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HomeMy WebLinkAbout032-2017-90-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: $t. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 165 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)). Parcel Tax No: Permit Holder's Name: City Village X Township 032-2017-90-000 Phaneuf-Vanasse American Legion tBMDesccdption-: Somerset, Town of ::j Insp. BM Elev: section/Town/Range/Map No: CST BM Eiev: 05.30.19.536D TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark %;hn 9 , ( X0 7 7 '713. Cp Dosing ~q Alt. BM Aeration 1 Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet ~~7 5 ~J5 95 TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet /3 5 C) 9 / 5 Septic Dt Bottom Dosing Header/Man. Aeration Dist. Pipe Bot. System Holding Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM PIT DIMENSIONS RPits Inside Dia. Liquid Depth BEDITRENCH Width Length No. Of Trenches DIMENSIONS SETBACK SYSTEM TO j L BLDG WELL LAKE/STREAM Manufacturer: INFORMATION Type Of System: Model Number. DISTRIBUTION SYSTEM x Hole Spacing vent to Air Intake Header/Manifold Distribution x Hole Size Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only xx Mulched Depth Over Depth Over xx Depth of x Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No [a-] Yes ❑ No Inspection #2: / --L COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 05.30.19.536D P c el No: aS~_ Location: 464 County Road W SOMERSET, WI 54025 (SW 1/4 IINE 1/4 5 T30N R1 9W) metes& bounds Lot l 102 ee r~ tt - -IPL-- OL ~j 1.) Alt BM Description = ~ C I t I~ ~l rl 2.) Bldg sewer length = lu W ► S Q~J~• 4b P I - - amount of cover h6 CL fAA5 at~o GO(~ W W t_ 2 'l Y~ 3 Plan revision Required? ❑ Yes R No Use other side for additional information. J Date Insepct s Sign re Cert. No. SBD-6710 (R.3197) County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN In accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT ` Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER ~VE's* 15.04(1)(m)) 1101 Carmichael Road Hudson, WI 54016-7710 FW 1 (715)386-4680 Fax(715)386-4686 Attach complete plans for the s stem on paper not less than 8-1/2 x 11 inches in size. Countto/ anita e ❑ heck if revision to previous application L!1 (0 Is 1. Application Information - PI a ` W-Mbe Location: Property Owner Name _ 1 11;)w - n S W 1/4 E 1/4, Sec S P l4 N l-1 - VAN SS F Y©S 7 30 N, R 19 E (or) Property Owner's Mailing Address Lot Number Block Number 7 C V T (0 Z/ CQ A) 7-Y ' 0 V City, State Zip Code Phone Numer Subdivision Name or CSM Number 'S` m C ►2S i'? W r 1:5- 5/O L S- 1 Type of Building: (check one) Mity ❑ Village ®Town of ❑ 1 or 2 Family Dwelling - No. of Bedrooms: ly[ Public/Commercial (describe use): 1n > So M1. (~S ❑ State-owned Nearest Road 1. Type of Permit: (Check only one box on line A. Check box on line B if applicable) C OU+NT`I A-0A V V V Parcel Tax Number(s) J1Repair ❑ Reconnection ❑Non-plumbing ❑Rejuvenation _ - ©Q A) Sanitation 03 Z Z O 1'7 0 B) Permit Number Date Issued ❑ State Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) to Non-pressurized In-ground ❑ Mound Z 24 in. suitable soil ❑ Mound s 24 in. suitable soil ❑ Mound A+0 ❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line ❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Other ❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating . Dispersal/Treatment Area Information: I1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed (Gals./day/sq.ft.) (Min./inch) Elevation 1. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks 7--1000 woo 7- I E56)z M ❑ ❑ ❑ ❑ 00 goo l I VV i E5 c a ❑ ❑ ❑ ❑ If. Responsibility Statement I, the undersigned, assume responsibility for repair/reconnenction/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installation of non-plumbing sanitation system. Plumber's Name (print) Plumbe Si ture MP/MPRS No. Business Phone Number dNN SCNMtrr ZZ 7Cn 7rJ-,760-`011196 Plumber's Addres 1,5 A s (Street, City, tate, Zi ode 6 0 TM v!