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HomeMy WebLinkAbout030-2037-95-000 Wisconsin Deportment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety 4nd, BuikJing Division INSPECTION REPORT Sanitary Permit No: 399464 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: Fox, Kevin I St. Joseph Township 030- 2037 -95 -000 CST BM Elev: Insp. BM Elev: IBM DDescri�ti D dAy`v��l TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic UJ / D Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet 7 TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet eptic 50, L + I / 00 Dt Bottom Dosing 7 ` Header /Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover �} GPM 3. 3 "/• Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. nches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L JBLDG IWELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number. DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded 1 xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes FE-] No ❑ Yes ❑ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 273 County E Houlton, WI 54082 (NW 114 SE 1/4 25 T30N R20W) NA Lot NAB Parcel No: 25.30.20.479A 1.) Alt BM Description = �o Mn ,jj SrG�.� 0-6, 2.) Bldg sewer length = 1 - Cc - t - v j� nV - amount of c = 33 �J�tQ�7�tQ 71 iOf C ad(tf'40" �I Ile u)"Ai� Plan revision Required? F ] Yes ❑ No lS / / Use other side for additional information. `` l � ` Date Insepctor's S' ture rt. o. SBD -6710 (R.3/97) Safety & Buildings Division 201 W. Washington Ave. Sanitary Permit Application PO Box 7302 isevnsii» In accord with Comm 83.2 1, Wis. Adm Code Madison, WI 53707 -7302 Department or Commerce Personal information you provide may be used for secondary purposes (Submit completed form to county if not (Privacy Law, s. 15.04(1)(m)] state owned. Attach c omplete plans to the c ounty copy only) for the system on paper not less than 8 -1/2 x I I inches in size. County State Sanitary Permit Number sion r ❑ Check if rev 1 ' lication State Plan 1. D. Nu mbgr I. Application Information - Please Print all In ormation Location: Property Owner Name�p ` O 3 Property Location F u , 7( A '' UJ 1/4 ft � �/4, S ;S T) qN, Rol or Property Owner's Mailing Address t 2d t Number Block Number e F r t City. State Zip Cale umber ubdivision Name or CSM Number I II Type of Building: (check one) ✓ 8 _' �_. ity g e j0, Z0, Jt[�TT 1 or 2 Family Dwelling — No. of Bedrooms: L Villa Public/Commercial (describe use): _ _ town of st ❑ State - owned III Type of Permit: (Check only one box on line A. Check box on line B j.f applicable) Nearest Road rl tl p� A) 1. ❑ New System 2. ❑ Replacement 3. WReplacement of ✓ 4. ❑ Addition to Parcel Tax Number(s) System Tank Only Existing System D 3 O B) A San Permit Number a /� Date Issued .421 ' San Permit was previously issued IV. Type of POWT System: (Check all that apply) ❑ Non - pressurized In ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In ground ❑ llolding'Fank O Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V Dis ersalffreatment Area Information: )(S7 1. Design Flow (gpd) 2, DispersalArea 3. Dispersal Are 4. Sob Applica n 5. Percolation Rate 6. System Elevation 7. Final Gra Required Elevation / VI Tank Capacity in Total # of Many(acturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks k Op IN SQ Con Con glass New Existing p N J N ji. Crete structed Tanks Tanks oU u - — ❑ ❑ ❑ ❑ 1 _ 00 ULV I W�QRJK _1 1 0 VII Responsibility Statement 1 the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (print) Plumber's Signa stamps).­ MP/MPRS No. Business Phone Number Plumber's Address (Street, City, State, Zip C ) 10 A 3s )J NVb VIII County/Departi6ent Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued 1 �A eipature (No stamps) proved ❑ Owner Given Initial Adverse Surcharge Fee) ��S e,p a/ p Determina IX. Conditions of Approval /Reasons for Disapproval:' 1. Effluent filter to be installed and maintained per manufacturer's recommendations. 