HomeMy WebLinkAbout030-1071-40-000 Wisconsin Dgpartment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
515216 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Conway, Thomas R. I St. Joseph, Town of 030 - 1071 -40 -000
CST BM Elev: Insp. BM Elev: BM Description: / � Section/Town /Range /Map No:
/DC� B vy\ CAS 26.30.19.253N
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER ^ 5 CAPACITY STATION BS HI I FS ELEV.
34
W Benchmark 160
no cl � 1Z /L�
_ A bjee L - Alt. BM
Aeration V Bldg. Sewer
Holding St/Ht Inlet -, 5 rt '
TANK SETBACK INFORMATION c 1 ? J
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD . Z
y, /1 1 r _ 3 Dt Bottom
Dosing / K, Header /Man.
Aeration Dist. Pipe
Holding Bot. System
Final Grade
PUMP /SIPHON INFORMATION
Manufacturer GPMand�
Model Number
TDH Lift Friction Loss System Head TD Ft
Forcemain 1 1�� ia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO BLDG WELL LAKE /STREAM LEACHING Manufa urer:
INFORMATION CHAMBER OR
Type Of System: UNIT Model rum der:
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia Length is S
SOIL COVER x Pressure ms Only xx Mound Or At Grade Systems O
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil M Yes 0 No [�] Yes 0 No
COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / / Inspection #2: / /
Location: 1378 Frog Pond Lane N w Richmond, WI 54017 (Gov't Lot 4 26 T30N R1 9W) metes & bounds Lot Parc No: 26.30.19.253N
- a= r.. t� Go�e� 64
1.) Alt BM Description = J
2.) Bldg sewer length = 7 J
- amount of cover = 41 e Z— GOJ 1� + 1/`Gn7 e (� d" Lm
Plan revision Required? Yes �1 No _ -
Use other side for additional information.
Date Insepctor Signatur Cert. No.
SBD -6710 (R.3/97)
commerce Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162
i sc o ns i n Madison, WI 5370
6 Sanitary Permit umber (to be filled in by Co.)
Department of Commerce 5
Sanitary Permit Applicatio State Transaction Number
In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental
unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Project Address (if different than mailing address)
submitted to the Department of Commerce. Personal information you provide may be used for secondary
p urposes in accordance with the Privacy Law, s. 15.04 1 m), Slats.
I. Application Information - 'Please Print All Informatio
Property O er's Name Parcel #
,07,4< ) � J t4 ),i U -*2' ��_ - //,-, 71 - -A19
Property Owner's Mailing Address Property Location /I Z53
/a z� ZAE I Govt. Lot t
XJ)
City, State Zip ode /
p PLAN OFFICE ! _�� 1A Section � CL
circle one
II. Type of Building (check all that apply) Lot #
T 0 N; REo
1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name
Block #
❑ Public /Commercial - Describe Use
❑ City of
El State Owned - Describe Use
CSM Number ❑ Village of
�, w ---"-' 0 Town of
III. Type of Permit: (Check onl one box on line A. Complete line B if applicable)
A. ❑ New System Replacement System ❑ TreatmentfHolding Tank Replacement Only ❑ Other Modification to Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision ❑ El Transfer to New
of Plumber Change List Previous Permit Number and Date Issued
Before Expiration Owner
IV. Type of POWTS System/Component/Device: Check all that appl
❑ Non- Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
Holding Tank Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
ersa reatment Area Information:
Design Flow (gpd) Design Soil App 'cation Rate(gpdsf) Dispersal Arep Required (sf) Dispersal Are Proposed (sf) System Elev lion
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units p v $
New Tanks Existing Tanks / 2 2 y
v in
Septic or Holding Tank
Dosing Chamber
VII. Respons' ility Statement- I, the undersigned, assume responsibil' installation o the POWTS shown on the attached plans
Plumbe 's a (P i t) Plumber's ignatur MP/MPRS Number Business Phone Number
5 J
_ Titmber'rAdaress treet, City, State, p Code)
VIII. Coun /De artment 10se Onl
pproved 1 Permmitt Fee j� Date Is uedd C, Issuing t Signatur
❑�vr Given Reas or Denial $ tp�V. /� Z �+
I . Conditions o fApproval/Reasons orDisapp val (�
Z D i�aje , tA�J OK, k� Qf /4 /1C�A�1 We.
