HomeMy WebLinkAbout018-1067-70-200
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AS BUILT SANITARY SYSTEM REPORT
OWNER i _ TOWNSHIP -SEC ~qY N - R/W
1 e
ADDRESS' ST. CROIX COUNTY, WISCONSIN.
*r
.e' . i
SUBDIVISION LOT LOT SIZE
PLAN VIIsW
Distances and dimensions to meet requirements of H63 `
n -_V FRYTHING WITHIN 100 FEET OF SYSTEM
F
01.4
s
v
Al A. ee
I di, a e oath Arroi4 !
SC LE
BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: .-,Slope at site: 7i-
SEPTIC TANK: Manufacturer: Liquid Capacity: _ .1,0671"q
Number of rings on cover Tanc-manhole cover elevatiraxt:
Tank Inlet Elevation: cL~- s Tank Outlet Elevation _ ? c.
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set or a cyc e gallons; to- taT capacity off
distribution lines gallon: size o pump head;
gallon per minute ; horsepower rant name of pump
and model number ;
Type of warning device _
HOLDING TANK: Manufacturer Number of gallons_
'Elevation of manhole cover
Type of warning device
SEEPAGE PIT SIZE: `lNumber_ off.--pits ~y--meet-c~iazretr
Z
feet liquid dept seepage pit inlet pipe-elevation
bottom of seepage pit e e atian feet. ,
SEEPAGE BED SIZE: number of lines w ctth J,61 _leugth,.~,$- tile depth? '
SEEPAGE TRENCH: w th. length
PERCOLATION RATE(, I MA QUIRED~REA AS BU~T~L
INSPECTOR
DATED_ ~ PLUMBER ON JO -
LICENSE NUMBS
77
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
MA.DISOBOXN, VNI 7969 53707 BUREAU OF PLUMBING
MA
®CONVENTIONAL ❑ALTERNATIVE State Plan L1,13, Number
❑ Holding Tank El In-Ground Pressure D Mound (If assigned
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
Bradley Patnoe RR#l, Box 24, Roberts, WI 11-18-93 0 0
BENCH MARK (Permanent reference pomt) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.
SW4 SW4, Section 30, T29N-R17W, Town of Hammond
Name of PI-her. MP/MPRSW No. County. Sanitary Perm,[ Number.
Paul Cudd 2739 St. Croix 43718
SEPTIC TANK/HOLDING TANK: ,
MANUFACTURER LIQUID CAPACITY. TANK yINLET E L E V.. TANK OUTLET ELE V.. WARNING LABEL LOCKING COVER
C J~'ROVI ED PROVIDED
,IA, YES LINO DYES LINO
BEDDING: VENT DVENT MATL HIGH W TER NUMBER F=~ROAD PROP'f TV WELLJBUILDIN VENT TO FRESH
ALARM FEET FRO`~ LINE. Li / J AIR INLET.
DYES NO DYES LINO NEAREST ••iv+~/' T
DOSING CHAMBER:
MANUFACTURER rj_I NGLIQUID CAPACITY PUMP MODE( PUMP;SI HON M_WARNING LABEL LOCKING COVER
PROVIDEDPROVIDED.
YES LINO DYES LINO DYES LINO
GALLONS PER CYCLE: PUMP AND Co NTROLS OPERATIONAL NUMBER OF PROPFRTV WELL BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN f FEET FROM NE AIR INLET
PUMP ON AND OFF) DYES NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil mots tyre at thQ,depth of plowing, JLEN(,7H JDIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, structl'00n shall cease until MARK E
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH. LENGTH NO. OF DISTR. PIPE SPACING COVE JINSIDE DIA xP1T5 LIQUID
TRENCHES MATrR.IA L' PIT
DIMENSIONS 3 `@ F. a.._ DEPTH
GRAVEL DEPTH FILL DEPTH DISTR PIPE DISTR. PIP@ DISTR PIPE MATERIAL. CIS7R NUMBER OF PROPERTY WELL BUILDING: VENT 70 FRESH
BLLOw PIPES AB0, E COVER ELLEEV If k ELFy,V. ENd dry, PIPES / FEET FROM , LINE f AI LET 2 7 ° l 'C^ II NEARESTs
'
7
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 t at it ON REVERSE SIDE. SHOW ELEVA-
meets criteria for medium sand. TIONS MEASURED.
