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HomeMy WebLinkAbout038-1197-70-000 / /* I VLconsin Department of Commerce y' Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count St. Croix INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanitarX2erBTo.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: ❑ City [I Village w f: State Plan ID No.: Kassel Construction Co., y Star Prraine Township CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.: vp 0 ` 11 L50 I O �� = CST 1l31M.',I TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic- 6LIO Benchmark 8 . Z �{ 1 24 I M . p' Dosing t. S•&° 1 oZ•b4 Aeration Bldg. Sewer t o. (- 3 qT 4 (' Holdin St /Ht Inlet ((. 3 14- r TANK SETBACK INFORMATION St/ Ht Outlet t'! TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic 7 (p5' _1 8 1 NA Dt Bottom Dosing NA Header / Man. (Z' 2 Aeration NA Dist. Pipe 5 /2. Z A) z ..7 z S• 92 Holding Bot. System s 13, 9cf 8� AJ t PUMP/ SIPHON INFORMATION Final Grade ;t 6L Man turer emand St cover Model Numb GPM TDH Lift L oss fiction stem TDH Ft F main I Length Dia. Dist. To we SOIL ABSORPTION SYSTEM _ BSO.KTRENCH W idth r Len th 1 No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIME 3 DIMEN I N SETBACK SYSTEM TO P/ BLDG WELL LAKE /STREAM LEACHING Man ufacturer: �.5 CHAMBER = �C INFORMATION Type O --� Mode Number: System: S} (�E� OR UNIT e 4 DISTRIBUTION SYSTEM kol — Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake r K Length AU _ Dia. y ia. Spa i 3 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 E] Yes [] No El [] No COMMENTS: I Jude code dd cr ancies, a son resent, etc.) ns ec ion 2( o I spec ion Location: ( �� T31N R18W� Nine Acre �6p II 1.) Alt BM Description =.�OV. 1,Q,� (k I 2.) Bldg sewer length = 0,o' - amount of cover = '.- 36 Plan revision required? ❑ Yes E?L(Vo Use other side for additional 1 2 - 1 a l zw d Z `< SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. R ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 3 L .. _--.. _.. 4--t- � a 3 3 E N y E } 1 � �1 -,::- Safety and Buildings Division SANITARY PERMIT APPLICATION 201 W. Washington Avenue Wisconsin P O Box 7162 In accord with Comm 83.05 Wis. Adm. Code t� Department of Commerce • • � Z � � �� 1� (2�aAIS•n, WI 537.7 -7162 • Attach complete plans (to the county copy only) for the syste , ' 14.0 County t than 8 1/2 x 11 inches in size. j • See reverse side for instructions for completing this applic ^ R('O Sanitary Permit Number Personal information you provide may be used for secondary purposes -- J ) d , 11 ; - h l it if revision to'previous application [Privacy Law, s. 15.04 (1) (m)]. ° u ►J 8 2000 St Review Transaction Number I. APPLICATION INFORMATION -PLEASE PRINT AL Propert Owner Name ��, _: zC� Locatio /C� i T , N, R �((or Property Owner's Mailing Addre Iqt y G Block Number 5 a, r5 7 L ' Cit ,State Zip Code Phone Number Subdiv on ame or CSM Number 15-56 a 5 (7/5) s Sig -:1 �.