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HomeMy WebLinkAbout038-1192-70-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Coun Safety and Buildings Division �t. Croix INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitallc� &rr,�,itNo -: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 3J 3y1 Permit Holder's Name: ❑ City I illa ❑ o of: State Plan ID No.: urch, David y Sta r raine ownship CST BM Elev.:- Insp. BM Elev.: BM Description: ParceLta�c n,92 -70 -000 a v /00 UU SS 22SS 1 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic v Benchmark Alt. _ --- - -- - Aer -atiGn Bldg. Sewer Z 7 G Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. ventto ROAD D Airplae Septic A/ �3 Z3 / NA ottom —� Doong- - -- NA Header / Man. a � 3 Aerati Dist. Pipe -r I T olding Bot. System « C .L PUMP/ SIPHON INFORMATION Final Grade �� 9 St cover Model Number _ GPM TDH Lift Friction estem TDH F oss Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM s BED / T NCH Width Len th No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth D I EN 3� S . ?, .5 1 Z- I DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manuf acturer: y INFORMATION Type Of �� , t , /� N � M Mod umber: System: b r !" NIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length / Dia. Lengths .5 Dia. Spacing 7 90 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 E] No COMMENTS: (Include code discre persons resent, etc. Inspection #1: 1/ z6 00 nspection Location: 2210 County Road ( New Richmond, W1 54017 (S� 1/4 SE 114 11 T31N R18W) - 11.31.18.995 Huntington Meadows -Lot 11 l.) Alt BM Description= 4,r o� 4t, Jodi ,-___ yJ V O 2.) Bldg sewer length = U / - amount of cover = > Vrr Plan revision required? ❑ Yes No Use other side for additional inforr aiion. 4D. U SBD -6710 (R.3/97) Inspector's ature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: .. _. E 3 E 3 I, t E { t £ J � a 3 � e � E ,_ -e.4 b,. ..�. ..._ .. , �... -. . �. _ �..._ ..,E .. , . i m,emmm ,. ,. i £ E d f E 3 _ E icy S i } i 3 § ? { a e r �, .... i �.._. ..... ,,.�.. . .. .m _ t .., ,.. �e s , a E 3 � t i j F £ 3 ..�� . . . . �--- �® a � E 4 e � S x ; y , z m , a ; g `% e, ... ; mm...® ®:,� F ....... ,mSm. ........... s ,.. ,...€ i i ro ' 3 i 1 �, E ' an ,S .... .. ,. II � j 7 £ s ; x q S ,v t . W. ,........ . _ >..�._. �w v � _ , ....... mom.. v < .......,.,.. .. ... s ..� s aalo C Safety and Buildings Division Vi sconsin SANITARY PER I 201 W. Washington Avenue P O Box 7162 Department of Commerce In accord with Comm 0 is. Pdm.4ae \ Madison, WI 53707 -7162 2f� �. • Attach complete plans (to the county copy only) forth s� em, on pap t less �, dunty than 8112 x 11 inches in size. l `= V ; • See reverse side for instructions for completing this ap tion a sanitary Permit Number ST GRax C 3 J Personal information you provide may be used for secondary purposes " ,1,, ZON1 Fl� Check if rev Sion to —previous ap plication [Privacy Law, s. 15.04 (1) (m)). \ ; `. �' `� fate Plan Review Transaction Number L APPLICATION INFORMATION - PLEASE PRINT ALL I Property Owner Name rd cation 4,5 ZZ T ,N,R ��C_4 45f Property Owner' Mailing Address D Lo Number ` Block Number City, tate Zip Code _ Phone Number Subdivision Name or CS Numb r t oe II. TYPE OF BUILDING* (check one) ❑ State Owned ° v a e t t Neare t Road / Public 1 or 2 Family Dwelling - No. of bedrooms own oI� �c r��gcl�O �l III BUILDING USE (If building type is public, check all that apply) �}' Parcel Ta Num er s g� .f 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. kNew 2 ❑ Replacement 3. ❑ Replacement of 4 ❑ Reconnection of 5. ❑ Repair of an - _ ---- _ystem_ - - __ - _ System____ _________TankOnly__ ____ - __ -- 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 Seepage Trench 22 ❑ In- Ground Pressure , 42 ❑ Pit Privy 13 ❑ Seepage Pit _ • 2 43 E] Vault Privy 14 E] System -In -Fill GGC a �a o/-t VI. ABSORPTION SYSTEM FORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade /L Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation q,5-452 Required — , ,Z Feet Feet VII Capacity TANK in allo Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete con Steel glass Plastic App New Existin strutted Tanks Tanks Septic Tank i ng T �.G �7 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ 1 ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber' e: (Print) Plumb gnature: (No amps) MP /MPRSW No.: Business Phone Number: tlr O 0 lr Plumber':A ress reet,City,State,ZipCode)- IX. COUNTY / DEPARTMENT USE ONLY C] Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing ent Signature (No Stamps) [Approved ❑ Owner Given Initial �� Surcharge Fee) Adverse Determination 2 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPR VAL: Flo _ gCf SBD -6398 (R.12199) 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 lumber requires a Sanitary Permit Transfer/ Renewal Form SBD -6399 submitted h 9 p p q Y ( ) to be s dtot e 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 the legal description and parcel tax number(s) of where the system is to oe 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 manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, purnp /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. -- ---- - ----- ---------- ------ ---------- - ----- - -- ------- - ---------- -- ----- ----- ----------- ----- --------- 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_ PLOT PLAN PROJECT U d/LC�L� ADDRESS -j �1145,e�Z 1 /4S // /T 3/ N /R /�K W TOWN y COUNTY MPRS Byron Bird Jr. 220527 s� � �e DATE 0 BEDROOM_ CONVENTIONAL )00C IN -GROU PRESSURE CONVENTIONAL LIFT HOLDING TANK \4OUND SEPTIC 'TANK SIZE �p- © LIFT TANK SIZE DOSE TANK SIZE A HOLDING TANK SIZE LOAD RATE ABSORPTION ARE A # of chambers BENCHMARK V.R.P. - ��p� G� S �A SUME ELEVATION 100' ,--�— ❑BOREHOLE O WELL *H.R.P. �O�l���,�, Le SYSTEM ELEVATION >12" ewinder High of Cover pacity Leaching amber with 31.8 2 per chamber 34 Grade at System Elevation 1 24-r (OM U4 SS ; pg $(Z o `�f�e' CL G S �s U b �5 i p S 5 a s � 9 �� Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in accordance with'Comrrl 83,09, Wis. Adm. Code X .. Attach complete site plan on paper not less than 8 112 x 11 inch #s.in`size. Plan must County ` include, but not limited to: vertical and horizontal reference po t (5M), direcbOn and. percent slope, scale or dimensions, north arrow, and locationtarrd distance to nearest road. Parcel I.D. # f APPLICANT INFORMATION - Please print all fbformation, f eviewed by Dal Personal information you provide may be used for secondary purposes jPdvecy Law, s :15;114 01(m)). Property Owner 0 bpigity LocatiQ Govt. Lot 1/4 �G'1 /4,S T E (ooV Property Owner's Mailing A dress Lot # Block# Subd. Name or CS�M Ci r fate } Zip Code Phone Number ❑ City Village Town Nearest Road M ew Construction Use: sidential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate 2 = bed, gpd/ft - trench, gpd /ft Absorption area required bed, ft 2 __.21�V trench, ft if Maximum design loading rate 2 = bed, gpd/ft � trench, gpd /ft Recommended infiltration surface elevation(s) �T! 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 I [ Ks ❑ U E�K ❑ U �4 S ❑ U .®`S ❑ U ,_ S A U ❑ S R'U SOIL DESCRIPTION REPORT Boris # Horizon Depth Dominant Color Mottles Structure GPD /ft Boring Texture Consistence Boundary Roots :":.Xa in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench , 6� -� Ground ! • ?:- elev. Depth to limiting 3( - factor �in. Remarks: N. loring # Ground ft. - Y. Y De th to limiting facto in. Remarks: CST Na (Please Print) Signature Telephone No. Z I f'rr4 /) r// �'� ✓� r 6 � Addres /'�� Date CST Number - SOIL DESCRIPTION REPORT PROPERTY OWNER � r � Page of PARCEL I.D.# oT�� Boren # Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots in. / Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground elev� , Depth to limiting ` 6 factor _in. "' Remarks: Boring # Ground e . i ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Structure GPD /ft in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench Boring # /eq'C;vf _ �l Ground A ev. D ?pth to yy y o limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in ' Remarks: SBD -8330 (R.9/98) Soil Test Plot Plan Project Name Byron Bird Jr, Address 'LVa/ CS Lot Subdivision a ate 20 -- ,� --��- 1 /4 _��f 1 /4 S N/R `- Townshi 713orinb O Well PL' Property Line County BM or VRP Assume Elevation 100 ft; 01 System Elevation *HRP� Go � G 1 Scale 1/4" = 10 1~t. When Dimensions aren't stated ST CROIX COUNTY _ SEPTIC TANK MAINTENANCE AGREEMENT AND — OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address