HomeMy WebLinkAbout036-1009-90-000
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j AS BUILT SANITARY SYSTEM REPORT
OWNER 1` ~ ) TOWNSHIP SEC _ NU
ADDRESS
COI 2,tsr4--,kj S'T'. CROIX COUNTY, WISCONSIN.
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances dud dimensions to meet requirements of H63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
I
ul a
5
l
i
i
Indic at N r h rr w
JZ
BENCHMARK: (Permanent reference Point) Describe: 61d iM
---Slope at site:
Elevation of vertical reference point:
SEPTIC TANK: Manufacturer: Liquid Capacity:Z~~ a, 11
Number of rings on cover ~Tank manhole cover elevation:
~~jo; s
'T'ank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set for a cycle- gallons; Total capacity of
distribution lines- -gallon: size of pump head;
gallon per minute horsepower ;brand 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;- Number of pits feet diameter
feet liquid depth seepage pit inlet pipe-elevation
bottom of seepage pit elevation _ feet.
SEEPAGE BED SIZE: number of lines width _length ;2/ithe depth
SEEPAGE TRENCH: width _ length-
PERCOLATION RAl'E-~ s![r~ AREA REQUIRED-/_~'!12 AREA AS BUILT
INSPECTOR
DA'Z'ED PLUMBER ON JOB
LICENSE NUMBER/
1
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969,
BUREAU OF PLUMBING
MADrSON, WI 53707
IM CONVENTIONAL ❑ALTERNATIVE state PlanLD.Number:
(If assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER'. ADDRESS OF PERMIT HOLDER: INSPECTION DATE'.
William Peterson 01 Bernds Ave.,New Richmond, WI
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: 7F . PT. ELEV..
SW-14, SW4, Sec. 4, T31N-R17W, Town of Stanton
Name of Plumber. MP/MPRSW No. County. Sanitary Permit Number.
Cal Powers 1563 St. Croix 4364
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. UID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
F✓ 7 ~7 PR V ED: PROVIDED.
j w _J YES ❑NO ❑YES ❑NO
BEDDING. VENT VEiii R NUMBER OF ROAD.
❑YES ❑N PROPERT WELL BUILDING. VENT TO FRESH
( FEET FROM LINE IAIR] L
O NO NEAREST
DOSING CHAMBER:
MANUFACTURER BE DDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MrjNLF ACT RER WARNING LABE LICKING COVER
J' PROVIDED. P OVIDED:
❑YES ❑NO ❑YE ❑NO ❑YES ❑ O
GALLONS PER CYCLE: PUMP AND CONraoLS oPERAT I ONJ1k MBER OF PROPERTY IVVtLL B ILDING VENT FRESH
(DIFFERENCE BETWEEN EET FROM LINE IAIR LET
PUMP ON AND OFF) ❑YES ❑N NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of owin,9 NGrH DIAMETER, MATERIAL AN A NG
or excavation. (If soil can be rolled into a wire, construction shall pease unfti FORC
the soil is dry enough to continue.) j MAIN/ /
CONVENTIONAL SYSTEM: I'
BED/TRENCH WIDTH / LENGTH NO OF STRPIPE SPACING COVER JINSIDE DIA SPITS QUID
TRENCHE:,Ip M IAL PIT DEPTHDIMENSIONS v/ GRAVEL DEPTH FILI DEPTH DISTR. PIPE DISTRPSTR. PIPE MATERIAL. IN D TR ' NUMBER OF PROPERTY WELL. _ BUILDING.
VENT TO FRESH
BELOW PIPES ABOVE COVER 19 ELE INNLET ELEV. END. E..r Z / - AIR IN LE.,T.,-
"I 1 3 FEET ' / 5 S PIPE NEAREST;_ uN/~
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the text e of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound syste s o make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the Iter' for medium sand. TIONS MEASURED.
❑YES ❑NO
SOIL COVER TEXTURE JPMA RKERS N WELLS
S ❑NO ❑YES ❑NO
DEPTH OVER TRENCH .BED DEPTH OVER TRENCHBED DEPTH OF TOP OIL SODDE SEEDED MULCHED
CENTER EDGES
❑YES~" ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:, /f
BED/TRENCH WIDTH LENGTH. NO.OF LATERftI-SPACING GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER
TRENCHES'.
DIMENSIONS
MANIFOLD PU MAN IFOL DISTR. PIPE MANIFOLD PMATERIAL NODIS DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEVELEVDIA ELEVPIPESDISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRIL CORRECTLY ERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: 777ATION WELLS: NUMBER OF PROPERTY WELL: BUILDING.
FEET FROM LINE:
-t) ❑YES ❑NO ❑YES ❑NO NEAREST
Sketch System on Retain.-4county file for audit.
Reverse Side.
SIGNATURE'. TITLE.
DILHR SBD 6710 (R. 01/82)
Ez Wisconsin APPLICATION FOR SANITARY PERMIT ®1 L H R OUNTY
(PLB 67) UNIFORM SANITARY PERMIT #
InOUSTR V,Lg60R 6HUmgn gELRTIOns
-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
PROPER Y OWNER I MAILING ADDRESS
PROPERTY LOCATION CTTY:
1/4 1/4, S T---/", N, R ' (or VILLAGE:
TOWN OF:
LOT NUMBER BLOCK NUMBER ISUBDIVISION NAME NEAREST ROAD, LAjKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
21 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.