DYES NO
SOIL COVER TEXTURE PMARKERS OBSEH NATION WELLS
YES LINO DYES NO
DEPTH OVER TR ENC H:BED DEPTH OVER TRENCH: BE L) qTHOFO_PS.IL-___,_1- S
ODDED JSEEDED MULCHEDTEDGES DY S LINO DYES LINO DYES LINO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH NOAOF LATER SPACING. GBELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH Tra'ENCHES: u
DIMENSIONS
MANIFOLD PUMP MANIFOL D PST H, PIPE MNO. DISTR. JD:STPIPE DISTRIBUTION PIPE MATLHIAL & MARKING
ELE VELEVDIA
ELEVATION AND LE VPIPES DA.:
DISTRIBUI ION
INFORMATION HOLE SIZE 1 HOLE SPACING DRILLS CO ECTLV COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
f,. YES LINO DYES LINO
COMMENTS: PF •MANENT MARKERS: JOBSERV ITN WELLS. NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
,
DYES LINO DYES LINO _ INEAFEST-
u
f
t
PK~E
Sketch System on e , d Retain in county file for audit.
Reverse Side. f
SIGNATURE TITLE
DILHR SBD 6710 (R. 01182)
DEPARTMENT OF APPLICATION 3 SAFETY & BUILDINGS
INDUSTRY, FOR SANITARY DIVISION
LABOR AND PERMIT P.O. BOX 7969
HUMAN RELATIONS (PLB 67) MADISON, WI 53707
Attach plans for the system on paper not less than 8% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal
and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter
H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master
Plumber, the date, signature and license number must be shown. The owners copy or a legible reproduction of the soil test report must be
included.
Property Owner: Mailing Address:
Bradley Patnoe Route 1, Box 24, Roberts, WI 54023
Property Location: City, Village or Township: County:
SW 11,SW 14S 30 /T 29 N/R 17 )OC W Township of Hammond St. Croix
Lot Number: Blk No.: Subdivision Name: Nearest Road, LalSe r Landmark: State Plan I.D. Number:
- ~.1! r P (If assigned)
TYPE OF BUILDING
Number of
❑ Public* ❑ Variance* ❑ Other (specify)*C~mr-/- Bedrooms:
IN 1 or 2 Family *State Approval Required. I 3
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY I 'o
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER:
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): ❑ New Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit
❑ Alternative (specify) ❑ Seepage Trench
E
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
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: Sig~Latar€. j f_. _ MP/MPRSW No.: Phone Number:
Paul R. Cudd 2739 715 425-2049
Plu b i s Address;_
ame Desilner:
W. , ox 364, River Falls , WI 54022 rthur L. Wegerer 576
COUNTY/DEPARTMENT USE ONLY
Signat re of Issuing Agent: V e
Date: Sanitary Permit N tuber:
r APPROVED
El DISAPPROVED ~
Reason for Disapproval:
Alternate course(s) of Action Available:
r
Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in-
stallation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Piuirber
DIL-HR-SBD-6398 (N.03/81)
Form - S '1' C 100
Owner of Prope rty--~6 "a~
Location of Property Section_ TN !tW
Township /~yytryy~~-y
Mailing Address;
/ . 'L-tom Gt.l1
Subdivision Name
Lot Number
Previous Owner of Property
Total Size of Parcel
Date Parcel Vuu Created
Are all corners identifiable? Yes No
Include with this application one of the following:
Certified Survey Map
.Deed
.Land Contract. or
.Other i:egal 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 1 (we) am (are) the owner(s) of the property described in this
information form, by virtue of a warranty dead recorded in the Office of the
County Register of Deeds as Do
current Na.TY'6 7~ • and
that I (we)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, 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.
WaNATURE pF WNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
I
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISP.O. BOX ON WI 7969
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/M iniiripoi I- V. LOT NO.:BLK. NO.: SUBDIVISION NAME:
s~o=iv'. / 4 /T N/R Y) E (or) W 4- " : ,ar ~1 -
COUNTY: OWNER'S/Rb*E-9'S NAME: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: I PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence i, ❑ New Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: ITV-GROUNDPRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
CJS ❑U ®S ❑U ~S ❑U ❑S ❑U ❑S ❑U
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s•H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: j\
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER44gG"E3 CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH t# ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
y
t' Ll
_ ~ Lan --•s ~ o• 9' T3~1 ti ; z- S t~'1, ,~tL~Ruu'
3 IS
B
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B QCs: R br r UY -S I-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER tf Ci4f'S AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P_ _ . J O rJ 3,%, 3~ ZZ
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. _ :_•,J _
Tc? _~T~`,~ v P- -
SYSTEM ELEVATION - '
I ,f FGA cC~ E -
etsr. k , t oCrti~Lro $oa,' n,s ?»vo bo'[~~ oF!
Z
B _ Py 18vL~s°'- ~~l SIn.L ~°-OCL[.1Lt2 Crt=-~~C1?UN 3,_
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93
e
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et)rlr=Wf&' Y
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:
2Trlv~2 ~GC'~1zr l )f- J~-
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST SIGNATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
Coo! 3. 4 1 046 t .-off W LL e W .
To be a cam, y,C'[. cam! am;
F3 t C
ate, T ~gl € s-.Cit .
