HomeMy WebLinkAbout032-2121-30-000 �
i
0 ■ ■ "0 n c
k E E / ¢ ) A �
V g -
_
/
® 7 7 z ° m) E§ S
e @ \ \ § (D ( / f . 2
Q/ c 0 $$ 2 7
\ \ § (D \ 2 f k \ 2
i ® ( ;§ { § ƒ
c �
� m v y §
CD
CD
a 0 \ \ 2 /
. ( ® f
Z k \ k $
C o o m § E 7
� 2
2\ CD 0 0 0 §-
6\ CO) 3 2\ k 2
m q =
f` -0 � c
C', �
2 m
} " I
E E £ 7
/ m2 -0 2g 0f
{ /� ($\£« !§§ -
I
0 �E 0 ) E ƒ 2K
a = CL �OL
\ 7� ±a53 -
f a k/ \ kz�
/ ¥ i c - » ■
\ E( B 9
q / #
% { / a ƒ � 7
RL o z $
C. ' q z \ »
2
CL
� � \
\0
z %
/m $
0 � )
0 K
f o
« �
� � \
I
at
� ) / \
%
\/ #�
i c= �k
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Coun
Safety and Buildings Division 9t. Croix
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanita grgt No -:
Personal information you provice may be used for secondary purposes [Privacy Law 15.04 (1)(m)], J
Permit Holder's Name: ❑ City ❑ illa e n of: State Plan ID No.:
hell, Robert §oir ers Yownship ` �
CST BM Elev.-. Insp. BM Elev.: BM Description: / Parce],Tax �21 -30 -000
I CNW vv�SLL L1
TANK INFORMATION ELEVATION DATA aO, t q, Lo
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic l S Benchmark _`Z J) .25— Co. O r
Dosing Alt. BM 01 8 y-�
8" 09•
Aeration Bldg. Sewer
JD S• 85 �
Holding St / Ht Inlet
TANK SETBACK INFORMATION St / Ht Outlet 1-8S /pY 3 4 - �
TANK TO P/ L WELL BLDG. ventto ROAD Dt Inlet
Air Intake
Septic ���' ]�rp' 3 NA Dt Bottom
Dosing — - NA Header / Man. I l• 0 3 . I a ,
Aeration NA Dist. Pipe /. t IT
/u3.D8
Holding Bot. System ] �' O �
02. t�
PUMP/ SIPHON INFORMATION Final Grade `� O /eS 23'
Manu er Demand St cover 6.37- b -
Model Number _ GPM
Friction He em TDH .� Ft
TDH Lift o � .
For�ain Length Dia. H Dist. To well
SOIL ABSORPTION SYSTEM
( 13-ED / THE -NeM Width / LenatF , No O T ench s PIT No. its Inside Dia. Liquid Depth
IMEN I N t _i `I' DIMENSION
SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHING u acturer:
SETBACK I CHAMBER
INFORMATION Type O r � � y{ � "Model Number:
System: fpO4- Q > CID ORU
DISTRIBUTION SYSTEM
Header / anifold d Distribution Pipe(s), i , , x Hole Size x Hole S acing Vent To Air Intake
�� � // i
Lengt �-�- Dia - � Length 3—a Dia. _y_ Spacing lD• > /�
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: 2f /al7 Inspection
Location: 830 165th Avenue, New Richmond, WI 54017 (SE 1/4 NW 1/4 12 T30N R19W) - 12.30.19.1095 North Bass Lake
Estates -Lot 26
1.) Alt BM Description= r
2.) Bldg sewer length = 4 3
— > FEZ. " b v.,,,Q
- amount of c v — '_ ,� ;��,�Q v'� q �o�' u;�,� -
�� N,_� 50( 1 � (�f
4) Rom
Plan revision required? J5. Yes ❑ No
Use other side for additional information.
SBD -6710 (R.3/97) \0 0 WL.,D, S -I ) 0_S Date Inspector's Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
E
e
3 E
j
t
e
t ._€
i
" n
E �
S i
' i f
E
a a c
F
c
e
_ € m
d <
e �
r
" e
3 ..