Attach to complete plans for the system and submit to the County on on paper not less than 8 1/2 x 11 inches in size
SBD -6398 (R. 02/09) Valid thru 02/11
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CONCRETE HOLDING TANK DESIGN
INDEX AND TITLE SHEET
Project THOMAS R CONWAY
Owner THOMAS R CONWAY
Address 4378 FROCK POND LANE
NEW RICHMOND WI 54017
Legal Description NE— NE-- SEC26-- T30N - -R19W
Township ST JOSEPH County ST CROiX
Subdivisim Name Lot No.
Parcel 1D Number 030 - 1071 -40 -000
Plan Transaction Number
Index and title sheet Page 1
Holding tank specifications Page 2
Site pian Page 3
Management & Continency Plan Page 4
Designer KIM A 9
Signature T Phone No. 715- 755 -3145
License - Number 224263 Date 12/27/09
Designed pursuant to:
Holding Tank Component Manual For POWTS
SOD4057f -P (R.M9)
Verstott Z O {03/04) Page 1 of A
HOLDING TANK SPECIFICATIONS
2 If one- or two- family, number of bedrooms
�,- .... Non-residential estimated flow per day
2000.0 Minimum holding tank volume required
2520.0 Total holding tank capacity proposed (gal)
1260.0 Tank 1 capacity (gal) 84 X for round tanks
4260.0 Tarik'2 capacity (gal)
WEEKS Tank -i-canufacturer
S.J.ELECTRO Alarm manufacturer
~41 Alamo, model• number
Tank in Exterior Dimensions in Ibs Ibs in ft
Information Liq Level Length I Width I Height Tank t Ancho Wt Soil Cover Max Bury
Tank 1 58 84 84 68 't6e 4f?'�. 8
Tank 2 58 84 84 68 -469q - 8
li (�
HOLDING TANK CROSS SECTION
Ma cover with locking
12" min. 4" min. device and waming label Finished grade
�y ��
Junction box
E— Vent pipe 18„
Blind plug to seat
t oaer�a 7 .Inlet
12. Not Manhole
and vent
locations may be
46,0 -in reversed
Tank 2 Tank 1
3 in. min. bedding under.tanks.
Anchor tanks as necessary to negate buoyant forces.
Electrical as per NEG 300 and Comm 16.
Note: All tank joints, and joints between tank
openings and piping are sealed watertight.
Project: THOMAS R CONWAY
Transaction Number: Page 2 of 4
HOLDING TANK MANAGEMENT PLAN
This Private Onsite Wastewater Treatment System ( POWTS) has been designed, and is to be installed and
maintained- according- to. Comm- a Was. Admin. Code the- Holding -Tank Component Manual (SBD- 1.0571 -P
6/11/1999}, and the ST CROIX County Sanitary Ordnance.
1. This POWTS .is designed to accommodate an estimated domestic wastewater .flow of 504.0 gpd.
2. The owner of this POWTS is responsible for system operation and maintenance, including all provisions in
the attached Holding Tank Servicing Contract and Maintenance Agreements.
3. Each time the wastewater in the second tank reaches a level of 12" below the inlet invert (at which time the
alar -m- will. activate) the - pumper listed in- the - current - Servicing Contract must be- called to empty the tank's
contents and dispose of therm in accordance with NR 113, Wis. Adm. Code.
4. At each service event, the service provider should visually inspect the condition of the tank, risers and
manhole cover(s) and verify that the alarm system functions and manhole locking devices are present.
Discrepancies are reported to the owner in a timely manner for corrective action. All corrective actions
shall comply with the county sanitary ordinance and Comm 83 and 84 Wis. Adm. Code.
5. All service events or inspections of this POWTS shall be reported to the county within 10 business days.
6. The owner may not remove any of the wastes from the holding tank(s), or cause such wastes to be
removed by any person not authorized to do so under Ch. 281, Wis. Statutes. The discharge of wastes
from this holding tank to the ground surface, including intentional discharges and discharges caused by
neglect, constitutes a failing POWTS and may result in issuance of correction orders or a citation by the
county or state.
7. No one should enter a holding tank for any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within these tanks may contain lethal gases, and rescue of a
person from the interior of the tank may be difficult or impossible.
