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HomeMy WebLinkAbout020-1125-20-000 t 0 <n O K v n C7 r_ 0 <D `r1 v I m I 0 °A° 0 ~ c k. (D C: SO N O C7 j~ C-D Get W W N ? O C N N CL D p ~ N 1 (D (D (D M co IP (P 73 C, O ON w 7 O O 7 VI C,) O N C CD r~ d a o R -i CD u> o CD n CD M N ('ZZ) CD - (p Q C'~ N co O v A ems W 0 ~D Z~ o O O O cn v_ j w m aQ V~ f- } '7U CD co m m m l►1 v o m N Q lZb N I S O Z W O O 00 v O D a w -I r (n o ::)7 cn h CD m oa ~ ~ (n I c~D m ~ `1 Q rn C CAD CD GO ° CD CD cfj Q v 2 A l,Zl N 0O co p .0 Cn --i ~ CD CD co (o TJ p z O K M lh M z N (D a W I D a a ~ o - m c I z a o m I y I I ~ A Q Z A 'v N O O a I A o CD O O O O y O CD ~ y O i Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER DLt s k IC" LLI TOWNSHIP Se)) I SEC. ~ T N-R ! W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISIONLeL5 /t P,'dag, LOT LOT SIZE 7 Ac c PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM «fa Q = fo A E I N / INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used f'-"e"to~'r~~'- X00 tj Elevation of vertical reference oint:©~~ G p Proposed slope at site: SEPTIC TANK: Manufacturer: (~Vd% zzL V" Liquid Capacity: V V U Number of rings used: Tank manhole cover elevation: f~ . SS Tank Inlet Elevation: Z_ 5 Tank Outlet Elevation: Number of feet from nearest Road: Front,(V~ Side 0 Rear, O / feet Qi From nearest property line Front,t~Side,O Rear, O S ~U feet Number of feet from: well building:Q3A dto 15-a~ Jib"Se__ (Include this information of the above plot plan)( 2 reference dimensions to septic tank) " . I ' I 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, CSide, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Co~tv~~cc?b~~i Trench: 4,(4 Width: Length : Number of Lines: Area Built: Fill depth to top of pipe: z- Number of feet from nearest property line: Front, O Side, Rear, O Ft Number of feet from well: 7 5 - r Number of feet from building: Z (Include distances on plot plan). SEEPAGE PIT A/ 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 TA 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: 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. BOX 7969 BUREAU OF PLUMBING MADISCN, WI 53707 ®CCONVENTIONAL DALTERNATIVE State Plan I D. Number. ' (If assign erl) Holding Tank El In-Ground Pressure ❑ Mound Z , NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE Sam Mien Tuut Brook Road, Hudson, W1 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PELEV. . , CST REF. PT. ELEV.. SOU SE, See.7, T29N-R19W. Twn.o6 HudtSon, Lot#39, Fagte Ridge Name of Plumber- MP/MPRSW No.. County. Sanitary Permit Number: Doug St ohbeen 5432 St. cuix 54935 SEPTIC TANK/HOLDING TANK: / I? ' ^T MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELF V.. WARNING LABEL LOCKING COVER /y Y PR OVIDED. PROVIDED: L11-;-5 /YES LINO EYES LINO BEDDING. ]TEr'TT-DIA.: VENT MATL. JHIGH WATER NUMBER F ROAD: PROPERTY WELL. BUILDING. VENT TO FRESH ALARM. / LINE AIR INLET. FEET FR YES LINO DYES LINO NEAR ES OM DOS NG CHAMBER: MANUFACTURER BEDDING LIQUID CAPACITY PU=OPERATIONAL SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. EYES LINO EYES LINO EYES LINO GALLONS PER CYCLE: PUMP AND CONTROLS NUMBER OF PROPERTY JWELL BUILDING I VENTTOFRESH (DIFFERENCE BETWEEN FEET FROM NE ' AIR INLET PUMP ON AND OFF) DYES LINO NEAREST 30 SOIL ABSORPTION SYSTEM. Check thesoilmoisture at the depth ofplowing FORCE IFNt;rr+ JDIAMETER IMATIHIAL AND MARKING or excavation. (if soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: --j BED/TRENCH WIDTH LENGTH No of~r, DIST$$$~~~IPE SPACING COVER NSIDE UTA ttPlrs LIQUID 6 T HE NCFIKS M IA': PI-r DEPTH'. DIMENSIONS " JJy 'll7j GRAVEL OF PTH FILL DEPTH IC's TR. PIPF DISTR. PIPE DISTR. PIPE MATERIA NO. DISH NUMBER OF PR OPERTV WELL. BUILDING'. VENT TO FRESH f3FLOW PIPES ABOVEV ER EL V_`INLE I ELEV. END t/ PIPES! FEET FROM , LINE AIR INL T. 1 ~.