HomeMy WebLinkAbout040-1064-50-000
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AS BUILT SANITARY SYSTEM REPORT
OWNER; J' TOWNSHIP ,r SEC. T N-Ri W
ADDRESS
RZPAO~ COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
YTHING WITHIN 100 FEET OF SYSTEM T
f 1"
ill
I di a e 110~th e Arrow
.SCALE: 1
BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: Slope at site: ;
SEPTIC TANK: Manufacturer: Liquid Capacity:
Number of rings on cover Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set or a cyc e gallons; total capacity o
distribution lines gallon:. size o pump head;
gallon per minute horsepower ran name of pump
and model number ;
Type of warning evice
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover
Type of warning device
SEEPAGE PIT SIZE: Number o pits feet diameter
feet liquid dept seepage pit in epe-elevation
bottom of seepage pit elevation feet-
SEEPAGE BED SIZE: number of lines wi th length' tile depth
SEEPAGE TRENCH: width length
PERCOLATION RATE AREA REQUIRED AREA AS BUILT
HEADER LINE ELEVATION DIST. PIPE ELEV. INLET ELEV. END /'y.
DATED PLUMBER ON JOB
LICENSE NUMBER
ST. CROI X COUNTY
WI SC O N S I N
ZONING OFFICE
796-2239 (HAMMOND)
425-8363 (RIVER FALLS)
HAMMOND, WI 54015
Octobetc 2, 1984
CaAt Hens e
1545 Centenn i.at Lane
Rivet PaU,6, WI 54022
DeaA Mt. Heise:
It has come to the attention of this o44ice that you iwstaUed a zeptic
,s yz tem Ooh Dennis Schuttz on SeptembeA 20, 1984. The pAopehty tis .Located
in the SB4 o4 the NE-14 ob Section 16, T28N-R19w, Lot# 4, Town o6 Ttcoy.
The peAm,i t 4otc this site had been taken out by Michae e Hawkins on NovembeA
21, 1983. Accotcding to 145.35, State Statutes, you wtce tequiud to have
the san.itaAy peAm,it tAan~s setviced to youA masteA ptumbeA',s name. This
AegwiAe,s that a PLB-67T be compteted, and a bee o4 $91.00 paid to the St.
Cuix County Zoning 046ice.
t I~ this i6 not done within the next ten (10) days, we w,i-U be 6oACed to
take .begat action.
Shoutd you have any que,6ti,onz Aegatding this subject, pte"e beet 6tte
to contact thi,6 o66ice.
Sincenety,
HaAVtd C. BatcbeA
Zoning Admini6tAatotc
HCB: mj
ST. CROI X COUNTY
WISC0NSI N
ZONING OFFICE 796-2239
r,
FiAMMOND, WI 54015
September. 21, 1984
Michaet L. Hawkins
536 N. Winter St.
Riven. FC(-Q.PiS, W1 54022
Dean Mike:
We have been holding the Sanitary Inspection
Sheet for the following system(s):
Robert 13n.owne, Town o6 Tnay ° .
Dennis SChu tZ Town a6 Tnoy/
Please turn the As-Built into this office as
soon as possible, so that we may complete ouv
file.
If you have any questions, please feel free to
contact this office.
Yours truly,
Thomas C. Nelson
Assistant Zoning Administrator
sl
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MpDISON;'W' 53707
CONVENTIONAL ❑ALTERNATIVE State Plan I.E. Number
(If assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
Dennis Schultz 1003 Birchcliff Dr., River Falls, WI
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. R F. PT. ELEV.: CST REF. PT. ELEV.
SE4 NE4, Section 16, T28N-R19W, Lot #4, Town of Troy
Name of Plumber. JMPIMPRSW No. County nitary Permit ~mber.
Mike Hawkins 5926 St. Croix 43720
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WANING LABEL JLROOCK~NG COVER
P PROMR ED: VDED.