3
I � �
i s F
3
€
} i
i
E
i
j
q ( 7
A
t
Y €
- ----- --- 5 ;R t..
B
E �
4 ¢ }
z Y
x
S
t _
t
q € ,
€
c €
e
e
F
E 1 t
� e a
s #
S t t
c
r
1
I r
e m
" ".
3
�. .
. .... . .. .
I
T
t € �
Vi sconsin Safety and Buildings Division
S ANITARY PER C s�R� d, 'ATTON,._ P o B. Washington Avenue
Department of Commerce In accord with Comm ode �� Madison, WI 53707 -7302
e
it
Attach complete plans (to the county copy only) for the se'r not less C:6u than 8 112 x 11 inches in size. ce See reverse side for instructions for completing this appli ,�
State ,nitary Permit Numb r
Personal information you provide may be used for secondary purposes h k if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. N t Plan I.D. Number
I. APPLI ATION INFORMATI N - PLEASE PRINT ALON '? v f
Property r Name Property Loc?ti
4, S T , N, R E (or
Property Owner's Mailing Addre Lot Number Block Number
J
City, ate Zip Code FPh ne Number Subdivisio Name or CSM Number sy
i )
I. TYPE OF BU ILDING : (check one) ❑ State Owned !t Nearest Road
❑ Village h
Public 1 or 2 Family Dwelling - No. of bedrooms E& Town OF f
111 BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
0 211
1 ❑ Apartment/ 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 box on line A. Check box on line B, if applicable)
A) 1. W New 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System ________ 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
110 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 []Seepage Pit I r 43 ❑ Vault Privy
14 ❑ System -In -Fill Z K -4-3 = S�i_(C)
VI. ABSORP 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./ i ) Elevation
Feet leg a Feet
Cap acit y VII. TANK in altons Total # of r Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existin strutted
Tanks Tanks
Septic Tank or Holding Tank Z12Z — 12 ❑ ❑ ❑ 1 ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ ❑
VIII, RESPONSIBILITY STATEMENT
1, the un ersigned, assume responsibility for in allation of the onsite sewage system shown on the attached plans.
Plumber' N e: (Print) N Plumbe S igWa t re: No S s) MP /MPRSW No_: Business Phone Number:
r �—
PfUm6er treet, City, State, Zip Cod
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved S nitary Permit Fee (Includes Groundwater ate ssue Issuing Agent Signature (No Stamps)
Surcharge Fee)
Approved ❑ Owner Given Initial c_
LIM, Adverse Determination UQD (��"2UdD ,A `
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -6398 (R. 4/99) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
I
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.
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 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 y
Wisconsin, Safety and Bwaklings Division, 608 -266 -3151,
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and 'mailing address, Provide the legal description and parcel tax number(s) of where the
system is to be instatfed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
M. 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 8 112 x 11 inches must be submitted to the county. The plans must
include the following'. 'A) plot plah, 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.
----------------------------------------------------------------------------------------------------
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.
V ���1c- ✓/�l�`'r,� � ��t� ..�/6�� is
✓� = 'sue �,
/ l
I
ay'
will eD ✓
10 J
' Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
i-0 '- 2� COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but St. Croix
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. 032- 2045 -20 -200
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION R IEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
Gerald Smith GOVT. LOT SE 1/4 NW 1/4,S 12 T 30 N,R 19 j(or) W
PROPERTY OWNERS MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
11160 190th. Ave. NW -5 na N. BA Lake Estates First Addn
CITY STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE R]fOWN NEAREST ROAD
tlk River, MN. 55330 1612)441 -8888 1 Somerset I 165th. Ave.
