HomeMy WebLinkAbout038-1190-10-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
Safelty 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)]. 370208
Permit Holder's Name: ❑ City ❑ Village ❑ jown of: State Plan ID No.:
Star Prairie Township -- '
CST BM El ev.:- Insp. BM Elev.: BM Description: Parcel Tax No.:
Puy CS — 038-1190-10-
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic o•p Benchmark IF I Z 3 -2� c7o,�'
Dosing Alt. BM 2.0 o (• Zb
Aeration Bldg. Sewer 3 ( 6 - 2- 6� I
Holding St/ Ht Inlet ,Sri
TANK SETBACK INFORMATION St / Ht Outlet
TANK TO P/ L WELL BLDG. Air ir I ntake ROAD Dt Inlet
A
Septic -� s� ' ( p r NA Dt Bottom
Dosing NA Heade /.Ir4E�r►- L
Aeration NA 'Bis#--R+ye G
e S. 3..
Holding Bot. System . ( 3
PUMP/ SIPHON INFORMATION Final Grade 2 p�
Manufacturer emand
St cover . 3 1 $ .
Model Number GPM
TDH Lift L oss Iction Sy TDH Ft
ead
F -main I Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
OE& RENCH Width r Lengt _ 1 No f renches PIT No. Of Pits Inside Dia. Liquid Depth
DIME 3 a DIMENSIONS
SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHING Manu ct rer:
-W - sik.,
INFORMATION Type Of CHAMBER Model Number:
System: p 4- -� S� �s '�� OR UNIT
DISTRIBUTION S YSTEM
Header /Manifold Distribution Pipe(s) x Hole Size ole Spacing Vent To Air Intake
Length � Dia. N Spacng 7 I n I
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only 64, j� IZ6
Depth Over c( 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: Gk .2 9 /e-'D Inspection #2: ' — T — T__'
Location: 1364 213th Avenue, New Richmond, WI 54017 (NW 1/4 SE 1/4 13 T3 IN R1 8W) - 13.31.18.972 Northgate -Lot
r
23 1.) Alt BM Description = �'^" S 2- f ? 5
2.) Bldg sewer length= 21 .p' ' r\ , 10
i-L
- amount of cover = g coo-
Plan revision required? ❑ Yes M No
Use other side for additional information. 02 1: Df Z
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
IN
ADDITIONAL COMMENTS AND SKETCH ,
SANITARY PERMIT NUMBER:
a a
,
F
e
N
v
I t
E
e s
..�.
i
I a�
I
,
i
a c
c
e
x
a
a a
t
x
e
i
3
c
}
E
E E
n
,
a
e
a
a
x
.z2
_ y r
3b �( 2 / e—
Vi sciidilnsin Safety and Buildings Division
SANITARY PERMIT APPLICATION PoB shingtonAvenue
Bo Washington 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 8 112 x 11 inches in size. / �✓�''o /�
• See reverse side for instructions for completing this application state sanitary Permit Number
34- 0Zo8
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. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATI N
Property Owner Na ery Loc 1�
e 9 / 0/4 4, S �� T , N, R (O
�c r
Property Owner ng Addr Lot Number Block Number
trJ
I t , Stat Zip Code Phone Number Subdivision Nw CSMULLMbe,
ll. TYPE OF B ILD N (chec one ❑ State Owned A ❑ It r - Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms ow OF /u`
III BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s)13 3/ /$ _ q 74
1 ❑ Apartment/ Condo s
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 [�CNew 2_ ❑ Replacement 3_ ❑ Replacement of 4. E] 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 ElCperimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 E] Specify Type 41 ❑ Holding Tank
12 Trench 22 ❑ In- Ground Pressure Z ' /s 42 ❑Pit Privy
13 E] Seepage Pit / low 3 ❑ Vault Privy
14 [] System-In-Fill ' l'� Cr � C : r
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 /s . ft.) (Min. /inch) EI vati
" — ?5 - Feet Feet TANK Capacit
VII. INFORMATION in gallo Total # of Manufacturer's Name Prefab. Con- steel Fiber- Plastic Exper
New Existing Gallons Tanks Concrete structed glass App.
Tanks Tanks
I
Septic Tank or Holding Tank �' ❑ ❑ ❑ ❑ ❑
i
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
t VIII. RESPONSIBILITY STATEMENT
j I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumb Name: (Print) r Plumb ignature: (No Sta MP /MPRSW No.: Business Phone Number:
um r'sA ress treet,City State Zi Code): `
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sa tary Permit Fee (includes roundwater r - 3 0 slue Issuin Agent Sign
roved ture (N Stamps)
A Surcharge Fee) c
pp ❑Owner Given Initial 0� Adverse Determination —
X. CONDITIONS OF APPR / REASON FOR DISAPPRO AL:
K& I c:
SBD -6398 (R. 4/99) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
° x
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 lank(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 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 publi(, 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.