r S YES ENO DYES ENO
FRESH
BEDDIN VENT DIA.. VENT MATL HIGH WATER NUMBER OF ROAD. PR OPERT WELL. BUILDING. VENT T ET
v ALARM FEET FROM LINE AIR INLr
YES NO 1. DYES ENO NEAREST
DOSING CHAMBER:
MANUFACTURER BE D DI NG. LIQUID CAPACITY JPUMP MODEL JU MP. SIPHON MANUF ACT UREH WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
EYES ENO DYES ENO OYES LINO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF FINE JWELL BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) EYES ENO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing ILII(,TH DIAMFTER MATERIAL 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:
SIDE DIA -PITSLIQUID
IN
WIDTH. LENGTH INO01 DISTR. PIPE SPACING C r
BED/TRENCH TRENCw~ ` AL PIT DEPT"
DIMENSIONS ~ V ~ ~ lJ %
GRAVEL. DEPTH FILL DEPTH UIST R. PIPE DISTR PIPE DISTR. PIPE MATERIAL'. IN R NUMBER OF PROPERTY WELL BUILDING: VENTTO FRESH
BFLOW P PES~j ABOVE CoER Et E INLFT ELE END. PI FEET FROM LINE. AIR INLET.
uI NEAREST
MOUND SYSTEM: laa " r
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-
meets the criteria for medium sand. TIONS MEASURED.
DYES ENO
SOIL COVER TEXTURE PERMANENT MARKERS. OBSEH NATION WELLS
DYES ENO EYES NO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH; BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES
DYES NO DYES NO DYES ENO
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 JMANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MAHKING
ELEV.. ELEV.. DIA. ELEV.'. PIPES DIA.:
ELEVATION AND
DISTRIBUTION
DYES E NO VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY covER MATERIAL PLANS D
YES ENO
I
L
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL. BUILDING.
FEET FROM DYES NO DYES ENO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
`.O
DILHR SBD 6710 (R. 01/82) GN T RE TITLE
-sconsin APPLICATION FOR SANITARY PERMIT
COUNTY
'~~DILHR (PLB 67)
h7EPRRTTnEnT OF
M UNIFORM SANITARY PERMIT #
InoU5TRV, LRBOR 6 HU TRn RELRTIOnS
-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.
'~)v'- K-) VI) r"~ ~ -7-- ~ (:-i c' k
PROPERTY LOCATION CITY:
1/4 ~i /4, S C0, T4-A, R 101 E (or) OWN oE:
LOTBER BLOCK NUMBER SUBDIVISION NAME NEAREST RfO.A~D, LA )E OR LANDMARK STATE PLAN I.D. NUMBER
TY OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms. ` ❑ Public (Specify):
TqIS PERMIT IS FOR A:
New System ❑ Tank Replacement ❑ Repair
Lj Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IFIS 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 -
E-1 An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total #of Prefab. Site
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: :S~' Q,i
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): PnRO UD (Square Feet):
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of PI tuber (Print): Si nature: M P / l142.ftft* N o.:
phone Number:
IM,
(L+ (7i ,_)¢za~~77
Plu er's Address:-,~ Name of Designer:
15 ~ C~ , Z Si1r ~-',f t (If: 1
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: ~Feve: Date: PH] Disapproved
Owner Given Initial
C (d 3 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.
Fu rill - S T C 1 00
I
I
•
Owner of Property R• 'L
Location of Property--~ Section T401? N Ry W
Township
Mailing Address 10 SOL
&J& Y -'VA' )A 2.
Subdivision Name
Lot Number )4P* do) ~s • •I •
Previous Owner of Property
Total Size of Parcel & Apr
Date Parcel Was Created
Are all corners identifiable? Yes No
Include with this application one of the following:
.Certified Survey
.need
.Land Contract, or
.Other Legal Document which describes the property
PROPERTY OWNER CERTIFICATION rer`!3
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 deed racordecL in the 0
County Register of Deeds as Document NO G , an that Fl(we) ISO
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an casement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
q a County Register of Deeds, as Ekocument No.
•
SIGNATURE Of OWNfiA SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
i
I~
I
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CERTIFIED SURVEY MAP
43.4415 These lots are located east of Glover Road.
R=125300
•1.08`38
\ Ob SCALE IN FEET
N-
2 O 1 O 100 200
174.2541 ASS 0\
IC+O, 4rt,~ \ I
pqC Gry
\ 0, T\ 9lr
\ y6%' 3bE o< JR 114G
~~O ~ SOli~9 ~F9q \OS I.
