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HomeMy WebLinkAbout032-1031-50-400 - ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner Property Address ` City /State Sn m o l 7 s Ss4 c)Q =, Legal Description: Lot _ Block A)P� Subdivision/CSM # C S pn S S R 3 7-/ vD 1 /a N 4, Sec. JL, TAN -R�W, Town of So 4,. gr s,�' PIN # c7 SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC 0 Setback from: House g Well P/L Pump manufacturer Model Alarm location (HOLDING TANS ONLY) Setbacks: Service ro Vent to fresh air intake --� ater Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: lr-e-nc Width 3 Length 5:� Number of Trenches o2 Setback from: House 2_ Well Qj� P/L - 3 0 Vent to fresh air intake / ELEVATIONS LO Cw►�a �. ,S`kt � Elevation a a / Description of benchmark N �— Description of alternate benchmark Elevation Building Sewer — ST/HT Inlet /4 3� 6 fe ST Outlet a3, 3 ' - PC Inlet --- PC Bottom Header/Manifold /b3. Top of ST/PC Manhole Cover Distribution Lines (1) d 3, /,� (Z) 0 - 7 ` Bottom of System ( {) r 0% (�) /© Final Grade o) 4 ` 105.1 f ( ) Date of installation Y / Y)w Permi mber 3- 5529 State plan number Plumber's signature License number -).>0557 Date Inspector Complete plot plan Or f NOTICE Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. �3 y� ( PLAN VIEW oZ�� D e" %- co V N ° b KATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count y Safety and Buildings Division 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)). 353294 Permit Holder's Name: ❑ City ❑ Village ❑ Tbwn of: State Plan ID No.: Janse Bernell I Somerset Township CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: � jou. & I To 6* S", 032 - 1031 -50 -400 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic �fl Benchmark 3, Z 13.7 D p , D _ I Dosing \� Alt. BM �- 3� oS•$ Aeration Bldg. Sewer Holding St /Ht Inlet 7, 6y TANK SETBACK INFORMATION St/ Ht Outlet c� q 1o3.29' TANK TO P/ L WELL BLDG. Air I ntake ROAD Dt Inlet Air Septic > lQp' a} NA Dt Bottom Dosing NA Header /Ma (o.rs 03•lo' Aeration a NA Dist. Pipe I ' ' ° l°36 S (0,20 ,o Holding ot. System 5"Z ' 9 Y , ,S3 O � , � PUMP/ SIPHON INFORMATION Final Grade Manufactur Demand St cover 8. p q. I D Model Number GPM TDH Lift Lriction m TDH Ft SS Forcemain Dia. Dist. To well SOIL ABSORPTION SYSTEM jc-1LQ__S Bf-W TRENCH Width / Length � o No O Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIME �J S DIMENSI SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING INFORMATION Type O CHAMBER a Rum er: System: OR UNIT Hj _ a DISTRIBUTION SYSTEM Header / M ni old Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing - 1- 1 O Z / 14 SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only s z Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes El No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: &t /oS/ Ov Inspection #2: / / Location: 606 Lakeside Lane, S merset, Wl 54025 (SW1 /4 NW 1/4 11 T31N R19W) - 11.31.19.150D -Lot 4 1.) Alt BM Description = - Twf t =^^�°" a oi.. - 2.) Bldg sewer length= 7,1 ` - amount of cover = ►{3 t, S­j c Plan revision required? ❑ Yes R1 No Use other side for additional information. 