( New Construction Use [x] Residential / Number of bedrooms 4 [ ) Addition to existing building
J Replacement [ J Public or commercial describe
Code derived daily flow 600 gpd Recommended design loading rate • 7 bed, gpd /ft • trench, gpd /ft
Absorption area required 858 bed, ft 750 trench, ft Maximum design loading rate .7 bed, gpd /ft .8 trench, gpd /ft
Recommended infiltration surface elevation(s) 104.1 alt. area =103.5 It (as referred to site plan benchmark)
Additional design / site considerations na
Parent material outwash Flood plain elevation, if applicable na It
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem ® S ❑ U ® S ❑ U ®S ❑ U CR S ❑ U ®S ❑ U ❑ S {7 U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
Boring # Horizon in. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
..................
.................
1 0 -9 10yr3 /3 none 1 2msbk mfr 9w if .5 ( .6
2 9 - 10ry4 /4 none sicl 2msbk mfr gw if .4 .5
Ground 3 23 -84 7.5ry4/4 none co s co s ml na na .7 .8
elev.
_ 1Q�1t1
Depth to
limiting
factor
+f34
3C� `
Remarks:
Boring #
1 0 -1:3 10yr3 /3 none 1 2msbk mfr gw if .5 .6
2 13 -29 10yr4/4 none sicl 2msbk mfr gw if .4 .5
3 29 -84 7.5yr4/4 none co s Osg ml 7 .8
Ground
elev. ,r•
10 ft.
`
Depth to .,
limiting
f +84 r R
`fa
Remarks: orp /cp
CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200
Address: 1554 200th. A New Ri mond I 54017
Signature: Date: 12 -1 -98 CST Number: m02298
PROPERTY OWNER Gerald Smith SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D. # 032- 2045 -20 -200
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bound3y Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ITrench
1 0 -11 10yr3 /3 none 1 2msbk mfr gw if .5 .6
"' ...3.. 2 11 -22 10yr4 /4 none scil 2msbk mfr gw If .4 .5
Ground 3 22 -84 7.5yr4/6 none co s Osg ml na na .7 .8
elev.
1
Depth to
limiting
factor
+A4
p,8
Remarks:
Boring #
1 0 -11 10yr3 /3 none 1 2msbk mfr gw if .5 .6
4 2 11 -21 10yr4 /4 none sicl 2msbk mfr gw if .4 .5
3 21 _84 7.5yr4/4 none co s Osg ml na na .7 .8
Ground
elev.
1 Q6,1t. —
Depth to -
limiting
f +E54" —
Remarks:
Boring #
1 0 -8 10 y r3/3 none 1 2msbk mfr gw if .5 .6
5..... 2 8 -20 10yr4 /4 none sicl 2msbk mfr gw if .4 .5
3 20-84 7.5yr4/4 none co s Osg ml na na
.7 .8
Ground
elev.
10.69_ ft.
Depth to
limiting
factor
+84
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBO- 8330(8.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel Gerald Smith 1554 200th Ave.
CSTM2298 SE4NW4 S12- T30N -R19W New Richmond, WI 54017
MPRSW -3254 town of Somerset (715) 246 -6200
lot #5 -N. BAss Lake Estates First Addn.
N
1 =40'
BM.= top of IOW lot pin C el. 100' n
Alt. BM.= top of NE lot pin C el. 106.40'
`I2 3 2 3 43 6
30 ,
0 30 •
Gary L. Steel
12 -1 -98
r ,
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGKLILti11':N'T
AND
OWNER - SHIP CERTIFICATION 1.01119
Owner/Buyer LV rt �__ 1 Yl� _- - - - - -- —
Mailing Address Q , lC�(�I , - I • 6 �®2 5
Property Address r e - 0 - -1 -� 1 —
(Verification required horn Planning Deparhncnt for new cutuuuc [loll )- -_____
City /State Parcel Identification Numhct
LEGAL DESCRIPTION
Property Location ' /4, ';:,, sec. � T� N -KJ'7-
Subdivision �� off' 1 �- GS�+^�� Lot #
Certified Survey Map # , Volurnc
Warranty Deed # ��-7,I/ Vulumc
Spec house ❑ yes fYno Lot lines idcntif iabIc yes i ] I lo
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result iu its prt•rt,atw C IatiluC w handle wastes. Yroper maintenance
consists of pumping out the septic tank every three: years or sooner, if urcdrd by :, It ru ed I;u:;a : c What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal systcut.