\ SOLD ry<9 °<s
9~N I \ 2 209 a'h°~F,S 'QC,
°'yyy
NW-NE NE-NE m, 1~ P T\ 9 \ O
_ W-NE SE
S -NE 9'P~ tJ° ~V1 ~9<~ ~(`/O
f \ qb 9y 3 °90 -
9,900.00 < N \
c\ E 2p 'y F \
S
E N D 1 a\ c P so°0 \
p E 90
o ('X24' IRON PIPE WEIGHING f\ f .'5 \
1.66 ?/LINEAL FOOT Z \ Y,,6~ 9< Ng'S $ 9,900.00
B COUNTY SECTION CORNER pp\ W IN
r3
MONUMENT, FOUND. y m ~ZC\ "j G4t~S
P
\ ~ h 5
NOTE: \6 ^yM^I \,PF
\ P 6
LOTS I AND 2 ARE
HEREBY RESTRICTED
TO ONE COMMON
DRIVEWAY, LOTS 3 Qi
AND 4 ARE ALSO vA
HEREliI' RESTRICTED ~p \ n 2N
TO ONE COMMON sg
DRIVEWAY, 4`.
Northea sterl R/W line
92 ~
\Vs P1111 1T £ Northerly
R/lY Ilne
BEGINNING $s NI•Sfi31~
APPROVED s
96.-
APPROVAL OF THIS MINOR SUBDIWSIO N'SGe 2 N87%figO W 33OC;
APR 26 1979 DOES NOT MEAN APPROVAL Fp0( -167.00' y 322.00
BUILDING SIZE OR SEPTIC SY,,TFM, L I 71, 10' E I/4 CORNER
ST. C?OI% C , REFER TO .42.20, -61'00'1 SECTION 16,
coxrcxa.vvE r.vRS n.wwHO T28N,R19W
AIO ca4H0 corwr>..
DEPARTMENT OF REPORT ON SOIL BORINGS ETY & BUILDINGS
INDUSTRY, /f
LABOR fAND ' Ao, ~G P.O. ISION
7969
HUMAN RELATIONS PERCOLATION TESTS (1 ISON, WI 53707
(1-163.090) & Chapter 145.045) 10 1g t_q
LOCATION: SECTION: TOWNSHIP MUNICIPALITY: LOT LK: D 10 - 1 ME:
'/w{Y N/Rft~, E (c, COUNTY: WNER'S UYER'S NAME: MAILING ADDRESS:
~ L.
USE •~~"'i/"-'r~ .ti r_ c_ ~
DATES OBSER S MADE
NO. BEDRMS.: JCOMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONRCO LATION TESTS:
Residence
®New ❑Re lace
L9
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONIA'L: MOUND: IN-GRO R11 RE1111RI SYSTEM-IN-FILLHOLDIING TA'NIII< RECOMMENDED SYSTEM: (optional)
~ C~J EV 91 S OUT ZS El V 11 S fl U El S 2 V
F P~ecolation Tests are NOT requird DESIGN RATE:
[Ffloodplain, any portion of the tested area is in the
r s.H63.09(5)(b), indicate: 07- indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B
C-5.
B-37 IE -3
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD t PERIOD 2 PERIOD 3 PER INCH
P_
~ c- .cam ...CS .,F~~:~~i ~ 7--T.fc_ - ,.•L--.
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
~ ✓~C ~ s<,-.i_. mot---'~!'`'-=,~ ~ l
,
i
d _
S
3
a
i
_ X a _ . _
i a 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):
/.`•i`- i._-'. .c-"~=. ! l~l~i. , +r'-lid<~ - ~T'> _ ~
CSTSIGNATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester, j i
l)ILHR-SBD-6395 (R. 02/82) - OVER
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Parcel 040-1064-50-000 01/24/2007 04:11 PM
PAGE 1 OF 1
Alt. Parcel 16.28.19.240E
Current X 040 -TOWN OF TROY
ST. C
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type COUNTY, WISCONSIN
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
JOHN L & RAMONA VENAGLIA O - VENAGLIA, JOHN L & RAMONA
PO BOX 33
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 367 N GLOVER RD
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 3.690 Plat: N/A-NOT AVAILABLE
SEC 16 T28N R1 9W 3.69 AC IN SE NE LOT 4 Block/Condo Bldg:
OF CERT SURVEY MAP IN VOL III PAGE 796
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
16-28N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 695/438
2006 SUMMARY Bill Fair Market Value: Assessed with:
158218 217,800
Valuations: Last Changed: 07/20/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.600 63,200 135,500 198,700 NO
Totals for 2006:
General Property 3.600 63,200 135,500 198,700
Woodland 0.000 0 0
Totals for 2005:
General Property 3.600 63,200 135,500 198,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 213
Specials:
User Special Code Category Amount
Total Special Assessments Special Charges Delinquent Charges
0.00 0.00 0.00