03 1 1 6 o l SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH ' SANITARY PERMIT NUMBER: a I P 3 a , , _ 3 E F � I � i Safety and Buildings Division A scons i n SANITARY PERMIT APPLICATION 201 W. Washington Avenue P O Box 7302 Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less county than 81/2 x 11 inches in size. kr t • See reverse side for instructions for completing this application State Sanitary Permit Number 35 c9 �4 Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLI ATION INFORMATION -PLEASE PRINT ALL INF RMATI N Prop y0`ror�2jTe G, P S1, 4 /4, S 1I T 3 1 , N, R 1 E-(%r W Pr Owner's M ail Ad ress Lot Number Block Nurpber City, State Zip Code Phone Number Subdivision Name or CSM Number c ) ,S 3 7 11 3 II. P BUILDING: (check one) ❑ State Owned itia Nearest Road vil Public 1 or 2 Family Dwelling - No. of bedrooms Town OF S l at III BUILDIN USE: (If building type is public, check all that apply) arcel Tax Number(s) 11 92 - M 1 ❑ Apartment/ Condo I O 3 01 —) 03 1 —sro — ({p J 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. gNew 2 E] 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 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 [gSeepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill S VI. ABSORP SYMM 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. .) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min. /inch) O/ d Elevation 5c7 SIp3 .�— / ' D Feet /0 Feet VII TANK in Capacit gallon Total # Of r Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete con Steel glass Plastic App New Existing structed T nks Tanks ' Septic Tank or Holding Tank 1 00 O � l,(,9 r S ❑ 1:1 El 1:1 11 Lift Pump Tank /Siphon Chamber ❑ 11 11 ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (P t) Plumber's Si at e: ( o Stamps) MP /MPRSW No.: Business Phone Number: �s D S 3 7!S S Plumber's Address (Street, Cit , State ip Code): 1.12S� IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved S nitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination�� X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R. 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 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 Wisconsin, Safety and Buildings 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 installed. 11- 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 manufa(turer'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 1'1 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with compfete 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 tKe "county; E7 soil test data on a 115 form; and F) all sizing information. ----------------------------------------------------------------------------------------------------- GROUNDWATER SURfHAtGE 1983 Wisconsi n Act 410 included the creation of surcharges (fees) f6r.,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. Frh JCAotspVN SW�� NWY l IV KC � Z't f ac 5 Sorv.e"s�e ca D �O 5 ; Sz. C a r slmriv ov W Wisconsin Department of Industry _ .._ ' SOIL AND SITE EVALUATION Labor and Human Relations '` Y! " Page of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper n IQS than A�jf;¢�N1 Zhes in size: +Plan must County include, but not limited to: vertical a zontal reference point BM), direction and per slope, scale or dimensions, arroy pTj lo„patiorll distance to nearest road. parcel I.D. # ft� ck — �r0 APPLICANT INFORMATION - k 4 epri, s Wmat ion. Reviewed by Date Personal information you provide may be us a`ry purp riY> , S. 15.04 (t) (m))• —2-(—OD Property ner 9 j t Property Location 77�- / Govt. Lot 1/4 1 /4,S T ,N,R (or)ffl Property Owner's Mailing