°.G G 7 LCD NEAREST► MOUND SY ~711, 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- E YES NO meets the criteria for medium sand. TIONS MEASURED. LI SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS EYES LINO EYES LINO DEPTH OVER TRENCH. BED DEPTH OVER TRENCH. BEU DEPTH OF TOPSOIL. SODDED SEEDED MULCHED CENTER IEDGES EYES LINO EYES LINO EYES LINO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH NO.OF LATERAL SPACING JGRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. jD:STRPIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEVATION AND ELEVELEVDIAELEVPIPES DA.: DISTRIBUI ION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS DYES LINO EYES LINO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY rLL: BUILDING. FEET FROM LINE ❑ YES 11 NO ❑ YES L] NO NEAREST- Sketch System on Retain in county file for audit. Reverse Side. SI kNA RE. TITLE DILHR SBD 6710 (R.01/82) Wisconsin ' APPLICATION FOR SANITARY PERMIT ' ~ DILHR COUNTY (PLB 67) OEPA;'TTT IEnT OF UNIFORM SANITARY PERMIT # InOUSTRV, LRBOR 6 HUMAn RELRTIOns ~~U-S -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS r 121 1111''t-f- /r c-" &-0-Ck Rd' En, X _'F 2- PROPER Y LOCATION CITY: Scc~ 1/45 _ 1/4, S T VIL_LG lt~~sc~H /tJr 5. S~~I~/W N, R % I (or)a OWN CF. LOT NUMBER JBLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER FAQ TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms. ❑ Public (Specify): THIS PERMIT IS FOR A: ] 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. 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 L~ 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 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): cy~ 6 / ~ ._V Z 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: ? MP/MPRSW No.: Phone Number: D,,~ - St/ b<- ~i ~ ✓I'1 b - 3? (-)_V7) 3Z3 3 Plumbe Address: (n~ V Name of Designer: COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved ❑ Owner Given Initial / - fJ 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 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.), 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. Form - S `1 C 100 Owner of Property Location of Property S C~_J 5F_4, Section- Z2,- N R f~ W Tawnahlp j Mailing Address Ar_4 / E y - 2- /At, d16 0 e7 Subdivision Name Lot Number y - Previous Owner of Property E L Total Size of Parcel_ Aw5 Date Parcel Was Created 7 - a S -7S' Are all corners identifiable? Yes No Include-with thiS al)plication one of the tollowi.iig; .Certified Survey Map .Deed .Land Contract, or Other l:egai Document which describes the property PROPERTY OWNER CERTIFICATION I (We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No..3.3 CI ~y-j ; and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an Oasement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Register of Deeds, as Document No. 2-5-0 ~s3 ) 'a SIGNATURE OF OWNER SIGNATURE OF CO-OWNER IF APPLICABLE) DATE SIGNED DATE SIGNED r-1 G . H ST C- 105 r v SEPTIC TANK MAINTENANCE AGREEMENT 0 St. Croix County d y OWNER/BUYER M ROUTE/BOX NUMBER JC LS'~,~( Z~ Fire Number CITY/STATE /`''~~r~ _ZIP PROPERTY LOCATION :~l~(1 Section 'I N, R i _ W Town of ~~ASca1 St. Croix County, Subdivision ",,~/,E 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 m 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. Ho E I/WE, the undersigned, have read the above requirements and agree C/) to maintain the private sewage disposal system in accordance with x r-~ 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 30 days of the three year expiration date. SIGNED f Ail Lo" 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. ' NT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS vSTRSTRY, G DIVISION LABOR AN P.O. BOX 76 HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707 (H63.090) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/ TY- LOT NO.: BLK. NO.: SUBDIVISION NAME: 1-t/ '/a J~F /T N/11/7 1(O fti,2 646-4,_ COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: AU USE DATES OBSERVATI S MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: [ Residence i /New ❑Replace f__ 7 6P S~,•/ ~~AP A©f3 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED~ YSTEM:(optional) E]S d/ If Percolation Tests are NOT required DESIGN) RATE- If an / y portion of the tested area is in the under s.1-163.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PR FItE DESCRIPTIONS ~ BORING TOTAL" ELEVATION DEPTH TO GROUNDWATER ~A16~16F. CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHS 'OB/SERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B C' /0,1.Y"' Mdse 7 ,5" • 7Q// .Y : 3 Is / i CS w r B < /0,2..x. ,t/d,ae ~ . 5" S. 5/ es B- -3 . S' tl v s -,%r. S. CS t C/ f . '7B r~~ 18•+ / Al" / t.` / 6 Bar c s B- d" 4 A91q Al 7.4". lokf B- PERCOLATION TESTS TEST DEPTH$ WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER 6146 1 E AFTERSWELLING INTERVAL-MIN. PERIODt PERIOD2 PERIOD3 PER INCH P- / Al, 3' c 3 E 1---3 P-_ 3 Ala 3 -4- 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- 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 Z e Ce^id i -ni 0A e- F. 100'%-et 4 3--;1 c~~~ rep OF q8' QreS k, e-) 0 -Peres (lest se 114'.. F,(, 9RrI'J -.3 07c VoAe sew R I~ ~ I 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: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional) CS TUBE: 1_ - - L i+ am! an (.ow&fn , X i>,r E w RULE 0 WK BASED ON SQ1 WNHATICS, OTHER SYTEMS MAKE A i 5tier F d _ sm Wring your - ,t W a 3<,_ ly A, q "Y yio, .=.W no v lk t w w< w m,io'nr wo clo t+ shoo. 1,,`u 1 .iIN , , _ i e 11 (l W& 3s i3._:y, NW14 _ zW& . !i ap ~ A, 6, the ttp_ oe,liavi id. , s LS Lomy, r clann SW P- T _ `a R f j m 5 ll,' pav ~Mv' Lam B& _.2,ET.'u ,psi` Con~ ! _ "ice a$: - by c aF' COV _ it } so? cWv LOW-rl milt So, i t% - Way, `vt 1 4 10 n i t, q 0 ny v L' "n I. t w 1V: 10 nor n vii t 9 a? a We Ett o e 1 I ~ v, ~~r1 Lt/cy ~ /o T' N U w . \ N ~ P \ i 4 ~ yc 4 w~0 r~ 1I a C1 ~ r ~ R ~ 1~1 ~ ~ U1 V L1 S S (Ai U ^ ~l ~Cl ~O p A 1A o~Q or, fi 4 O =c O ~O a 1 1 b CA,( ~ f I ~ i1 ~y`_~~i Vi`i'. , - x._-_-._ ~ i f .ti w A. i f LA V ail t C U 3 I I c~ D ILHR "'s`°"~' SANITARY PERMIT C A r,ousTra%,uaeoR6►wxrwr,~~ GROUNDWATER SURCHARGE 6" Sanitary Permit No. J_49 2s On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more com- monly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that is used in your building is returned to the groundwater through your soil absorption system or the disposal site used by your holding tank pumper. The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting., Ground #t» Signature of Issuing Agent, Gro ndwater Fee: Date: Wisco .buried. DILHR SOD-7289 (N. 05/84) 6 ~t