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HomeMy WebLinkAbout038-1099-60-000 o y0d c d ~1 c 0 to c rr I M A <D 1 3 ~ O C: lot :y d ° N ° A a d j W *..4 C; CD co a z a: y N N o 2 3 A O7 ~ ~ 7. ~ CD K LI y fl7 y •P 1 N N a 7 O A a. SD m O 0 0 (y 7 A 7• O 3 O N I° n O 0 C) O N A y 0 = O C !r 0 N A O 00 m c m N a a c 00 A (n W 3 a O O ov a O o Q a X lot C) 0 w CL o z c° co -1 c P TJ ° 00 m N rv rn o lei 3 0 3 a4 ;:3- 0 CA cn CA A Z j N m - 5'i m Q° c!~t 411 :5. 9L (3 c oa 3 -,j CL N a y N ° z co °z 0 y a 7 0 r o' m C CD CD N CD C. V S` C A N A i ca 'm a CD (6 :t --I cn oa oa p 3 p ? n .p c, W y a A z 7 c, z 77~ W o a oa (n a Z n ~ ~ n o' 9 I .A ~ --1 C " 00 b m Z A ~ p~ fo I w v ~ ~ 4" m v = a n a x o: - ° z 3 °x ° N m m o a a y a A CL d I ~ a ~ I a v S A fi N A o n 3 A 3 O co N n m o N a V 0 Z7 C A N ti 00 o 0 ~ 'ayy O a v ~i Form - S T C V-O4 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC.-1 T- / N-R W 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 I I i l t j INDICATE NORTH ARROW BENCHMARK: Describe the verzical reference point used tij } ~L 1 Elevation c,f vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: liquid Capacity:( Number of rings used: - Tank manhole cover elevation: rr Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side,Q Rear, O feet from nearest property line Front, 0Side, 0Rear, 0 feet Number of feet from: well building- i' (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE KEVRIZSI? S I DF f 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: r Number of Lines: Area Built:/ Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side,O Rear,r' Ft: f 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 0 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: / ter,' _q { Dated Plumber on Job: 7 if, i r,c .~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 MADISON', WI 5707 nCONVENTIONAL ❑ALTERNATIVE st ate Plan l).D. Number I El Holding Tank El In-Ground Pressure ❑ Mound If assigned NAME OF PERMIT HOLDER'. ADDRESS OF PERMIT HOLDER'. INSPECTION DATE. Denniz Hu ins R. R. 2, New Richmond, W1 I --a 4y BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV. SW SW, Section 24, T31 N-R 18W, Town o j Sta t PnaiAie Na-, of Plumber. JMPIMPRSW No. County. Sanitary Permit Number. Cat PoweAz 1563 St. CAoix 49482 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIOUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING CrOV / P OVIDED PROVID X5.5 YES LINO ❑ 4N0 BEDDING'. VENT DIA.: VENT MATE. HIGH WATE NUMBER OF ROAD'. PROPERTY WELL BUILDING VENT O FRESH ALARM LINE. AIR INLET. r FEET FROM DYES LINO G DYES LINO NEAREST DOSING CHAMBER: MANUFACTURER. BEDDING. LIQUID CAPACITY PUMP MODEL PUMP; SIPHON MANUFACTURER JWLOCKING COVER PROVIDE: PROVIDED'. DYES LINO DYES LINO DYES LINO J WELL BUILDING; I VENT TO FRESH GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY (DIFFERENCE BETWEEN FEET FROM uNr[~~ AIR INLET. PUMP ON AND OFF) DYES LINO NEAREST JJ SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING, or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH NO. OF DISTR. PIPE SPACING COVER INSIDE DIA UPITS LIQUID BED/TRENCH TRENCHES M/~iiir AL. PIT DEPTH. S Z L DIMENSIONS 1112 GRAVEL DEPTH FILL DEPTH K PIPF DISTRPIPE DISTR. PIPE MATERIALNODIST NUMBER OF PROPERTY WELLBUILDINGVENT TO FRESH BELOP PEI AE CpvER INLE END t. PIP FEET FROM LINE AIR INLET. l// NEAREST Y 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 ma certain ~thit ON REVERSE SIDE. SHOW ELEVA- meets the criteria for med m sand TIONS MEASURED. DYES NO ~ / A ERMANENT M RKERS OBSERVATION WELLS SOIL COVER TEXTURE ❑Y S LINO EYES LINO DEPTH OVER TRENCH:eED DEPTH OVER TRENCH BED DEPTH OF TOPSAIL OD ED SEEDED MULCHED CENTER EDGES D D LI ❑Y NO YES LINO YES NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO.OF Lf ERAL PACIN RA L DEPTH BE W PIPE FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DIST .PIPE ANIFOLD MATERI IN O. DISTR. DISTR. PIPE DISrHIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV. DIA. ELE PIPES DIA.: ELEVATION AND DISTRIBUI ION INFORMATION HOLE SIZE HOLE SPACING DRILLED COR C LV COV MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED ❑Y LINO DYES NO COMMENTS: PERMANENT MARKERS: OBSERVATION WEL [NIMBER OF PROPT OM LINE: ❑ YES ❑ NO ❑ YES D NO 3,31 REST 2 I z 6-32.