2. Floo p am mapping = Zone 3. All setbacks to system and residential structure must meet applicable code requirements. 4. Well setbacks to be maintained per NR 811 & 812. 5. This POWTS was originally designed for a three - bedroom house. The home owner is moving the septic tank because of a garage addition. 6, The existing septic tank must have it's contents pumped and properly disposed of by a licensed pumper before it's abandon. ald -S,'d e a)l nclers - _ ^ _ ID Qe t, �pNX w) A io a;'o ��� s�� ►„ � ao 39' S x s 7 � �x�sfi ►N� w ill WO O G aR �► p d � w � � ua (�QXVhb -0 Ec` co co � T e ^ (a N E E - U `c x m M W 1 0 c� > �c } v,00 C Z T a v w 0 c o o ` a ..C2 4) S a a CO = W a ca I -- '� = a5 E u, c x co Cl) c '� t �� U C ?� L L co L4 O N Q — II "seeeeeeeeee "" — _ tQ cD = N -0 C (a C " "e��\ - am ►I J CD '�w�c° x w v �� v o. ,z 3 � C) C _ Wo a -U m cr " ;� CF a a n U) a c 0 m Q � _ v o X00 a (D (D cn CD N W X N :3 Q 3 % - - -- -, (D _ Cr 0 cr Un X (D O= N C W voyp9y/9voy / /vv (o C_7i Q 0 ; = .. O W (C) CD w w w�� I __) v N v: m u k � ,ot °O ,ol L.7 .... f C — ,T Uno _ __ .._... __ C'�,j n YlAltlN .51 - d P. f rt7 Private Onsite Wastewater Treatment System Management Plan Septic Tank And Gravity In- Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWTS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- 10567-P (R.6/99). Table 1: System Design Specifications Sanitary Permit Number ?v Number of Bedrooms Design Flow - Peak (gpd) 1tS Estimated Flow - Average (gpd) 1 S Septic Tank Capacity (gal) 6� Soil Absorption Component Size (ft Type of Wastewater Domestic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow - Peak (gpd) ! f Maximum Influent Particle Size (in) 1/8 Maximum BOD (mg /L) 220 Maximum TSS (mg /L) 150 Table 3: Maintenance Schedule Septic Tank Inspect and /or service once every 3 years Outlet Filter Inspect once a year and clean at least once every 3 years Soil Absorption Component Inspect once every 3 years Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the Management Plan for a Septic Tank and Soil Absorption Component filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of scum and sludge in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of an assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. Manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No one should enter a septic or other treatment or holding tank for any reason without being in full compliance with OSHA standards for entering a confined space. The atmosphere within the septic or other treatment of holding tank may contain lethal gases, and rescue of a person from the interior of the tank may be difficult or impossible. Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. Soil Absorption Component The soil absorption component serving this structure is designed to accept domestic wastewater from a residential facility. The limits of operation of this component are shown in Table 2. The longevity of a soil absorption component depends greatly on proper and timely maintenance, and system use within or below the limits of reliable operation. Good water conservation practices by all occupants and the installation of water conserving plumbing fixtures are key factors in extending the useful life of this component. The soil absorption component's operation must be assessed by inspection at least once every three years. The inspection shall include recording the levels of ponding, if any, in the observation pipes, and a visual inspection for any evidence of surface seepage or discharge from the component. On steeply sloping sites, areas of erosion should be identified and reported to the owner for repair. The surface discharge of domestic wastewater or sewage from the system is prohibited and considered a human health hazard. Traffic