HomeMy WebLinkAbout026-1119-14-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and �Buildings Division Count Croix
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanita3 � JJ 5SrgttNo.:
Personal information you provice may be used for secondary purposes [Privacy Law 15.04 (1)(m)].
Permit Holder's Name: ❑ City ❑ �] n of: State Plan ID No -:
ubler, Paul & Patty K1cnrTlOIn ° 'pownship
CST BM Elev.( I Insp. BM Elev.: BM Description: Parce c
s V,� * Z 1 cv� ti.�S- CST Q w,Z o2&- 1 )1 4 1 - ► -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic `ZS'a Benckmark'_ d I (�A► 95`.60
Dosing Alt. BM 5 33
Aeration Bldg. Sewer (, 0 OS.fl
Holding St /Ht Inlet - , -7 .92- ro3. IS '
TANK SETBACK INFORMATION St/ Ht Outlet �• (o I Oz
TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet -
Air I
Septic 1 �p * - � q NA Dt Bottom —
Dosing NA Header /Man. yc?
Aeration NA Dist. Pipe y•y a (o(.oS'
Holding Bot. System // 38 9- 70
�1_ z
PUMP/ SIPHON INFORMATION Final Grade
Mano"tur€r Demand St cover S
Model Number GPM
TDH Lift L ction Sys -_ TDH Ft
Force Length Dia. H ead
Dist. To Well
SOIL AB TION SYSTEM ;—d- CZ a) =
RENCH Width Len Z No. Of enches PIT No- Of Pits Inside Dia- Liquid Depth
DIMEN I 3 DIMENSION
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING
fa�t
INFORMATION Type O / r _ CHAMBER M del Num w
System: �j OR UNIT
DISTRIBUTION S (,,STEM1„
Header / M nifol ` Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. �'' _ ngth Dia. Spacin
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: � /IG / Inspection
Location: 1285 146th Avenue, New Richmond, WI 54017 (SE 1/4 NE 1/4 22 T30N R19W) - 22.30.19.326A Pondview
Meadows -Lot 14 3 j �9
1.) Alt BM Description = -T c -
2.) Bldg sewer length = 3a' `T3
- amount of cover= ' ;I '
S,L ko fX- tB�. -r� 8•' ° p- Q. -�.""" . �, 5�' fiJc -���
Plan revision required? ❑ Yes No o � 16 W /
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature ='er
ADDITIONAL COMMENTS AND SKETCH
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SANITARY PERMIT NUMBER:
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Safety and Buildings Division
%Lonsin SANITARY PERMIT APPLICATION 201 Box Washington Avenue
Department of Commerce In accord with Comm 83.05, Wis. Ac)m:•Co� O Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the syste n paper of esst , my
than 8 1/2 x 11 inches in size.
• See reverse side for instructions for completing this applic ion _ , f State Slpnitary Permit Number
35 3( S
Personal information you provide may be used for secondary purposes ` 3 Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
a State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL I WIFORMA T
Prope Ow er Nam d Low on
1�� fi 1 1/4 1/4, S Z T �� , N, R f 9 E (or) 69
Property Owner's Mailing 4dress fir' Block Number
w -r aa-
4INTYPE y, State Zip Code Phone Number Subdivision me or CSM Number
BUILDING: (check one) ❑ State Owned E] Cit Nearest Road
l�
Public 1 or 2 Family p Village Dwellin - No. of bedrooms Town OF (o
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number 624 cb
1 ❑ Apartment/ Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. GerVew 2. ❑ Replacement 3, ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an
- ___"_'_''_system ________ System __ Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 []Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 &Seepage Trench 22 ❑ In- Ground Pressure E] Pit Privy
13 ❑ Seepage Pit e ` ❑ Vault Privy
14 ❑ System -In -Fill 5;k M 2
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/daaY /sq. ft.) (Min. /inch) Elevation
( 60 /Z 00 126 $ J c ) l `g X? Feet 10Z.j Feet TANK Capacit
VII. FORMATION i g llo Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Exper.
Gallons Tanks Concrete glass Plastic App
New Existing strutted
Tanks Tanks
1 e — pticTarij or Holding Tank b — ��� Q ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamberl I ft I ❑ I ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sew m shown on the attached plans.
