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HomeMy WebLinkAbout020-1159-30-000 0 fA O I 3 m o d Lo~ 3 (D CD I p ~ 'O ~ • `G ID m 3 s z 0 -4 10 1:1 CD 3 CD 00 Q I to CN\)1 W A OD CD 0) to 3 CO (D C1 O 7 W O O co Oco OQ = O c.n N) co C: 3 -0 C) 3 fn O Q N ~ c CL CL rn m a' ID N j w ? 3 O N' O C O W ' O m m m m , Q 0 CL OOD co (.0 O co 'O n r co 3 Z i I rt ~ z O O O o 5~ U) 0 P3 a H n 3 Cl) N co t y w c 3 CD m ~d o td o 3 v v O (D 3 ~c 4 c+ •a o rt ~C m = CU U) x W z 3 in V A ° C 00 z Oo O m CD O 0 x a 7 O N) 10 o y H 4~ O 7 c z CA v N -7 a w m C 0 3 7 r I t-' z cn A Z ° m d W r w c - r z CIO o I ~ 0 a A O V 0o b M W m po o 0. (D z m a 3 (D Z p m (O 0 :21 (D H rt p F'• N n 93 Fl CL - N) ;w (D F-h O o Fi rt u) A o a CD I l o it v N 00 I 0 w m w < Al rs~ O 'r v I o g c ,b O L ti 'y Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 7~e TOWNSHIP ✓L 4G~IA SEC. _ T N-R W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION ,rc, LOT 7 LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of 11HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM _ Y dam" 5 I _j X21 J y~~ ~ J INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used G~ `V/"Ac e, Elevation of vertical reference point: mil} G z Proposed slope at site: SEPTIC TANK: Manufacturer: &A Liquid Capacity: _j 2 1 a Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest- Road: Front,O Side,@ Rear, O d feet From nearest, property. line :.-',:Front 10Side, J( Rear, O S feet Number of feet from: well U , building: / er (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE t 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, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: Lendth: Number of Lines: 9 Area Built: P2 0 Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, (9) Rear,0 P't. Number of feet from well: ~Q Number of feet from building: v 7 (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, 0 Side, o Rear, 0 Ft. 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: e > Z;Z 3/84:mj 74 ? ~A Oct- t 13 1 b Flo S ~G ~ 5D~ 1 ►e yv~ y ~ Gv P Crum. L ~ ~ Sc DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & WUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 E7CONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number: (if • ❑ Holding Tank El In-Ground Pressure 1:1 Mound NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSP CTION DATE. John Trieb R. R. 5, Box 5248, Hudson WI 54016 / - F- BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.. NE SE Section 20, T28N-R19W Town of Hudson Lot#7, Pine Grove Hei is Name of Plumber. IMP/MPRSW No.. CSanitary Permit Number: William Schumaker 6382 St. Croix 74980 SEPTIC TANK/HOLDING TANK: MANUFACTURER. r LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER 125 C '0 l PROVIDED PROVIDED. 6 DYES ONO OYES ONO BEDDING: ENT DIA.. VENT MATI HIGH WATER NUMBER OF ROAD PROPERTY WELL. B)ILDING. JVENTTOFRESH ALARM LINE AIR INLET. DYES ONO DYES DNO FEET F R OM NEAREST DOSING CHAMBER: MANUFACTURER. MIYLIQUID CAPACITY PUMP MODEL PUMP:SIPHON MANUF ACTUREH WARNING LABEL LOCKING COVER PROVDEDPROVIDED: ES ONO DYES ONO DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS. OPERATIONAL NUMBER OF PROPERTY WELL BUILDING IVENTTOFR ESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET. PUMP ON AND OFF) OYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing I 1111AMIT111 MATE RIAI AND MARKING 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: WIDTH. LENGTH INOOFIPE ISTR PSPACING COVER JINSIDE UTA SPITS LIQUID BED/TRENCH TRENCHES MATERIAL, PIT DEPTH. DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR PIPE DISTR PIPE DISTR PIPE ATERIAL NO D(ST i NUMBER OF PROPERTY WELL. BUILDING VENT TO FRESH BELOW PIPES ABOVE COVER EL EV INLF T ELEV. END PIPES LINE. AIR INLET. ,f FEET FROM NEAREST ► 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 MEASURED. DYES ONO SOIL COVER TEXTURE PEHMANI NT MARKERS IIIIISIHVATION WELLS DYES ONO OYES ONO DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL SQU)FU SEEDFD MULCHED CENTER EDGES DYES. ONO DYES ONO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO UISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV. CIA. ELEV. PIPES DIA.. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS OYES ONO OYES ONO COMMENTS: PERMANENT MARKERS. JOBSERVATION WELLS. NUMBER OF 1PROPERTY WELL. BUILDING. FEET FROM LINE. DYES ONO OYES ONO NEAREST---> 0t/ o Z? Sketch System on r v .1 Retain in county file for audit. Reverse Side. JSIGNATUR TITLE. DILHR SBD 6710 (R. 01/82) 77 w15con5,n 10 APPLICATION FOR SANITARY PERMIT D I LHR &`~COUNTY OEPggTR7EnT OF (PLB 67) inou5TRV,Lg9og6HumqnqELqrlOns UNIFORM SANITARY PERMIT # ~`t98Q -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER rpGh~ MAILING ADDRESS ~3 T P OPE T L CATION CITY: % 1 Al 4/ i 461 /4 = 1/4, S , T N, R j E (orW VLLI-WN O LOT NUMBER BLOCK NUMBER SUBDIVISION NAM NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED . OV 0 y 2 /Y'1 [X1 or 2 Family Number of Bedrooms. ❑ Public (Specify): THIS PERMIT IS FOR A: K New System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. 54 Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank ❑ System In Fill ❑ 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 Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total #of Prefab. Site Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): WATER SUPPLY: 0 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): Signature: ~J IVIP/MPRSW No.: [Phone umber: Plumber's Address: Name of Designer: COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: p~ O ❑ Disapproved Owner Given Deterlm nation Reason for Disa Approved ❑ Adverse pproval Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber r INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 639$ 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.), location 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/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. - - - - - - - - - - ff- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property ©i1 n I Y i Location of Property E 'r1%, Section, T N - R W 'T'ownship I Ju- So o Mailing Address f)l--r-le.) 1-00e, Pe h 4s Lo I eo Lc 7-C-- &'t' 7`a Subdivision Name P r e You He_ f• h -S Lot Number Se y e n ( 7 Previous Owner of Property Total Size of Parcel I. 33 4d r. Date Parcel was Created Are all corners and lot lines identifiable? _ Yes No Is this property being developed for resale (spec house) ? Yes No Volume and Page Number I QI O. 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) eeAti.6y that aU statements on thus 6ohm cute tAue to the best o6 my (ou%) knowledge; that I (we) am (oAe) the owner (s) o6 the pnopeAt y dm cAibed in thii s .016u,Lmati.on 6o4m, by vi tue o6 a wahhanty eed Aeeokded in e O66ice o6 the County RegiSteh o6 Deeds as Document No. 1sr~nd that I (we) pn."entty own the puposed site 6oA the sewage di6posat system (oA 1 (we) have obtained an easement, to Aun with the above de,6cA bed pAopenty, 4oA the c n,stnuction o6 said system, and the same has been duty %ecokded in the 066ice o6 the County Reg-usteA o6 Deeda, a6 Document No. '~OcaS 3 ) . S GNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) /U"ZZ DATE SIGNED DATE SIGNED En H a STC - 105 r r a H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z . t7 a • OWNER/BUYER ~Jp Yl Y' e • ROUTE/BOX NUMBER 6_14 T4~ ~X Fire Number ~~,~Q/~~ l.Vl ZIP ~5°~~ih CITY/STATE PROPERTY LOCATION:A(E14, 5C !4, Section, T7,q N, R W, Town of /✓aal_50A) , St. Croix County, SubdivisionpjjleC;rvge Ile tg~J~S , 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 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. -3 0 I/WE, the undersigned, have read the above requirements and agree N to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- b ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within days of the three year expiration date. SIGNED Zw DATE U^Z 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. D N r ' S Ul Ul N p W N N ~ ~ ~ (gyp ~ ~ `G O ~ (D (D o o 7C a 3 A A (D ~ y, 0 c C co~ Z ? O? ID 'o a tD (D O A CD m c (D CA (D N N ..a vl m O r► a p A w o o CD :E n S' m a (D = 8 Q r A 3 a O ~ cp ~ W 7 7? C O> Al O O CC Al ~ ? > G C- c: 3 C O 3 O a A Zto C Q m jocm o~(=Dr oCA - W y - co D m wAC~c7~ < N Q ~ Q O (D p O N O C - =5TO ac) =r 4 a A w a O QO W C _ O r. ~ m O N ~D U) (D Z a 7 fA `G ~ ~ (O c~c ~I w CD cD Q: 5'= CD C m CA (a cm Jw CD o A a ~ m M w s ~ tv o w Qy ~ ~ N sacs' V) ~ 0 avci w w D.~ C m E; -4 ~d 3 c~ -Coll am - a n 'ate w~(=D* _ o 60 o a_~~ a N c CD cQ~c3CL ro = m m CL Q A Q~ w CLw 3 co ~.wo 0 OO D coo acs cco°' c -ic~cm s ' CL ~co ~c~D?w=+A~ c.~3 c mO°,3 i 3 Y w a a 0 CL 0 to z DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BU{ DIVISION IN ~1Jt°YOiV15fON i +t JR BOX ND C PERCOLATION TESTS (115) MRL7)soN w1 7969 HUMAN RELATION (Hfi3.09(1) & Chapter 145.045) 1_M~71-, 51,69 SECTION: - T HI MH1 Y: TOT NO.:BLK. NO.: SUBDIVISION NAME • NC I/S61/ ao /Tz S N/It/stor ,Sa COUNTY: WNE 'S A L N D `~TCka►X 36 S~CtP6iy Si okTN ubsoxl W1 i USE DATES OBSERVATIONS MADE NO. BEDR 1COMMERCIAL R TION: R A ON TESTS: Residence 3 New ❑Replace n1-fi /1~5 ~~~5 Q`T 20 /~ja t ~ILs 1900K QGL S8 -504-s t~Z - c~r'KUai'L~r RATING: Sm Site suitable for system U- Site unsuitable for system ICONV N ! N L: MO`U~]N(►D: 1N-iROOU"N E S EM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) i'LUS OU ts.~l U Y4-t5 L._7U EIS ~U ❑S ZU CUI/t/6~/ I /aNA L IZCl~ If Percolation Testa are NOT required DESIGN RATE: y If any portion of the tested area is in the • / under s.H63.0915)(b), indicate: CLMsS r / Floodplain, indicate Floodplain elevation: A LLL~~~_ PROFILE DESCRIPTIONS BORING TOTAL a PI ATER-INCHES HA TER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER F.P7F♦# ELEVATION OBSERVED TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- , 0-/•O- &,L TS /•O 2.0 ~i?s ~r r.7-T.tJGRC_b~+ C?Ao /01;.3St' WONE 9.46 2.0.4.0' C To Mit S f6R 4.0:9.4' Rrn r.e•( S I n-/.o' RLL -r7S ac . 6e B 2 9.~0" /ns.lt Nd?VE y' 2a /.R-3,2' Cs .46k -16 t 0-0,1b' $tL TS &,4 L B 3 9,66, d62,sk NaNS 9.60' 7.'%'ed S# v. C) -2` $L L Ts /,2: „L 2. A' z~t G Cciri+ 9,26' /00 ,"X N is 9.2v 3. > 9. io O-o.7'$L LTS o.7-1,7 i&eNs~L e.4'1,7'6Pc:6m g. 10' [B- PERCOLATION TESTS TEST DEPTH WA7 ) HOLE TES TIME -1 H S RATE MINUTES NUMBER f S AFTER ELLIN INTERVAL-MIN. PERIOD I Mop 2 PER INCH P. o Z >tS ~_3 P- z .o ' N"I 6 z > 6 > 3 P- 3 /o ,AS' Z >Ic P_ P_ taUkle tLdV4 ION All fttec W.0-Las Lp o c Tes-T Ig 'M i CaRRt: Pohl tas .o N ~4~sT ~nlau 'LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori 'ontal 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 A land slope. SYSTEM ELEVATION _ goo.©o A N t: q k % L L t ar' N 6N r: ~6X t PA ,rvt'~~ ~kdN CV - Lax y it- /JO.. ♦ XALTeANAT!_ v+'J _ ! ~r3' Z CALL l4v 'ZI ' f I 1 3 S. YSTfr1 ~ / ' 'd A A,, % 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 4dministrative Code; and that the date recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print : TESTS WERE COMPLETED ON: 94*VP Jo 14/v so-4 ONTO E 20 /9$ S' ADDRES CERTIFICATION NUMBER: PHONE NUMBER(optional) $ r'~ ~T1 T /VoR'c+J ct& o Wl ~'a4- 38G-5999 CST I ATURE: l DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SSt>~~1 SkIP~j pVER_