�- II. TYPE OF BUILDING: (check one) ❑ State Owned it Nearest Road p village Public 1 or 2 Family Dwelling - No. of bedrooms Town OF J� C 7 - 1 Z 1 - L III. BUILDING USE: (if building type is public, check all that apply) Parcel Tax Number(s) _ ,,� r �� r Art SR - nt /Condo 0 -M I � 3( � /T i o4i 1 E] A I - 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. [k 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 Seepage Trench � '�� 22 E] In- Ground Pressure 42 ❑Pit Privy 13 ❑Seepage Pit o 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 C ( � Required (sq. ft.) Proposed (sq. ft.) (Gals/day/ q. ft.) (Min. /inch) Elevation /o � _5_ r Feet Feet VII Capacit TANK in allo Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Exist in strutted Tanks Tanks Septic Tank or Holding Tank boo r l00 0 l ❑ ❑ ❑ ❑ ❑ 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. Plu be 's Name: (Print) Plumb s Sig ature: ( 5 mps) P MPRSW No.: I Business Phone Number: Plum be / yAddre S reet, it , St Zip Code): -7- �© C e IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved SaI njitary Permit Fee (Includes Groundwater I ate Issued suing Agent Signature (No Stamps) Surcharge Fee roved i g 7° pp ❑ Owner G Initial �- � Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R.12I99) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS ' Ali Y.. 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 toinstallation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every to 3 years. If have questions concerning our onsite sewage system, contact 6. you a e uest o s co ce , our local code administrator or the State of Y q 9Y 9 Y Y 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. 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 sery ce; 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. ®, O �7 • d o VA a Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of J Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code Attach complete site plan on paper not less than 8'//2 13Ffies+a e. Plan must County include, but not limited to: vertical and horizontal r recce point'(BN�F ;direction and , percent slope, scale or dimensions, north arc 4 #act location and distance to nearest road. Parcel LD.# APPLICANT INFORMATION - P sip>~ e r `jt Pending p �pj lrmetlOn:: a iewed By . Date Personal information you provide may be used r °secondary purpasw ( cy Law S. 15 (1) (m)). `/ 1 to Property Owner r 9 P perty Location Lakes &Hills D evelopment G4 .Lot 7/4 NW 1I4,S 13 T 31 N,R 18 W Property Owner's Mailing Address - L # Block # Subd. Name or CSM# `,; i : ' 46 Pine Acres I State Zip t9de PhoneNumber ❑ Ci qe Mown Nearest Road ❑ New Construction Use: Residential / Number of bedrooms 3 ElAdditon to existing building -g ------- - ❑ Replacement ❑ Public or commercial describe Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpolft .8 trench, gpd/ft Absorption area required 643 bed, ft' 56 2 trench, ff Maximum design loading rate .7 bed, gpd/ft .8 tr ench, gpd/ft Recommended infiltration surface elevation(s) 95.0 ft (as referred to site plan benchmark) Additional design / site considerations Parent material- - - - - -- Flood plain elevation, if applicable -- -- ft S= Suitable for system I Conventional Mound In - Ground Pressure AT - Grade System in Fill Holding Tank U= Unsuitable for system N S U N S ❑ U ❑ S❑ U ❑ ❑ s❑ U ❑ S® U ❑ S M U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring# Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Bed Trench 1 1 0 - 9 10YR3/3 ------------ - - - - -- 1 lmsbk mvfr as if .4 .5 2 9 - 18 10YR4/3 ------------ - - - - -- I lmsb mvfr gw 1vf .4 .5 Ground 3 18 -33 10YR4 /4 ------------------ cl lmsbk mfr as - - -- .2 .3 elev 98.5 ft 4 33 -58 7.5YR4/4 ------------ - - - - -- cs osg ml gw - - -- .7 .8 5 58 -83 10YR4 /6 ------------ - - - - -- s o sg m l - - -- - - -- 7 ! 