Address Lot # lock B Subd. Name or CSM# 7 d•) City j State Zip Code Phone Number Nearest Road ❑ C ity El Village Town ( ) - f J EZ New Construction Use: E4 Residential/ Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow (, 'ee:PO gpd Recommended design loading rate gy bed, gpd trench, gpd /ft Absorption area required _� bed, ft ft Maximum design loading rate bed, gpd/ft trench, gpd/ft Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design /site considerations�� Parent material 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 S❑ U ®S ❑ U S❑ U �fl S ❑ U ❑ S O U [:]S V U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft Texture Consistence Boundary Roots , / in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 7 Ground elev. _ ft. Depth to limiting 101 ; facto in. 0 Remarks: Boring # 3 L Ground — — — elev. :z Depth to limiting fact r 6 in. Remarks: CST Name (PI as rint) Signature Telephone No. Address D to CST Number 3 p SOIL DESCRIPTION REPORT PROPERTY OWNER Page .1:2 of PARCEL I.D.# Boris # Horizon Depth Dominant Color Mottles Structure 2 Boring in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench ti Ground elev. / Depth to limiting ; fac o � 7 Remarks: Boring # JV 4Z , 7 . D - Ground elev. Depth to limiting factor CL� in. Remarks: Horizon Depth Dominant Color Mottles Structure p Texture Consistence Boundary Soots GPD /ft2 in. Munsell Qu. Sz. Cont. Gr. Sz. Sh. Bed , Trench Boring # J S S - 7 _ Ground elev ^ /iz ft• G Depth to limiting M facto n. Remarks: Boring # i Ground elev. ft. Depth to limiting factor 'n ' Remarks: SBDW -8330 (R. 08/95) O c .�f e . 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'.O .. o t t O !, .N o m< w m v - OL'ShL 3u00�S£o00N co `� `� 00 LJ 0 C. ri w � m �OL'SLL l00' l9£ I U) Q. _ L �I c LLJ U p W �I Z t 1� N In C:> • in 00 C x ° // I � t m I— o _r J a 4-4 �� L .•- LJ- N O W L e- co C Q Q o z{ O c c 4 u L o 00 }..I U u Z p U 04 4J Ztn 8 �£h'£LL IiOM£o00N 3C V) I£h I � 00'SZ£ , LL'$Zs — � i86*bZ£l p ,LZ'S8£ '00'l9£ b J all 31100 1 r t LZ' 9tL 3U0� 1 S£p00N t0 _ 3110 MOON 7 £ o 0 Q) U b/I MN 3H.L 30 3NP7 1S3M � a, I. � II H• l � � U � a 0 o,.. ! V.dNn c o cd v� s U c c Y s > o .. E E5 s CO x CD cn rJ O C O N Q yr >. O U Q _ i E ro a co N �{ 9 N X_- 3, U N cu Qn rV7 i v) , N E O O (dv�.Q {+'U Co J O o:3 V d � a = c C U- U U -p �- O) CD +. c -q- c _ t �s Y7 MJ CD N O N �� d • • • • LO 3� e N ® ro _ ®Z 3 oLL „s o L C M CS ^ _ u n .Y.L • a • s a. U o o -` � W � „s S ` ° a o V ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 'E jL WG: L l.. G. �p til S�y.9 Mailing Address , �--Z [q AN1e 5 0 M�'TL SET W S + Z 5 60 40 Property Address 4 �. -a1cS t D E tJ c (Verification requir from Planning Department for new construction) City /State M , `t` �� Parcel Identification Number LEGAL DESCRIPTION Property Location :5u '/4, N%-j '/4, Sec. 11 , T 3i1 N -R Q Town of 0M'M 5 � - Subdivision Lot # Certified Survey Map # S S S 374 , Volume J , Page # 3-2 Warranty Deed # S 81 S S Volume 3 S . Page # "Z1 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 dayar expiratio dat s the three ye e. 6 7 ` of / /r /b SIGNATURE OF APPLICANT 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 p perty desc 'bed above, by virtue of a warranty deed recorded in Register of Deeds Office. �r • 00 // 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 II I / C-0114 ' psry Ii r; r 5 0 158 it STATE BAR OF WISCONSIN FORM 2 — 1982 WARRANTY DEED !I DOCUMENT NO. VOL 11,59, PAU?79 I f II h E Plmrde a/k/a Joseph F. Plourde i REGISTER'S OFFICE i by Vincent Plourde under Power of Attor ST. CROIX CO.. WI NNNr'a for Itwirrd recorded in Vol. 1255, Page 616, as Doc. No. i 563426 SEP 2 3 1998 II and warrants to- e>iC1_ell G.