Plumber's Name: (Print) PI sSignature: tamps) I MPRAPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, p Code):
IX. COUNTY/ DEPARTMENT US ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate ssue Issuing Agent Signature (No Stamps)
,Approved []Owner Given Initial Surcharge Fee)
Adverse Determination ; as-- a 3-2LVD
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -6398 (R. 4199) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS '
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division,- 608 -266 -3151. -- .
To be compl and accurate this sanitary permit application must include: i
L - Property owner's name and mailing address._ Provide the legal description and parcel tax number(s) of where the
system is to be installed.
11. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type -
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc,),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County / Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss, pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; Q soil test on a 115 form; and F)' all sizing information.
----------------------------------------------------------------------------------------------------
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) fora number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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Wisconsin, Department of Industry, e 1 of 3
Labor and Human Relations SOIL AND SITE E V A L U \. _ I� E.#:� R T Pa —
Division of Safety & Buildings in accord with ILHR 83 5�` fs`. Adm. ,Code l
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in i@. Plan must mc(U�e;ut St. Croix
not limited to vertical and horizontal reference point (BM), direction an % `of slob; Sc4e gr J? RC W ED EL I.D. #
Ci � dimensioned, north arrow, and location and distance to nearest road. i „ 026- 1065 -50 -000
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION BY DATE
r �� ESLIlaL-1 elf- sr -► -i�
PROPERTY OWNER: PROPERTY Lot ow,,' `
Richard Derrick 'GOVT. LOT SE 1�4' E 1/4,S 22 T 3o AR iw peww
PROPERTY OWNER':S MAILING ADDRESS LOl # SUBD. NAME OR CSM #
1310 Hwy 11 65" 14 Pondyiew )XI
CITY, STATE ZIP CODE PHONE NUMBER [ ❑VILLAGE 19OWN NEAREST ROAD
N ) H
(� New Construction Use [ iq Residential / Number of bedrooms 4 [ j Addition to existing building
j J Replacement [ J Public or commercial describe
Code derived daily flow 600 gpd Recommended design loading rate .4 bed, gpd /ft .5 trench, gpd /ft
2 2 2
Absorption area required 1500 bed, ft 1200 trench, ft Maximum design loading rate .4 bed, gpd /ft — .5 trench, gpd /ft 2
Recommended infiltration surface elevation(s) area A =98.6/ B =99.77 ft (as referred to site plan benchmark)
Additional design / site considerations na
Parent material glacial drift Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN GROUND PRESSURE AT GRADE 7 SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem z] S ❑ U C1S El CA S El U ®S ❑ U ®U ❑ S ® U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
..................
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
.................
1
2 9 -19
Ground 3 1 Q-6n
elev.
10 4 60 -84 7.5 r 4 6 none sl lcsbk mfr na na .4 i .5
Depth to
limiting
factor
+84
A46?
Remarks:
Boring #
-12 10 r 3/3 none 1 1f P1 mfr QW if n .3
2 2 12 -21 10 r 4Z4 none sici lcsbk mfr 9W if .2 .3
.................
Ground 3 21 -80 7.5 r 4/4 none sl lcsbk mfr na na .4 .5
elev.
103.