----------------------------------------------------------------------------------------------------
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.
Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of _ 3
Labor'andFHuman Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but St., rroix
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. 038- 1055 -95
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION FLE VIEW DBY DATE
4,K .8 1
PROPERTY OWNER: PROPERTY LOCATION
Greenwood Enterprises, Inc. GOVT. LOT NW 1/4 SE 1/4,S 13 T 31 N,R 18 :2 (or) W
PROPERTY OWNER' MAILING ADDRESS LOT # I BLOCK # SUBD. NAME OR CSM #
1416 Third St. 23 na NorthGate
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE ®TOWN NEAREST ROAD
Hudson, WI. 54016 (715) 386 -3674 Star Prairie I 214th Ave.
�] New Construction Use [ x] Residential/ Number of bedrooms 4 [ ] Addition to existing building
[ j Replacement [ ] Public or commercial describe
Code derived daily flow 600 gpd Recommended design loading rate - 7 bed, gpd /ft gpd /ft
Absorption area required 858 bed, ft 750 trench, ft Maximum design loading rate .7 bed, gpd /ft —a trench, gpd /ft
Recommended infiltration surface elevation(s) 95.35 ft (as referred to site plan benchmark)
Additional design / site considerations na
Parent material outwash Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem $7 ❑U Lis ❑ EIS ❑ 0S ❑U i7S ❑ El ®
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Bou Y Roots GPD /ft
Boring # Horizon in. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
..................
......... ........
1 0 -11 10yr 2/2 none 1 lcsbk mfr yw if .4 1.5
1
2 11 -27 10 r 4 4 none sicl lcsbk mfr QW if .2 .3
Ground 3 27 -84 7.5 r 4/6 none cos 0SCI ml na na .7 I .8
elev.
9 9.1 ft.
Depth to
limiting
factor
+84" S
Remarks:
Boring #
1 0 -12 10 r 2/2 none 1 2csbk mfr c4w if .5 .6
2 2 12 -26 10 r 4/4 none sici 2msbk mfr qw if .4 .5
Ground 3 - 10 5/4 none Sill lcsbk mfr aw .2 � .3
elev. 4 129-84 7.5vr 4/6 none Cos osa ml na .7 .8
99 ft.
Depth to
limiting
factor LL
+Rd
I r
.8
Remarks: :''� ST CR
CST Name: -- Please Print Gary L. Steel Phone: 715-246 Z0NING OFF
Address: 1554 200th. Ave. Richmond WI 54017
Signature: Date: 4b r:' 98
10 -30 -98
PROPERTYOWNER Greenwood Enterpris DESCRIPTION REPORT Page ?, of , 3
PARCEL I.D. # 038 - 1055 -
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourtary Roots GPD /ft
.................
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
..................
.................
..................
.................
..................
3 1 0 -8 10 r 2/2 none 1 lcsbk mfr 9w if .4 .5
2 8 -28 10 r 4/4 none sicl lcsbk mfr 9w if .2 .3
Ground 3 28 -84 7.5 r 4/6 none cos osq ml na na .7 .8
elev.
9 9.1 ft.
Depth to
limiting
factor
+84
Remarks:
Boring #
1 0 -9 10 r 2/2 none 1 lcsbk mfr w if .4 .5
ca
4 2 9 -29 10 r 4 4 none sici lcsbk mfr gw if .2 .3
Ground 3 29 -84 7.5 r 4 6 none cos 0sq ml na na .7 .8
elev.
98.9 ft.
Depth to
limiting �(Z
factor
+R4
Remarks:
Boring #
1 -12 10 r 2/2 none 1 lcsbk mfr w if .4 .5
`: 5 " 2 12 -28 10 r 4/4 none sicl lcsbk mfr if .2 .3
0
3 28 847 5r46 none cos 0sq ml na na .7 .8
Ground
elev. f
98.9 ft.
Depth to
limiting �2
factor
+84
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
7 / / axle Plot Plan 9 �X a'g lll O��ir
PROJECT O G C ��� / / / ADDRESS
u 1 1/4 114S �� /T ' N/R /� W TOWN �� COUNTY G/
Byron Bird Jr . 220$27 � DATE /� BEDROOM
CONVENTIONAL IN -GROU PRESSURE 6 NVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE Z-2d—e LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE ABSORPTION AREA �j&J # of chambers
, BENCHMARK V.R.P. %� oz� �G �✓ ASSUME ELEVATION 100
❑ BOREHOLE WELL *H.R.P.