S. In the event that this POWTS fails- and cannot be repaired, a code compliant replacerment holding tarn may
be installed in the same location (a new sanitary permit is required for such a replacement). Connection to
municipal services would also be considered at this time if they are deemed available to the property.
9. If this POWTS is replaced, or its use discontinued, components no longer in use it shall be abandoned in
accordance with Comm 83.33 Wis. Adm. Code.
10. If there is a problem with, or question about this installation, the following persons should be contacted:
a. Installer ........................... KIM A OCONNELL Phone: 715 - 755 -3145
b. Service Provider ................ Phone:
c. County Zoning or Health Dept. ST.CROIX Phone: 715 - 386 -4680
11.
I
Project:
Transaction Number: Page 4 of 4
ON
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LOT 1.
628
66 225'
140TH AVE. .... _.._.,_.._. ._.._.._.._.._.._...._.._.._.._
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04/20/09 MON 12:38 FAX 715 386 4686 ST CRX CO ZONING W002
HOLDING TANK SERVICING CONTRACT
Contract Date
/ ✓°� 0 This contract is made between the
Holding Tank Owner(s) Name(s) and Pumpe ' Name l
HOMA R. CO - f
We acknowledge the installation of (a) holding tank(s) on the following property: rovide legal descriptions:)
1378 FRob POND LAMF NEW MCH M000 VJ 1 51017
70..sn; e1= sr. _1015F Pw 0 1071 40 -000
---------------------------------------------
1. The owner agrees to file a copy of this contract with the local governmental unit that has signed the
pumping agreement required in Comm 83.52(1)(c)1. Wis. Adm. Code and the approved Holding Tank
Component Manual. This agreement will also be filed with the St. Croix County Zoning Department.
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper
to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner
agrees to maintain the access road or drive so that the pumper can service the holding tank(s) with the
III pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the
holding tank(s) as mutually agreed upon by the owner and pumper.
3. The pumper agrees to submit to the local governmental unit that has signed the pumping agreement and to
the County, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further
agrees to include the following in the semiannual report:
a. The name and address of the person responsible for servicing the holding tank;
b. The name of the owner of the holding tank;
c. The location of the property on which the holding tank is installed;
d. The sanitary permit number issued for the holding tank;
e. The dates on which the holding tank was serviced;
f. The volume in gallons of the contents pumped from the holding tank for each servicing;
g. The disposal sites to which the contents from the holding tank were delivered.
4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a
change in this contract, the owner agrees to file a copy of any changes to this service contract or a copy of a
new service contract with local overnmenta unit and the o named above within ten 10 business
g 1 e C unty am b O
days from the date of change to this service contract.
Owner(s) Name(s) (Print) Ow ex's Signatures) Subscribed and sworn to me on this date:
"TH R_ CONwgY 2
I v 3 I D
Toda s Date
Pumper's Name (Print) Pumper's Si natu Notary Public Signature
C� 2/,
Pumper's Registraton Number Commission Expiration
• r
DOCUMENT NO. NAitRARTYr` L/G�D THIS SPACE RESERVED FOR RECORDING DATA
STATE BAR OF WISCONSIN FORM 2 —1982
519614 �,... _ .
VOL 10 9PaIFT27
HAZEL E,.- "FELIO, a single woman residing in_ Rock ,.
REGISTER'S OFFICE
! ST. CROIX CO., WI
County,... sconsi n - - -- -
- - - - - -- ii Recd for Record
- . - - - -- - -- --
-- . . - - -- -• - -- - - -- - JUL 2 9 1994
j;
- - --
i conveys and warrants to _7H0MAS_. R.._ C0NWAY.,__ a -- - - of -_ - -- s : 15 A.
Ramsey..Collnty_, -- Minnesota ! 0.
I - - - - -- - .. - - -- -- - - - - -- - - -- - - --
-------- - - - - --
Register of Dads
------------ - - - - -- --------------- - - - - -- ---- - - - - -- -- - -
i
............... --------------------------------------- ....--- _.- . " " "..---- ----- -.. .- _ - --- "- __ -_ - --
RETURN TO
... _.
,I for - $1..00. and- other. good- and..valuab -l:e con- sJder_ati_gn .....
