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HomeMy WebLinkAbout040-1204-30-000 Form - S T C - 104 t AS BUILT SANITARY SYSTEM REPORT SEC. T N-R W OWNER TOWNSHIP j f C ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM f)p,.~ / 6 3r ` /lot/ i L'A L- 00 ? `L 27 3- 7 j2)( S :iZ :S i--,CEr C- L;- j✓ L-~ _ Pell J 1i v' 1 y; INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used t F `7'~_j -7 ~r Elevation of vertical reference point: (j~?, f ? Proposed slope at site: 3 SEPTIC TANK: Manufacturer: Liquid Capacity: i ? 1 Number of rings used: f Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front, ~Side o Rear, O feet ti From nearest property line Front,O Side,` Rear, O` feet r , 4V C Number of feet from: well building: (Tnclude this information of the above plot plan)( 2 reference dimensions to septic tank) 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, 0 Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: L-Trench Width: 1 Length: `jam Number of Lines: A- Area Built Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, Rear, O Ft Number of feet from well: Gr`y~ 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: _ t Dated:' Plumber on job: License Number: y~L'7 3/84:mj DEPARTMENT OF INDUSTRY, LABOR & INSPECTION REPORT FOR SAFETY & BUILDINGS HUMAN RELATIONS P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION MADISON. WI 5:+.707 BUREAU OF PLUMBING J kkCONVENTIONAL ❑ ALTERNATIVE State Plan LD Number. Holding Tank ❑ In-Ground Pressure 11 Mound (11 assigned) NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPEC ION DATE. James Palechek R. R. 1, Hudson, WI 54016 - YS J BENCH MARK _(Perrna-t reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV SE NE, Section 25, T28N-R19W, Town of Troy,Lot#3, Plainview Acres Name of Plumber_ MP/MPRSW No. Count y Sanitary Permit Number: Donavin Schmitt 3205 St. Croix 64855 SEPTIC TANK/HOLDING TANK: MANUFACTURER.- ' LIQUID CAPACITY. TANL V.. TANK OUTLET ELEV.. PWARORNING LABEL LOCKING OV f y v VI ED . PROVID.~ 'Z~7~L 7JV Z L~ YES LINO ~ES NO VENT DIA.VENT MATLHIGH WATER NUMBER ROAD: PROPERY WELLBUILDINGVENT TO FRESH L( ALARM FEET FRLINE s / AIR IN" EYES LINO \ EYES ENO NEARES%/{ DOSING CHAMBER: (MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: EYES ENO OYES ENO EYES ENO GALLONS PER CYCLE: PUMP ANDCONTROLSOPERATIONAL NUMBER OF PROPERTY WELL BUILDINGIVENTTOFRESH I (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET' PUMP ON AND OFF) EYES ENO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moistureat the depth of plowing LENGTH DIAMETER MATERIAL AND MAHKIN(, 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 NO OF DISTR PIPE SPACING COVER INSIDE DIA xPITS LIOUID TRENCHES. MATERIAL' PIT DEPTH. DIMENSIONS Z 2- G Y GRAVEL DEPTH FILL DEPTH DISTR PI PF DISTR. PIPE DISTR. PIPE MATERIAL. IN DIS NUMBER OF PERTY WELL BUILDING: VENT TO FRESH BELOW PIPES ABOV O ER ELEV. INL FT ELEV. END i AIR INLET: ~O . T~ PIPES FEET FROM uNE ROP~ ~ Z NEAREST- MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- E YES NO meets the criteria for medium sand. TIONS MEASURED. E SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS EYES ENO DEPTH OVER TRENCH BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED EYES ISEEDOEDNO CENTER EDGES. MULCHED EYES ENO OYES ENO EYES ENO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH TRENCHES LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATEHIAL & MARKING ELEV.. ELEV. DIA. ELEV.' PIPES. DIA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS EYES ENO EYES ENO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING. FEET