The property owner agrees to submit to St. Croix Zoning Department a ceruttcation torm, signed by the owner and by a
master plumber, journeyman plumber, rcstrictedplumber or Iiccnsed pumper ventyut,' tlu,t ( 1 ) (I 1C 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.
t /we, the undersigned have read the above rcquirenrents and agree to ifiamt.tt,i the lu H alt ,c��'•iZ'.c d11'11os:d system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natuual hrsoutcc:;, �t.ttc of Wisconsin. Certification
stating that your septic system has been maintained must be completed and retuntcLi tti JJW tit t hOu, ('ounty "Zoning Office within 30
day of the a year on date.
SI NATURE OF APPLI ANT DATE
L
OWNER CERTIFICATION
I (we) certify that all statements on tits form arc true to the best of uty t:,ui %t���� I,.i��,c- I (���) aut (a,e) rite owner(s) of
the property described above, by virtue of a warranty deed recorded in Register o) 01 I lk
SIGNATURE OF APPLICANT"
r••.•* Any information that is rnis- represented may result in the sanitary pctutut hcil - it, i I,N till. Zonmg Department.
'• Include with this application: a stamped warranty deed from the Register of
a copy of the certified survey map it teteteuer',, ;uadc ill tlt, ;:attanty decd
it
!
STATE BAR OF WISCONSIN FORM 2 - 1998 6Q796►7
WARRANTY DEED KATHLEEN H. WALSH
REGISTER OF DEEDS
Document Number
vo►.1446PAG,_ 427 ST. CROIX CO., WI
RECEIVED FOR RECORD
This Deed, made between Forest Oaks Condos, Inc. , 08-03 -1999 10:30 AM
a Minnesota Corporation,
_ VARRNM DEED
Grantor, EXEMPT N
and Robert L. Thell and Sharon Jo Thell, CORY COPY FEE.
COY FEE:
husband and wife, TRANSFER FEE: 85.20
RECORDING FEE: 10.00
PAGES: 1
Grantee.
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate in St _ Crni x County, State of Wisconsin:
Recording Area
Name and Return Address
KRI"'TINA 4GLAND
Zilz, Estreen & Ogland
P.O. Box 359
Hudson, WI 54016
032 - 2045 -20 -200
Parcel Identl Ication Number (PIN)
This is not homestead property.
%mss (is not)
Lot 26, North Bass Lake Estates First Addition in the Town of Somerset,
St. Croix County, Wisconsin.
Exceptions to warranties:
Dated this ?_1 day of August, 1999
Forest Oaks C n .
(SEAL) BY (SEAL)
* Ger d ith, President
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) Gerald J. Smith, President,
State of Wisconsin,
Forest Oaks Condos, Inc., ss.
County
authenticated this VA. day of August, 199 Personally came before me this day of
the above named
Kristina land
TITLE: MEMBER STATE BAR OF WISCONSIN — to
(If not, me known to be the person who executed the foregoing
authorized by §706.06, Wis. Stats.) instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY —
Attorney Kristina Ogland
Hudson, WI 54016 Notary Public, State of Wisconsin
My commission is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not
necessary)
Names of persons signing in a— uist be typed or printed below their signature.
STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc.
WARRANTY DEED FORM No. 2 - 1998 Milwaukee. Wis.
r
U
N O
U 1 _
I
QI >i
SZ :T b9' M „OZ,8z.00S -- I L
l;ls
LO
An
m m
LI-j L14
r'a z
om per' o `a)
Cn
r c
LLJ
r 1 I i p
- C) I I+ 1
,
,
fo
k'
Q
N
LL
co
i
\ Y i
V)
❑ I (_l l
cn
\ "� -� g -- -- %� • , • `' �� '� :� . -
i
00 m �
i
/ r
� S I
w
t ,
00'Z£6 =A3 { z
3dld NONI d01
:A8VV4HON38
\ I
3 \ H - 1 - �- 0 - N o'
/