Loading...
HomeMy WebLinkAbout030-2106-20-000 c r Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 ( 1)(m)]. 363948 Permit Holder's Name: ❑ City ❑ Village ❑ T n of: State Plan ID No.: Madlung, Jarvis St. Joseph Township CST BM Elev.:- Insp. BM lev.: Description: Parcel Tax No.: �# S 030- 2106 -20 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark W � Dosing Alt. BM ' -6s► Aeration Bldg. Sewer Holding St/ Ht Inlet , /� g3.4C TANK SETBACK INFORMATION St/ Ht Outlet G •�{ 3 q3• fob' TANK TO P/ L WELL BLDG. Air I to ntake ROAD Dt Inlet Septic f �3p r ( r NA Dt Bottom Dosing A Header / Man. r Aeration NA Dist. Pipe Holding Bot. System 12_. kS- 3Z PUMP / SIPHON INFORMATION Final Grade Manufac er De nd St cover Model Number G M TDH Lift L rictio System TDH t Fo ain Length Dia. I f e I SOIL ABSORPTION SYSTEM �� W.& (TRENCH Width 3 j Length N f renches PIT No. Of Pits Inside Dia. Liquid Depth DIME g •� 5� DIMEN SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manu adurer rr SETBACK CHAMBER 5� INFORMATION Type Of Moe Number System: 7 OR UNIT — DISTRIBUTION SYSTEM 1 ) . 30 ` Header / M ni old Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia - ngth Dia. S SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over , N 2 D a Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed/ Trench Center Z ` C l - 7 Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) 1: ®/ d/ 0 ection #2: -- f Ins 7r Inspection #l: � � v Location: 364 117th Avenue, Hudson, WI 54016 (SW 1/4 NE 1/4 6 T29N R19W) - 062919886 Evergreen Ridge -Lot 2 1.) Alt BM Description = 2.) Bldg sewer length= IL' _ - amount of cover = > r8 S CA7tief. 3) UeQQ . S �u✓�e� Plan revision required? ❑ Yes No p2. I S 0 I U ot IiIona in a on. SB -6710 (.3/97) Date _ Inspe or's Si atur n n — C ert.�NY. y- o�r.••y -ir e- u•..• ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: , + w � � I � F g R A gp Z P c _ .d........ � �..�.. T..,...e� .�,„.. .. �.. .�... 2 — .__.-- F..e�....�..... ., .�i..,...,,..�.. .�...,a..........�. ..�.�.a __.....p..®...,.�.,»......_. }......,i.� -&mow qq E 3 R s a i t i # g j T, 1 r p t y { t + 1 Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. N0 reverse side for instructions for completing this application PO Box 7302 Oepertment or Commerce Personal information you provide �onry purposes Madison, WI 53707 -7302 [Privacy L� ; 1�f�4 1 rn (Submit completed form to county if not state owned. Attach complete plans to the county copy,4ftWWr the slitem, on less than 8 -1/2 x 11 inches in size. County ` C © State Sari t q P git Num C k ,t q to pre a lication Stat Plan 1. D. Number — J tI J C I. A plication Information - Please Print all Inforrollift0i Location: Property Owner Name ! ! I ; Property Location ` // qq �� S T G�OIX r' - - S W 1/4 N£ 1/4 S 1p TV*. R E or W I lb P Owner's Mailing Address Lot Number Block Number Property g E o A Go City, State Zip Code P Subdivision Name or CSM Number S�,ll�l� ,NN 55o�a b3S8 �ve --G�� QJ II. Type of Building: (check one) EI Ci ty ® 1 or 2 Family Dwelling - No. of Bedrooms : 3 g e • Public /Commercial (describe use):_ ®"town of • State -Owned S i ' 'TO Nearest Road Oii_e QJ1 x 75- Parcel Tax Numbers) O ' III. T ype of Permit: Check only one box on line A. Check box on line B if applicable A) 1. oKNew 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to System System Tank Only Existing System B) Permit Number Date Issued Sanita Permtt was reviousl tssued IV. Type of POWT System: (Check all that apply) XNon- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland • Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line • At-grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. S st r�9} Elevation 7. Final Grade Required Proposed Rate (GalsJday /sq. ti.) (Minlinch)v .o; U Elevation 5Q G93 I Uo ;G,) • 7 sb. .Ao I Ll), .40 VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks /U -) ���f - ❑ ❑ ❑ ❑ VIII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's N (print) Plumber's ature (nos stamps): MP/MPRS No. Business Phone Number Plumbers Address (Street, City, State, Zip C ) )WO Pw 33 rJ Pu o IX County/Department 14e Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps) Approved ❑ Owner Given Initial Adverse jWharge Fee) Determination o'Za2S� CD /0' Zft X. Conditions of Approval /Reasons for Disapproval:_ sf L ►� - r .