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HomeMy WebLinkAbout030-2086-20-000 o m o< m m 0_ \ (D ) ®% 2/ J© 0 w \ ® w S w \ \ $ m \ \ G $ / o / -_ ' } $ ( ® E / ° \ / $ \ 2 fj k Cl) lu (D E 0 0 © :E @ ; 2 g2 « :0 ( / # CD ) 0 4 0 o \ \ \ k n r ® ) . 0 0 2 i & § z � CL 3 J 3 / 2' 0 * -4 ) \ 0 c 2 a I§ 7 \ ƒ J 7 ` 2 ) \ } K * z r \ k z \ z c ® _ \ § }\ \q \\ . \ \ \ f } § m - mc \7 . \ E I o % \ \�/ � 0 0 o- \ k < k// ®\ $ ® ` � i z E ) § ; p2 6- CD CD 0 CL \ 2 ` / z C.) \ C/) a R i ( § 1 * z CD z z 2 \$ � & §f t . Z) CD CL § U) N .33/ c \ CD 0 % eoE(D z \(\ ° ®EE ( \}( / \7ƒ \ C CD ; ( / . . � \ \/ } Er \ . 0 \ f o \ k . @ i \ ti L I N h ^' I � I � I �L I I N I c LL C O 4 I 3 N I v � Z H i E �� $ Z a m I 0) N f- to O ° Z V c o y d Z� c o I cn F- �' E N U 3 CD N C o C I • ^� a L L � I = C O O Z F- Z N LO z V E . N N CL a 'R > c v 'A °' ► �' W o O N D D d Z.-' CD555 n. m o I Z •N m a m IL c I 0 o vii co ao y V Im rn 4) I w O C ° _ E y a 2 m n m co i �p °—' Q Y n m I O O C E O o� I Q) c v a `° ° r O M m O C : N V O LO n c c c m y c v �n I 00 N E T o E° a • ��' oN= 8 z ° — �' =F din 2 j L: • c� a m d E ` c c r A 0 42 0 in0 ' Wisconsin Department of Commerce Y Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count St. Croix INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary PermitNo.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)I. .570226 Permit Holder's Name: ❑ City ❑ Village ❑ T n of: State Plan ID No.: Offner, Randy & Diane St. Joseph Township = ----_. CST BM Elev.; Insp. BM Elev.: BM Description: Parcel Tax No.: I O , IA,* 1 - 030- 2086 -20 -000 TANK INFORMATION ELEVATION DATA 32• 30 - /9' '3a TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. Septic 5 16-CO Benchmark 1, o /.35 d 1 °D • 0 Dosing Alt. BM L.e a • o 1 r 0(0 Aeration Bldg. Sewer t!� b�' - Z T6 4 Holding St /Ht Inlet d 5qS'" 1.-Z,c(I�� TANK TBACK INFORMATION St/ Ht Outlet 6 'z °! 10 1 7-T, r TANK TO P/ L p WELL BLDG. Ae Intake ROAD Dt Inlet Septic / do � o r NA Dt Bottom ---- Dosing NA Header / Man. 'S �o QS. (.S- Aeration NA Dist. Pipe 7 'T r qIS. e s" Holding Bot. System PUMP / SIPHON INFORMATION Final Grade 3.z o •IS/ Manu ctur mand St cove Model Number GPM TDH Lift L oss Ion System TDH Ft ead —1 Forc In Length Dia. Fi Dist. To Well SOIL A RPTION SYSTEM berms RENCH Width / Length r No. O Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIM (0 2S 2 DIMENSION SYSTEM TO P J L BLDG' WELL LAKE /STREAM LEACHING' Manu ur r. SETBACK CHAMBER �� INFORMATION Typeo M delNumber: System >4 41D > (6b OR UNIT u DISTRIBUTION SYSTEM Header / Manifold C Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. t ength ia. g 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 : v"-/(°►1rTn nspectlun /:_: Location: 407 Rolling Hills Lane, Hudson, WI 54016 ( /4!/ 1 �a �� T30N R19W - 32.30.19.732 Johnson Parkivay - Lot 11 1 ,' S W�'� , 6m p �! _ � 1.) Alt BM Description = 2.) Bldg sewer length= • S r - amount of cover = Plan revision required? ❑ No Use other side for addition ation. SBD -6710 (R.3/97) 3 oat Inspector' Sig t: re Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: IN <51 3. ®� .....m,®.� ..�..w....,..»e,. a^^'..� t� �m- .......,... e..e,:. $., .: ? ....� "` - w�•._..,..... �.. Ste- ..,.. ._.., � [[ �� . «, qg� k { A � i s i 1 a i f i E ,.,.. ..« a .....,. .« �..«�.. $ } ..«�....� s �. ..