Loading...
HomeMy WebLinkAbout038-1186-60-000 I Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM County 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)l. 363870 Permit Holder's Name: ❑ City ❑ Village ❑ TAwn of: State Plan ID No.: Geurkink Jim Star Prairie Township CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: ICU-0 '( ? UC 038-1186-60-000 TANK INFORMATION U ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. Septic Benchmark . 3 Dosing Alt. BM 3 S, j � Aeration Bldg. Sewer 2 06 r Holdin St /HtlnletZO c��,lp` ANK SETBACK INFORMATION St/ Ht Outlet ,62 cm .(.8 TANK TO P / L WELL BLDG. Air Intake ROAD Dt Inlet — Air Septic (OS X65-' 2 r NA Dt Bottom Dosing N Header/ Man. Aeration > < N Dist. Pipe ' aS� Flo •25'' Holding Bot. System �' ?�45B6 PUMP/ SIPHON INFORMATION Final Grade , `� R , 10 1 Manufactur Demand St cover 5. -7 9 -S - 5 ' ' Model Number GPM TDH Lift TDH Ft Forcemain Length Did. Dist. To Well SOIL ABSORPTION SYSTE t C& BED/TRENCH Width c Len gth\ N Z Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 � 1l ��' �11 DIMENSION SYSTEM TO P / L I BLDG WELL LAKE/STREAM LEACHING Manufa rer: SETBACK INFORMATION TypeO CHAMBER Mo um er. �O �`f 3 � .} 9 `-r-1 OR OMIT System: DISTRIBUTION SYSTEM Header /Manifold �� Distri:n:g on Pipes) x ol e Spacing Vent To Air Intake r Length �e- Dia. th �an 3 SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded Jxx Mulched Bed/Tr nch Center Bed/ Trench Edges Topsoil El Yes [] No El Yes ❑ No COMMENTS (Include code discrepancies, persons present, etc.) Ins ection #l:eo / / Inspection #2: Location: 1375 211th Avenue, New Richmond, WI 54017 (SW 1/4 SE 1/4 13 T31N R18W) - 13.31.18.947 Prairie Flats - Lot 16 _ pQ _�- c' ? 1.) Alt BM Description = 1rof 2.) Bldg sewer length = - amount of cover = Plan revision required? ❑ Yes )Z(No Use other side for additional information. ©q 1 2 - 1 Le ( 1 0 2_ j e q� SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH ' SANITARY PERMIT NUMBER: m � z x 8 f a , s a I � j 9 � 3 l 137 � 2,1 1 t4 U e - ' Safety and Buildings Division 201 W. Washington Avenue V isconsin SANITARY PERMIT APPLICATION g P 0 Box 7302 Department of Commerce In accord with Co Code Madison, WI 53707 -7302 e Attach complete plans (to the county copy only f t 1 Ste on t less County than 8 vi x 11 inches in size. le ,,r- e See reverse side for instructions for completing applid�t+`dr1 °, State Sanitary Permit Number ; 0 Personal information you provide may be used for secondary p rposes r F �'- Check if revision o revious app iication t h c; i ❑ 3 P [Privacy Law, s. 15.04 (1) (m)]. �- State Plan I.D. Number ST C I. APPLICATION INFORMATION - PLEASE P iNT ALL I T Property Ow er Name Z Pr ation t /a,S 13 T 3 1 ,N,R 18rE Property N er�'s Mailing Address, �• er Block Number City, State Zip Code Phone Number Subdiv i, Name or CSM N ber A iprs (716) !9 T YPE F BUILDING: (check one) ❑ State Owned " Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms ❑ Town o f ` TFw III. BUILDING USE: (If building type is public, check all that apply) � B Parcel Tax Nu 1 E] Apartment/ Condo 0 v�?; —� ? (0 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, E] Replacementof 