HomeMy WebLinkAbout032-2117-00-000 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)]. 363869
Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State Plan ID No.:
McAlpine, Pat I Somerset Township
CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.:
�t Im , &. w► oa� W¢Q� W / 032 - 2117 -00 -000
TANK INFORMATION ELEVATION DATA �y �/• 9` / 70
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic �� Benchmark , �,� Ol3 .O e
Dosi ng Alt. BM b qq, I
Aeration Bldg. Sewer 5: 3 0 %-as- l
Holding St /Ht Inlet g q2. F0
TANK SETBAC NFORMATION St/ Ht Outlet e- - fg
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic 75 a�- f NA Dt Bottom
Dosing NA Header/ Man. ct, 2- X2.2 f
Aeration NA Dist. Pipe to 2, z�
r
Holding Bot. System to 116 � I ' l
�
PUMP/ PHON INFORMATION Final Grade
7f'8 0 1 3- sS'
Manufacturer emand St cover N 3. SS
Model Nu GPM
TDH Lift Lricti S stem TDH Ft
o
Forcemain gth Dia. Dist. To
SOIL,k60RPTI0 N SYSTEM C
TRENC Width ( Length N f nches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN • 2� DIMEN I N
LEACHING nyr ur r:
SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM
INFORMATION Type Of , _ CHAMBER Mo el Num er:
System: 09M4J 0 OR UNIT -1 O
DISTRIBUTION SYSTEM
Header/ anifold it Distribution Pipes) x Hole Size x Hole Spacing Vent To Air Intake
Lengt Dia. L Spacing 7
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over of Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched boll
Bed /Trench Center # Bed / Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: Off 0 /ap Inspection #2: �---f
Location: 2158 59th Street Somerset, WI 54025 (SW 1/4 NE 1/4 15 T31N R19W) - 15.31.19.1070 Shadow Pines -Lot 13
1.) Alt BM Description )fs-VIK . + t7-
2.) Bldg sewer length = 30 ` i r
- amount of cover = 36 u + - , Z
w
M" i 3� w cam•
Plan revision required? ❑ Yes &I No n 1 4�
Use other side for additional information. 05- vo ,?
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 W. Washington Avenue
Vsconsin P 0 Box 7302
Department of Commerce In accord with Comm 83.0 o Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the , on
1' pa r riot Iesj county�� „r� l -�
than 8 1/2 x 11 inches in size. �r
_E1l D
• See reverse side for instructions for completing this a p`Tiation $tate Sanitary Permit Number
x 3�0 FSCO
Personal information you provide may be used for secondary purpose r s - 211 Check if revision to previous appii tion
(Privacy Law, s. 15.04 (1) (m)]. „_. ST G901X ate Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT N QN �` l
Property Owner Name r y a
N Lv1 /� , S /S T .3l , N, R E (or)o
Property Owner's Mali g Address =' u�rl a Block Nu mber
City, tat� / Zip Code Phone Number Subdivision Name or CS y Number
T YPE OF BUILDING: (check one) ❑ State Owned - v lag a „., ����� Nearest Roams !
Public 1 or 2 Family Dwelling - No. of bedrooms own of f9 r>�
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 4 5.31. / /C7t)
C} 3Z- a117- 6q = �d 6
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. ,� 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
11 ❑ Seepage Bed 21 []Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12,1�j Seepage Trench // , ape, ❑ In- Ground Pressur , 42 ❑ Pit Privy
13 [] Seepage Pit 61 .8,j-4+- 3 , x C—' 43 ❑ Vault Privy
14 ❑ System- In- Fill� , �fiCa7a . d <� s ? 3 x 7 - %
VI. ABSORPT 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/da /sq. ft.) (Min_ Elevation
yJ 3 7 7-- q / Feet 9j d Feet
VII Cap acit y
TANK in allo
g Total # of r Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete con Steel glass Plastic App
New Existing structed
Tanks Tanks
ptic Ta or Holding Tank Oro 0 dl� ❑ El El 1:1 ❑
Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑
VI11. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
umber's Name: (Print) Plumber's Signature: ( Stamps) MP/ PRS o.: Business Phone Number:
14 j um¢ r sA dress (Street, City, State, Zip Code): U 41
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater r / ?/Z006 te issued Issuing A nt Signature (No Stamps)
ff ' Approved ❑Owner Given Initial _ vim Surcharge Fee)
Adverse Determination I�aJ /f eb
X OF APPROVAL / REASONS FOR DISAPPROVAL: — 7 f Q " .0 _.K C 8{,,, �yl Q��
r" bOVV�'� �� y �n'Pi G rr ltJ /l�1 � � ►'�J eGZSGWL21V['S . It
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SBD -6398 (R. 4/99) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
WSTRUCIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be 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:
I. Property owner's name and mailing address. Provide thelegal description and parcel tax number(s) of where the
system is to be installed.