� �.�� • _ .1 _ - ...r.l`�J� ate- S - rn -IVA Z40 aL • 0 71 - 1100 12 (3r�� = Na,l " >u 1rJ� �r►.� l�.l ��0 3 3N Q'N ?o0Q !- �viN OI ry 3S BmIll i z 3)(M,-7S 3 A1 � QRQ� 'as XXXXXXXX ca cc W Coc�� O 2r, e — Iv r I� 9v a o 9d.ao 0 cn 1 > g Ci . j n ro cti p x vi Oc v n to ro N E E U C ,C X co (h -- I U U i �- ,- N Z3 (A C9 r' '> 3 cc Q O 0 C' @a g co ' o 6 v M o (D o CL % co J Cl) LL 0 WisconsidDepartment of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of 3 Bureau of Integrated Services I'a n S. ILHR 83.09, Wis. Adm. Code C6 - `` ' ; ` County Attach complete site plan on paper not less x 11 1 size. Plan trtust Q include, but not limited to: vertical and hori z fer� ), directiond J 4 . C percent slope, scale or dimensions, north a nd location and distance t road. Parcel I.D. # LO tl APPLICANT INFORMATION - e rint alkjnr Lion. 1 Reviewed by Data Personal information you provide may be used for purpose N s�1��4 1) (m)). Property Owner roperty Location Govt. Lot 5 Gt,/ 1/4 ,(/T /4,S (( Tay'jo N /y z0 E (or) Q Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# JIS yhC L9` /' " j>r' Z City State Zip Code Phone Number Ci ty ❑ Village [� Town Nearest RoabJ ❑ Sr' r", I L_j( I g 1 (7,S) — &Yy gf. as-- h i C rey 09 New Construction Use: residential /Number of bedrooms � Addition to existing building Replacement Public or commercial - Describe: Code derived daily flow 60 gpd Recommended design loading rate ' 7 bed, gpd4F • L trench, gpd* Absorption area required bed, ft 7 � trench, ft Maximum design loading rate bed, gpd/il _,��_ trench. gpd/ft Recommended infiltration surface elevation(s) JW 1"f1t nc h 9 Z o ft (as referred to site plan benchmark) Additional design/site considerations '� e r`� r� �� �6 � , Z 0 / Parent material LJ ':�tG I'C' Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system [�U S ❑ U EW S ❑ U [A s El u M E ❑ U ❑ S R U EIS Q U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench i 0 - Y !o r 3 y- S h1 �b PL-C( C -5 1 • S ;`�c C'5 Ground '� f elev. q � Depth to 40 • Z o limiting factor a / in. Remarks: Boring # Ground elev. ' 9z, Depth to limiting � f ctor in. Remarks: CST Name (Please Print) Signa a Telephone No. Q pv S� lw (�-e ,- �� —�/� ��- X5/7 yoo Address Date CST Number �/oFr e -ewer S�` ,r1 . �- ,� c,�s2 f— �✓ 'YOB PROPERTY OWNER `[ /f iAJ-e1--� SOIL DESCRIPTION REPORT Page of 3 PARCEL I.D.# Boris # Horizon Depth Dominant Color Mottles Structure 2 Boring Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench i �E3 G -� /o Z vF /a, .�- Ground lev. Depth to limiting factor Remarks: Boring # / f Oslo G � 3/ r_ � I H1a `v ✓' � • , �XO • �{ `/ /C 5 s l C-5 — 7 Ground gle 2d� Depth to limiting factor Q/ in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots PD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ' d — !0 / Z J1 //11Q 5 2 o7 er Xk t lam " C S , S — : , • S Ground elev. Depth to limiting factor -4—' Remarks: Boring # =F Ground elev. ft. ' Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) orb e 4-0 i i 4 9d, z o o r-I 8Ft `n1CLr l BZ � o �a e -e loc- I _ 153 C4- ozr M I ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer J U 5 Mailing Address c T7 Property Address �w (Verification require from Planning Department for new construction) 0 