Depth to
limiting -7 9 5�'
factor
+80 1,
Remarks:
CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200
Address: 1554 200th. Aye.. New RichnaorW, WI 54017
Signature: Date: 4 -23 -99 CST Number: m02298
PROPERTY OWNER Richard Derrick SOIL DESCRIPTION REPORT Page 2' of 3 '
PARCEL I.D. # 026- 1065 -50 -000
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boa rd3y Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed !Trench
0 -10 1 lcsbk mfr Qw if
2 10 -20 10 r 4/4 none sicl lcsbk mfr gw if .2 .3
Ground 3 2sl 2mar mvfr qw if .5 .6
elev. —
1 02.6 ft. 4 6sl lcsbk mfr na na .4 .5
Depth to
limiting
factor
+84"
Remarks:
Boring #
1 0 -9 10 r 3/3 none 1 lcsbk mfr 9w if .2 .3
<..4...: 2 sicl lcsbk mfr qw if .2 .3
Ground 94 7 w f .4 ! .5
elev. 4 48 -80 7.5 r 4/6 none sl 2m r mvfr na na .5 .6
Depth to -
limiting
factor
+80
Remarks:
Boring #
1 0 -12 10 r 3 3 none 1 lcsbk mfr gw if .2 .3
5 2 - 4 none sicl lcsbk mfr gw if .2 .3
Ground 3 24 -62 7.5 r 4 4 none sl 2m r mfr gw if .5 ,.6
elev. r 4/6 none sl lcsbk mvfr na na
1 - �4 -.5
Depth to
limiting G
factor
+84"
Remarks:
Boring #
Ground
elev.
ft.
i
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel I Richard Derrick 1554 200th Ave.
CSTM2298 SE4NE4 S22- T30N -R18W New Richmond, WI 54017
MPRSW -3254 lot #14- Pondview Meadows (715) 246 -6200
town of Richmond
This soil evaluation was conducted to satisfy a zoning requirement, it may or may
not be suitable for your use.
N
1 =40'
BM.= top of SW lot stake @ el. 100.00'
Alt. BM-= top of NW lot stake C el. 95.60
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GAry L. Steel
4 -23 -99
ST CRCIX COUNTY
SEPTIC'—,'ANY, MAJNTI AGR.EEMIiNT
AND
OWNERSHIP CEkt11 ICATION FORM
Owner/Buyer,
Mailing Address ��
Properly Address /--z if � 7
(Verifieatton required iron i Planning Dopertment for new construction)„_ __- (/
City /State Parcel Identification Nttrrtber 07 v r;s - iv a �� /ci► s' //l
s - o�
L E GAL DESCRIPTIO
Property Location , � _ 'A, y,, Si C. --Z - 7 - . T 2 C� - R/ - q W, Town of
Subdivision �(!1`� w' . — _ , Lot # _
6osst�8"
Certified Survey Map # �? , Volume ��. Page #
War ranty Deed # /.? y �o Volume Page #
Spec house 0 yes 6 no Lot lines identifiable K` yes ❑ no
SYSTEM MA UENANCE
Improper use and maintenanceof your sel pc systotn could result in its premature failure to handle wastes. Proper ma,intesrance
consists of pumping out the septic tank every tbri a yesn or sooner if tied dedby a licensed pumper. What you put into tht system
can affect the function of the septic tank. as a trr► 0nent stage in the waste disposal system.
The property owner agrees to submit to SL 05roix Zoning Degaruneut a cottik?cation form, signed by the owner and by a
master plumbcr, journeyman plumber, restrietedpl umber or a licetmeApumper verifying that (1) the ots - site wastewater disposal system
is in proper operati condition and/or (2) after in: �ection a:pd parnplag (if necessary), the septic =k is less than 113 full of sludge.
1lwe, the undersigned have read the above requirri rents and agrea to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Departm of Com "me card the Departmont of Natural Resources, Stato of Wisoonsia. Ce ls-w -ation
stating that your septic system bas been maintainer i must be completed and raturned to the St. Craix County Zoning Office within 30
days the three year expiration date.
SIGNATM OF APPLICAlTr DATE
OW NER CERTJ C TA ION
I (aye) cextify that all statements on this i irm axe true tx) the best of my (our) lcoowtedga. I (we) am (are) the owner(s) of
th erty described above, by virt►,e nf a warm ity deed recorded itk Rtgister of Deeds Offi
' -- L�A (
SIGNATURE OF APPLICA1'Q't �~ DATE
Any information that is mis- represented rr ay result in the sanitary permit being revoked by the Zoning Department."""