MAX IRA! 3€W) . tiot
01HER SYSTHA, ARE RULED DIN BASED ON SOIL COWRIONS;
6- PLEASE use die binmiahuns sn ra do3 . for orKing [noble ioa t[NAs and comp king the pn
t M Ali',._, ~A-S l_F"( 3'",€ d iag4 ;-,rn accui ad v C)C,ni!ng r`cmr tmt ¢C?(ot ons. D 1 ,',n¢j to scab, I'.: prf-lfC
No sop vain m.e.,,, and A,';?t t} a<. n t")(,TT_ vA ~-C
aprainninc
10 "v , ow E ,.d an a a. Novi l&v W . a.a no W n n of, dip, [tW(p
culAWK3, Uri, SS smostione
Sonv Lowi Ian Than,
_ Wtt. Wit? Rnwn
SK lwm~
Sill
m Coy
W t: Gov , 'mot
Y `t t-
l~ _ tFE}atYt rz sflt. W:i: de
S
op"Jorn
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tir € - fro L , Al . ,s?r, s San "a' Y CS;--1'ts t, ;la: (eviI T .r, 'f e- L'f,j,3l TC~"3.. iPali re€,",ues",
.;rz[€. of c , 3 t in in o W w% Y J t.s€ .i St,;-. ,'h 1 CY,: s at W r= tc:! die p, ;Sr€?ti
- - San. Perms No.
Owner's name
H63.05 PLOT PLAN
Show:
NA
Location of buildin c served posinc chamber
Septic tank Vertical reference point
Q a
Q Building sewer Q Horizontal reference point
Effluent system Q Well
Vq. Replacement system -rea F-~71 Property lines w/in 50' of system
Distribution boxes Scale = 1I1= ? b , or dimensioned
Pump and controls: -
`--fr. & Model No. Vertical Lift Size Force Main
Friction Loss T. D. H. Vol. Dist. Pipe Gal. per _ 1-gin, Gal. per Cycle
Place check mark in appropri=te box, indicating item is shown on plot plan below:
3 5 E~,c1 S-r' -TrNNlz '3E
- - - - - - - INSrn~k., 1- JiFJ~OU 3)
~ \euo 6nt..
t up_iT~ 6, w 1 C sue?
i ~o of ,y°`
z
6• o'
lvl~
Fi n d F2?
S }I,- - - - -
0 3 , -~1 2.5
J sQ
UI
~I
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I BN- E~~• lvO•oOor..~ Et~T"rC~'t OF
ft S SttowN
By the granting or approvinc_ of the above plan, or upon the event of a subsequent
permit being issued, ~•cROlx County and the sr.cRolx County Zoning Administrator, does
not assume or hold itself liable for any defects in plans or specifications, plan
omission, examination overs:::ht, construction, or any damage that may result in or
after installation. ,
Plu.;r"='r's signature
PAS E
CROSS SECTION.] OF A BED S~f STENO
11YvEPT [PIPE \Z j~QOVE
1 2 OF AGC PEGATF-
I
DiSTRIBUTIOQ PIPL- i APPpOVLD S`3QTHF-TIC COVE
FRIAL OR S" OF STR
cJO / OF, MARSH HAS
`o (a OF%Z-ZI/2 AGGREGATE t
> LTV. OL FEET
b~ ~'~UM OF ~C
DIST RIFUTIOM PIP[: TO BC AT LEAST MCHES BELa-/ ORIGIUAL GRADE
FIiIAL GRADE
AUD AT LCAST20 1V1CHCS BUT Mo MORC THA1.1 42- IUCHES tD--'-t-C)W
- 3~
6F
MA\IMUP% DEPTH OP EXCAVATIOU FROM DRIGWAL GRADE WILL 1>JCHEs
INCHF-S
MINIMUM DEPTH OF EXCAVATIOIU FROM ORIGIIUAL GRADL WILL BE
X,
SIC-lUED:
L IC E IJ 5 L l.IUMHE
' j q T r - -
Parcel 018-1067-70-200 01/23/2007 11:36 AM
PAGE 1 OF 1
Alt. Parcel 30.29.17.462D 018 - TOWN OF HAMMOND
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
12/27/2005 00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - PATNOE, BRADLEY R & SHARON
BRADLEY R & SHARON PATNOE
719 150TH ST
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 719 150TH
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 8.579 Plat: 4986-CSM 19-4986 018/05
SEC 30 T29N R17W W 501 FT OF SW SW NKA Block/Condo Bldg: LOT 02
LOT 2 CSM 19-4986 (8.579 AC)
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
30-29N-17W SW SW
Notes: Parcel History:
Date Doc # Vol/Page Type
05/25/2005 795898 19/4986 CSM
07/23/1997 670/218
07/23/1997 447/281
07/23/1997 446/391
2006 SUMMARY Bill Fair Market Value: Assessed with:
172544 164,300
Valuations: Last Changed: 07/06/2006
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 8.579 43,500 83,000 126,500 NO 05
Totals for 2006:
General Property 8.579 43,500 83,000 126,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00