.. ----------------------------------- - - - --
the following described real estate in ------------ Croi County,��•_`
.State of Wisconsin:
.Y
Tax Parcel No: -___-
A part of Government Lot Four (4) of Section Twenty -six (26) Township Thirty (30) North,
I Rage Nineteen (19) West, described as follows: Commencing at the Northeast (NE) corner
of the Northwest Quarter of the Northeast Quarter (NWI /a NE' /a) in said Section Twenty -six
(26); thence West 628 feet; thence South 269.5 feet; thence South 43 30' East 484 feet;
thence South 50 East 462 feet to the point of beginning; thence South 50 East 66
feet; thence South 40 West to the East shore of Bass Lake; thence Northwesterly along
!! said shore to a point South 40 00' West of the point of beginning; thence North 40 00'
East to the point of beginning; together with an easement consisting of permission to use
a strip of land not over 2 rods in width for purposes of ingress and egress to said property
I located along and which said strip of land shall be g the North line of Lot 4 in said section
` Twenty -six (26) and the Northwest Quarter of the Northwest Quarter (NWI /a NWl /�) of
Section Twenty - five (25) all in Township 30 North, Range 19 West to connect with the
present highway now located in said Section 25.
j Commencing at the Southeast (SE) corner of above tract of land, thence northeasterly
(NEly) along the East (E) line of said tract of land to the Northeast (NE) corner thereof;
'i thence at an angle of 90 to the right in a Southeasterly (SEly) direction to the north line
of the south fifteen (15) rods of Government Lot Four (4); thence west along said north line
This _...._.5 -- ,''lot____ - - - -_ homestead propert (CONTINUED ON BACK)
(is) (is not)
i I
Ii
Exception to warranties:
li
j
i �
Dated this -- - - -- 25th ------- ---- - - - - -- -- - - -- -- day of -------- -- - - - - - -- -- July -- 19.9
4
- - - - -- (SEAL) _ (SEAL)
I ! Hazel E. Fel io
- - - - - -- _.. - ..._..._ .. .___
I. __(SEAL) ___(SEAL)
� - - - -- -- ------------------------------ "-- - - - - -- -- -
AUTHENTICATION ACKNOWLEDGMENT
Signature (s) ------------------------------------------------------ _ STATE OF WISCONSIN
ss.
--- ---•---- -- - - - - -- ----------------------------------------------------------- ___ RQG k ---- ---- -- --- -- --- -- - - - - - - county.
authenticated this -------- day of --------------------------- 19 ------ Personally came before me this ---- 2- 5 ------- -day of
July--- _ --- - - ---- 1�J_ g4__ the above named
I I — - ---
------•-----------
l --- -- ---- --------- ---- - - -- _ ------ - - - - -- --- ----- - -- - -_ _ ----- -
Hazel_..E., Fe io ----------- - - - - -- - - -. -.
l -------------- - - - - -- -------------------------------- - - - - -- -- - - - - -- -- - - - - - -- - - - - --
!j TITLE: MEMBER STATE BAR OF WISCONSINi -
(If not- ------ ------------- -•--- - - -- -- ------ ----- --- •- -•-- -- - - - - --
_� '
authorized by § 706.06, Wis. Stats') to me xn_ri to } who executed the
.fore * mstrvmen and aek 'owle"d ve the same.
THIS INSTRUMENT WAS DRAFTED BY - I
I
William J. Gilbert Attorney
•• --
-
WI 54016 ..^ •_._ . - - - - - - -- - - --
t
206 Second Street, Hudson, Notar �6 h
• Public _ -- ..__.._- . County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (if not, state expiration
are not necessary.) Oct. 15 19 95 )
date: ---- --- -- ---- - - - -- - - --- - -- - -- - - ---
"Names of - persons signing in any capacity should be typed or printed below tbei + sigtnat n +* s
ommm� r Wisrnnsin I rnal Rlank (fin Inr,
pp _ V
VOL 1089PA.E428
of said south fifteen (15) rods of Government Lot Four (4) to the shore of Bass Lake;
thence Northwesterly (Nally) along the shore of Bass Lake to the point of beginning.
