IS FOR A: X New System ❑ Tank Replacement ❑ Repair El Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. ❑ Seepage Bed Tel Seepage Trench ❑ Seepage Pit ❑ Holding Tank System-In-Fill jj]] In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity ~(S Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: c ^S IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): v~ ~ C, ,670<j X Private ❑ Joint . ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signatur PRSW No.: Phone Number: u-;. , r , 4,. Gam' • ~-r.~ y Plumber's Addr s: Name of Designer: COUNTY/DEPARTMENT USE ONLY Signat a of Issuing Agent: Fee: Date: ❑ Disapproved ❑ Owner Given Initial ~ J ~C aJ Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: i r' DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.) ; 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms,' etc.),' Iodation of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. APPLICATION FOR SANITARY PERMIT S T C - 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/contracto-g,("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 `W/ 4 /V4~/ ''4, Section T 2j2_ N - R W Township (~'G e Lr1[~ Mailing Address JQ~' 043 Subdivision Name Lot Number Previous Owner of Property A? D 44 ~l Total Size of Parcel ZZ O id Date Parcel was Created R!12? Al RA .9ef Are all corners and lot lines identifiable? Yes No Is this property being;developed for resale (spec house) ? Yes _ No Volumeand Page Number /7 as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1 Warranty Deed 2. Land Contract 3. Other recordings filed with the Register of Deeds Office 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 the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (We) ceJctiby that a.P2 4tatement6 on this banm ate tAue to the best ob my (out) knowledge; that I (we) am (cute) the owner d b ) o b the pto pent y deg n i.b ed in th z .inbonmat.ion bonm, by vi tue ob a wathanty deed tecotded in the 066ice ob the County Registeh ob DeeA a6 Document No. and that I (we) ptaentty own the pnopabed site bon the bewage paaa~system (an 1 (we) have obtained an eabement, to nun with the above dedctibed ptopetty, bon the condttuction ob t,aid 6y.6tem, and the .tame has been duty necolcded in the 046.ice ob the County Regizten ob Deedb, a~5 Document No. 7~~ SIGNATURE OF OWN SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED H • • y S T C - 105 r ti SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d OWNE BUYER NI f1 V / N 7e i~eN ROUTE BOX NUMBER Fire Number-' CITY/STATE 6:1 etNtc<ao d el Z IP PROPERTY LOCATION:_S_YV '4, ~'-4, Section_?,~_ T_?o N, R/_:$-W, Town of ~LeNw©u d 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 falling 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 E I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- 'v 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 e-A 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. i v r LA x ~ s N g a ow xwnRc o o..3 ca :,r gw fO o ~`<w i c S ° c y u°n c m twn N a N o O 1a g a ° c og.w po ° phi o ,~cu w w Qo _ =w-00 ~wMay:A~ °ma r---L < 8r co03a o0 MCD OD 3 00 w CO 3 c' l< C- a c o 0? N a~ a O 1 7 y=~Dw w.-.t' O w l O ° d w low a'A;c~~Di t<p m c cn ' cp sr- O r.oo aD w°=o c 1a °'•mto o aQ0 w 0 0► ' 0 -0 y N y W" w y C N 1 y? w o co 0 D wwCD .•w-i' o Z aCDo y w w ~ fOD W 2:a ((OD ° CA fm 0 a > D a~ a N 0Qo w @E aco*m~ (A v 3w u,yww_. G m (D C CL O y cD to . w ,!t ii, 0 N ~oc woa=ocoo a -•i CL c Q° c f' 0 CL f yccawo m w o w cD • O cc y O O a v' y o ° c '<co cu 3 rn A m p c -4 (p m ~O y' ~ n N O d O 7 o (a a C y c a c-4 w -,w-Imcw Si B O O, ~ =r A CL C °a ° 3 s m a .:~•~~:"~y: a 3 V 4 DEPARTMENT OF REPORT ON SOIL BORINGS AN G~ . ILDINGS INDUSTRY., + ;'p t;t IVISION LABOR AND PERCOLATION TESTS (115) `n ~~,P OX 7969 HUMAN RELATIONS W NI WI 53707 (H63.090) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOTNO.:BLK.N DIVISION COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: S4 . r u i r IJ 1A -re;,.- abilwo-d y0/3 USE DATES OBSERVA S MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: [Residence YNew ❑Replace 4~' a~ 11! f RATING: S= Site suitable for system U= Site unsuitable for system CONVmso L: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM:(optional S ❑U 'S ❑U ❑ S (g)U ❑ S ®U &O-qyew onq If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s.H63.09(5)(b), indicate: F Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 13-/ U? f ~ t9 ti t'°' > , 8, 0 bl7~' 4, _.Lsw 3d /15 42OW-3 B-„Z /0/1, u > I, 1 -3 "19 3- OR 4914 C 1 B- PERCOLATION TESTS TEST DEPTH, W TER;IN H9 ° TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AF ( R S~VELL'l G INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- 1 AT No p ! / #1 1 P_ rr . .3 7 41 1" 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 ltd I E t I j _ ~ r _ ~~o _ t' _ _ 4 € l [ i E r _ _ d.,.W ....,.e~., i E 1 4 I, 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: A If ADDRESS: CERTIFIC I NUMBER: PHONE NUMBER (optional): r noWnYl" CST S G ATURE: "CTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. X395 (R. 02/82) -OVER J ' r M 4 t TRL _,T- _ _ 1 C a FORM 116 - D - 6396 To be a cc r and ac test, your report must include: 1. oimpip- ' HPscr'l0 2. The _ whether this is a re !nce or commercial project,: 3, MAXI,"' ' - or commercial use 4, Is is E FCif# A W,; . T NLY IF ALL. _CONIDITIL.~ is and cornp t; 7, Drawing to seal A point dre clearly shown, an ; t as, flood plain data, per rr ti T T FILE 'I, "VIATION C CERTIFIED SOIL TES, and Textures Other Symbols s - Pa. , - _ r I _ lit It ° f, r~ J TO THE OWNER: Tt it 'est report is the first st, i curing a sanitary permit. The county or'' ay request ~n of this soil test , prior to permit issuance. A cw- the private s.-rn and a permit _ p, mist be submitted to the api j rity in order to o ertni . The sarfiTary per tit st be obtained and postQ'd prior to e st t of*any construetio_n. Smith Plumbing & Heating PHONE (715) 265-4838 I- ill-It GLENWOOD CITY, WISCONSIN 54013 ~r f, ypAR 0 vars r3 0 Z 00 of S, ' l k V, J~v /