Ci ty /State / _-a/Zt� S DA bb L Parcel Identification Number LEGAL DESCRIPTION Property Location , ' /,, Al,� y,, Sec. �, T4 MN -R jj , Town of Subdivision i1,�y'cf /'� �� �f ,�� �, , Lot # Certified Survey Map # . Volume , Page # Warranty Deed # Voltune / I / ,-) u , Page # Spec house 0 yes dno Lot lines identifiable 0/yes O no SYSTEM MAINTEN NCE Improper use and maintenanceof your septic system could result in its premature failure to handle wastes. Proper maintemance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the firnction of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification foam, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 hI1 of sludge. Uwe the undersigned have read , lm d the above,'...: and ag to maintain the p rivate sew disp a wi • ;the standards gm P 8 Po Yam► set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 . da of the three year expiration date. X -moo 7 NATURE OF APPLIC DATE OWNER CERTLFI= N I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. 6 /,? 2100 NATURB OF APPLICA10 DATE Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department.****** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed rIL 1400eAa255 i{ STATE BAR OF WISCONSIN FORM 2 - 1982 ii KATHLEEN H. WALSH WARRANTY DEED ii REGISTER OF DEEDS ST. CROIX CO., WI DOCUMENT NO. RECEIVED FOR RECORD 02-01 -1999 1:30 PM `! Richard W. LaCasse, a married p erson# (i !' IDIRRRRiY DEED EWPT 1 ii CM Cane FEE: COPY FEE i! + conveys and warrants to Jarvis J Madluna and Cindy J. I? TRRRSFER�FEE. 137.10 RECORDING FEE: 10.00 Madluna, husband and wife PAGED 1 THIS SPACE RESERVED MR RECORDING DATA i ' ; i NAME AND RETURN ADDRESS i� the following described teal estate in Cf r'rni x County, State of Wisconsin: F! L, e i i �I j! ,I !` Lot 2, Plat of Evergreen Ridge in the Town of St. Joseph, I� j St. Croix County, Wisconsin. r I i+ �� I I ' i h I' F i s not ij This homestead property. Xft (is not) i Exception to warranties: Easements, restrictions and rights —of —way of record, i if any. ! I! Dated this 1 day of January A.D., 19 -2 -. ! r � (SEAL) li (SEAL) i Richard W. LaCasse is (SEAL) (SEAL) 1 i' AUTHENTICATION ACKNOWLEDGMENT i Signature(s) State of Wisconsin, -{- S l C f2 t� (� County authenticated this day of ' 19— Personally came before me this Z 4 day of January __ ,19 99, the above named Richard w Tat- asse,a married . TITLE: MEMBER STATE BAR OF WISCONSIN ,r N•• b, (If not, N d! authorized by 0706.06, Wis. Stets) � ' � : to me o be jthepeTSon ho xecuted the foregoing instya�me admge the THIS INSTRUMENT WAS DRAFTED BY Attorney Kristina Og2aT -d {k h S7� Hudson, WI 54016 i _ tep Notary Public, 5 �� County Wis. i (Signatures may be authenticated or acknowledged. Both aie not My commission is permanent. (If Ito[ necessary) , state expiration date: (�Iz 19 • Names of persons signing in any tapacily should be typed or printed below their slgnatum. STATE BAR OF WISCONSIN wi—w legal SO* Co M WARRANTY DEED Form No. 2 — 1982 Mil A kee. VAa. ' J �' I / •, /.� .0,9 V Oo � � W W r4 Ld ~ y W w co W M Q 1` a Q' i o o' Z N I O I I— I— NI) w Ix Q I IQ �Ls M ,**,90.00 N� ----- - - - - -- `- ./ �— I I V4 04 W E•, .......... W P,L Q c i in w k6 PC 0 It N� O) I Q, W �� i 0 � cn W i ^^ O N i 00 M '1 O 44 � Oi �• I O i ,£ L'0" M ,",90.00 N ! 00 � ti !� Z ~� E � q' o;; ® rZ4 ` ���; 3 J O ° A ° (n a° (n 'n ' y to O 1 O a C, c O N O 11 W t0 � J O N w N r r ' U I U A ,80'8Z* 3 „S£,£ 1. l0 N ^' / Icy N / o d' 001. / i c o �' 1 ' �' N ~ / / ; �1 J � 00 °0 w �` / / _ W I N I 001 v vii •/ N v cn Q ° cn �I i � n-I— ' I PO M I ' I (0 '1 J o I I .............................. . > I 'y'I � W T Co i o v I ' oo Ov Z °'� ° N1 C), � F I Ui J I ao LLI Z fn N 1 r� 3 „Z L, L LOO S M - --taJ O ro r rn O tt p LO N - - -- °---------°------ TLT/T T'T/T � A I