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HomeMy WebLinkAbout030-1093-60-001 n cA O ''n n Lo1 v c O F; 3 . y v c CD C3) O C O O N co _ 3 ° C L W ° -r O 5 rt W O O- Z CD cn CD W O rn rn W t_ :5 O ° '0 (D (0 O SL !n W W 1 N s N C% O O A O~, O CD CO C) -t, co cn O j Qo 3 N ~ ~ O O C v O O D d a = y D A N O I O c o O C W O O O O cn 00 cn o O C 0) Z C d ~ o Z * < CO Z j A vcA n D 3 v v q O co N cn a) R 77 R (D m - A Vl (a !V N N 3 SL 2 ~ i, D) W _ N Ic 3 _ z m z O D CD O a v m m N. CD N N N C (D (D d 1 O Z M A Z A 7 d A Z G) CZ W N W A < O CL Z 3 A .Z1 O Z <D 3 j g Z C W I2 ~ o - T Z O O t F Z A 4 N N O O A c b o ffl o r O O O j Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER :..moo-f'7< TOWNSHIP SEC. 3 T ;~Q N-R~-W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION 1gOT ~3 LOT SIZE ! ( . v3u- 1~~3 - ~°-cz~ 1 PLAN VIEW Distances and dimensions to meet requirements of ILRR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM j; 0 '5 Imo/ ~ 1 r- d- INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used --v fJ~ ifs~ Elevation of vertical reference point: 'rJ Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: G Number of rings used: L Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side 0 Rear, O z,-', feet -From nearest property line Front, &Side,O Rear, O Les- feet Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE 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: Length: Number of Lines:~ Area Built: ~r Fill depth to top of pipe: 32 Number of feet from nearest property line: Front, O Side, O Rear P't Number of feet from well: Number of feet from building: (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, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: ~L~,Lc~-~. r Dated: Plumber on job: License Number : 3/84:mj DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS INSPECTION REPORT FOR P.O. BOX 7y69 PRIVATE SEWAGE SYSTEMS SAFETY & BUILDINGS MADISON, WI 53707 DIVISION BUREAU OF PLUMBING CONVENTIONAL ❑ALTERNATIVE El Holdin Tank Sate Plan LD Number 9 ❑ In-Ground Pressure ❑ Mound ulasslgned, NAME OF PERMIT HOLDER Bradley & Maren Coulter ADDRESS OF PERMIT HOLDER INSPECT "DATE Hudson, WI BENCH MARK IPermanenl reteren e , . c point) DESCRIBE IF DIFFERENT FROM PLAN / I E,4_'LEV..,S CST RE F1 REF. PT. PT. ELEV NW-'4 NE4, Section 32, T30N-R19W, Town of St. Joseph,-Lot#3 c. NarnN of Plumher. MP/MPRSW N,~ Coi,niy William Sehumaker 6382 t San,,d69630 r SEPTIC TANK/HOLDING TANK: S • CYO1X MANUFACTURER ~J • LIOUID CAPACITY TAA INLET ELEV A' TANK OUTLET ELEV. WARNING LABEL ; C/ Gj ~ PROVIDED LOCKING COVER BEDDING VENT CIA : ^f PROV IDE D vENT MAT I HIGH WATER r . (02, YES ❑ NO IALnRm NUMBER OF ROAD : ❑YESNO ❑YES FEET FROM PROPERT WELL NO uN BUILDING TO FRESH I j Y-_ ES _Y(~O NEAREST IAIR INLET DOSING CHAMBER: t! ( DOSI AC HA BEDDING I-IOUID CAPA, I TV PUMP A~1I)DE I - ~UMP.SIVH()N 11 AnJ lJI A(:T liHk V1 ❑YES ❑NO WARNING LABEL LOCKING COVER PROVIDED PROVIDED GALLONS PER CYCLE: PUMP AND CON TFT LS EHn I IONAL (DIFFERENCE BETWEEN _ ❑YES ❑NO JIYES ❑NO PUMP ON AND OFF) NUMBER OF PHOPFHTV VJELL BUILDINr, VENT TO FRESH FEET FROM Nr SOIL ABSORPTION SYSTEM. Check the soil moisture at the dYEh of plowing JI NO_ AIR INLET _ NEAREST---)P. or excavation. (If soil can be rolled into a wire, construction shall cease until ' the soil is dry enough to continue.) FORCE nMF TeH vATE HInE AND r.