4_ E] Reconnection of 5. ❑ Repair of an - ______ystem ________ System __ ________ ___ Tank Only______________ ExI ti ig System _________Existin�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 135 Seepage Pit 16Z)l - �, f ault Pr'v i 14 ❑ System -In -Fill t,,,� l;,r g WUtea l 1. e -s:%,,PLt � 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 . ft.) Proposed (sq. ft.) (Gals/d y /sq. ft.) (Min. /inch) q Elevation �5& `7 , -------^ ! y 7s Feet 99.,7 Feet acct VII. TANK in Ca gallo s Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks 1 c Septic Tan an o�c�� . ❑ ❑ ❑ 1:1 1:1 Lift Pump Tank /Siphon Chamber 1:1 El 11 C] ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: nt) Plumber's Sig ture: o Stamps) MP /MPRSW No.: Business Phone Number: �DS'3 7 Plumber's Address (Street, City, State, Zip Code): o , 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 perfnit issuing authority. 4. Changes Pn 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 puirped 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 be installed. 11. 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, s' ig n application form. IX.. /: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. p P [0, n Su.) S.E S i 3?-3 Leto '7 9' D _ P ry n1 T p ,, Q � vc � P f� a b s Q 4-1 77 i gg.c3 e � B\ `7S` 64 a,so' 171 0 0 t C1 1 � o cl G) :3 CX. Q- 20 > Z4 ' rr .� 0 U) 0 0 N 0 CL (D (C) (o 0 =r 0 zr (U (D (D 0 X =r cD =r cD sD rl D CL 0 X EF ................ CL Q CL = (D C ) 0 0 ---------- - 0 0 - Z CD ,� w (D 0 0 0 c 0 0 -4, ......... Sv B a CD C) ............. 0 :3 CD = (D ja) 0 rl) 0 q I ......... .... CD OL (D CJ (C) x W =1 f1 W 3 3 (D cr 0 CD 0 ili o < w II m x :3 9 - p 63 -x sa 5 C - 0) 2 c a ............ ... o6 CD W (0 3 C 0 cD 3 c Invert I V CD 0 D Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of .. Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code Gille Trucking & Excavating, Inc. Attach complete site plan on paper not less than 83/2x I 1 inches in size. Plan must County include, but not limited to: vertical and horizontal refere direction and __ St. Croix percent slope, scale or dimemsions, north arrow, 1 c ti d i�t e to nearest road. Parcel I.D.# APPLICANT INFORMATION - Pie nt I inp I nri'" a .. Personal information you provide may be used for ary pu f r cy Law,'s. 15. (1) (m)). l Date/ Property Owner P'r6ke Location �;� Case , Dan ' ;� .4 Gov Lo SW 114 SE im,3 1 T 31 N,R 18 Property Address "? p rty Owner's Mailing t � ;a✓ t ,.,� ''Lot Block # Subd. Name or CSM# 323 Saw Lane _ rO `��✓,�,, ^ 16 Prairie Flats City State Zip ode`. Phon j City E] [' Village Town Nearest Road New Richmond W1 540 /- 246- 4.00`t Star Prairie Hwy 65 Olt New Construction Use: Residenti edrooms 3 [_]Addition to existing building ( I Replacement 1 Public or commercial describe Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/ftz .8 trench, gpdM Absorption area required 643 bed, f1 562 trenc fF Maximum design loading rate .7 bed, gpd/ftz .8 tr ench, gpd/f 2 Recommended infiltration surface elevation(s) 7 It (as referred to site plan benchmark) Additional design I site considerations