� i.e. F s t �4J r°a F 3 g d LA 4'e— Safety and Buildings Division S Y P I T API'Li Q 201 W. Washington Avenue Vis P O Box 7302 Department of Commerce In accord with Comm 83.0 1 AfEl.1. _ _ Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the , on al* not teas... ounty C than 8 1/2 x 11 inches in size. w o ti`: : • . See reverse side for instructions for completing this ap II tion St to Sanitary Permit Number ELI Personal information you provide may be used for secondary purposes r 3 1 heck "r.viou.ppk.tio if revision [Privacy Law, s. 15.04 (1) (m)]. SA X f to Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT A fam Property O er Name UN Q ,S3) T 3 01N, R E(or)W Property yrn�r's NJd , Addres r f Block Number l � 5 KD N NA City, , 5 to y Zip Code Phon Number Subdivision or CSM Number ADS U S' - ( 04 N II. TYPE F BUILDING: (check one) ❑ State Owned E] it ,) '� Nearest d Public 1 or 2 Family Dwelling - No. of bedrooms 9 Town of III. BUILDING USE (If building type is public, check all that apply) >Il� Parcel Tax Number(s) ,p 32.30, 1V7 3,2 1 r Apartment/ dwHle ©W _,J0o 2 [] Assembly Hall 6 ❑Medical Facility/ Nurs 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. RNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of S ❑ Repair of an ------ System System Tank ank Only stem ______________ Existing Sy ________ 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 r 1 21 E] Mound 30 ❑ Specify Type 41 E] Holding Tank 12 Seepage Trench�i_t t KA04.) 22 ❑ In- Ground Pressure f 42 ❑ Pit Privy 13 ❑ Seepage Pit C 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM FOR ATION...., 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade Re uired (sq. ft.) Pr osed (sq. ft.) (Gals/da /sq. ft.) (Min. /inch) Elevation I to o 0 C i 1 . (� Feet 9 R, Y Feet Cap acity VII. TANK in Ca allons g Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con Steel glass Plastic App New Existing strutted T nk Tanks Septic Tank Q f' ❑ ❑ ❑ 1:1 1:1 Li Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature. (N Stamps) MP/MPRSW No.: Business Phone Number: 1M 50 Lk 'Al 90 Plumb Address ( treet, Cit te, Code)• �^ V W J9 IQ fl uoyUN , f <' J IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Age t Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination r c4D . CO DITI lO^N5 OF APPROVAL/ REASONS FO DISAPPROVAL: SBD -6398 .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 maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Adrfti_ni#tgAive 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 rrieintained.`The septic tank(s) must be pumped by a licerised - 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 acid- Buildings- Division; 608 -266 -3151. - - - - To be complete and accurate this sanitary permit application -mpst include: y I. Property owner's name and mailing address. Provicfe -tbie 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, 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 rnust 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 coun "ty;" E) soil test data on a 115 form; and *) all sizing information. ---------------------------------------------------------------------------------------------------- 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. t . )) 1, JhNf�N PAn1 -W� A = &.a P K -'Iov 01 '�a Seel Po st � lev -lou.o 5 V (? U Noe p -qNk ARC �PrLtk t4)1) (OU �mor gS �-- -30 61 31 WRoU�+ °Well r� p 3 S� J Baq F 3X - -� 4v' i ` tront�n0e04- ir^r�tollr•QWlrr, V llVrt 11 )�JIL UI:�Lhll' 1 N I i10Or and human Fttlalionl (Attach Soil Profile location Ma To Scale - On A Se irate, Signet! Sheet) � Ma d oe Page e R. _ _ C t uwurrr uro L" V" tA'M ►yyR reMy Re►v�y woos at �ootasa Cm turf a► / - ! 4 tAf ►O�OWO ►Owe ►oc.rw aa�+oe ro.e�aw uric 1ne /MCR MI.<aU t lJ� _ CSSU LOT BLOCK SUBDIVISION wew _ atr►aet 11 - / Hot ton Ototh Oominsnt Color Mottles Structure In Mumtell Oy St one of Of Teel t Gr, t. h. C n Ht n f Il llmtUn Follett laoneGPO IQ n. }.