HomeMy WebLinkAbout030-2085-90-000 Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count
INSPECTION REPORT
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)]. 370293
Permit Holder's Name: ❑ City ❑ Village ❑ Awn of: State Plan ID No.:
Stoerzinger, Dennis St. Joseph Township
CST BM Elev.:. Insp. BM Elev.: L BM Description: Parcel Tax No.:
CO. � �D' _1 - 030 - 2085 -90 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic
O ex
Benchmark 3
Dosing r '
Alt. BM 3 ` �
Aeration Bldg. Sewer g,�� ���p 2 )95: 3:'
h
Holding St /Ht Inlet ,6 9 � t 19`f.
TANK SETBACK INFORMATION St/ Ht Outlets •q�f 9 r l (fi ) q • 3
TANK TO P/ L WELL BLDG. Air i to ntake ROAD Dt Inlet
Air I
Septic }5r - (,S 7, 2,0 NA Dt Bottom
Dosing NA Header /Man. S.I3'S� S la
Aeration NA Dist. Pipe v S lo " , 3 9
oya Holdin Bot. System �•, c 8 , „s •fey
PUMP / SIPHON INFORMATION Final Grade 5 �
Man cturer Dema St cover 6 • (� / 7 4 9 /2
Model Num GP
TDH L* Lric S stem TDH Ft
rcemain Length Dia. Dist. To Well
SOIL AUQRPTION SYSTEM tL"
TRENCH Width r Length N Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
IMEN 3 ,LS 2 DIMENSION
SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING Man u act ^�
�rt c�
INFORMATION Type O / r CHAMBER o e Num r:
System: "- 0 q fl % X 20 OR UNIT
DISTRIBUTION SYSTEM 444114 P t
Header anifold u Distribution Pipe(s) x Hol x Hole Spacing Vent To Air Intake
Length Dia. l ength 5 ac
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 I Trench Center Bed / Trench Edges Topsoil ❑ Yes ❑ No []Yes
❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
Inspection #1: 05'/ /D/ Inspection #2: t
Location: 406 Rolling Hills Lane, Hudson, WI 54016 (NW 1/4 SW 1/4 32 T30N R19W 3 Johnson Parkway -
Lot 8
1.) Alt BM Description= �
2.) Bldg sewer length =3 O - n
- amount of cover= l'B a w co "a csvc co* �
/ P ❑ Yes 3K No fl
U e oth r side f infor tl n. (S - v
-(� -Se' 5 ^° `' 5 �`�� ap a �� Q c Inspector's Signature Cert. No.
S D- 710 (R.3/97)
ADDITIONAL COMMENTS AND SKETCH ,
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
, SANITARY PERMIT APPLICATION 201 W. Washington Avenue
Visconsin
In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302
Department of Commerce Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, a d County
than 8 112 x 11 inches in size. G�QI
• See reverse side for instructions for completing this applica > i i t�lfe Sanitary Permit Number
4 n
Personal information 3
y ou p rovide may be used for second ���� y �� "
y p y ry purposes �] Check if revision to previous application,
[Privacy Law, s. 15.04 (1) (m)]. ( �) � State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT AL R
Property O ner Name cation 3 Cl ' ( & ZL9
/4 T N � R E or
Property Owner's Mailing Address t Number Block Number
City, State Zip ode Phone Number ivi ague 6r;CSIVl Numb
y rc p ;71;_ y f
11. TYPE OF BUILDING: (check one) ❑ State Owned ity Near st Road
❑ Village
Public K 1 or 2 Family Dwellin - No. of bedrooms Town OF _ a l
111 BUILDING USE (If building type is public, check all that apply) q Parcel Tax Number(s)
1 ❑ Apartment/ Condo 3a. 3 0. 1 9. 7 ;t I
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 M-New 2 ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
____ystem -------- 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
1 eepage Trench 22 ❑ In- Ground Pressure 42 ❑Pit Privy
1 ❑ Seepage Pit is 43 ❑ Vault Privy
14 ❑ System -In -Fill lT` � S L f i f6 e.