~AHKINC, CONVENTIONAL SYSTEM: MAIN WIDTH LENGTH NO c7T BED/TRENCH E7IDIMENSIONS UISTH PI SPA) N HFN(~~H[S` ~N:InE l)I,v - /~rEVln,_ PIT D =uoulo A VFI. DEPTH DILL DEPTH DISTR PIPE EPTH FF LOA PIPFS~ DISTH PIPE DISTR. PIPE MATERIAL ABOVE COVER E I f V INL f ! . NO DIS NUMBER OF PROPERTY WELL ELfV FNU ENT TO FRESH PI{ Ens FEET FROM N~ BUILDING V • S /5 AIR INLET l MOUND SYSTEM: - / NEAREST----- o. Jl i Mound site plowed perpendicular to slope and furrows thrown perpendicular Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM upslope: mound systems to make certain that' hat it ON REVERSE SIDE. SHOW ELEVA- ❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE PE I(MANF N T MIT, I HS o!tsLHVAnnN weI Ls UFPTHOVER TRENCH BED DEPTH OVrr+THFNCI11iFU ❑YES ❑NO ❑ YES CI-NTER EDGES U(PTHOF T/>f~507 ❑ND I suln)pI' srtuFn - =ZYESONO PRESSURIZED DISTRIBUTION SYSTEM: _1 YES. YES EJNO BED/TRENCH WIDTH ENGTH NO OF - FL LA TEHAL SPACIN(; (;HA VCL DEP TR yOW PIPE DIMENSIONS TRENCHES MANIFOLD PUMP ELEV. MANIT OLD DISTR. PIPE MANIFOLDMATFHIAL N(7 OISTF2 ELEVATION AND ELEV. DIA DISTH PIPE DISTRIBUTION PINE MnTEHIAL&MAHKING ELEV PIPE$ DISTRIBUTION D1A INFORMATION HOLE slzE HOLE sPACwc, DhILLFD cr)HHFCT I Y COVER MAT EHIAL VFH FICAL L IF T COHRFSPONDS TO APPROVED ❑YES PLANS COMMENTS: PERMANENT MARKERS ❑ NL ❑YES JoBSO HVATION11E ITS ❑NO C! NUMBER OF PROPERTY WELL BUILDING E' ❑YES ❑ NO ❑YES FEET FROM LIP ❑ NO NEAREST - v _k '7.7 y IUIe Z. System on ~Side. Retain in county file for audit. SIGNATUR TITLE ,710(R.01/82) ~ C7 ~ wlsconsln D' APPLICATION FOR SANITARY PERMIT LP (PLB 67) COUNTY - InoUSTRV,LRgOR&HUMRn RELRTIOnS UNIFORM SANITARY PERMIT # i -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/z -See reverse side for instructions for completing this application. PLEASE PRINT x 11 inches in size. PROPERTY OWNER MAILING ADDRESS PROPERTY LO ATION r -Y ( Z 'Lf1/4 CITY: 1:. t41_1 T ~N,R ~ E(or LOT NUMBER BLOCK NUMBER SUBDIVISI N NAM TOWN OF: ~ T ROAD, LAKE OR LAN MARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED mot, / ~~i7 r~ 1 or 2 Family Number of Bedrooms. Public (Specify): THIS PERMIT IS FOR A: New System EJ Replacement Soil Absorption System ❑ Tank Replacement ❑ Repair El Alternate System ❑ Revision El Privy ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Seepage Bed El Seepage Trench System In-Fill ❑ Seepage Pit ❑ Holding Tank ❑ In-Ground Pressure ❑ Vault Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # El Pit Privy ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions issued Total #of Prefab. Gallons Tanks Site Septic Tank Capacity Concrete Constructed Steel Fiberglass Plastic 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. Gallons Tanks Site Septic Tank Capacity Concrete Constructed Steel Fiberglass Plastic Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA (Minutes per inch): REQUIRED (Square Feet): ABSORPTION AREA /t PROPOSED (Square Feet): I WATER SUPPLY: Jr~ 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 M 9 ~e 1 