=, d M G4?5 T VV I 54102-S_ 111. County Use Only / Disapproved Sanitary Permit Fee Date Issued Issuin gent Signatur No sta ps) Approved O.n.er Give itial Adverse 2,Z °b 3/ Z 7/1 ion X. Conditions of Approval/Reasons for Disapproval: r- ~o~~.~e,✓v` ~c~...~ a / Pe Cam. d~ Rev: 8/05 c o m o M O p N 6s 4 0 0 0,0 y c E~S o cap > 0.003 N N .c O N U Q E C V N N C M Y Cc: (L) 3 y j O m rc N `-'~m"a '0 c m c m o E Q momE~'-m0 E a) w c rn c m O p a` c c co -7, Q) .2 U) m o O ~O D C L a) 7 N N i a O 7 m 5 O. cn r- 3: c oN CLC cnt U O ma C: N CD U ~ m cc N W 00 c E I~ C _N (D m m O N a) C: Z N y 0 m C E p C N O lL c U~ j C O> O a0 w C: 0) 0 a omE~m1-0ccac m Q c°~ c co pd= Co U s m ` =m y o u a~ c I 0 0 a~ ~ II w E m z o v £ Z d m E cn Fm- d m p L O O C U m O z C y U Q Z O 0 ~ O !q F- m 0 m U Z a 0 N -a E C0 F1 w N D c _U (YW~}J N b m 'O m O a -c O U E O N z z z N LO z m c li 'S N E N i R C E2 CL M m C: a) N m i ~ 0 E D D a m Q O N y E w z F- F- F- a_ co > o o o z • N*v II ~ a a a i d o "O O cn 2:, O p ~1 N J U o 0 0 :03 V z N N v p o C _ a lrrj a - QI Z is O ~i a m O 0 N 0 !l 00 C N N c C C E o ~~-~i O(o 0 m U O O U = p V M ca ~0 N m~ m U ~ r a U w m N -0 G' O ca a) C C Q) O ~ N co E E m c vUi T T co Lo 0 V e-, O O cn a N a UJ E ~ E m V~ 0 a 7 L: a c°ii 'E E c c 0 :3 I ~Wisconsin bepartmentof Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 113 113 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 Phaneuf-Vanasse Post III Somerset, Town of 032-2017-90-000 CST BM Elev: Insp. BM Elev: Description: Section/Town/Range/Map No: job BM LJoAk cvk S- C y; 05.30.19.536D TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark I~wl a~~ 7. Dosing Alt. BM Aeration Bldg. Sewer (P Holding St/Ht Inl t1; 9-2- IV, TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. V ent to Air Intake ROAD DtInlet Septic Dt Bottom I E Dosing Header/Man. Aeration ` Dist. Pipe Holding Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number s TDH Lift Friction Lops . iSy term Head TDH Ft ! C Forcemain Length Dia. Dist. to ell SOIL ABSORPTION SYSTEM BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/ BLDG WELL LAKE/STREAM LEACHING Manuf N<_ INFORMATION 6. 4 CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM rHeader/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) ngth__ Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or rade Systems Only Deptli Over Depth Over xx Depth of jxx Seeded/Sodded xx Mulched Bed/Trench Center BTopsoil Yes No Yes No COMMENTS: (Include Code discrepencies, persons present, etc.) Inspection #1Inspection #2: / / Location: 464 Ccu,ity Road VV Somerset, WI 54025 (SW 1/4 NF_ 114 5 T30N R19W) NA Lot Parcel No: 05.30.19.536D OV 1.) Alt BM Description 2.) Bldg sewer length = amount of cover = ~2 , Z.Z. ,ZAr , A ~1y~„~~ ~ 7 ~ •Ii4~l~ 6-*Je~ -cam. Plan revision Required? Yes No Use other side for additional information. i i Date Insepctor's Signature Cert. No. SBD-6710 (R.3/97) R-AJ RECEIVED R County Sanitary ermt piicati n ~IAY 2 5 2~cROI couNrywlscoNSIN In accord with Chapen 12 St. Croix County Sanitary Or nanc 7#N ING ZONING DEPARTMENT Personal information you provide may be used for seconda purposes ST CCO TY GOVERNMENT CENTER [Privacy Law. S. 15.04(1)(m)] ST. CROI Cb110 Carmichael Road Huds n, WI 54016-7710 (715)386-4680 Fax (715)386-4686 Attach complete plans for the system on paper not less than 8-1/2 x 11 inches in size. JC u Sanitary Permit # ❑ Check if revision to previous application 1"3 i. Application Information - Please Print all Information Location: Property Owner Name -1&,> 1/4 ,1/4, Sec .57 a SSG- PD S I ~ ~ f~✓~G. N, R E ( . S 3 ! ~ 2L. a, __1r__ - V ct A., A Props Owns s Mailing Address , / 1 / Lot Number Block Number I V City, State Zip Code Phone Numer ubdivision Name or CSM Number a ) S ~Da~ 1 e of Building: (check one) amity ❑ Village Town of 1 or2 Family Dwelling No. of Bedrooms: Public/Commercial (describe use): 40 ❑ State-owned Nearest Road 1. Type of Permit: (Check only one box on line A. Check box on line B if applicable) A) ar ax Number(s) J1.E3 Repair Reconnection 3.