IL Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
111. 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 1/2 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 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.
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GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) fora 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.
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ksconsim Department of Commerce SOIL AND SITE EVALUATION
Df Ision 6 and Buildings Page 1 of 3
Bureau of Integrated Services in accordance with s. ILH - 83:Os3„JNis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in si , PI,r1'must' Co ty
include, but not limited to: vertical and horizontal reference point (BM) der @coon aid St . Croix
percent slope, scale or dimensions, north arrow, and location and dis
p rovide may y p y to neart3st coal _ _ Parcel D. # D03 Z _ ZI 17 „ 00— QQ
TT5 , s�1C. /
APPLICANT INFORMATION - Please print all infor &in =- Reviewed y vat
Personal information y ou be used for secondary (
rypurposes Privac t�v s. 15.04(i
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Property Owner
Richard Stout uL Lot SInL 1 NE 1/4 T 31 N,R 19 E (A)XV
Property Owner's Mailing Address f2 l9ck ' [ Subd. Name or CSM#
1353 Awatukee Trail 13 Shadow Pines
City State Zip Code Phone Number ❑ City :1 ty Village ❑X Town Nearest Road
Hudson fqi P4016 (715 )549 -6731 Somerset 160th Street
[2 New Construction Use: Residential / Number of bedrooms 4 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 6 gpd Recommended design loading rate ' 7 bed, gpd /ft • 8 trench, gpd/ft
Absorption area required 8 5 8 bed, ft 7 5 0 trench, ft 2 .7 8
Max' �up�e,�ign loading rate bed, gpd /ft • trench, gpd /ft
Recommended infiltration surface elevation(s) See plot pla� / / UU � — ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material CoC2 Flood plain elevation, if applicable ft
System in Fill Holding Tank
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade
U = Unsuitable for system 1:3 S E] U [IS ❑ U [2 S ❑ U ® S [__1 U ❑ S ®U ❑ S W U
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD /ft
g Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
....1. 1 0 -5 1 Oyr2 /1 -- sil 2 MA mfr cs if . 5 � .6
2 5 - 1 0yr3 /6 -- is 2 mA_,C� ; mfr cs -- . 7 , .8
Ground 3 27-E5 10yr4/6 -- ms osg ml cs -- .7 .8
elev.
95
Depth to
limiting
factor
85 in.
Remarks:
Boring #
1 0 -4 1 0yr2 /1 -- sil 2 r'ybt� mfr cs if .5 ;.6
2 2 4-42 1 0yr3 /6 -- is 2 rrlA -aK mfr cs -- .7 ; . 8
3 42-El 10yr4/6 -- ms osg ml cs -- .7 .8
Ground
93 . 10 ft.
Depth to
limiting
factor
81 in. Remarks:
CST Name (Please Print) Signature Telephone No.
Address Date CST Number
sc, c
PROPERTYOWNER Richard Stout _ SOIL DESCRIPTION REPORT Page 2 _.o 3�
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
3 1 0 -4 1Oyr2/1 -- sil 2yy, mfr cs 1f .5'.6
2 4-23 10yr3/6 -- is 2mPek mfr cs -- .7;.8
Ground 3 25-83 10yr4/6 -- ms osg ml cs -- .7 .8
elev.
94
Depth to
limiting
factor
83 in.
Remarks:
Boring #
1 0 -2 10 r2 1
4 2 2 -15 10yr3/6 1S 2 mqb K mfr cs -- .7 .8
3 15 -89 10yr4/5 TIS osg ml cs -- .7
Ground
elev.
95 .50 ft. yS ` 7 _a
Depth to
limiting
factor
8 9 in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # 1 0 -2 10 r2 1 -- it
2 2 -1 3 1 Oyr3 /6 -- s 2 rn615 mfr cs -- .7 ;.8
SMIM 3 13-90 10yr4/6 -- s osg ml cs -- .7 ;.8
Ground
elev.