FROM LINE EYES ENO OYES ENO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE TITLE: DILHR SBD 6710 (R. 01/82) I wlsconsln , APPLICATION FOR SANITARY PERMIT / A0 ' D 1 L H R (PLB 67) COUNTY r~ oECSRRTmEnT of InOUSTRV, LRBOR 6 HumRn RELRTIOnS UNIFORM SANITARY PERMIT # , 41 f~~ -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS j / P, Ril PROPERTY LOCATION CITY: 1/4 j'-I , S ,!!r , T' N, R VI G LOT NUMBER JBLOCK NUMBER SUBDIVISION NAME ST ROAD, LAKE O LANDMARK STATE PLAN I.D. NUMBER f'Z If 1:ev G' l L tL _ TYPE OF BUILDING OR USE SERVED /LC/ X 1 or 2 Family Number of Bedrooms. 3 ❑ ublic (Specify): THIS PERMIT IS FOR A: X 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. 9 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 Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity f.' Lift Pump Tank/Siphon Chamber Holding Tank capacity 7y77-- 7777-- Y 1' Manufacturer:' v a-Al 4, 6' IF THIS IVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure QIZL- #of Prefab. Site Steel Plastic Gallons Concrete Constructe .Septic Tank Capacity Lift Pump/Siphon Chamber PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOS/EDD (Square Feet): ~7l ? [ 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): Signa e: M PRSW No Phone Number: Plumber's Address: Name of Designer: 1 1 r COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved ,~,Q / 6 q ~j~l 7 (,r7 4 j/ % p~ ❑ Owner Given Initial u.~- r °j e! Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber t 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 th, 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 inadequawies 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 AAIA,( Location of Property Section ZS , T 1o N - R 2-0 W Township Mailing Address ~DUJ~ 3 FL t kIVI EW A-CPC5 ffsou wl- (raltl cl SSr o/k~ Subdivision Name e-LA A/ ILL--w 14eE -S Lot Number Previous Owner of Property rZ iSTOPf~ Qf VQjkN Ey- d -VIE L-LV2V BL6t Total Size of Parcel Date Parcel was Created 7 Are all corners and lot lines identifiable? C Yes No Is this property being developed for resale (spec house) ? Yes No Volume -70.1 and Page Number SD 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. PROPERTV OWNER CERTIFICATION I (We) ee ti6y that aU statemen-ta on this 4onm aAe .tAue to the best o6 my (ouA) k.nowtedge; that 1 (we) am (cute) the owneA(6) oA the pnopen,ty dan bed in th.iz in6o4mati,on 6o4m, by viAtue o6 a waAAanty deed teco4ded in the 066ice o6 the County Regi-6teA o6 Deed6 as Document No. ; and that I (we) pnesentey own the p!toposed site 6oA the sewage dEzpo.6aZ system (on I (we) have obtained an easement, to tun with the above desn bed pnopeAty, bon the cons.tAucti.on o6 said system, and the same has been duty neconded in the 066ice o6 the County Regis teA o6 Deeds, a6 Document No. 190,3o, ) . S URE OF 0 R SIGNATURE OF CO- WNER (IF APPLICABLE) DATE SIGNED DATE SIGNED H En H 9 r ST C- 105 r' 9 ti SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d a ff~~.. H OWNER/BUYER ~IGS ROUTE/BOX NUMBER ~oyTL 3 ,PtA/vvler.✓ A!~ ~ Fire Number CITY/STATE Z I P SO~fo PROPERTY LOCATION: 14, 4, Section, TZO N, R Z.a W, Town of D(/1 St. Croix County, Subdivision ~LE})IV1~lLW ~T~~'~=°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 H three year expiration. 0 E z I/WE, the undersigned, have read the above requirements and agree Cn to maintain the private sewage disposal system in accordance with H the standards set forth, herein, as set by the Wisconsin Depart- rn 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. 