µ / P/MPRSW No.: Phone Number: Plumber's Address: L.L-j~G'"~ Name of Designer: COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ' ❑ Disapproved Reason for Disapproval: JApproved Owner Given Initial Adverse Determination Alternate course(s) of Action Available: 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; stem 6. PRINT the name of the master plumber or master plumband er res ricted pewho rm tlinlt stall tnature b , circle the appropriate license classi- fication, place your license number in the space provided 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 very 2 to 3 years. If you have questions concerning must be properly maintained. Have a licensed pumper clean your septic tank whenever DILHR State of Wisconsin. your system, contact your local code administrator or the Bureau of Plumbing, 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 s old-and-submitted-to this-office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property B f, (V-1 ' e + M 0, - - - - - - - - - - - - Location of Property l,Lo Section T N - R W Township Mailing Address ~110 Subdivision Name Lot Number j c Previous Owner of Property ' Total Size of Parcel d.. Date Parcel was Created noj ~T Are all nerd ndJlot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes ~ No Volume and Page Number I 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, 'certified surve , if of the reviewin available, would be helpful so as to avoid delays g process. I the deed description references to a Certified Surve Map, the the Certified Survey Map shall also be required. y PROPERTY OWNER CERTIFICATION I (We) cmti, y that aQ,Q 6 ta.tement6 on this 4o4m ane t4ue to the beat od my (ou4 knowledge; that I (we) am (ahe ) the owneA (6) o6 the pnopen ty deb c4 bed in .thi.d ) in4oAmat i,on 4ohm, by viA tue o4 a wa4Aan.ty deed neeoh.ded in the Oj 6ice o6 the County Regiz ten o6 Deedd ad Document No. puz entf-y own the pno pos ed dito 6ok the b ewa e ~ppoo Zz ; and that I (we ) obtained an easement, to hun with the above deeeAi.bed upeent ( 6on I (e have conzt upon o6 eaid system, and the dame had been duty necohdedin he 066.ice o6 the County Reg.i.d.te4 o6 Deeds, ad Document No. SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED H z cn H S T C - 105 9 r r SEPTIC TANK MAINTENANCE AGREEMENT 9 H St. Croix County o z ` ry OWNER/BUYER_~C~`Cea'l-~crc~ ~Cc 14~" 9 H rn ROUTE/BOX NUMBER Fire Number CITY/STATE a~L~~.1 ZIP PROPERTY LOCATION: 'V~~'1 Section, T 30 N, R_ 9_W Town of-. Zn---_cPoh St. Croix County, Subdivision Lot number ~3 C 6- m u i 5' per- r I g 7 1 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. H O I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- .u ment of Natural Resources. Certification form must be completed H and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date.l S I C N E D~~~~~c e,~ `~L~ jJ . Owl D/1 DATE -rat 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. 