- Jansen- and- Kathleen_ M:_ 3d 9�' - �kfi � Jansen n . hu sband and wi as survivorshiR marital ji g i -D Qm ty i.. Of o.6& THIS SPACE RESERVED FOR RECORDING DATA I i ''NAME AND RETURN ADDRESS the following described Tea( estate in St. Croix County, State of Wisconsin: I KRISTINA OGLAND Zilz, Estrcen & Ogland P.O. Box 359 j' ii Hudson, WI 54016 032-1031-50—M it I, PARCEL IDENTIFICATION NUMBER I i I II 1 Part of the SW's of NWh of Section 11, Township 31 North, Range 19 West, St- •i Croix County, Wisconsin described as follows: Lot 4 of Certified Survey Map filed April 24, 1997 in Vol. 11, page 3243, Doc. No. 558374. 1 1, (f T RANSFER f i� This homestead property. y (is) (is rat) Exception to warranties: Easements, restrictions and rights -of -way of record, if any. !; , Dated.this. I_ ( 00''` day.of September 98 If �i (SEAL) / L) II • Joseph E. Plourde aka Joseph F. P lourde f! (SEAL) by John Vinfent Plourde under (S Power!! • 1255, vane 616 as Doc. No. 563426' jj AUTHENTICATION ACKNOWLEDGMENT j John Vincent Plourde, POA, for Signature(s) JaSenh F.. Plourde aka Joseph_ State of Wisconsin, ss. j F. Plourde County. , �! authenticated this 1 day of September , 19 98 Personatl came before me this day of 19_, the above named ii Krishna Ogland I, TITLE: MEMBER STATE BAR OF WISCONSIN jI (If not, authorized by $706.06, Ws. Stats.) to me known to be the person who executed the foregoing instrument and acknowledge the same. '• THIS INSTRUMENT WAS DRAFTED BY ii Atteirney Krictiraa Orland !' Hudson, Wr 5401$ Notary Public, County, Wis. (Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (if not, state expiration date: l i necessary.) 19 ) ' Namcs of persnns signing in any apnny should by Iyycd or printed below Iheir signatures. STATE BAR OF WISCONSIN W°O0^s^ Uval BIN* Co_ Yie WARRANTY DEED Form No. 2 - 1982 MWyrsM W& UNPLg TED L PIDS' Cn r 00 C•T H. 11 ( 11 E T E OF THE Nw 1/4 (D rt N00 °35'00 "E O ¢' N00 °35'00 "E °, N00 °35'00 "E 746.27' t rt �; - 361.00' 385 — 1324.98' � ♦ � -- -x$'71 ' 385.43' I U� 328.00 I w N00 035100 "E 8 713.43' 8 0 ;t CU Ct Co I e 0 0 p .R .� O i0 F 1� O ,�,' ly n x rt o I —I 0 m 4r -4 1171 0 OD 7 IC rt V4 3� 33' k ar• 00 p O G oo' m 0 328.00' 387.70' 1 w r a w r a O (p Cn 361.00' 715.70' '. 'aNO I g rn C7 0° " N00 °35'00 "E 748.70' o w � n o n � o �i• 10 a W00 H r pl - - N CT a _ w �. r. a o F.. g .. , w w m 4r -4 . M - 716.92 —33.00' ' i =' w v w 0 C CI c N00 0 35'00 "E 749.92' a r0 Co ;, W Ct Ct Ct ft 6-4 ,... .. 0 m n` rt Cn n ::r C N l l - w N a a (D X � �. CAI M Co ° I rn o Ln 1.1 a -• a r -< N n O I V / - lJ1 '7 N -1 v 3 W OD Ct X e 7 � I rt e m y n J� 0 W 0 w Ir- Iz �w D ; 0 W ' o - v' -4 j 0 1'h Co OD •G V Y 3 -- - OD O Cn . OD v CD - 33.01' 720.54' N -mi S00 ° 25'22 "W 753.55' i z m �^ L� R'CZL IN V. 598, PG. 531 0 x M a o� O �. m 7 C O V W O ttt . o O C• 2 7• t<DD ~ 1 O N 7 C w Ct N tAi'r 0 �'� C C A lY C acao � �o , ° Bearings are referenced to the z O o y west line of the NW4 of Section � M Ct a 11, assumed to bear N00 ° 35'00 "E. J o Y O o a c Ln f M o • C it