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HomeMy WebLinkAbout032-2102-40-000 Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y INSPECTION REPORT St. Croix 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)1. 363973 Permit Holder's Name: ❑ City ❑ Village ❑ T5vvn of: State Plan ID No.: Goodman, Robert Somerset Township CST BM Elev.:- ' Insp. BM Elev BM Description: Parcel Tax No.: 6D c� IV e v� Cs�� ►'� 032 - 2102 -40 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 2 Benchmark 4 �, (o5 I tT20 , D Dosing Alt. BM of ©•55_ 03.03 ' Aeration Bldg. Sewer Holding St /Ht Inlet 633 q$ -Zs TA K SETBACK INFORMATION St/ Ht Outlet S 4f 9 g }' TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet - -1 Air intake Septic y ` N 5 NA Dt Bottom — Dosing A Header /Man. ( L� 31 r r EHI ion N A Dist. Pip .3 2 - ��.2 ng Bot_ System `(3 PUMP / SIPHON INFORMATION Final Grade Manufactulr Demand St cover Model Number GPM TDH Lift L oss riction stem TD Ft Force ain I Length Dia. Dist. To SOIL ABSORPTION SYSTEM ONY4, TREWA Width p Length No O Trenches PIT No. Of Pits Inside Dia. Liquid Depth D IMEUSIONS 3 I V . 3 DIMENSION SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manu ct r r: Stc,s SETBACK CHAMBER INFORMATION T ype O i e Number! Ss l� � '� Sys tem: o- 9 OR UNIT T- c,!* DISTRIBUTION SYSTEM Header/ Manifold , a Distribution Pi x Hole Size x Hole Spacing Vent To Air Intake Length - j Q� Dia. Length Dia. Spacing 3Q r 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.) Ins- ection #l: (o /(g/yo Inspection #2: Location: 430 Rice Lake Road, omer et, WI 54025 (SE 1/4 NW 1/4 9 T31N R19W) - 093119971 Lolly Acres -Lot 4 1.) Alt BM Description T� r _ A � t � 14 �S- 2.) Bldg sewer length = l 0 - amount of cover = Plan revision required? Yes No 02- 1 0 o 1 S Us �g of O e . r _ s n id for �� dditional i fo at ig(� �e T - auY SAX 3 Cert No. S13 -6710 .3/197 L�;,.��` o� a-0-. sti S "t� �s a-� 9 ati2Q, ADDITIONAL COMMENTS AND SKETCH i SANITARY PERMIT NUMBER: X € S . .... , m.t m -.W ,.. ....., a._.. .. <._.. ... . .mom..,...... . «.. s � 4 Wr j E t 9 ~4 x 8 y s 3, S 3,i i 4 - 4 i 1 T � � 4— 4 x ._ 4 x ' t I � T E , I s �{� �+-c.� 1 :� 2� RECEIVED `�� �I 51.14. cf 4" Sanitary Permit Applic tco ale y & Buildings Division �' In accord with Comm 83.21, Wis. A ode J 1.A C i 2000 201 W Wash ington O Box 302 14scons See reverse side for instructions for completi t applicati� CR X Madison, WI 53707 -7302 MM Personal information you provide may be used fo gyo dary pu TY Department of COmmerce [privacy Law, s. 15.04(1)(m)] -+v1,11Nd; F � l � ub ' pleted form to county if not state owned. Attach complete plans to the coup co only) for the system, on par es in size. State Sanitary Permit Number ❑ Check if revision to previobwfli t S E} trr I. D. Number I. Application Information - Please Print all Information Location: Property Qwne r Name Property Location 0. 1 /4tJW14,S T3 ,N,It� W Property Owne s Mailing C ss i 1 Lot Number Block Number 1 1 4 La o 4� ` v L\ ©cQd City, State - Zip Code Phone Number Sub Sion Name or CSM Number II. Type of Building: (check one) ❑ city 1 or 2 Family Dwelling - No. of Bedrooms : ❑ Village 9(fown of Public /Commercial (describe use):_ ❑ State -Owned 5O m e r Ne - st Road C C-0 Parcel Tax Numbe s) 6 p al CQ Ill. Type of ermit: Check only one box on fine A. Check box on line B if applicable A) 1. ew 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to stem System Tank Only Existing System B) Permit Number Date Issued ❑ A Sanitary Permit was previously issued IV Type of POWT System: (Check all that apply) gressurized on - pressurized In- ground ❑ Mound ❑Sand Filter ❑Constructed Wetland In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. Dispersal/Treatment Area Information: a • a 960 r<,� ma I. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation Grade Required Proposed Rate (GalsJday /sq. ft.) (Min. /inch) Elevation 6° /16 / o y9 - to VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete strutted Tanks Tanks VIII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. PI be 's Name p' t) Plumber's Sigr�a�no stain ): NIl`/N1PRS NO. Business Phone Number vSv� � erg O.S 715 Plumber's Address (Street, City, State, Zip ode) lct koFt - f �S� e. O-Q-jt� IX. County /Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps) Approved ❑ Owner Given Initial Adverse Su harge Fee) Determination I - ) , a S O X. Conditions of Approval /Reasons for Disa r val: �nrt atQ1� 2 - �, _ D Pi - II WAS Az 51 FF I 13 , , I — 4 4 I y 1 , : i I , : I 1 � I , I : t I , �— I i = : I : ! I : I I i : y 4 � ' i r ! 1 i 4 _ , --- -- — --- 1 1 , I , { i ! I , I - I ' s 1 I : 4 , i I 1 I ; i I , I i 1 I ^onsin Department of Indust '�eUOr and Human Relations Indust SOIL AND SITE EVALUATION 2 � . , Divisibn of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Page of : ✓ Attach complete site plan on paper not less than 8 1/2 x 11 Inches in size. Plan must County _ Include, but not limited to: vertical and horizontal reference point (BM), direction and ✓�/ GiC'ai X percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. # APPLICANT INFORMATION - Please print all Information Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Proper Owner / Property Location p I �G SG�I If Govt. Lot SE 1 /4 NU 1 /4,S / T21 ,N,R E(or� Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 2 5 I s T - A ✓t - s o • y , pop, s vt?p , City State Zip Code Phone Number Nearest R • Road - S > f iA V ❑ Ci Villa a Town �- SSo7s �J is ty [� �N (G ) y5 I Yi o sE� E New Construction Use: ❑ Residential /Number of bedrooms ' Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily 0 S y flow 0 9Pd Recommended design loading rate bed, gpd/ft G trench, gpd/11 Absorption area required _bed, ft /� trench, - ft Maximum design loading rate s bed, gpd/flZ • G trench, gpd/ft Recommended Infiltration surface elevation(s) _3 ft (as referred to site plan benchmark) Additional design /site cons orations ZlSE " Tit -t�G6i ! :S " �/ti°!/ 4D e4 G'p.v fp v,0e Parent material 5c5 2 C�fE TEiE� - � .tlil.K14 LS-14 r Flood plain elevation, if applicable _ ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System In Fill Holding Tank U = Unsuitable for system ❑ U L�rs' ❑ U [f ❑ U Eirs' ❑ u Cam'❑ U ❑ S P-tr SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure ry GPD /ft In. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Bounds Roots Bed , Trench O ` �D r4 • �O�l�/ Z.,tii Sli,� '► vF,e C S 2 tf , S G Ground 3 y 10 7, s YR Y y si /• 2,�, s!k nvf f �'� . S' , G elev. N 9� yo ft. 0 7 S r/e 4/ /, 4-f O se, I s - • s . G Depth to -� Ji9 - M le" 5 1� .S, OS . limiting factor Remarks: Boring # 6 0YA 3/ — Si' /, Z f iwf e 3 Ground Y 7 5 d elev. 97 1ft. s - / Oxf s s 0 4 d-t — — .7:.0 Depth to +..- -- limiting `f 3 factor 7 %Q—ln. Remarks: CST Name (Please Print) Signature Telephone No. �or3�,e >` 7�/l�3�E' /ClirT I 't7� "�.a j4 7 5- 3 Flo - �r�,S -- Address Date CST Number Private Sewage Consultants 855 O'Neil is Hudson, Wls. 54016 / ORIG s o ✓ ld�r /�" SST 11,r- r PROPERTYOWNER �' 1= Lt�S ( '�,rfi�/� SOIL DESCRIPTION REPORT P 2- Pa ge _ PARCEL I.D. # G O T 3 — tit /}- J ,y S(113,0 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boufty Roots GPD /ft In. Munsell Qu. Sz. Cont Cola Gr. Sz. Sh. Bed TWnch l 0 -7 YR 3 /. – la - FSbK nMf/2 a S 2— Z/ , 5 -` Ground 3 Ps qs 7,,5 ye f � s yl R /rv�ufe es S, G 5� Depth to i limiting factor q3 •� i Remarks: Boring # / D -� /Oy� y,� S io �/ 1 s �,� nr. z w /� f • S Ground y 7, s Y� y� s. D S �?,2 7 lo� pG ft. � � r i Depth to limiling factor Remarks: Boring# `F b,:: S CT Ground e GS it. - 9 � . S •S k/ y!