0 r y s s, m m~ p 3 0 or oo co m m c c, m O o 00 a tp A 0- 3 cr 0 cc W-7 > >0`~~ 3~cnco~~~ N ~J D C N 0 COD a- 0 O O N pp 0 CD 0 CD a) -0 CD ~w W CD [D cn CL N fD .n+ CD `C C C~ coo3a o~mmm~ ^ O m c I ca w co o 0) o co 30C ~C-c cFn' 0 > > 0 1 3: N' W C`G Qj a0 _r m 0 _ C O- (n C W O O o O N M' in rD - a D m W 00-N 'U-0 < O N 0 is (D C co Q O A c Wm .00 0 o Dc 0-•m1 C O_ w 0 O - C N n p~ _ O m Cl. E5 - SaQ~ N C ~m o.N~ (n co ch = W (n 0 `D ~ co' D w CD IN - 0) -4 M CD CD - 3mC'cc=r a aCD 0 ( 3 D nnca os~~0 C: W -t SE w :3 CL CD N ~M ~D o ac o f m Cl) v m wm C CDC o n=mS~ M C* O m CD W om v,3=p 55- n 0 a c0 N O Q C, O ~l y 0 O cn O co D G~ j 3 o CD cn (n. c 0-0 G) naionFi CDc.5amo. m i C CL a m cn <fn C,. cyo Na l CD mnc 0co C ~ mm ,3 H a0 v 0(0 a o v, o m 0 co W a o a CD CD Co m =r o CL C m 3 O m w O 0 DJt w5L aCD X03 m CD CL 0 < ° - z o INDUSTRY' DEPARTMENT OF SAFETY & BUILDINGS REPORT ON SOIL BORINGS AND HUMAN AND RELATIONS PERCOLATION TESTS (115) DIVISION P.O. BOX 7969 (H63.09(1) & Chapter 145.045) MADISON, WI 53707 LOCATION: SECTION: ` V4 'V/4 7 Afc,` N/R (or) TOWNSHIP/Nfty}pf may: LOT NO.: BLK. NO.: SUBDIVISION NAME: COUNTY: /BUYER'S NAME: L Z, Q ~ ry AILING A DRESS: 14. CW USE 'C ty) t 1* 4 2- ±T NO. BEDRMS.: COMMERCIAL DESCRIPTION: DATES OBSERVATIONS MADE esidence PROFILE DESCRIPTIONS: PERCOLATION TESTS: RATING: S= Site suitable for system U= Site unsuitable for system CONVZ TI:ION'AtL: ; I I=[]U UNND -PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMLr4S ~u nS ©u ~J ~u If Percolation Tests are NOT required DESIGN RATE: under s.H63.09(5)(b), indicate: If any portion of the tested area is in the ~l Floodplain, indicate Floodplain elevation: '0 S, An Al PROFILE DESCRIPTIONS NUMBER pEVp+-I,N, ELEVATION BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOI WITH THICKNESS, COLOR, TEXTURE, AND DEPTH OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) ZS l l 44- r 1 ` B-.2 B-3 /L1 7 4B- ,z 100 5'0 s . 19 1. If a 3 Z5 z 5 ,33 B- PERCOLATION TESTS TEST DEPTH ATER W IN H OLE TEST TIME NUMBER INCHES FTERSWE LING N L INTERVAL-MIN. DROP IN WATER LEVEL-INCHES P_ PERIOD 1 PERIOD 2 RATE MINUTES PERIOD 3 PER INCH P- 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- of land slope. 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 SYSTEM ELEVATIONS 3 . 13- _ ~n - . 4v W, 7- /444Ym4 r rE 1 3z /n5~r~ll~it~s~ _ 0, N 4all Ste, 3 - F o 2 _ i i L K fir I, the undersigned, hereby certify eJ V y that the soil tifsis reported on this form were made by me in accord with the Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. procedures and methods specified in the Wisconsin NAME (printl: TESTS WERE COMPLETED ON: j ADDRESS: J?,. CERTIFICATION NUMBER: PHONE NUMBER (optional): Z z.' CST SIGNAT Zoo DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DiLH'R-SE--8395 (R. 02/o?) I O V E R . C4 4 F ~ p a ,e y , a ! t =-`it'}r iii u I I ilf t a E Fi S,tSl ERAS ARE f Ol~ ( S cri here Q 06N '~S c Ems' W- i diag4a'rn aC:C.ar:ntnl t tclc3 i, a Yo or ,-.~.,,s7o xs_ D 3VL de i;~10 i k F F i WKWI r r~ _ i TA. m Me t1pp ,lit"i . box, s ED ,*r1= - 1,kk,k,xi ii , uk-t rc' i TES IFS kiEn, Si IF;F,- P , Kovno { co-Own W", SAO 00- Loan; H GO", Vkh Aand Coo so So ll"! Pen pe-~ , ' L til We Sw-i tia} Loamy Saod Sandy Loa;-, Low! . B t i:;5 s L Coy Locun Saxn My R ph i ii (y ii4y }3tiii M -u t ; W S kts chy i. P'n NA tlfiE u f', t 'AVON, , ,F O<.r "v cf.u_•+~ui,. ^ ~ off.. n 4 f~ 41, 5 fry 1o s~