N,' 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: 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):
❑ Private ❑ Joint ❑ Public
1, the undersigned, hereby assume responsibility for installation e private sewage system shown on the attached plans.
--C, Namaof Plumber (Pant): [S, gn e: MP/MPRSW No.: Phone Number:
Plumb is Address: J
Name-of Designer:
~ I
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: ,Fee: ° Date: ' 1:1 Disapproved
G
El Owner Given Initial
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.
i
F urIII ~c fuu
Owner of Property rile ~hf fy f'+ f' 1r
Location of Property Sw Sum%y, Suctiu►i-~ N K ~W
u ~ - . - > -
T o w r► a h i p Ci I1 f l1'l
A._j11~C) C (Y7 y{ 1
Ma111nb Addrebb"~_-
Subdivision Name
Lot Nuwber
Previous OWLler of Property 0,\i C Y V'le So r\
r
Total Size of Parcel CkC av~
Date Parcel Waa Created 4
Are all corners ide►itifiable? X Yes No
include wlth Clit Li al'L 11L:uCiu11 onu of Llic tul.lowiiil~:
.Certified Survey Map
.Deed
.Land Contract. or
.Other legal bocuwcnt which deSCribuS the PrOpurty
PROPERTY OWNER CERTIFICATION
(We) certify that all statements on this form are true ta-M&--bm of my (our)
knowledge; that I (we) am (are) the owner(5)o-fthe property desC bed in this
information torm, by virtue of a warranty sued recorded in the Office of the
County Register of Deeds as Docume No.
;,and that I (we)
presently own the proposed site for t le sewage dispos*sWiem (or I (we) have
obtained an pasdrnent, to run with thu~bovo described property, for the
construction of said system, and the some has been duly recorded in the Office
of the County Register of Deeds, as Document No.
~1
SICINATUgE Of OWNEq SIGNATURE O, CO-0WNEFi (IF HPPLICAbLk)
DATE SIGNED DATE SIGNED
DEPARTMENT.9 p~eo..REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOF#''AIV~~ PERCOLATION TESTS (115) P.O. BOX 7969
HUMAI, prLAfIONS \ / MADISON, WI 53707
(H63.09(1) & Chapter 145.045)
P:.;ATION: SECTION: TOWNSHIP/k1UNfGIPAL+T-y: ILOTNO.:BL14NO.: SUBDIV,I$ION NAME:
w k~/ /T N/R (off) W % )/.7 fin//
COUNTY: OWNER'S I/ ER'S NAME: MAILING ADDRESS: _n
21. C G) I X (~I s2 n b~ Q/VYI C~ Jet v 11 JL is r~~l I JJ 1~
USE 12 J` YA~~ DATES OBSERVATIONS MADE
NO. BEDR COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence l)
4 ,New ❑Replace -
RATING: S= Site suitable for system U= Site unsuitable for system
67 S I S~ ,
4VU
+t CO NTI❑U: MX_COLUNS.❑U IN-GROUNND-PRESSURE:SYSTE~`M-IN-FILLHOLDIING ANK:REC MENDED SYSTEM: (optional)
[2 T;N El S c:
If Percolation Tests are NOT required DESIGN RAT If an
y portion of the tested area is in the
under s.H 33.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: 1.4
- PtROFFI DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATE - S CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH W, ELEVATION OBSERVED EST. HIGHEST TO BEDR_ OCK IF OBSERVED (SEE ABBRV. ON BACK.)
B fS-~.~(insl
0 / O t Cila ~j , -2.L rise
IX S-- B t ) 1 an r C) CUl, i 5'-7 ris; E
C, st 1; or)
/ s. -
B- ' ® `1V~7Cfrs~/; ~7,r 2.96,7.5./
7 _W, r) e -5 11-7 2
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER IAIE#L+S AFTER SWELLING INTERVAL-MIN. PERIOD t PERIOD 2 PERIOD 3 PER INCH
P_ I 5- r) ah s O
P- 2 vQ ` E- _1
P_ _3 6
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
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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:
A ESS: / CERTIFICATION NUMBER: PHONES NUMBER (optional):
CST I NffURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester,
DILHR-SBD-6395 (R. 02/82) - OVER
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Parcel 036-1009-90-000 01/24/2007 02:43 PM
PAGE 1 OF 1
Alt. Parcel 4.31.17.59C 036 - TOWN OF STANTON
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 - PETERSON, WILLIAM J & SHERYL
WILLIAM J & SHERYL PETERSON
1604 CTY RD H
STAR PRAIRIE WI 54026
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 1604 CTY RD H
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 2.220 Plat: N/A-NOT AVAILABLE
SEC 4 T31 N R17W 2.22A SW SW LOT IN CSM Block/Condo Bldg:
VOL 5/1326
Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
04-31N-17W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 670/633
2006 SUMMARY Bill Fair Market Value: Assessed with:
166393 245,700
Valuations: Last Changed: 05/05/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.220 20,000 186,800 206,800 NO
Totals for 2006:
General Property 2.220 20,000 186,800 206,800
Woodland 0.000 0 0
Totals for 2005:
General Property 2.220 20,000 186,800 206,800
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 220
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00