� /s l f iw, vf',� — .� i Depth to = limiting factor - i Remarks: Borin g # t C- 2 Ground `3 /0 5 ,4e s! elev. ft. Depth to lim - ilin L g __ factor y — Remarks: /IPA- o/c = eon 000nio ncmrn I ...• �� 3 /, co v = f3.9- cKl�oe P�'Ts �o 13 Iry Tl'o-u S yo B 3 �P� Pd 5 SuG6E5TED Tp;eA�)cot, 6 C��E� Ri- >31 13 5 tAJ - `d? COI�N�� C L l i a. k ,,- :E (0 0 M o m 0 rC 12 CA) CX• zz m 3 0 0- CD ............ .. 7: 7 z 7. M: -� • .............. . -4 2 (.n 0 0 N 5!Z 0 r r- CL (D 0 CD cc D (C) c zr (D =T o ' C O D (0 CD X : r ( 7 - n r (0 C) CL . CD 07 c (D M -0 0 c o ti (D q c T f 0 ' G) .......... 07 0 (D 0 c ;:r fl) i 0 0 ......... : - n E3 ------------- CD 0 —(0 .............. 0 CD N -------------- ci (0 0 X 3 (D — — -] - - -- -& 0 0) x 0 - a U cr 0 :3 (D 0 a) CD c ----------- j 0 (D -.0 T 3 =!� C 0 (D 3 :3 :3 Invert 1 V— 9 0 w 4 — ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer .Mailing Address \ .L �C� .� ` �(� n''41 2- Property Address x l-�Q �C� Q C �� � 2- (Verification required from Planning Department for new construction) City /State ParcelIdentification Number L 4 0 - o m LEGAL DESCRIPTION Property Location J� ' /4, N w ' /4, Sec. �, T N -P\j_? W, Town of -Qc5n- Subdivision � `1 �e- r � ,Lot # Certified Survey Map # , Volume , Page # ( Warranty Deed # bas alp ,Volume S ,Page # a4?) Spec house ❑ yes ❑ no Lot lines identifiable 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 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 Zoning Office within 30 days of the three year expi date. Lim -C- Z 0 IGNATURE OF APPLICANT DATE bWNER 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 th p — rty y described a ve, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT 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 r JUL -12 -00 WED 09;54 AM FAX N0, P. Ol V o l. i52lna 248 ,,::a e51:2 4s-ja KA 1-1. WALSH 4 STATE BAR QP WISCONSIN FORM 2 - 1999 REGISTER OF DEEDS WAJ2RANTY UF.ED ST. CR6IX CO., WT Document Number RECEIVED FOR RECORD This Deed, made between William Ax tell � ___.,�.�• 06 -23 -2000 10:30 AN WARRANTY DEED EXEMPT PY FEE Grantor, and Robert TRANSVER A. Croodm anan Tatnara A�Coocicna husband COPY FEE: FEE: 1 44 .00 and wife — _ �. RECORDING FEE: 1 _._. -._�. PAGES: GraUl.ee. conveys s to Grantee the Grantor, for , valuable cansidcration, y County, following described Teal estate in S C roix —.. S of Wisconsin (if more spice is needed, please attach addendum): Recording Arca Name an d Return Address� Lot 4, flat of Lolly Acres in the Town of Somerset, St. Croix County, Wisconsin. 032 - 2102 .40 - 000 — parccl Identification Number (PIN) 1¢omestcad properly, This is n {} (is not) Exceptions to warranties: pascments, restrictions and rights -of -way of record, if any. Uatecl this W day of 2000 - t Willia Axtoil -- - —' — ACKNOWLEDGMENT AUTHENTICATION STATE OF WISCONSIN } Siznawfc(s) ) ss. County , �r'1J _ day of authenticated this_ of T " _.�,,._. - personally came Ucinrc ¢ 200 0 - � the above named _ — „- -•— — — — `— Witlian Axtell -- — l'MIZF S TATE WISCO — k wn to be the •rson(s) w110 e If xecuted tt►e foregoing y L l3AR OF M ' R TA �A rat i !e ged i sA not, ¢ str liethorizcd by § 7U6.06, Wis. Siats.) Pub��' - -- -- N el 0� w1s Notary Public, Z't1lS iNS'I'YZ[JM! ?N`f WAS !)RAHTI'D 13Y u lic, State of Wisconsin Attorney Q-ln - -� - "' - My Cpinmisslon is pcnnanent. (If not, slate expiration date: (Sign.1(11reg may be aulhcnticated or Acknowledged. Boll are not necess-ary. ) —. -- i,ftm °twn Prorbss my, Fond pdu� L ac, zi *Nantes ui'r ersons signing in nny enpn must bC typed or pr inied below DAR 1l 5 'WISC:ONSIN WARRANTY ItI%ED FQttMNo . 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