around or over the soil absorption component should be avoided particularly during winter months. The compaction or removal of snow cover over the component may lead to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or impossible to repair until weather conditions improve. In general, soil compaction over this component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to more intense, and earlier, organic clogging of the soil. 2 Management Plan for a Septic Tank and Soil Absorption Component Plantings of deep- rooted trees and shrubs directly over or within ten feet of the component should be avoided since root intrusion into the component may obstruct wastewater flow. When system fails, we will replace with another system at owner's expense. Alternate area must be left undisturbed. St Croix County Zoning Office 386 -4680 Boumeester & Sons Excavating 386 -9020 Tri- County Sanitation 386 -2130 3 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer �LZ,. © x Mailing Address Property Address . (Verification required from fanning Department for new construction) City /State i9L / f��� Parcel Identification Number b "' O LEGAL DF�C iPTlci,ty Property Location i %., _ %,, Sec. 15 , T ,� / LN -R_O W, Town of �. Subdivision A k , Lot # Certified Survey Map # Volume , Page # Warranty Deed # ,��� Volume ` 7 , Page # Spec house ❑ yes ❑ no Lot lines identifiable ❑ yes ❑ no Improper use NA 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 atfeot the limction of the septic tank as a treatment stage in the waste disposal system. Tho property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master journeyman plumber, restrictedplumber or a licensedpumper verifying that (1) the on -site wastewaterdisposai system propel operating condition and/or (2) aft,iat,Qecdon and pumping (if necessary), the septic tank is lea shwa 113'Atp of sl udge. Uwe, the undersigned have read the abov�s r and agree to maintain the private sewage disposal 11y84ay tandards set focfb, herein, as set by the Department o , and the Department of Natural Resources, State of Wtermndn! Cettitiatim s &8 that MW ftPdc system has been aiota�ned must be completed and returned to the St. Croix County Zoning Of�e within 30 d ays of the three year expiration date. ' ' ONATURB OF APP CANT DATE r. I (we) certify that all statements oaahis`fonp are true to the best of my (our) knowledge. T (we) am (are) the owner(s) of e property described above, by virtue of a mprrwty deed recorded in Register of Deeds Office. I(INA OF L r DATE •••'•• Any inf tion that is mis -re pray result in the sanitary permit being revoked by the Zoning Department. •••••• •• Include with this appltcatton; a sta roped, jsiz g " deed from the Register of Deeds office a copy of die certified survey map if reference is made in the warranty deed ' . DOCUMENT N O WARRANTY DEED THIS SrA::E RL.+ERVED FOR Rtf:ORDMG DATA STATE BAR OF WISCONSIN FORM 2-1988 4840 1 _ V::� y53PA,� 1 2 REGISTER'S OFFICE Lorraine G. Andrews a /k /a Lorraine G. Lutton ST C,ROIX CO.," . � Rec'd6orRetotd and Lawrence.L..Lutton, JUN 011992 convoy and warrants to Kevin M. Fox. and Sheila K. 8:30 A. M Fox, husband and wife - - �I RW*92 of D"& the following described real estate In . - . St. Croix... County, State of Wisconsin: Tax Parcel No: .............................. North 100 feet of East 550 feet of NW% of SE4 of Section 25, Township 30 North, Range 20 West, St. Croix County, Wisconsin. Part of SA of NEa of Section 25, Township 30 North, Range 20 West, St. Croix County, Wisconsin described as follows: Commencing at SE corner; thence West 550 feet; thence North to the Highway; thence SEly to the point of beginning. k'RRNS`f'L! F.Etrl is not r „ ! t easements, restrictions and rights -of -way of record, if any. 2 May 92 n F 11.: i.. \I Lorraine G. Andrews a /k /a Lawrence L. Lutton Lorraine G. Lutton AUTHENTICATION