- 1 Z0 1 Sketch System on ty file for audit. Reverse Side. 49 SIG E TITLE. DILHR SBD 6710 (R. 01/82) ~ n wisconsin APPLICATION FOR SANITARY PERMIT ~COUNTY (PLB 67) Ct,SPRRTTEn?i OF UNIFORM SANITARY PERMIT # In OUSTRY, LRBOR 6 Humpn RELRTIOnS -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 inst ctions for completing this application. PLEASE PRINT PRO RTY OWNER MAI NGADDRESS PROPERTY LOCATION -r-LT-Y: j VI~.LRGE: ~f 1/k;/0 1 /4, N, R / (or(VO ~'owN OF: LOT NUMBER BLOCK UMBER SUBDIVISI N NAME NEAREST ROAD, LAKE R LANDMARK STATE PLAN I.D. NUMBER ( ?(2 TYPE OF BUILDING OR USE SERVED 0 ` - - 1 or 2 Family Number of Bedrooms. ❑ Public (Specify): f 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. X 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: r 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): ~1ti 'z """2 Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of he private sewage system shown on the attached plans. Na of Plumber (Prit): Sign urei' MWMPRSW No.: Phone Number Plum be s Address: 1 / Na me o#~Designer: f/ COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved ❑ Owner Given Initial i~,~lit c/ 47 (p'lF~ ~!t } 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 F 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/contractQZ,("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 r X241 2~ 1 Location of Property , Sy1 4, Section , T N - R y _ W Township Mailing Address 2J Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel Date Parcel was Created Id all corners and lot lines identifiable? Yes No I Is this property being developed for resale (spec house) ? Yes No 1 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 Map, the the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION 1 (we) een.titby that a" Statements on ,thin 6onm ane t ue to the best o6 my (oun) knowledge; that I (we) am (ahe) the owneA(s) ob the pnopenty dani.bed in th,u6 inbowation bon.m, by vi tue ob a wa"-anty deed neconded in the Obbice ob the County RegiAtei. ob Deeds as Document No. ~-V, ~2 and that I (we) pneseWy Own the pn.oposed site borp, the. sewage .bpoha~system (OIL I (we) have obtained an easement, to n.un R i th the above d"oL bed pnopeh ty, bon. the co"t&uctior ob said system, and the same has been duty n.eeonded in the Obbice ob e Couw y Regi -tvL ob Deeds, as Document No. SIGH E CF O'WNEE SIGNATURE OF CO-OWNER (IF APPLICABLE) ADATE/SIGN,E/D DATE SIGNED r S 'f C - 105 r y H SI?P'1'IC TANK MAINTENANCE ACREEMENT o St. Croix County c7 H OWNER/BUYER r rn z 4441 rS - - - - ROU`1F/BOX NUMBER Fire Number C I' T Y / ";TA T E - -LIP ~ PROPERTY LOCA'TIUN: %4, `-4, Section i'N, R__Ls1 __W 'L~ , St. Croix County, Town of Subdivisions Lot number-_~ Improper use and maintenance of your sirptic system could result in its premature' failure to handle wastes. Proper maintenallCC coll- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed sel)tic tank Dumper. 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 maw be eligible to receive it grant Cur a maximum of. 60% of the cost Of replacement of a failing; system, which Was in operation prior to July 1, L978. St. Croix County accepted this program in Atrg,,ust 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. o I/WE, the undersigned, have read the above requirements and agree u, to maintain the private sewage disposal system in accordance with ~ the standards set forth, herein, as set by the Wisconsin Depart- b meet of Natural Resources. Certification form must be completed and.returned to the St. Croix County Zoning Office within 30 days of the thi yc,ir S I C N 1', 1) 1) A' C F. 5 f~ St. Croix County 'Louing O1 Lice 1? . 