1 SIGNED J DATE 7 le6--- St. Croix County Zoning Office P.O. Box 9S Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. v N ~ Cn N ~ N p_ 0 X-n n ci N > o c c w w cn w E _O c 0 "C 3 s ~ Ti c to 0 CD •O a (D (D p? a to D 0 (D N CD N N ` n - a 0 0 w O° CD O CO n CD O (D a w w A w w (D ~ (D N ~ N o 3 a O -t D O GJ O CD S O w 0 3° c ~c c c w= N 3.C, c~3o: w ~ Q ~ p O -C, CCDD O 0 O (D w N - (D a D = 70 ° w ~ CCDD c n N Q c° Co O g a o F m O N N CD ~ w N. Z N m N -I 0 ~ f Cp ~ CD CD C~ w 0 ~ COD ~ Z 1° a C 0 3 CD CD a D D a w ~ O ? O ITf v;wa ac~ato~ ~ `m 3 w o CD a w 3 CD c ~ O a lD !P > N ~p N CD .N+ N --ate w 3 vw w a 0 f Ccn c c° c 0- 'n w w CDaaCD 0 j R1 a0 CCDD asN. c G~ . S.~ NCO w BCD 3 n y (D n C 0«a = O N n O O c~ 7 C O a c N (~D " Oi «r a c c-N w (D CD C a C O = C C?D w 0 00 fp = 3 O p O OO w a3. aCDD = 0 3 0 CD N a ° m 3 0 oz DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS I%DUSTRY, y7 LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 539069 HUMAN RELATIONS E (H63.09(1) & Chapter 145.045) UMM: "u I ION: 6OWNSHIP/Mb4#tetf`Al=4+Y: OT NO.:BLK. NO.: SUBDIVISION NAME: sE 1 y 25 ITa N/R E (o T,Poy 3 ~i~ iE w Aces COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: f ZV j X 4,.e.-E- A, EG (n ~(t 1-171~ Th M L Y h Lie . ~3p . I-A kZ E/M 0 , "~{.••t...~ . SJ0 USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMM R AL DESCRIPTION: PROFILE DESCRIPTIONS: IPEACOLATION STS: Residence N- C.New ❑Replace ~DV,~l~-~ /GDD•~f!-~ RATING: S- Site suitable for system U- Site unsuitable for system ONVEN 1 NAL: IMOUND: OU~`IN-GROUNDESSURE: S STEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) NV ZS ❑U BS ❑U QS ❑U ❑S EA ❑s ©u CONVfAJfiO.J 1>RN'-1fICLV ' If Percolation Tests are NOT required DESIGN RATE: squired if any portion of the tested area is in the ~w under s.H63.09(5)(b), indicate: CG~7 SS Floodplain, indicate Floodplain elevation: , PROFILE DESCRIPTIONS /N 14.tCeMAL +-t- BORING TOTAL ELEVATION DEPTH T GR UNDWATER CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH OBSERVED ES HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) r r 701 /.33'Adv0a. Si B- ~O 9'V > TAB ~ s ,u• i ~ /.7S' L A . i , T.0 q y p ~ f' W. a, yam it 6.6 74 V S 113A). S1 1; f. 7S UL7 C-S 7 B_ 3 10.5 o% ys 91, >i 0• s y .s-RNs;~~ Jj I. r .;'5 B- x.1,5 ~a 26 /.1. S el. GA C's ; GR. G' 4 N a C S ( . 7s' A- as . s'/ .7 s' 13)j. S/; /.ZS a. ,3. C-tm. t B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER IN% AFTERSWELLING INTERVAL-MIN. PERIOD 1 P RI D P PER INCH P 1-- , P- CS P- L P- < P- Y 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 77 ys : m _ /~,c, S, ftS This test site APPROVED for conventional I ' b s~.~iE = 30 , asystem. 1~ ~•u.;rHvA, ~o ,,~,~Ef~>/-~ f` rhlste aL ; -,o P Y 1 t cony 1 st Site ~4pp ' ~oQ t RO p -2? ' is T N 11017,1/,Sep tic a ~ t} //0 c to , as 2o 0,, 1 VA 3Y9. so. oaf ~;~F . S~ L UE,t T • Rte /~1`• : s Told dj ~,~t, $f L 773 -7 : A r s w, ►c'F CoRa L-14 D tFLE UATioN = /00. O f 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. 1 NAME (print : TESTS WERE COMPLETED ON: rr7r• /L ADDRESS: RT. 3 O'NEIL RD., HUDSON, WIS. 54016 CERTIFICATION NUMBER: PHO E NUMBER (optional): ROBERT ULBRICHT Q Y 3 WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. CST SIGNATURE: MINN. INSTALLER & DESIGNER LIC. NO. 00663 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. y~GhS; i ~ VIT" > r q,A tie; Ty i'AR ~vv~R Nv 5111/f 9 i R'1' c' ~ cis L-" /J P120 P jp f~ j c~1> tl CA TA`s t~1 a 5r p v ASiTr' sr~p~&E6EP act SCI ~ do 1,00 0, IV' Na ACA cam' ago r 1 p1 w`~ -2-23 -7 kr w 4o cvaN-Ae1L !f-I9 - f3ti t4l