ACKN0WLEDGMEN'C Signature( -) Lorraine G. Andrews a /k /a STATE UF•' WISCONSIN l Lorraine G. Lutton; Lawrence L. 1 ss. Lutton _ __ ... (aunt }. authenticated tl ! dad of. May 1` 92 ! cr. n,;l } r.:n:e me tF.'s { n:' the above nan• - Kristina Oyland Kristina Ogland Attorney at Law w LL. alt g t c e A A, tN h N, 1�1�� ,r12R►' N O y co � f cwt L is 2r m I d MrAs j o pa lug In w At V Q LL — I o m cc ell to r � N °°' m ob W CD o m CJ o a I I d. I y 3 N y a co tu CD co W I j . - a 3 r a- 3 1 011 C �,1 Q I QQ m i O s, • ,o9ve9 ,....: ponoc on co Z g. ' . a v°' so ►- °fit! t m I O Aalm J � 1 1 I to OD I s to 0 ► co o VI ,9002► OJ. se U � t Gera_ a_t0 m Ott ' 008 j .� to • M to •ir. � � � C'00 J Q \\ S / / ti z _ N O t0 ' '1.0 OM •7170oM .. M N ti 8 ,\ OJ tD Got M (� N 3► 1 N . O . N 25 N . N i cc t w o , ae•210 , Q . J / m . \ — ti U. co o co / 0 3\ v oy�\ mto ° \ IJ WV -ELI" rig vj m � / ` 00 0r a r m y ' I \ a �; a ��• / 41 ''s � M60tt a j saris b3leiia - -I � 99 R'009 e0Y9a OLE ,►reOL ,a1'909 OD ` N �o \ ►cyan �o\ — m M = O OD Q alt J\ 07 J - m \ � � I t — , 9c9s9 Z y t►•►1c1 C •, .00'099 111 w I STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER K�(,�f /�/ F O ADDRESS Q� / C T Y L r SUBDIVISION / CSM# LOT # SECTION � T 3() N -R ,,Z O W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM J / s EePAC C- T/�ervt�ES r + I �� I /000 GL. S, Tr G PIpE A INDICATE NORTH ARROW e . Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. . 1 . r BENCHMARK: ���P O ;VYl TE ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: C� /�_f�/' Liquid Capacity: 1,600 Setback from: Wel House Other rer Model# Size Float seperation Gallons c Alarm Location SOIL ABSORPTION SYSTEM Width: Length 7 Number of trenches _ Distance & Direction to nearest prop. line: f Q Setback from: well: House Other ELEVATIONS Building Sewer ST Inlet: 7 S, ZL ST outlet PC 0 om Pump Off Header /Manifold 1, Bottom of system q3, 1 17 Existing Grade C / Final grade ? 9 DATE OF INSTALLATION • �", - y PLUMBER ON JOB: LICENSE NUMBER: J INSPECTOR• 3/93:jt ;iL Gt p vG�sQe�h9irtrrf�lr� ;d'tr�i'tstr9 . 19. 9 �IVATEA SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division ST GROIX GENERAL INFORMATION (ATTACH TO PERMIT) SanitaryPermitNo.: 186549 Permit Holder's Name: ❑ City ❑ Village ❑Vown of: State Plan ID No.: SHEILA A ST. JOSEPH T B E ev.: Insp. BM Elev.: BM Description: Parcel Tax No.: a 020- 1021 -10 -000 TANK INFORMATION ELEVATION DATA A9300 9' 30 70 a TIM TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic t 0 Benchmark � W /001 Dosing Aeration Bldg. Sewer Holding St /Inlet ,� �5•t, l TANK SETBACK INFORMATION St/ Ht Outlet L 197 q s ,33 TANK TO P/ L WELL BLDG. Air I to ntake ROAD Dt Inlet Air Septic ► ' a O >�" NA Dt Bottom Dosing NA Header/ Man. 9 S� Aeration NA Dist. Pipe 7 9 q4 Holding Bot. System .79 c�35; ` PUMP/ SIPHON INFORMATION Final Grade 1 5,3 q7, Manufacturer Demand Model Number GPM TDH i, Lift Friction System T Ft Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. O renches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS J S DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of � CHAMBER Model Number: System:-} .,.,r,,) 1 10 , 51 3 `) l o l� OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s), x Hole Size x Hole Spacing Vent To Air Intake Length Dia Length Dia. Spacing 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 4 Bed /Trench Edges,. Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (include code discrepancies, persons present, etc.) 1 c LOCATION: HUDSON 1: CO. RD C—Y 1f` v � ' .2 Plan revision required? ❑ Yes ❑ No / Use other side for additional information. O go l ?3 SBD -6710 (R 05/91) Date Inspector's Signature Cert. No. 1 ADDITIONAL COMMENTS AND SKETCH ' SANITARY PERMIT NUMBER: I =Z : 1 1 a l HR SA NITARY PERMIT APPLICATION ...,..,�..,e. In accord with ILHR 83.05, Wis. Adm. Code C' my STATE SANITAFffPERMff # —Attach complete plans (to the county copy only) for the system, on paper not less than ❑ ` 8% x 11 inches in size. C if evisio evious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION L,,--- '/4 5 '/4,S v ? , 5" T ,N,R O )W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # 'f0 0# 3 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 116b 1516M O II. TYPE OF BUILDING (Check one) CITY NEAREST ROAD State Owned VILLAGE: ,_ 0 ❑ Public X 1 or 2 Fam. Dwelling —# of bedrooms TAX NUMBER(S) 111. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/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 in line A. Check line B if applicable) A) 1. � New 2. ❑ Replacement 3. E - 1 Replacement of 4. El Reconnection of 5. ED Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit ## — 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 M Seepage Trench 22 ❑ In- Ground 42 El Pit Privy 13 Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System -In -Fill 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 /day /sq. ft.) (Min. /inch) ELEVATION _�50 5 6 3 7 O 9 3 . Feet Feet VII. TANK CAPACITY Site in ga Ions Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks strutted Se tic Tank or Holdina Tank Lift Pump Tank/Siphon Chamber EIE VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plu is Signature: (No Stamps) SW No Business Phone Number: 6- — ,_� Plumber's Address Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date issuing Agent Signature No Surcharge Fee) Approved ❑ Owner Given Initial �- Ad v rse Determination X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber r INSTRUCTIONS 1. , A sanitary permit is valid for two (2) years. . 2. Your sanitary permit may be renewed before the expiration date, and a tho 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. On §rte sewage systems must be p roperty maintained. The s se tank (s) must e m b pumped b a l g Y P P Y p (r P P Y 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 & Buildings Division, 608 -266 -3815. 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 bedroorns if 1 or 2 Family Dwelling. Ill. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in 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 in ##1 -7. VII. Tank information. Fill in the capacity of every new and /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 9ppropriate 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% 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 oi' holding tank(s), septic tank(s) or other treatment tanks; bkdiding sewers: ve0s; water mains /water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorr !cn systems; replacement system areas; and the location of the building served; B) horizontal and vertical 1cvation reference points; C) complete specifications for pumps and controls; dose volume; elevatk r lifferences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross sect n ,J the soil absorption systE:m if required by the county; E) soil test data on a 11 -5 form; and F) all sizing i !formation. ----------------------------------------------------------------------------------------------- - - -• -- _.------------ ---------- ---- — ------- -- I GROUNDWATER SURCHARGE ' ,33 `:tV sconsin Act 410 incluied the creation of surcharges Uat: :) "o, a nuvi' s ; regulated practices which can effect groundwater. The monies collected thrGLIgh these surcharges are used 'or mLcmf •)rin(- gr;��; �s rrakc�r, ground- . wafer c;ontarnination investigations and establishment of stan dard,- SBD -6398 (R.11/88) 1 T e� o c 7` � P 3 P��� 3 °,f ° r ' P� � P�' c 6" C Ty #W y L - - N ' 3.8 Y A CR 'FS a p (IJEccS c T�2E ARC I� m w ir/f /iv b o' o � New Sep ys rem, �Ao p85�a 1000 GL, SST Ai \� t EL ) m •n ?Rekcy � 82 �hR M /00. o ,9R,4WI,V eoR; 1 1, nRAW/A l,E a Iq Fa x bi G y'61 NUN'TC-/R 14 %C & RO ' 586 v Acce % U dl rR. HOD50M r5o/+/ERS�T etjl - •�r/d25 -#3 5 Qn S - � ► i 7 /1 N � 1 - 7 n' !