Parent matedal -wash Flood plain elevation, if applicab ft S= Suitable for system Conventional Mound In - Ground Pressure AT - Grade System in Fill Holding Tank U= Unsuitable for system NS El U X S❑ U ® S❑ U ❑ S U ❑ S® U ❑ S N U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring# Horizon in Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. onsistenc Boundary Roots Bed Trench 1 1 0 -10 7.5YR2.5/1 ---- - - - - -- SIL IFABK MVFR AW 1VF .2 .3 2 10 -31 7.5YR4/6 - --- - - - - -- CL 1FA MVFR AS 1VF 2 .3 Ground 3 31 -99 7.5YR5/3 ---- - - - - -- S 0 -GR M - - -- - - -- 7 8 ele — - - - - - -- - - -- - - —�� V .o3 Depth to limiting factor 99 in. -- Remarks: 2 1 0 -10 7.5YR2.5/1 ---- - - - - -- SIL 1F MVFR AW 1 VF .2 .3 -- -- -- 2 10 -27 7 .5YR4/6 ---- - - - - -- CL 1FABK MVFR AS 1VF .2 3 Ground 3 27 -96 7.5 ---- - - - - -- S 0 -GR ML - - -- - - -- .7 .8 vS7, g3 _ Depth to - - -- 36q -� -- - - -- - -- - - -- - - -- - - - -- — limiting Z, 9 factor _ 96 i n. Remarks: CST Name (Please Print) ignature: Telephone No. Dennis Gille ✓-Q j„Lia _ 715 268 - 6637 Address CST Number Ref # p t 372 140th Street Amery, Wl 54001 x6/97 3409 107 PROPERTY OWNER: Casey Dan SOIL DESCRIPTION REPORT Page 2 of PARM I.D. #_ Gille Truck & Excavating, Inc. Horizon Depth Dominant Color Mottles Texture Structure onsistence Boundary Roots �P in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3 0 -15 7.5 YR2.5/1 ---- - - - - -- SIL 1FABK MVFR AW 1VF .2 3 F2 2 15 -27 7.5YR4/6 ---- - - - - -- CL 1FABK MVFR AS 1VF .2 3 Ground elev 3 27 -96 7.5YR5/3 ---- - - - - -- S 0 - ML - - -- - - -- .7 .8 ` - - - a Depth to -- limiting -- factor 96 in -- -- - - Remarks: _ _ 4 0 -12 7.SYR2.5/1 ---- - - - - -- SIL 1FA MVFR AW 1VF .2 .3 2 12 -35 7.5YR4/6 ---- - - - - -- CL 1FABK MVFR AS 1VF .2 .3 1 3 Ground - elev 3 35 -98 7.SYR5 /3 ---- - - - - -- S 0 -GR ML - - -- - - -- .7 8 Depth to limiting Z - - -- — - -- factor 98 in- -- -- - — — - - -- — — - Remarks: -- r 1 0 -14 7.5YR2.5/1 ---- - - - - -- SIL 1F MVFR AW 1VF .2 3 2 14 -32 7.5YR4/6 ---- - - - - -- CL 1F MVFR AS 1VF .2 .3 Ground — , — elev 3 32 -96 7.5 ---- - - - - -- S 0 -GR ML - - -- - - -- .7 .8 Depth to — - -- limiting - -- factor 96 in. — Remarks: _ - elev Depth to limiting - factor I Remarks: — Dw� 'M ZTT- P, Two Lo7 6 -17 P,/c oy Sv Za T 166 14 RP Q Z. T r 1 � i ;2 I 3S 3 LCD qo C �9 T7 � �o Y t . ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer o (Y1 ( Mailing Address Q 0 I e� - 1C, [' h 1 �S� , �y :� ( O 7 Property Address 1315 Al a.�.. (Verification required from Planning Department for new construction) City /State Parcel Identification Number LEGAL DESCRIPTION Property Location Sko '/4, '/4, Sec. 1 3 , T-31N -RJ.KW, Town of S Subdivision 1' �f`ali r4 �.. � 4$S , Lot #. Certified Survey Map # , Volume , Page # Warranty Deed # ( do ('0 Z� , Volume I L4 I , Page # 3 Spec house ❑ yes K no Lot lines identifiable X 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 masterplumber, journeyman plumber, restricted plumber or a licensedpumper 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 da# of the three year expiration date. J1A 24 v / 0_P GNATURE 