SYSTEM ELEVATION
Vent
>12" Sidewinder High
Of Cover Capacity Leaching
Chamber with 31.8 ft ^2
6' Long 6
per chamber
N 34„ Grade at System Elevation f
U to
IN
I�
- .A
� I/ - �
C
STEEL'S SOIL SERVICE
Gary L. Steel 1554 200th Ave.
CSTM2298 Greenwood Enterprises, Inc. New Richmond, WI 54017
MPRSW -3254 NW4SE4 S13- T31N -R18W (715) 246 -6200
town of Star Prarie
lot #23- NorthGate
This soil evaluation was conducted to satisfy a zoning requirement, it may or may
not be suitable for your use. The location of the test may or may not be as shown
as permanent lot lines were not established at the time the test was conducted.
N
1 =40'
BM.= top of 2 pvc pipe C ef. 100'
Alt. BM.top of 2 p c p ipe C el. 97.40' 1'
4`
2 �g�
�c
l
V
Gary L..Steel
10 -30 -98
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer
Mailing Address
Property Address`
(Verification required from Planning Department for new construction)
City /State ��, ��C � / /' Parcel Identification Number
LE GAL DESCRIPTION
r
Property Location / " =-- ' /a, Sec 4 L , T N -RZI��& Town of
Subdivision ' Y' �� ��� Lot # s�
Certified Survey Map # , Volume - , Page #
Warranty Deed # (o Z, 69 t , Volume /S(3 , Page # S (o
Spec housed yes ❑ no Lot lines identifiable Oyes ❑ 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 b e
lumber, journeyman � !� Y � owner and by a
master
P yman 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.
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
da} of tfi ee ye a iration date. Tr .%
S
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 prop describe bove, 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 reference is made in the warranty deed
10
VOL 1513 PAGE 561
STATE BAR OF WISCONSIN FORM 1- 1998 KATHLEEN H. WALSH
DonomeatNumber WARRANTY DEED REGISTER OF DEEDS
ST. CROIX CO., WI
This Deed, made between Greenwood Enterprises. Inc. a Wisconsin RECEIIM:D FOR RECORD
corporation. Grantor, and Todd Marek
Grantee. 05-25 -2000 3:20 PM
Grantor, for a valuable consideration, conveys to Grantee the following IARRANTT DEED
described real estate in St. Croix County, State of Wisconsin (The "Property "): EXEMPT M
CERT COPY FEE:
COPY FEE:
TRANSFER FEE: 71.70
RECORDING FEE: 10.00
PAGES: 1
Recording Area
N am and Rctum Address
/GlSuv�7 NCI4,
?q- s
035- 1190 -10
Parcel Identification Number (PIN)
Thi. v not homastead property.
Oa not)
Lot 23 of the Plat of NorthGate, recorded in the Office of the Register of Deeds for St. Croix County, Wisconsin on May
20, 1999 in Volume 7 of Plats, at Page 46 as Document No. 603503.
Together with all appurtenant rights, title and interests.
Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances
except easements, restrictions and reservations, if any, of record.
Dated thisj2W&y of 2 Z Z & , 1999.
GRIj00D , INC.
s �L1.�
+ *Japes L Rusch, its presid
i.'
li
+
*Mary FcAm r 46sec
AUTHENTICATION ACKNOWLEDGMENT
Signature(,) James E. Rusch, its president STATE OF WISCONSIN )
ss-
�A C roix County )
aufhenticat th' II 9�ay of M , 2 Personally came before me this a� day of M
the above named Mary R. Rusch. its secretary to me
known to be the person(s) who executed the foregoing
instrument and acknowledge the same.
11A Q, RA
E: ME ER STATE B SCONSIN
(if
authorized by § 7116.06, Nis. Stara.)
Notary Public, State of Wis nsin
THIS INSTRUMENT WAS DRAFTE ' sion is pertna nt. (If not, state expiration date:
Lois A. Murray, Zilz, Estreen & 9,P�CA J. PHANEU > ,L )
304 Locust Street, Hudson, WI 4016 NOTARY PUBLIC
(signaturos may be authenticated or acknowled Bot T WISCON
necesmry -) •
*Nam s of persons signing in any capacity should be typed or printed below their Agneturcs
WARRANIT DEED SrATR EAR OF WISCONSIN
FORM No. 1 -Ire
INFORMATION PROFES 0NALS COMPANY FOND DV LAC, W1 e004W2021
MAY-10-00 08:45 AM SANDY GEHRKE 725 381 29e4 P.06
C) ,�
j
.... ... 13
rl
cl
31AI Ok 0 JIV ICIA 0
v i�
tl
�j
CD
CP
tj
l oop
(IN