- n n 0) �} s N ccpp O W I W cn fl T<I o N N OD N N W ci \ . r �`�F !w ---•-•--•-�\ �•• it 100 / 8 / ► ` ®� A t A CA W o� �s s y� a`• �� a Cb • Q �� I -a��;' D UI• � � p �o, �l� I OD oD • t0 O I 4 30.06' w r' • 11 y I O p 0 a t0 r, �- - 0) p (D —i 312,00 255. p 32 / 6Q N4:jV - 4^0 5V'V c r ro.v Wisconsi �� Lrpartment of i ndustr y. SOIL DESCKIPTION REPORT Safet R 79 gs Divisi Libor and Human Rel ti P.O. eon Wl $3707 + N (Attach Soil Profile Location Map - To Scale - On A Separate, Signed Sheet) Madison, WI • 3 ��° ASS 3 Sc S �l/ ��� /� p A-5 60. Z Page % 01 2. uswmer Name r atwn ate ! uasat to u►e or Vegetative over Parent Materm r k o>< Shy € /q o M,q / ¢- y� ssj,�n P�.�.�•E- - yrgss A'7- G�fw -4s�. sumate a owat roar waur � P rjt� ounty ax ar _ ystsm Loa mq to in a ns Pa t. sr ay ST .%Czi � l T.f�f A GLt Lotle9a scrrpaon yusm romeuya -C a %Wtt S T.3 0 .v Z o c v ?�Pz` t-- / 2 Z I V Horizon Depth pW>witWtnt Color Mottles Structure Remarks: clayskins Loading In. II u. Sz. Cont. Color Texture Gr. St. Sh. Consistence Roots Bounda ores H and other GPD/ft.2 16 YX y / 2 S �� �*+ G iYn-Q f' f s N GuT o ff 0 00 Horizon Depth Dominant Color Mottles Structure Remarks: dayskins Loading In. M II u. St. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Bounda ores PH and other GPO /�ft.� "f}R f/o�i 24 •J � d r 13 a -/X 1 /s . 0 .1 """e- l f �s � o /32- .2 ea Horizon Depth 0Qmiwt Color Mottles Structure Remarks: dayskins Loading in. ` M ell Ou. St. Cont Color Texture Gr. Sz. Sh. Consistence Roots Bounda ores H and other GPD /h? 0 - l 3 /C4 R l� Z s / ^� 9ie ' v tit { �- S '� P �o �:zo v �---. G' �o / Q YI ✓`^ — S S M, Gc S sTiP�rit,;Ev - . /�. Horizon Depth Dom irtquttColor Mottles —� Structure Remarks; clayskins Loading In, Mu II u. Sz. Cont. Color Texture Gr. Sz. Sh Consistence Roots B nda t ores H and other GPD /ft.2 A "fib Y/ !y Horizon Depol Dominant Color Mottles Structure Remarks: clayskins Loading In. Mum II u. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Boundary res o H and other GPD h) /o o e 4/g s ©�,� s �►� r C - S te, s. HOME5ITE SEPTIC PLUMBING CO. 6b5 O'NEIL RD., HUDSON, WIS. 54016 ROBERT ULBRIGHT 0 s 7 1 y8Z r /IS. MASTER PLUMBER LIC. NO. 3307 MAKS, q.. PAal {aye. C al "I-e 44 0 ` 1 f v D r, :>J ���1 /'CQJ2 S a � �I obi Zoti �' f � •� �-- � Ce.c�¢_ .�P �"�- / �.5� _ _._. Olher Site Fealutgs: AI M-- w P 244 i Gu- I (— � y f � -- { 7/S , 3 � (- �r�S 2y <P I! limiting Factoli/Depth: CS1 Signature Uste Signed Telephone No. CST / r , lU0-41.0IN DIM) r. „ yo - Sc�4Gc ( 5 2- t 13 3 � i'�' • Sfo " PROVED , This'�st site �'e tic system. �,1, for a conventions P -' s { - - -- _ G/ _ -- 94 - -- • _ Ile - - f I ,y o 135 '_ s Y , i 5y5TEH �lEt�r►T /O�uS 1 fl 14I' �`' TR e N o ki - r ee N e-& 93 .SO <r /10W 7kae s c ti, 9 0 �� "',�'oX � nv u p 8 kA A Pi'leo Y- . S w nor COA-bR . / -,4 S SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER /BUYER Kevin & Sheila Fox ADDRESS: 273 County Road E FIRE NO: 273 LOCATION: Nw 1/4, SE 1/4, SEC. 25 - -T N -R TOWN OF: St. Joseph ST. CROIX COUNTY _ SUBDIVISION: LOT NO. 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 septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system: St. Croix County residents may be eligible to receive a grant to help with the cost of the replacement of a failing system, which was in operation prior to July 1, 1978. St Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to the St. Croix County Zoning a certification form, 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 (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification from will be sent approximately 30 days prior to three year expiration. I /WE, the undersigned have read the above requirements and agree to maintain the private sewage disposal system-in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification form must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED• DATE: St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 5 t APPLICATION FOR SANITARY PERMIT STC -100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor,(spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property Kevin & 5heild Fox Location of property NW 1/4 SE 1/4, Section 25 , T 30N N -R 20 W Township St. Joseph Mailing address 401 Hunter Hills Road #3 Hudson. Wisc. 54016 Address of site 273 County Road E 4 Subdivision name n /a Lot number n. /a Previous owner of property Lorraine G. Andrews & Lawrence L. Lutton Total size of parcel 3.84 acres Date parcel was created 10/31/56 Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? Yes x No Volume 953 and Page Number 72 as recorded with the Register of Deeds. Doc. # 484 061 INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(We) certify that all statements on this form are true to the best of my (our) knowledge'; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty de d ecorded in the Office of the County Register of Deeds as Document No. ���a� ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the cons ruction of said system, and the same has been duly recorded in the Office of. a County a stet of Deeds, as Document No. ). 1 Signature of Owner Signature of Co- ner (If Applicable) 8/17/92 8/17/92 Date of Signature Date of Signature � '. DOCUMENT NO s *" A Y N "M :F STATE BAR O1r=;�VISCOi3IN FORM 8 -=!M! Vill REC Lorraine... a.....Andr.e�+s..a /k /a .Lorra.ine �.....Lut.tom.. ta�; . ,. w and .. Laxrl�nce.. L,... i, u. tton . ........................... _ ....... ... ........... ..... .......... . .. . . JUNd YL r.' I� conveys and warrants to . .Kevin M... Fox- and...Shei.la.. K... of 8:30 A. �! Fox,..husband. -and wife..__ ... .... .... ............... (I _ ................. ... ... _. _ .. ......._ ............. , ... .. .. _.. ........ ... .. ... ..... .. wrturcH TO ii _ �! the following described real estate in ..... .Count St. Croix ................. y, State of Wisconsin: T ax Parcel No: .............................. North 100 feet of East 550 feet of NW4 of SE4 of Section 25, Township 30 North, Range 20 West, St. Croix County, Wisconsin. Part of SWk of NE4 of Section 25, Township 30 North, Range 20 West, ; St. Croix County, Wisconsin described as follows: Commencing at SE jj corner; thence West 550 feet; thence North to the Highway; thence, SEly to the point of beginning. Nrt FA ffi ^. Thi, is not h,tm f,ad pr,yttrt.. I:\'' I easements, restrictions and rights -of -way w of record, if any. Z� May ut 92 � I I . ' (S EA 1 t �.. Lorraine G. Andrews a /k /a 1,awrence L. Luttor, ,t. 1 Lorraine G. Lutton:, �I ISEA1.r r • 7 gY p AUTHENTICATION ACKNOW LF.DGMEN'C Si�nsturcl.;, Lorraine G. Andrews a /k /a ;'r. `! r: + +r NVISI ttx lx ; Lorraine G. Lutton; Lawrence L. ,s. ,• {g _LUttOn" authenticated t!�is; dsc of May I1; 92 I t t . c:;nti . , ,++ro Ine ti. day of the :,Los•c naro �e • Kristina Oc land Kristin Ogl:,nd `1tt:G: alt 1,ak' T NVAW s } t •+I .•fit 1 1 n REPT131 St. Joseph ST. CROIX COUNTY ZONING PAGE 1 0,4/29,/93 16:20 REQUESTS FOR INSPECTION WORK SHEETS FOR: 4/30/93 AREA: MJ -------------------------- " Activity: A9300006 4/30/93 Type: CONV93 Status: PENDING Constr: Address: HUDSON 14.29.19.96B,NW,SE, CO. RD. E Parcel: 020 - 1021 -10 -000 Occ: Use: Description: 186549 Applicant: FOX, KEVIN M & SHEILA A Phone: Owner: FOX, KEVIN M & SHEILA A Phone: Contractor: SCHMITT, DONIVAN Phone: 568 -4948 -------------------------------------------------------------------------------- Inspection Request Information..... Requestor: Donavin Schmitt Phone: Req Time: 10:04 Comments: !G �ou Items requested to be Inspected... Action Comments Time Exp 00012 FINAL INSPECTION -------------------------------------------------------------------------------- Inspection History..... Item: 00012 FINAL INSPECTION