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 perty described above, by virtue of a warranty deed recorded in Register of Deeds Office. NA 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 1 VOL STATE BAR OF WISCONSIN FORM 1 WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS DOCUMENT NO, ST. CROIX CO., WI ------ - RECEIVED FOR RECORD This Deed, made between Daniel J. Casey and 04-05-1999 9:30 AN Betty D Case�hus�band and wife as survivors NAMMY B EM ED PT # M . r 4 tal property Grantor, CERT COP FEE: it COPY FEE; and aamesn. Geurkink and Rose Ann Geurkink,- TRINIVER FEE- 53.70 hushand and wife as survivorship RECORDING FEE: 10.00 PAWS: I marital property Grantee, Witnesseth, That the said Grantor, for a valuable consideration-- THIS SPACE RESERVED FOR RECORDING DATA ng described real estate in 1 3t- Croix conveys to Grantee the followi - - --------- - - C State of Wisconsin: NAME AND RETURN ADDRESS Lot -111-11E-prairie Flats Addition in the 'y S tar Prairie, Croix County Town of S S- L 1-lisconsin. H *No k- 7: :Z -- - - ----- --- - 038- 1186 -6 -000 This is not homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And panip'l .7. Casey and Betty D. Casey warrants that the title is rod, indefeasible in fee simple and free and clear of encumbrances except recorded covenants, easements and rights of way. 1: and will warrant and defend the same. March Dated this 31st day of .19 (SEAL) SEAL) V Daniel J. Cas Be t y D. Casey e3l (SEAL) SEAL) ACKNOWLEDGMENT CKNOWLEDGMENT i i Signature(5) State of Wisconsin, St. Croix County. authenticated this day of 19 Personally came before me this 31 s t day of C Ma rc It - 19-2 L. the above named Daniel J. Casey an Betty D..Casey i1 1 TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Scats.) to me known to be the person 6 who exec ed the foregoing instrument an c knowle d a the same THIS INSTRUMENT WAS DRAFTED BY John D. Walsh G/John D. Walsh Notary Public, St. rrniX County, Wis. (Signatures may be authenticated OT acknowledged. Both are not My commission is nrinanent. (If not, state expiration date: necessary.) November 2001 jowl -- - ------ p- ......... • D AAA111i I : : - - - - - - - - - - - Names Of persons signing In an Capacity should by t or printed below their signatures. wilailin Notary PUbfic STATE BAR OF WISCONSINMY C01mr"W Expires Nov. 25, 2 Legg Dam Co.. In WARRANTY DEED Form No. I - 1982 MilwaLxee. Wis. s 9 2".92' 393.50' 29. 3922 OF ;3oar t: to 9 0 0 N 0 M u IS 01 E 330.07' I - ? ,— imor 14- In T to ROAD 4 1 co o" �44 .. . 1 $: 0 1 /1 . - - I- - - - X c l I Q) In PUBLIC N ' cdc— it k 930. 00 ' 1.3 DOM 00' t 001 E f N 00 .0 0 00 E 700.00' 270 97 2@8 00 Noo 00 00*. - 1 14 3 A5 d Ct 9 21 00' M 9 -- - -- — — — — — — glg In :Cb P 9 11 00 r 273 92 01' cc . 8 M p� 3' i 268.DO' WV 0 , �, IN v 7Z, • 275.J9 N 00 vo 00 w V 0.Q >ga 100 , OZ �zj n 33.1 Z� Cot W 700.00' a 865.33 ---Z •x =F co l d -al id p 0 I 11 41 s la 15 — m 34.32. 334.87, N 00 W 590.07' 1 011001MY111? N 51 ! I t 1h p) . 0 i a O N 00*52 111 Sf 33' 33' ltn N 00 W 324.90' (A Ito .4 ig 32•,18• N00 395.16 qN N 00 ot 0"313" • - tA3T LWE or - lK SCl/- 1 4 '06 7 UNPLATTED S. T. H. 1. 6 LANDS