HomeMy WebLinkAbout036-1030-30-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
Safety s 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)]. 3$3366
Permit Holder's Name: ❑ City ❑ Village ❑ jown of: State Plan ID No.:
Stanton Townshi — �
C M E r, v.; Insp. BM Elev.: BM Description: Parcel Tax No.:
CD . O f � • 0 EST 6 "'c I 6- 1030 -30 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ` 2,S-p Benchmark 9 0 y v �eD "
X°
Dosing !`� lly•3
. -- Alt. BM �.,.,«
Aeration Bldg. Sewer a b- 90 '
rls
Holding t /Ht Inlet L
g � -� �[S•(�
TANK SETBACK INFORMATION St /Ht OutletC/A 6 - L3 If
TANK TO P/ L WELL BLDG. A ir ir I to ntake ROAD Dt Inlet - - --"
A
Septic �, ` y g� f ` r NA Dt Bottom --
K
-. _.. NA Header /Man. `
Dosing 5 9.4
Aeration ' > NA Dist. Pipe ct S LS r
Holding -° Bot. System [l.rt 93- T-1
PUMP/ SIPHON INFORMATION Final Grade
Ad i
Manufacturer - ---- - - -- —Cli7ancl °/ [ Ib .3o
St cover
Model Num er PM
TDH Lift ,.-- Friction System TD Ft
ss Head
Foryefnain Length '�° fjist. To Well ,
SOIL ABSORPTION SYSTEM r w o ( ` { e Ck 3�K�Z- ro' •�,,2,.
S&M� - TRENCH width / Length No. Of renches PI No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 Se 3 DIMENSION
SYSTEM TO P / L BLDG WELL LAKE / STREAM EACHING Manu ctur r.
SETBACK
INFORMATION TypeO r (CHAMBER M odel Numb
System: �/ �° �' 7 ° OR UNIT — mu
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size ,i x Hole Spacing 1 Vent To Air Intake
p�
Length 1fi6 Dia. � mg
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. 6q/ OV 00 Inspection #2: �
Location: 2132 200th Street, )Deer Park, WI 54007 (NF 1/4 5 131N R17W) - 13.31.17.193A
1.) Alt BM Description = j -- ie r , 0,-1
2.) Bldg sewer length
- amount of cover =
3
Plan revision required? ❑ Yes No
Use other side for additional information. 04 )C) oo
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
e.
-
I J00 t r '6afety and Buildings Division
r SANITARY PERMIT APPL ,. T h 201 W. Washington Avenue
Vbconsin - �. s� P O Box 7302
Department of Commerce In accord with Comm 83.05, Wr Madison, WI 53707 - 7302
• Attach complete plans (to the county copy only) for the systeln, pap tess County
than 8 112 x 11 inches in size.
• See reverse side for instructions for completing this applica�io'c �ti� -: State Sanitary Permit Number
L ✓"
Personal information you provide may be used for secondary purposes " ` i G�,v r ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. X71
Ord ?_Y State P(an I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL I O
Property Owner Name rtyoca
I.tJa i T3 ,N,RI� E(or)45
Property Owner's MailinVddress Lot Num Block N umber
/ 3 z ;?,60 s 7 — �
Ot , State Zip Code Phone Number Subdivision Name or CSM Number
•ter A. /C 5 (7/r LZG9 -S.Z95
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ it _ Nearest Road
Vile
El Public 1 or 2 Family Dwelling - No. of bedrooms O jq Town OF 5 74n /O ;zoo i 7'
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) t jt A
1 C] Apartment/ Condo 3 (, - /D -? o l - 3 C) . Oa O
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_ ,g� 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 f5] Seepage Trench 22 ❑ In -Grou d Pressure _ 4 - 42 ❑ Pit Privy
13 ❑ Seepage Pit .L 3 Z & 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION 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. /inch) T Elevation
(p00 1 /O ad o /"r 14 60 — `/ . y Feet 7% 39_�Feet
Cap acity
VII. TANK in Ca allo s Total # of Prefab. Site Fiber- Exper-
INFORMATION g Gallons Tanks Manufacturer s Name Concrete Con- Steel glass Plastic App
New Existing strutted
T nks Tanks
eptic Tank r Holding Tank 0 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber El 1:1 1:1 1:1 ❑ 1:1
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage s stem shown on the attached plans.