8 Depth to — -- — - -- -- - - -- -- — - - limiting fys ❑ factor -- -- — — >83" Z Remarks: 2 1 0- 9 10YR3/3 ----- - - - - -- 1 lmsbk mv as if .4 .5 2 9 -19 10YR4/4 1 lmsbk mvfr gw lvf .4 .5 Ground 3 19 -31 10YR4/6 ------------------ cl lmsbk mfr as - - -- 4 5 elev — 99.0 ft 4 31 -56 7.5YR4/4 ------------ - - - - -- cs osg ml gw ---- .7 .8 5 56 -89 10YR5/6 ------------ - - - - -- s osg ml - - -- 7 8 Depth to - limiting factor >89 �(s �`� Remarks: CST Name (Please Print) Signature: Telephone No. Jacque Hawkins '17Z - k y 9 S- Addness � Q Date CST Number Ref # U av-C �u�l� � }��13 4/12/00 Z. 419 40PERTY OWNER: Lakes & M11s Development SOIL DESCRIPTION REPORT Page 2 of 3 PARCEL I.D.# Pending Depth Dominant Color Mottles Structure GPD/fl? Horizon in Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. onsistence Boundary Roots Bed !Trench 3 1 0 -11 l 0YR3 /3 -- ---------- - - - - -- I 1 msbk mvfr as if .4 .5 2 11 -20 l 0YR4 / 4 ------------ - - - - -- 1 l msbk mvfr gw l of .4 .5 Ground elev 3 20 -29 10YR4 /6 ------------ - - - - -- c1 lmsbk mfr as - - -- 2 3 99.2 ft . 4 29 -50 7.5YR4/4 ------------ - - - - -- cs osg ml gw - - -- . .8 Depth to 5 50 -90 10YR5 /6 ------------ - - - - -- cs osg ml - - -- - - -- 7 8 limiting factor y , y >90 01 — — Remarks: 4 1 0 -10 10YR3 /3 ------------ - - - - -- 1 lmsbk mvfr as if .4 5 - 2 10 -20 10YR4 /4 ------------ - - - - -- 1 lmsbk mvfr gw lvf .4 .5 Ground elev 3 20 -32 10YR /6 ------------ - - - - - - c l Imsb mfr as - - -- 2 3 99.5 ft. 4 32 -57 7.5YR4/4 ------------ - - - - -- cs osg m1 gw - - -- 7 .8 Depth to 5 57 -93 10YR5 /6 -- ---------- - - - - -- s osg ml - - - - - -- .7 .8 limiting - — -- factor >93" Remarks: 1 0 -10 10YR3 /3 I lmsbk mvfr as If .4 5 5 ------------------ 2 10 -19 10YR4 /4 ------------ - - - - -- I lmsbk mvfr gw lvf .4 .5 Ground elev 3 19 -29 10YR4 /6 ------------ - - - - -- cl lm sbk mfr as - - -- .2 .3 99.5 ft. 4 2 -59 7.5YR4/4 -- ---------------- ---- osg ml gw - - -- .7 .8 Depth to 5 59 -95 I OYR5 /6 ------------ - - - - -- s osg ml - - -- .7 . 8 limiting -- - — factor >95 11 — — Remarks: Ground elev - - - -- - - -- ft. Depth to limiting -- -- factor Remarks: b = � N, 0 Qk I I _ _ W FROM : P C COLLOUP BLDRS, INC PHONE NO. : 715 549 5911 Jun. 05 2000 04:16PM P1 .. jury TX ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM i rr Owner/Buyer G ; j2� , M l, Mailing Address . /}2, S" 4: ) w _ Propaty Address (Verification required from Planning Department for new consttuction) City/State r` 1D arcel Identification Number 3 ! �Osy �OG� LEGAL DE$CRIPTiX Property Locatio %, LA /., Sec. l 3 T 31 N - W Town of .S AQ Pm/&(. E S ubdivWon FF-',� /�1� /� 1��" �' • Lot # _ Cerif led Survey Map # . Volume . Page # Warranty Deed # - —� .. _ Volume j 7 Page # , Spec houso yes ❑ no G -W yys Lot lines identifiable ycs ❑ no SYSTEM MAINTENANCE Improper use and matntenanoeof your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic task every three years or sooner, if needed by a ticenscd pumper. What you put into the system can affect the f motion of the septic tank as a treatment stage is the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a oettification form, signed by the owner and by a masterpbnnber, joumeymanplumbey restrietedplumber or a Hccmdptmgper verifying that (1) the on -site wastewaterdisposai system is in prom operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 113 hill of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards W tog* herein, as set by the Department of