0 . Box 93 Hammond, W : 54015 715-796-22:19 or 715-425-8363 Sign, date and return to above address. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDING INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS \ / MADISON, WI 53707 (H63.090) & Chapter 145.045) LOCATION: SECTI N: TOWNSHIP/MUNI IPALITY: LOT NO.: BILK. NO.: SUBDIVI ION NAME: /I3 N/R (or) VII r C NTY-,: OWN R'S/BUYER'S NAME: MAIL NG ADDRESS: USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL,DESCRIPTION: ~~yy PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence ❑ New XJ Replace } 3 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYST M-IN-FILL OLDING TANK: REC MMENDED SYSTEM: (optional) E 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: LFloodplain, indicate Floodplain elevation: / / T3 PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHf$1, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) _W 4664 - lUe rye //`,).E/t B- 7 17 ' iat t B B- Fr PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER I-14CHeS AFTERSWELLING INTERVAL-MIN. PERI 1 PER10 2 PERT 3 PERT H P- 3 ~ 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 o the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. n k 6 / s~~O SYSTEM ELEVATION 1 sC~C .?.Q o S7T~ -1 4 TG-ST'S - ' 70 t - , I 83 AD _sOul 7! oT..~i,Jc 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. NAMErint): / TESTS WERE COMPLETED ON: AD R S: CERTIFICATION NUMBER: PHONE NUMBER (optional): CST 4Sr AT U R E: l DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. ° DIL-HR-SRD-6395 (R. 02/82) - OVER - . A a9Igd ..3 ¢S. <it r v i b 3E}1-?;. ae Y ~ f .7_ 4 + t i - .<<, ass, .%f•~:,~i'£:~. >'Ic Ici at C, ;.e, y-, u j E?t32 cti=n;' i3? a~ f.E~3 ' e I,4, !"t z~'F~ i;(,f• apt `'.iY" g -°i7£~, i~#:. F,,,:x ~ r e u o, s e a S 2° 1 r > s ,,F z... - t i u,t PAGE OF r uSS r~ Fresh Alf Inlets And Obcervotlon Pipe ~ Approval Vent Cap Mlnlmum l2" AbuVs Fl-al Grad. ~U- 42" Above Pipe _ 4 Caof Iran To Flnal Grads Vent Pipe Marsh Hay Or Synthetic Covering min 2" Aggregate - o•er Pip. DlefrlDullan Pipe-' 0 0 0 0 -Too G Aggregole Beneath pipe 0 Perlorn led Pipe Belaw o Caypling Terminating At Bottom Of Syalam 1J l 1 (1 c. I t~ I"'G. C'1 { ._~-.,F_. 1.`a.•~-. / I SOIL FILL DISTRIBUTIOF.1 PIPE, ~NTM APMOVEO S ETIC COVER aMATMJW OR 9" OF STRAW 2"oFAGGfRFGAlE --J~~ OR MARSta HAS / OF 1z 21/Z AGGREGATE E V OF F EF.T__,~ DISTRIBUTIc71J FIFE TU BE AT LEAST szL_L_- IIJCHES BELOW ORIGIIJAL GRADE ARIL AT LEASTZO IIJCHES BUT 1.10 MORE THAI H2 INCHES bLLOW FINAL GRADE MAXIMUM DkPrH OF F-XCAVAT100 FROM U►{IGMJAL 60K WILL BF_ IKJCHES MMMUM OCPrH OF FACaVATID0 iKOM C4~ i(,IWAL 6RAPE WILL BE INCHES ~ ^ t LIC E IJ SE IJUMBE 13: DATE : Ila r - - 34 ' - i ..,6 - ~ Ste'`- ~ r- ' Parcel 038-1099-60-000 01/31/2007 09:41 PAGE 1 OF I F Alt. Parcel 24.31.18.415C 038 - TOWN OF STAR PRAIRIE Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - NIELSEN, KAREN C KAREN C NIELSEN 2009 CTY RD CC NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 2009 CTY RD CC SC 3962 NEW RICHMOND SP 1700 WITC Legal Description: Acres: 1.640 Plat: N/A-NOT AVAILABLE SEC 24 T31 N R1 8W 1.64A IN SW SW COM SW Block/Condo Bldg: COR SEC 24, TH N 236 FT TO POB: N 260 FT, E 275 FT, S 260 FT TH W TO POB Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 24-31 N-1 8W Notes: Parcel History: Date Doc # Vol/Page Type 09/19/2005 806706 2890/459 WD 04/26/2001 643821 1626/307 QC 07/23/1997 512/404 2006 SUMMARY Bill M Fair Market Value: Assessed with: 175515 155,500 Valuations: Last Changed: 10/14/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.640 41,000 96,400 137,400 NO Totals for 2006: General Property 1.640 41,000 96,400 137,400 Woodland 0.000 0 0 Totals for 2005: General Property 1.640 41,000 96,400 137,400 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 305 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00