��� _ 12244 4,X Oaplk Trench Old 13 , Monson Depth Oomrnant Color Mottles Structure In Munstll v t, 00 rit, Co lor T e f limeiln reciter laon9 GPdtio n Gr. St. h. Conte tent Ro !o n r Depth ttench 966 l E lev = Al j la a 3 13 - 2 I Horton Ototh Oom nant Color Mottles Structure Ling a Faelen laonpGPO►o n. �J In Munstll on Dior T t ►f Gr. St h, n i t n Flo B nda Dion Trench Bed Elev se ' - Honaon Ototh Dominant Color MottUl In Mun ell ZUUtlurf llmrtine Faererr LaaepGPO>q n. St. n .Color T riurf Gr Sh on 111 n e A ot► ! n Op teancn B.e Elev S Sr q?.g� A2 _ B - Hot -ion Death Dominant Color Mottles Structure In M n ell Limlllne Fatten laanpOPp� n, On , 1 r T e r r h, n r nt Soot% BO ndar apt inner Sid Elty = / IeAl 7 Additional Remark►: RECOMMENDED SYSTE. TYPE: r �Othheerr Site Ffatute►: Ae Sytlem Elevation nature atf i9ne el ilpnoneNo. — CST g CST Name (Ptku) City Slala lip L a'OsQ -) ,11 �ir/ j} .c'/�- y A N 90 Go' 33' ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerMuyer __ 114 2. / Mailing Address T q a , Property Address 2/0 (Verification required from Pladning Department for new construction) / 1i City/State (1 r SDAJ Parcel Identification Number 0-?10 - 'A - LEGAL DESCRIP / N Property Location /V yV %. 1 �p P �Y /4 Sec. T N -R W �� w , �t�, �Q _1__L ,Town of Subdivision , Lot # /� Certified Survey Map # / 90 q , Volume , Page # 73 Warranty Deed # �Q 12, (� 9 Volume /.� /� , Page # Spec house ❑ yes R no Lot lines identifiable !( yes ❑ no SYSTEM MAINTENANCE Improper use and maintenanceof 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 master plumber, journeyman plumber, restrictedplumber 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 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 expiration date. c 0) SIGNATURE OF APPLIC&ft 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 OF APPLICA 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 .1514mc 532 DOCUMENT NUMBER wARRAINI'Iff DEED x,23889 KATHLEEN H. WALSH Loren M Thompson and Michelle D Thompson husband and wife as REGISTER OF DEEDS ST. CROIX CO. WI survivorship marital property RECEIVED FOR RECORD conveys and warrants to t2nndaII C Offner and Mary Diane Offner husband 05-31 -2000 9:00 AM and wife pa sunivorshio marital aroverty WARRANTY DEED EXERT W CERT COPY FEE: COPY FEE: the following described real estate in St. Croix County; State of TRANSFER FEE: 135.00 RECORDING FEE: 10.00 Wisconsin: PAGES: 1 A parcel of land located in the NW % of the SW Y4, Section 32, Township 30 North, Range 19 West, Town of St. Joseph, SL Croix County, Wisconsin, THIS SPACE Roll,ED POI RECORDING DATA described as follows: Lot 11 of Johnson Parkway. NAME AND RETURN ADDRESS; GWIN LAW FIRM, S.C. 430 Second Street Hudson, WI, $4016 -1510 This j&a9A homestead property. 030 - 2086 -20 (is) (is not) PARCEL I.D. NUMRFR OR 0.1.8. Exception to warranties: TOGETHER WITH AND SUBJECT TO any other easements, covenants, reservations or restrictions of record, if any, but this shall not be deemed to extend any such other recorded encumbrances beyond the term established by law therefor. Dated this 30 day of May, A.D., 2000 (Seal) (Seal) on P (Seal) (Seal) * Michelle D Thompson AUTHENTICATION ACKNOWLEDGMENT STATE OF WISCONSIN } Signature(s) Loren M Thompson and Michelle } T o son COUNTY } auth ca —day of MaY'20 00 Personally came before me this day of , 20 , the above- + H Groin named TITLE EMBER STATE BAR OF WISCONSIN (if not, authorized by §706.06, Wis. Stats.) to me known to be the person _ who executed the foregoing instrument and acknowledge the THIS INSTRUMENT WAS DRAFTED BY: same, Attv.HuxhH.Gwin, A S.C. 430 Second street Hudson WI. 54016 (Signatures may be authenticated or Notary Public, County, WI. acknowledged. Both are not necessary.) 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