94 ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R. 07/96)
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ST CROIh COUNTY
SEPTIC 'ANK MAJNTf N ANCE AGREEMENT
AND
OWP CERTIFICATION FORM
Owner/Buyer q�tT—
Mailing Address SO
Propet•ty Address
(Verifiaatiou required frov i Planning Dopartrnent for new construction) — • T
D 32 - Zl 17 00 —000 City /Statc ` � _ parcel Identification Number
S � ( � 1 �I _ 1 � - ZO _...._
L EGAL DESCRIPTIO
Propaty Locatiows'63 '/4, A� ' /,, Si C. T �? � t }�,�. W Town of t � �
Subdivision � L� - M — - -- , L-ot #
Certified Survey Map # Volume pagc # M __
W arr anty Deed # (0; 1 co Volume � � Page # _3
Spec house ❑ yes A no Lot lines identifiable X yes ❑ no
SYSTEM MAUq ENANCE
Improper we and maintenanceof your sel pc system could result in its premature failure to handle wastes. Proper malinte -nance
consists of pumping out the septic tank every thrt a years or sooner, if tteadod by a licensed pumper. What you put into the system
ran af'cct rile fumcdon of the peptic tank as a trai 4nent stage in the waste disposal system.
'rho property owner agrees to mbrruit to Ste Croix Zoning Degattsncut a cartifloation form, signed by the tr mcr and by a
master plumbor, jouxneymanplumber, restrictedpl. mnberor a licetutApumperve ifying that (1) the on - site wastewater disposal system
is in proper opera ft condition and/or (2) after in:' ection "d pumping (if ueees sary), the selstic ta»lr is We than 1/3 full of sludge.
]Uwe, the undersigned have read the above requires I nents and agxac to maintain the private sewage disposal system with the standards
set forth. herein, as set by the Depa ent of Cain omce said the Departsuotit of Natural ResourtaA, Sttto of Wisoonsln CFttiftcation
st4ting that your s tic system teas n maintainer I nuat be completed aad ratrtrnod to the St. Ctotk County Zoning OfFioe tri win 30
days et t a expiratio date.
/ ZS,�oo
sIGNATURB OF P1, wr DATE
OW NER CE C TA ION
(A ce that all statem is on this : irm are tme to th e best of my (our) knowledge. T ( we) am (are) the owners) of
the p p 9.5C d ve, by vi �fic of a warra lty deed recorded io Register of Deeds Office.
- 4S
S I GN ATURE O F A.P� _1'C__ _2_ - DATE
Any information that is mis- represented it ay result in the sanitary permit being revoked by the Zoning Department.
*' Include with this application- a stamped wan Ittty deed from Oic Register of .Deeds off, ice
a copy of the a rtifued survey inap if reference is ,Wade in the wgnauty deed
STATEBAR OF WISCONSIN FORM 2 1998 • 621633
WARRANTY DEED K ATHLEEN H. WALSH
REGISTER OF DEEDS
Document Number
Vo 1504 PAGE 356 ST. CROIX CO., WI
RECEIVED FOR RECORD
This Deed made between RTC'14ARD C) RTnJJT and 04 - 24 -2000 9: AM
JANET P STOUT, h Shand and wi fe
WARRANTY DEED
Grantor, EXEMPT N
-- CERT COPY FEE:
and PATRICK T140MAS MCAT PTNE andARLENE M COPY FEE:
McALPINE, husband — and — wife- TRANSFER FEE: 158.70 , RECORDING FEE: 10.00
PAGES: 1
Grantee.
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate in St. Croix County, State of Wisconsin:
Lot 13, Plat of Shadow Pines, Town of Recording Area
Somerset, St. Croix County, Wisconsin. Name and Return Address
,4 �114- 7�-
This lot shares a joint driveway along the
common Lot line with Lot 14 as shown on the
plat.
032 - 1042 - 50;032- 1042 -10
032 - 104 30- 00011O42 -40 -0 00;
Parcel Identification Number (PIN)
This is not homestead property.
(is) (is not)
i
Exceptions to warranties: easements, restrictions, rights -of -way and covenants
of record.
Dated this 21st day of April 2000
ant by:,E(,7,iNA REALTY HUDSON WISCONSIN 715 386 1502; 04/26/00 10:40; j tL& #430;Page 3/3
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