❑Non-plumbing . ❑ Rejuvenation Sanitation '93d- ^r~d - I B) Permit Number Date Issued ❑ State Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) Non-pressurized In-ground ❑ Mound t 24 in. suitable soil ❑ Mound :5 24 in. suitable soil ❑ Mound A+0 ❑ Sand -Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line ❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Other ❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed (Gals./day/sq.ft.) (Min.lnch) Elevation Tank Infor on Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete strutted glass Tanks Tanks ? Lv ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 11. Responsibility Statement I, the undersigned, assume responsibility for repair /rec nenction/rejuvenationfinstallation of non-plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the inst I of non-plumbing sanitation system. Plum s Name (print) Plumbs nature (no stamps): MAP/MMPRRS No. Business Phone Nuumber a lG /~l'S t Z t L7/L2 IJ''crTGs r Plumber's Address (Street, City, Stat Code) It. County Use Only ved Sanitary Permit Fee Date I71 ed Issuin ent Signature s (Approved Owner itial Adverse Z 5 DD 5~z 5 -1 ~atlon X Conditions of Approval/Reasons for Disapproval: 3~ cJ l _ t~r e.,~ 5 ~c~ SYSTEM OWNER: 1. Septic tank, effluent filter and 54-o rc. ~ b.~l ✓%C ~ dispersal cell must all be services / maintakwd as per management plan provided by plumber. ~ugd-o ` /v o L ,GTP~C1 2. All sebwX requirements must be maintained as per applicable Code) ordhlaR m. I,,)" LJ'1" r / ~ . 6, 1<'e 77 y) _ I, PLOT PLAN PROJECT Phaneuf-Vanasse Post 111 ADDRESS 464 Ctv Rd VV Somerset Wi 54025 SW 1/4 NE 1/4S 5 /T 30 N/R 19 W TOWN Somerset COUNTY ST. CROIX SEPTIC TANK SIZE 2-2000 gallons CONVENTIONAL LIFT XXX DOSE TANK SIZE 800 BENCHMARK V.R.P. Bottom of Siding ASSUJEE;TION 100' fJ WELL H. R. P. Same as Benchmark ~ ~ ' J 515' Property .t 2 to, DT Approx System Area 30 \~v 10' ~Q 16 G V/ r~ S ra-d- C.~t~ s . 90' Cleanout to be installed 136' Property Line 15' 60' 0' 10' 15' Existing Bar Existing Cabin 1 QQ' System Well location unknown AOnly!, est is storage 150' 263 Property Line Cty Rd VV I PLOT PLAN PROJECT Phaneuf-Vanasse Post 111 ADDRESS 464 Ctv Rd VV Somerset Wi 54025 SW 1/4 NE 1/4s 5 /T 30 N/R 19 W TOWN Somerset COUNTY ST. CROIX SEPTIC TANK SIZE 2-2000 gallons CONVENTIONAL LIFT )00( DOSE TANK SIZE 800 BENCHMARK V.R.P. Bottom of Siding ASSUJETI ON 1 00' Yv - O WELL *H. R. P. Same as Benchmark 12~ J 515' Property 4 10' tA,~ ~Aj DT x Approx System Area 30 T T 90' 50' 80' Cleanout to be installed 136' Property Line 15' 60' 40' xisting Cabin 1015 Existing Bar S stem 100' y A k4 Well location unknown Addition/Bathrooms Only!, the rest is storage E: 150' 263' Property Line Cty Rd VV I ST. CROIX COWTY ZONING OFFICE CERTIFICA ION STATSb=T FOR MMIZAT70N OF AN EXISTIM SEPTIC TANK This is to certify twat I have inspected the septic tank presently serving the ~~.s~ ' yp n f", , .r Zd residence located sec . a : 7-3o , R/9 . _W, Town of = M. da St. Croix County, wisconsix. Upon inspection, Z certify that I have found tba tank and baffles to be in good condition, and it appears to be functioning properly. Lest time serviced t1~7 , Did flow back occur from absorption system? Yes D3o~ (if no, skip n*Xt line. Approximate volume or length of time: gallons ~ minutes Capacity.- 2-°.l~~ Construction; Pra abconcrete steel Other Manufacturer (if ;spawn): Age of T ' f known).same) Please Print itle License Number Dste) Form to be completed by licensed plumber (s. 145.06, wisconsin Statute) or licensed disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Flumber (applying for sanitary permit) Certification: In accepting the above statement regardiag Exist• septic tank condition, I certify that the tank, to the best of my kna dge, will conform to the requfrmcit nts of TUM $3, Wiz- Adm. Code (axe* or inspection opening ove- outlet bafOlet. N Signature MP (1KYRS . r ~ ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer J~ v Mailing Address T &Y - 4--Ifs Property Address (Verification required from Planning & Zoning Department for new construction.) City/State Parcel Identification Number LEGAL DESCRIPTION Property Locatior~ 1/4, ,/a , Sec. S , TC~N R~W, Town of S.