Plumber's Name: (Print) Plu is Signature: o Stamps) M R o.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code) -
,> /4b S r ;4/1 e & S5�cx�
IX. COUNTY / DEPARTMENT USE ONL
❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate Issued Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee)
� 4
� °
Adverse Determination � `� 26o
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
I) k PEA- ca-Q _ .
S
BD -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 licensecrpumper 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 the legal description and parcel tax number(s) of where the
system is to be installed.
II. 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
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.
1
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 Ooints; Q 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) 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.
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T z i nsin Department of Commerce SOIL AND SITE EVALUATION
n pf S and Buildings Page l oft
Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code
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
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
Via- / 0 30
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)).
Property Owner Property Location
C' Govt. Lot & 1 /4SE-� 1/4,S /� T ,N,R / 7 E (oC-)
Property ner's Mailing Address Lot # Block # Subd. Name or CSM#
1 Z a oa Sr
L State Zip Code Phone Number ❑ City ❑ Village -91 Town Nearest Road
k/.T I XY oo 7 1 P /x' X69 -sz s S7nn7os, 1 boa ST'
❑ New Construction Use: E •Residential / Number of bedrooms Addition to existing building
(� Replacement ❑ Public or commercial - Describe:
Code derived daily flow 60 gpd Recommended design loading rate i S bed, gpd /fi b trench, gpd /ft
Absorption area required /aO® bed, ft /000 trench, ft Maximum design loading rate r S bed, gpd /f1 trench, gpd /ft
Recommended infiltration surface elevation(s) 7'y. y ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material ca A n d
Flood plain elevation, if applicable It
F�nsuitable uitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holdinn
for system RS El U �} S ❑ U ®-s El El s 2 ❑ S Eau E:1 S
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
2 -92. ,._nes/3 i4 AK mecte a ; .
Ground �- / — f Ale
elev.
9 ° I.3s" ft .
Depth to
limiting 57 - ,
factor
in.
Remarks:
Boring #
oc
m d4e m
q 7
Ground
elev.
Depth to
limiting C -;
factor
79 in. Remarks:
CST Name (Please Print) gnature Telephone No.
/7m cs
7I 265"' 37
Address Date CST Number
� _ J
SOIL DESCRIPTION REPORT
PROPERTY OWNER Page - of
. I
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Structure 2
Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed . Trench
•� `/ J 3��d -r SSG ��s4 M!/F.i? GkJ
Ground 3 R b7 rS �j _ /h L -� ��
elev. / � / �
Depth to
limiting 5
factor
IO�in.
Remarks:
Boring #
b -Io )s 1hkF ak> /r, .Z ; .,
2 0- z sW? 3/'/ L°2p 6 S'L I"
Ground S
elev. '�
7
Depth to
_
limiting
factor
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 #
Ground
elev.
ft.
Depth to
limiting
factor
' Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
SBD -8330 (R. 07/96)
E.
N 6 S 13 T3 A/4 /7 w
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ST CROIX COUNTI
SEPTIC TANK MAINTENANCE A OREEMENT
AND
OWNERSHIP CERTIFICATIO, -1 FORM
Owner/Buyer _U 11/r 4 r ,. LA.l Z 2 A S n
r
Mailing Address 2/ 3 Z aaa
Property Address- -L
(Verification required from Planning Department for new .;onstruction)
City /State 0-0-4, 1 /A S'"/dd'7 Parcel Identification Nui rtber _ 3 - /d 10 3 d - mo®
LJGAL DESCRIPTION
Property Location M E A, 5L '/-,Sec. � T ,? I N -R / ? , W, Town of S74_4 % ,n
Subdivision , Lot #
Certified Survey Map # , Volume 4 *_%NG- , Page # <
Warranty Deed # - �"c�S'_5� 3 , Volume 1 d 2 ,Page #
Spec house 0 yes ❑ no Lot lines identi; *)able 0 yes ❑ no
SYSTEM MAINTE
Improper use and maintenance of your septic system could result in its pro nature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed b a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste dispa al system.