Commerce and the Depaztment of Natural Resources, State of wisconsin. Certifteation stating that your septic system bas been maintained must be completed and retumed to the St. Croix County Zoning Office within 30 days the ar lion te. /DO t3NA7,'M OF APP CAM' DATE 9 1. KK R'X')E r CATYON Y (we) certify that all statements on this form are true to fire best of my (our) lmowledge. I (we) am (are) the owner(s) of the sty d c a vc by v' a of a warranty dead recorded in Register of Deeds Office, l R5" SIGNATURE OF r.P CANT DATE e "ran Any information that is mis- represented tray result in the sanitary permit being revoked by the Zoning Department. *"9090 " 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 VGI. 1517P 624445 KATHLEEN H. WALSH Document Number Document Title REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 06 -07 -2000 4:00 PM WARRANTY DEED EXEMPT # CERT COPY FEE: COPY FEE: TRANSFER FEE: 74.70 RECORDING FEE: 12.00 PAGES: 2 Recording Area Name and Return Address 1 Oo t`kSl W e Sf' I t 1' f c qojd E SCraer 'ExiIe Salo v5e\ N-R ) 5 52; !0 O O sq - ' Parcel Identification Number (PIN) Q 3c6 ^� 0 5 — (,0 ^coo 0 This information must be completed by submitter: document title. name & return address, and PIN (if required). Other information such as the granting clauses, legal description, etc. may be placed on this first page of the document or may be placed on additional pages of the document. te: Use of this cover page adds one page to your document and 52.00 to the recording fee Wisconsin Statutes, 59.43(2m) WRDA 2/99 215-32 (2199) r ' Form No.9- M— WARRANTY DEED Minnesota Uniform Conve ancin Blanks 1978 Holstad & Larson, P.L.C. Corporation or Partnership to Corporation or Partnership VOL 1517PAGE 334 No delinquent taxes and transfer entered; Certificate of Real Estate Value ( ) filed( ) not required Certificate of Real Estate Value No. , 19 County Auditor by Deputy STATE DEED TAX DUE HEREON: $ (reserv for recording data) Date: May 31, 20 00 FOR VALUABLE CONSIDERATION, Lakes and Hills, Inc. , a Corporation under the laws of Minnesota , Grantor, hereby conveys and warrants to Kassel Construction, Inc. ,Grantee, a corporation under the laws of Minnesota real property in St Croix County, Wisconsin, described as follows: Lot 46, Pine Acres, St. Croix County Wisconsin "The seller certifies that the seller does not know of any wells on the described real property: together with all hereditaments and appurtenances belonging thereto, subject to the following exceptions: Easements, covenants and restrictions of record. Lakes and Hills, Inc.. By: 1tic6ardS Nelson Affix Deed Tax Stamp Here Its: President STATE OF MINNESOTA SS. COUNTY OF Ramsey The foregoing instrument was acknowledged before me this 31st day of May , 19 99 by Richard S Nelson, President and the and of Lakes and Hills, Inc. a Corporation under the laws of Minnesota on behalf of the Corporation NOTARIAL STAMP OR SEAL (OR OTHER TITLE OR RANK) DEBORAH L. TEICH SIGNATURE OF PERSON TAKING ACKNOWLEDGMENT NOTARY PUBLIC •MINNESOTA MY COMMISSION Tax Statements for the real property described in this instrument EXPIRES JAN.. 31, 2005 should be sent to (Include name and address of Grantee): THIS INSTRUMENT WAS DRAFTED BY (NAME AND ADDRESS): Kassel Construction, Inc. Northwest Title & Escrow Corp. 5765 — 213th Street N Suite #120 Forest Lake, MN 55025 3535 Vadnais Center Drive Vadnais Heights, MN 55110 59442