Property Address v��l z� (Verification required from Planning Department for new construction) O�;� City /State A k,' 16 �l 4 a/� Parcel Identification Number LEGAL DESCRIPTION Property Location ' /4, t�K V4, Sec. T_,4N -R W, Town of Subdivision /7�u g'7 �/ ^ o �� o , Lot # �. Certified Survey Map # , Volume , Page # Warranty Deed # w °�� 1c7 - 5 Volume Page # �? Spec house dyes ❑ no Lot lines identifiable N� 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, restrictedplumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal 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. Uwe, 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 expiration date. �1 d xt a 16' � s l l06 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office. oa4e4_ 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 01.1500PAGE 3 STATE BAR OF WISCONSIN FORM 2.1998 620G'33 Document Number WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS This Deed, made between Clay A Edin ST. CROIX CO., WI RECEIVED FOR RECORD Grantor, 04 -05 -2404 9:30 AM conveys and warrants to David E. Burch and Bonnie K Burch husband and wffl WARRANTY DEED EXEMPT N Grantee. CERT COPY FEE: Grantor, for a valuable consideration, conveys and warrants to Grantee the COPY FEE: TRANSFER FEE: 71.70 following described real estate in St. Croix — County, State of Wisconsin (The RECORDING FEE: 10.00 "Property "): PAGES: 1 _ Recording Area Name and Retur Address iat,d apt{ �a�a5t t>3�ta9.saD� Parcel Identification Number (PIN) This is not homestead property. - Lot 11, Plat of Huntington Meadows in the Town of Star Prairie, St. Croix County, Wisconsin. Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this 3 day of April, 2000. + • Cray A. n ■ w ACKNOWLEDGMENT STATE OF WISCONSIN ) AUTHENTICATION ) ss. ) Signatures) Clay A. Edin ST CrsiY County Personally carne before me this day of April, 2000, authenticated this day of the above named _ e" n v fl — FA . rd April. 2000. [o me known to be the person(s) wh executed the foregoing instrument and acknowledge the Z. • IGtsuna Ogland �ff TITLE: MEMBER STATE BAR OF WISCONSIN " (If not, Notary Pobi' Late of Wi sin authorized by § 706.06, Wis. Stars.) My Commission is permanent. (If not, state expiration date: / /�17 THIS INSTRUMENT WAS DRAFTED BY Attorney Kristina Ogland Hudson, WI 54016 ( Sigmtures may be authenticated or acknowledged. Both am not necessary.) �{�.N� 7 OW H• of �u '"" nWfi * "Names of persons signing in any capacity should be typed or printed below their signatures WARRANTY DEED STATE BAR OF WISCONSIN FORM Na 2 . IM INFORMATION PROFESSIONALS COMPANY FOND DU LAC. WI WO655.2821 I I I — N00'55'12 "E 655.89'— - -- 626.82' - - -- -- --� 313.06' 313.76' 40' WID DR AINAG E EA SEMENT • 00 N00'55'1 2 "E 242.62" ' I rn N o p Ol O •� C N : OD N W Oo v I A y m °) o CD w 0 y c o I m l � P PO > � D O O I N� V SAD 0 it D m N m m l D w D + rri O • m IV I m O I 2 •• Z • �•,•• -� N I I Z =0 rr Fri 0 00 - - -- -- i /•Q \\ j 31 If I 0 V D 'E 205.30 w O I 0 m A ^ -� - I - N00'55'12 "E 226.71' D (o -P. Ni /'CLT'- 4h. fTl u) r w I 201.40' `J C W 205.22' w Q 9 , EAST 52.55' N C I z OD - - -- - -� �� ' " I / 10 S6\ ►v I f 50' BLDG \/ 5 1 � 'I's: I rn O i D i �s 900'61 N I 1 1 m F D. j .lq..• _� I OD W p I r, I r A W O 0 D a --� I I 0 -� �A X10 OD z i z D; N OD C I m n� i u (� • m1 N 81.34' JL 111.76' Ln N00'55' 12 E " v' \ N00'43'55 "E o N00'43'55 "E 193.10' / r, 229.00 I 202.00' p • Z o M Ln 00 I o. so N N - O I z o _ 14 p H wV (' N DN-.4 � Z00 � w p �A m�Z m AN gym= N rn '^ w y� N N D O N Ut s �. • o w n w 66' JOINT DRIVEWAY Z °- EASEMENT - { l yja • • �" m ••. O 99 cnr66 0' 2F�� •�•........... N00'4 '55 "E .... z 9 .................... .... " . ........ .. . ?+ �' �• I m e 00 to 100 R O F`s o `D o co - - 12" U77UTY 0 0• I a ° EA SEMEN T \ 112.51 — — 191.56' ''�� 33' 33' N 0'43'55 "E 506.07' Incorrectly Recorded As 604.37' �O c (TO BE DEDICATED TO THE PUBLIC) Ln C, T, H, 'C' rn °- - -- --- _-_ (§9 1 13 .. W 1968.39 -- S00'S1 13 " W 656.13 ------------- S00'51'13 "W 2624.52'---- - - - - -- c --------------- - - - - -- - -— EAST L /NE OF THE SE 1/ OF SECT /ON 11 T LINE OF THE SE 1/ ?� R.O.W. C.T.H. "C" UNPLATTED LANDS 0 co D r I I I p 0 �... �. �. c' m r- r r r � 00 0 00 4 � -4 -4 rn �t rn rn D .