VI. ABS ORPTION 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/day /sq. ft.) (Min. /inch) 9T- 2 E��pa' Elevation
� y `l w lam -ap t
VII. TANK Capacit in g allons Total # Of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existin strutted
Tanks Tank
Septic Tank or Holding Tank r��� std 3 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber I ❑ I ❑ I Eli ❑ 1 ❑ ❑
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's l Name: Print) Plumbe " re: St ps) MP /MPRSW No.: Business Phone Number:
o�Of l
Plu er' Address (Stre tt y, State, Zip C
�lell
IX. COUNTY I DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate ssue Issuing Agent Signature (No Stamps)
g Approved F] Owner Given Initial `KK Surcharge Fee)
Adverse Determination aag.�
X. rONDITIONS OF APPROVAL / REA ONS FOR DISAPPROVAL-
! 6r +>✓.
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To. ety & Buildings Division, Owner, Plumber
INSTRUCTFONS "
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit maybe 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.
A
4. Changes in ownership or plumber requires a S @nitary Permit Transfer/ Renewal Form (SBD -6399) to be submitted tothe
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 complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. 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, oe 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 81/2 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; E) soil test data on a 115 form; and F) all sizing information.
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GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a 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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RECOMMENDED SYST M TYPE:
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM-
Owner/Buyer
Sao e�
Mailing Address �a
- _
Property Address 41 S Q A
(Verification required from Planning Department for new construction)
City/State 2� . Parcel Identification Number �3G — �CJ4 r pQ
LEGAL DESCRIPTION
Property Location AL "%, .G Z%, Sec. 3,2 T 30 N- Rj_`_W, Town of
Subdivision Ll G ��" Crc Lot #
Certified Survey Map # G �3 Volume , Page #,�.
Warranty Deed # _ �[o to 9 Volume Page #
Spec house R5 yes ❑ no Lot lines identifiable E' yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
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 function 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 form, signed by the owner and by a
masterplumber, journeyman plumber, restrictedplumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
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
days of the three year expiratio te.
SIGNATURE O DATE
OWNER CERTIFICATION
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.
SIGNATURE F 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
S66(;62 VOL 1269 PAUE '85
• STATE BAR OF WISCONSIN FORM 1 — 1982
WARRANTY DEED
DOCUMENT NO.
REGISTER'S OFFICE
This Deed made between Glen H. Flynn and $T, CROIX CO., WI
Julie A. Flynn, husb and w Reo'd for R999N
. Grantor OCT 0 9 1997
and Dennis L. Stoerzinger and Melody L. 9:30 A M
Stoerzinger, husband and wife, — �,¢! �--A U)."
Re atm of Doody
Grantee,
Wit nesseth, That the said Grantor, for a valuable eonside:•.ui'xL
conveys to Grantee the iollowing described real estate in St. Croix THIS SPICE RESERVED FOR RECORDING DATA
County State of Wisconsin: NAME AND RETURN ADDRESS
Lot 8, Johnson Parkway in the Town of DAVID J. ESTPEEN
St. Joseph. 304 LOCUST S r. ,
HUDSON, WI 54016
030-2005-90
PARCEL IDENTIFICATION NUMBER
TRANSFER
This is not homestead property.
XOEX (is not)
Together with ail and singular the hereditaments and appurtenances thereunto belo in
A Glen H. Flynn and Julie A. Flynn, husban end w ife, A
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements,
restrictions and rights -of -way of record, if any. '
and will warrant and defend the same.
day of September 1G 97
Z. t
(SEAL) 1_sL -'� (SEAL)
• en H. Flynn Julie A. Flynn
(SEAL) _ (SEAL)
=t5s
,a
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) St of Wisconsin,
C �l Cougt
authenticated this day of , 19 Persona!ly came before me this day of
September . 19_97 the above named
Men H. Flynn and Julie A.
Flynn, husband and wife, ;
TITLE: MEMBER STATE BAR OF WISCONSIN ''
(If not, •'�
authorized by §706.06, Wis. Stars.) to me known to be the person who executed the foregoing
it ent and a wledge the t e Uy Co wrs €
THIS INSTRUMENT WAS DRAFTED By , e
1
A *-tQr�PrKr Og11nd wISco"Pr,
Hudson, WI 54016 Notary Public, County,Wis.
(Signatures may be authenticated or acknowledged. Both are ncx 111% :on son is permanent of not, state expiration date' , S
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tAtF BAR OF N4 hC O \
1 \aRRA%1Y DI 1 "D
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JUN -02- 2000 09:26 FROM: T0:17153866885 P.004/004
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