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HomeMy WebLinkAbout038-1157-50-000 n u> O 9 to o d 2. "0 CD ~ AI -o x* 1 d (i Y rr O (n 2 cn z O Ln = U) N O ce h • : 3 m c CD ® m j r-0 (n CD ° N A O _ w a m co 0- :z ? v cn p 5 --J ° CD N cn a) (n r . rt 1 N) N) p O n 0 ° CD (D N N w o O ° rCD C CD CD n z o cn 3 (n y (n w = O p .i (D O p 4 U3 D F P• O5~O CD` n a CD Cn m 4 CD w w o CL ° D - N , O N 1: CD ° ro O m co ~ C7 Cn '7_, fd x n z ~o (o (n E o CO CO cn or Z cCD ~d ~ ~ O s v -0 0 CD Z 0 H. _0 -u Ln CA, CA ~~JJ n~ v m O O v, 0 CD A v '6 CD 0 O !V Z ~p m y (D r H N_ N o Zco z D CD o 0 o n J (D OJ C CD ((DD W CD n ci (D 7 -I N Z O A Z K a^ ro z H z rt o w t~ n a. N `v ~ W m w nNi (D O r- m co t~ :5~ (D z x I-d F-3 rt co O E t" H. N O Z (D O w U] h-h z4z N N CI] In . D CL rt a U~ I v z a 0 I ~ N ,A I a I v i O tv O O .T A O lz O (D tia O n en O v a CD ro I 0 n Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT r' r OWNER, ;ri~i TOWNSHIP SEC. T .N-R W ADDRESS ST. CROIX COUNTY WISCONSIN SUBDIVISION ; LOT - LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 -_-STM-EVERYT=G-=HTN-'1-0 FEET"--0F SY 7F.M`___----_ r /7C cc5/~i i8 I r INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: G} Proposed slope at site: SEPTIC TANK: Manufacturer: /I (rE.. ~rJ i, ji giquid Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: C~ t j / Tank Outlet Elevation: ~ Number of feet from nearest Road: Front, Side,O Rear, O J feet i From nearest property line Front,O Side,O Rear, ©j feet i i Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) r 4 It 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: X Trench: Width: Length : Number of Lines: Area Built:~j~ Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, © Rear, O Ft Number of feet from well: Number of feet from building: f`~1 (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: Dated: Plumber on fob: License Number: f e~ 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 79x9 BUREAU OF PLUMBING MADISON, WI 53707 CONVENTIONAL ❑ALTERNATIVE StateBI-J.D.N-ber: Ilf assigned) ❑ Holding Tank ❑ In-Ground Pressure D Mound NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER: INSPECTION D TE. Larrv Hanson R. R. 2, New Richmond. WI z 21 9 7y C''06 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.. CST REF. PT. ELEV. NE NW, Section 22, T31N-R18W. Lot#15, Northwood, Town of Star Prairie Name of Plumber. IMP/MPHSW No. County Sanitary Perm,, Number_ Cal Powers 1563 St. Croix 54941 SEPTIC TANK/HOLDIN TANK: MANUFACTURER'. ¢'.F LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER ' PROM DED. PROVIDED. OYES ONO EYES ONO BEDDING. V NT DI A.: VENT MATL.. HIGHRWMATER NUMBER OF ROAD'. JPR~~(Qpp~~Q RTV`.. WELL: IBUILYIV.A, IVENT TO FRESH LI V G~ AIR"LET. ALA FEET FROM I l( DYES ONO OYES ONO NEAREST V J DOSING CHAMBER: MANUFACTURER JBEDDING'. LIQUID CAPACITY PUMP MODEL IPUMP,SIIHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: EYES ONO DYES ONO EYES ONO GALLONS PER CYCLE: PUMP AND CON TROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING (VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM a AIR INLET. PUMP ON AND OFF) OYES ONO NEAREST--)P- SOIL ABSORPTION SYSTEM. Check the soil moistureat the depth of plowing Nc;rr, DIAMETER IMATIHIAL 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 LEN NO. OF DISTR. PIPE SPACING; COVER INSIDE DIA -PITS LIQUID BED/TRENCH TRENCHES MA#; f AA_ PIT DEPTH DIMENSIONS e' GRAVEL OFPTH FILL DEPTH DISTR PIPE DISTR. PIPE DISTR. PIPE M ERIAL NO. DIS NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH BE LOW PIPS ABOVE COVER ELE V. INLET ELE V. END PIP EA-1 I iLIN 5(1 A ,AIR INLET'. .~J FEET FROM ( NEAREST-► 4;- 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- O meets the criteria for medium sand. TIONS MEASURED. YES ONO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS OYES ONO EYES ONO DEPTH OVER TRENCH BED DEPTH OVER TH ENC H;BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES. OYES ONO DYES ONO EYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH NO. OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. IN O DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV.. CIA ELEV.. PIPES. DIA.: ELEVATION AND DISTRIBUI ION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS OYES NO OYES ONO COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: NUMBER OF PROPERTY WELL'. BUILDING'. • FEET FROM LINE. / OYES ONO OYES ONO r NEAREST e f ~ F Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE. TITLE. DILHR SBD 6710 (R. 01/82) 7777 cons' APPLICATION FOR SANITARY PERMIT J/ D I LHR p COUNTY r o(r LB V7) UNIFORM SANITARY PERMIT # STRV, LAnoR 6 Hums4n RELRTIOnS -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 MAILI..NG ADDRESS PROPERTY LOCATION CITY: VILLAGE: - 1/4/ 1/4, S J T , N, R H (or y'W: TOWN OF: LOT NUMBER BLOCK NUMBER ISU71VISION NAME NEAREST ROAD,,LAKE OR LANDMARK STATE PLAN I.D. NUMBER i % Tr TYPE OF BUILDING OR USE SERVED i 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 Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: J - 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): f Private ❑ Joint ❑ Public 1, the undersigned, hereby assume responsibility for installation of rivate ewage system shown on the attached plans. Name of Plumber (Print): Sign re MP/MPRSW No.: Phone Number: i Plumber's Address: Name of Designer: COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved 'j-,v ❑ Owner Given Initial /t9 a 7 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. r APPLICATION FOR SANITARY PFRM!T S T C - 'OO This application form is to he completed in ful'_ 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. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property ~1 x 1/ N - R W Luca r. i ,n of Property 't T!;~j Section Township -"=~rjf G=!! Mailing Address Subdivision Name Lot Number ~y Previous Owner of Property Total Size of Parcel Date Parcel was Created Are a l f corners and lot lines i dent i_l iah l e? ~ Yes _ No K this property being developed for resale (spec house) ? Yes No Volume and Page Number 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 _ "ap, the the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPFRTV OWNER CERTIFICATION I (ale) ee tljy that aft statements on this foam ante Aue to the best Q my (out) knowledge; that I (we) am (cute) the ownea(& o4 the pnopenty deAelibed in thins Qoomattion loam, by vixtue of a waymanty deed neeonded in the 014ice of the County RegiAteA of Deeds as Doeumen.,t No. and that I (we.) r),~csent('.y own the pnoposed site {ion the 6 wage.o-a2. sy6tam (on I (we) have obtained an easement, to ttun with the above demni.be.d pnopehty, {ion the conAtAuction. Q said system, and the same has been duty neeonded in the OAlke. 01 the. Cou Re-gk6te.n. of Deeds, as Document No. ) . SIGNA'I' ZIE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) )AT. SIGNED DATE SIGNED I r r Vi ri r S T C - 105 r y ti SEPTIC TANK MAINTENANCE AGREEMENT a St. Croix County c7 OWNER/BUYER I ROUTE/BOX NUMBER Fire Number _ CITY/STATE/~;, j l _ZIPjl PROPERTY LOCATION: Section rN> R ----W> St. Croix County, Subdivision Lot number_ _ I Improper use and maintenance of your septic system could result in I 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 sek'tic 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. t St. Croix County residents maw 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 s_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. F. I/WE, the undersigned, have read the above requirements and agree V, x to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Depart- rb ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Off' - e within 30 days of the three year expiration'date. x S I C N E Y D ATE 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. E:: ;;~SANITARY PERMIT D' L H R County GROUNDWATER SURCHARGE 114 MJfTIR11F~1,gTlOf15 Sanitary Permit No. 4/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 Signature of issuing Agent: Groundwater Fee: Date: Wisco WAF bused #ib~t DILHR SBD-7289 (N. 05184) an DEPARTMENT OF SAFETY & BUILDINGS INDUSTRY, REPORT ON SOIL BORINGS' LAND DIVISION LABOR AND PERCOLATION TESTS (115) MADISP.O. BOX ON WI 539069 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK.,NO.: SUBDIVISION NAME: COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: O New DESCRIPTIONS: PERCOLATION TESTS: 4Residence I ' 1 New ❑ Replace RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE:SYSTEM-IN-FILLHOLDING'TANK:RECOMMENDED SYSTEM: optional) s❑u Qs❑u as❑u ❑sau ❑sEA 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: / Floodplain, indicate Floodplain elevation: y PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH rN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) i Zj, 6- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH 1 I 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 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. I. SYSTEM ELEVATION i ~CL't7~'~f G='~ _-,`•<17~ _ ? E ' ~ _ ` _ ~ I ~ 1 I I , , , I >>1 y , i - E i t:. I, the undersigned, hereby certify that the so I 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 ~•int): TESTS WERE COMPLYTED ON: ADDRESfS: CERTIFICATION NUMBER: PHONE NUMBER optional): CST-SIGNATURE: r , i_ /y DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. 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NO , F ° _ 1 01 swax r O p1 ware 1 , , o :0, ,w .F i E _uth Faty ifl a,rtFsr C'o 'v' i, .F .e~ PAGE OF c) 1 13 r S y 5 Frekh Air Inlelc And OboervaUon Pipe Approved Vent Cup Minimum 12" ADOre Final Grude ~+r 20- 42" Above Pipe Cool Iron To Final Grade Vent Pipe War on Moy Or Synthetic Covering MIA 2" Aggregate Ore( Pipe DI►IrlDullon pipe 0 0 0 0 0 - Tee Ag;regale a Per fora led Pipe 9dor Beneath Pip u - ' Coupling Terminaling Al botlom Of Syclem / Propose D Plc-I SOIL FILL DISTKIBLITIOf.I PIPE A $PPR.OVEO 'INTHETIC COVER ° "'-'MATERI~► OR, 9" OF STRAW 2'e OF AGGREGATE / OR MARSW HA,y (o OF 12 2.1/Z AGGREGATE ELEV OF -fEE-T- .J DISTRIBUTI(DH PIPE TO BE AT LEAST iUCHE5 BELOW ORIGWAL GRADE AUD AT LEASTZO WCHES BUT KIO MORE THA J H2 WCHES BELOW FINAL GRADE MAXImut-A ®EQrli OF F-XcaVAT1(D0 Kam OK,& to (bKAK WILL BE IU(_HES MINIMUM OQrtt OF E•ACAVATImN 'FROM CAk6lWAL GRAPE WILL BC / INCHES r, SIGIJED : Z' LICEKISE KJUMBER: i DATE Ila - - l - XLl r - J i r i I _ i I ~ i 'Z, - It - I} -T J! t _ 1 i I .