~^ Subdivision , Lot # Certified Survey Map # , Volume Page # Warranty Deed # Volume U ✓ 'U , Page # ? (I Spec house yes no Lot lines identifiable es no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St., Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department 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/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, 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 Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property descrid abo , by virtue of a warranty deed recorded in Register of Deeds Office. J tai d 7 SIGNATURE OF AfPLICANT(S) DATE Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department.*** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) r DOCUMENI NO. SATE BAR OF WISCONSIN FORM 1- WARRANTY DEED 446224 vo ' 836 Pa~E ~6 ThiS Deed, made between REGISTER'S C`FFI :E Bank of Cameron $T MIX ~ Vti • Recd for Record L r v Grantor. ~R 2 1989 and..... Phaneuf-Yanasse Post 111, Inc. 8:30 A.M webagwW of0eeds Grantee, Witnesseth, That the said Grantor, for a valuable conrideration__..•. one- . dol lar_ and.. other.. . valuable. _ eons iderat.iol . conveys to Grantee the following described real estate in St.. -Croix "v."Bank of Cameron County, State of Wisconsin: 612 Main Street Cameron, WI 54822 Tau Parcel No. Parcel "A" Part of the S1/2 of the NE1/4 of Section 5-30-19 described as follows: Commencing on the Wly line of said SW1/4 of NEl/4, at the intersection of said Wly line and the Nly Right of Way line of State Trunk Highway 64-35; thence N along said 1/4 section line, a distance of 4251; thence E at right angles a distance of 5151; thence S at right angles to the Right of Way of State Trunk Highway 64-35 for the point of beginning; thence N to the Nly line of the S1/2 of the NE1/4; thence E along said Nly line of S112 of NE1/4 to the Right of Way of State Trunk Highway 64-35; thence SWIy along said Right of Way of State Truck Highway 64-35 to the point of beginning. Parcel "B" A parcel of land located in the SW1/4 of NE1/4 of Section 5-30-19, described as follows: Commencing on the Wly line of said SW1/4 of NE1/4 at the intersection of said Wly line and the Nly right of way line of State Trunk Highway 64-35; thence N along said 1/4 section line, a distance of 425 feet; thence E at right angles a distance of 515 feet; thence S at right angles to the right of way of State Trunk Highway 64-35; thence SWly along said right of way of State Trunk Highway 64-35 to the point of beginning. Containing 5 acres, more or less. This is not homestead property. ~J■~~ A (is' not) 'liYl SM Together with all and singular the hereditaments and appurtenances thereunto belonging; 33-1"0 And... tnr - _.....~'E~''._.... warrants the the title is good, indefea's'ible in fee simple and free and clear of encumbrances ex-cept easements, reservations, restrictions of record and zoning ordinances. and will warrant and defend the same. Dated this .....17t...... day of .----•-..March 19....09. BANK OF CAMERON BY: - - -(SEAL) Donn(SEAL) ' . resident-•--- :Z .........(SEAL) c...L=....................(SEAL) = Martha Gifford Asst. Cashier AUTHENTICATION ACHNOWLZI)G RNT Signature(s) STATE OF WISCONSIN BARRON ss. - -----.County. authenticated this ........day of 19 Personally came before we this _17.0 day of March -19....8 the above named Donn -Idendorf_and __..Marth a Gi•ffocd......... .TITLE: MEMBER STATE BAR OF WISCONSIN (If not_ authorized by § 706.06, Wis. Stats.) to me known to he the person A.......... who executed the foregoing instrument and acknowledge the same: THIS INSTRUMENT WAS DRAFTED BY t • elan. L._. Sykes - SYKES & KORF, Rice Lake, WI 54868 (Signatures may be au*h-