"* Include with this application- a stamped warr ltlty deed from the Register of Deeds affSrc
a copy of the c rtified survey inap if reference is ,trade is the Warranty deed
r
r vOL iMeAG 121 613456
STATE BAR OF WISCONSIN FORM 2 -1998 KATHLEEN H. WALSH
REGISTER OF DEEDS
5T. CROIX CO., WI
This Deed, [Wade between Loren D Derrick Rose H. Derrick. RECEIVED FOR RECORD
Ri d L. Derrick a L Derrick and Robert J. Derrick 11-06 -1999 9:30 AN
WARRANTY DECO
EXEl1DT D
CERT COPY FEE:
Grantor, conveys and warrants to COPY FEE:
Paul H ubler and Patricia Hubler, husband and wife TRANSFER FEE: 86.70
RECORDING FEE: 10.00
PAGES: 1
Grantee.
Grantor, for a valuable consideration, conveys and warrants to Grantee Recording Area
the following described real estate in St. Croix County. State of Wisconsin Name and Return Address
(The "Property "):
WESTCONSIN CREDIT UNION
P.O. BOX 269
NEW RICHMOND, WI. 54017
026- 1065 -10 dt026- 1065 -50
Parcel Identification Number (PIN)
'Ibis isis_ot homestead Property.
Lot 14, Pond View Meadows in the Town of Richmond, St. Croix County, Wisconsin.
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this day of November, 1999.
�-R�osee ren D. Derric
hRrrick
H. Derric r
`ACKNOWLEDGMENT
* Robert.,. Derr' STATE OF WISCONSIN )
AUTHENTICATION ) ss.
County )
signature(s) Loren D Derrick Rose H Derrick, Richard Personalty came before me this day of June .
L Derrick Joan L Derrick and Robert J Derrick 1999, the above named
to me known to be the
persons) who executed the foregoing instrument and
authenticated thi day of acknowledge the same.
November, 999.
* Kristin gland Notary Public, State of Wisconsin
My Commission is permanent. (If not, state expiration date:
T1TLE: MEMBER STATE BAR OF WISCONSIN
(If tat,
authorized by $ 706.06, Wis. Smts.)
THIS INSTRUMENT WAS DRAFTED BY
Attomey Kristin Ogland
Hudson, WI 54016
(Signatures may be authenticated or acknowledged. Both are not
necessary.)
*Names of persons signing in any capacity should be typed or printed below their signatures
wARRANn P® SPATE BAR OF WISCONSIN
FORM No. 2. 1"S
INFORMATION PROFESSIONALS COMPANY FOND DU LAC, W1 BOD45M -1021
I
D DERRICK AND OTHERS
GH WAY "65" �•�S
3HMOND, WI 54017
NOTE t1
vNQ.= PLATTER TO RETAIN OWNERSHIP OF OUTLOT 1. ® \
❑UTL ❑T 1 IS RESERVED FOR TOWN ROAD EXTENSI ❑N. \
LOT 11 TO HAVE EASEMENT OVER ❑UTL ❑T 1 FOR
ACCESS TO 146TH AVENUE.
AREA ❑UTLOT 1
ANY FUTURE ROAD EXTENTION WOULD 0.159 ACRES
EVENTUALLY ACCESS TO C.T.H. 'G'. 6 930 SQ. FT.
S86 °40135 11W 355.38'
13.2' +
Tcf
_ --
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-•
N i Q Z 2.004 ACRES _
iN i o 87,313 SQ.FT.
v 100 in
r`i w L
8.25'-- !'— S89 °43'03 "W 380.66'
3 , 14.7' + /- I
I
33'
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87,318 SQ.FT. o i i
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O 2.005 ACRES I
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tment.
,
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vision 22 2' +/ 1 5 '`••,. / �i�
: 1
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.ding 2 .006 ACRES
9
87,362 SQ.FT. �,P,��