The property owner agrees to submit to St. Croix Zoning Department t certification form, signed b the ow ga y r and by a
master lumber, journeyman p > J ytrtan plumber, restrictedplumber or alicensed pumper ven lying that (1) the on -site wastewater disposal syst
is in ro er operating condition
p p and/or (2) after inspection and pumping (if aeces .a the se ptic tank '
ry)� P is less than 1J3 tirll of slud
Uwe, the undersigned have read the above requirements and agree to maintain th( private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of N �itursl Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be c ompleted leted and return
- d to the St. Croix County Zoning Office within 30
days of the three year expiration date.
"2 .3 /2.
SIGNATURE OF APPLICANT DATE
QWNER CE RT ICATION
I (we) certify that all statements on this form are true to the best of my I our) knowledge. I (we) am (are) the owner(s) of
the property described above, 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 referenc - is made in the warranty deed
5itr4 r*r:,air .: detjr:'. .. .. s. � ..
is si-
VOL PAfE`�
'550553 State Bar of Wisconsin Form 5 — 19t2
PERSONAL REPRESENTATIVE'S DEED i -
i AF * WTTE E R S GiFiCE k o
,., DOCUMENT NO
s — Vivian J Wildasin - ' OCT, 1996
I;
__ as Personal Representative of the estate of Bt� ��M
Mar or R. Hily
i
Rrlstw of DOE&
for a valuable consideration conveys, without warranty, to Viv J
V Wil a
4 I;
THIS SPACE RESERVED POR RECO IDIND DATA
Grantee, j I NAME AND RETURN ADDRESS
4 . the following described real estate in St. Croix County,
State of Wisconsin (hereinafter called the "Property "): REINSTFA b VAN DYK, S.C.
i 201 South Knowles Avenue
New Richmond, Wisconsin 54017
it
u
036-1030-30
(Parcel Identification Number) _ — ._-- - - -..
South Half of Northeast Quarter of Southeast Quarter (Sj of NEI of SED of
Section Thirteen (13), in Township Number Thirty -one (31) North, of Range
Number Seventeen (17) West.
. TY.
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MPT
I
1
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' Personal Representative by this deed does convey to Grantee all of the estate and interest in the Property which the Decedent had immediately
prior to Decedent's death, and all of the estate and inter%t t' the Property which th Perso leprescritative has since acquired.
t�� jam. II
11 Q-
li Gated this da y of
!i
I
I, �I
(SEAL) _. (SEAL) j
— y
• Vivian J Wildasin • !{
., .I Personal Representative Personal Representative .i
I� JJ
AUTHENTICATION ACKNOWLEDGMENT
�P + ' Vivian J. Wildasin STATE OF WISCONSIN i
Signatures) ..
l
County.
�i S tem r Ig 96 Personally day of
authentica this 30 day of Y came before me this
19_ the above nan. A `
Hend rik W. Van D k
II t<
+" TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by §706.06, Wis. Slats.) to me known to be the person who executed the
�I foregoing instrument and acknowledge the same.
a2 ii THIS INSTRUMENT WAS DRAFTED BY d
�
REINSTRA & VAN DYK, S.C.
— 201 Suut2>- Knowles' Avenue - _ -
w
Rchmo*td 54 017 Notary Public ____ -- _ . County, Wis. I!
!i (Signatures may be authenticated or acknowledged. Both are not My commissicD is permananr,. (If not, state expiration date:
; necessary.)
'Names i4 persons signing in any capacity should he typed or primed nelow their signatum.
PERSONAL REI'RfiENTATIVE'S DEED STATE S.AR OF .. iaCONSIN Wisconsin legal 6i3nk :.0., Inc.
FORM %. - S — 1982 Muwaukee, Wis. ('"'
P. , ....rte.. s- ;;its_ : r® �.: tg. r�,,. �.x:rs. ^:+�sa+reE?��'lp"e.Rt4" "�: #*' s �•_, ��,`:�'�T'V :�:.?i;..� ak 5 ;.'�:.. � �.a.:tbit., �pG$.'.!� ° �?'1ii,
:_� .:.'fiw.,.