From an iron stake on the North line of said Section Twenty -six (26) which is a distance of
Thirteen Hundred Twenty (1320) feet West of the Northeast corner of said Section Twenty-
{ six (26), go south 3 East a distance of Seven Hundred Two and five - tenths (702.5) feet,
} thence South 72 East a distance of One Hundred Twenty -nine and five - tenths (129.5)
feet, thence South 10 54' West a distance of One Hundred Thirty -two and five tenths
(132.5) feet to point of beginning of parcel to be conveyed herein; thence South 10 54'
West a distance of Sixty (60.0) feet, thence North 50 West a distance of Sixty -six (66.0)
t feet, thence North 40 00' East a distance of Thirty -five (35.0) feet, thence South 75
East a distance of Forty and six- tenths (40.6) feet to place of beginning; being a part of that
- parcel recorded in Volume 333, Page 4, in the St. Croix County Register of Deed's office;
together with an easement over the access road from the above described parcel to the town
road as now opened and traveled.
(This deed is given in satisfaction of a Land Contract dated September 1, 1976, recorded
September 2, 1976 in Vol. 542, Page 294, Doc. No. 335263 in the office of the Register of
Deeds for St. Croix County.
Parcel #: 030 - 1071 -40 -000 10/30/2009 01:36 PM
PAGE 1 OF 1
Alt. Parcel M 26.30.19.253N 030 - TOWN OF SAINT JOSEPH
Current ! j(1 ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units
00 0
Tax Address: Owner(s): 0 = Current Owner, C = Current Co -Owner
0 - CONWAY, THOMAS R
THOMAS R CONWAY
1038 SEMINOLE AVE
ST PAUL MN 55118
Districts: SC = School SP = Special Property Address(es): ` = Primary
Type Dist # Description
SC 3962 NEW RICHMOND
SP 8040 BASS LAKE REHAB DIST
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: N/A -NOT AVAILABLE
SEC 26 T30N R1 9W PRT GL 4 COM NE COR TH Block/Condo Bldg:
W 628 FT, S 269.5 FT, S 43DEG E 484 FT,
TH S 50DEG E 462 FT TO POB S 50DEG E 66 Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4)
FT, S 40DEG W TO BASS LK, NWLY TO PT S 26- 30N -19W
40 DEG W OF POB, TH N 40DEG E - POB ALSO
COM SE COR ABOVE TRACT; TH NE ALG E LN
more...
Notes: Parcel History:
Date Doc # Vol /Page Type
07/23/1997 1089/127 WD
07/23/1997 542/294
2009 SUMMARY Bill M. Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/08/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 110,900 47,000 157,900 NO
Totals for 2009:
General Property 0.000 110,900 47,000 157,900
Woodland 0.000 0 0
Totals for 2008:
General Property 0.000 110,900 47,000 157,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch M
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
ST C RO � x cO UNTY
October 21, 2009
Mr. Tom Conway L-�2_ 2 — s'-� 71
1038 Seminole Ave.
ST. Paul, MN 55118
Code Administration RE: Land Use Permit Review for Principal Structure in Shoreland District
715 - 386 -4680 #26.30.19.253N -1378 Frog Pond Lane, Town of St. Joseph
Land Information & Dear Mr. Conway
Planning
715- 386 -4674
1 have determined that your proposed project to reconstruct the roof on an existing
Real Property principal structure will not require a land use permit. This decision was based on
715- 386 -4677 the site plan and building specifications that you submitted to the Planning & Zoning
Department today. The cabin is located within the Shoreland District for Bass Lake,
Recycling
715 - 386 -4675 but the project will not require any change in the existing structure's footprint. Filling
and grading will not be necessary to complete the project, but does require a
building permit from the Town of St. Joseph. The site plan indicated that the cabin
is approximately 80 feet from a channel between Kelly Pond and Bass Lake and is
100 feet from the lakeshore, which meets the minimum 75' setback from the OHWM
pursuant to Section 17.31(2).
Please contact the Town of St. Joseph to obtain the required building permit.
If you have any questions or concerns, please contact me.
Si
4,
Pamela Quinn
Zoning Specialist
Cc: Town of St. Joseph Building Inspector
ST. CROIX COUNTY GOVERNMENT CENTER
1 10 1 CARMICHAEL ROAD, HUDSON, W1 54016 715 - 386 - 4686 FAX
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