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HomeMy WebLinkAbout038-1166-70-000 Wisconsin Department of Commerce SEWAGE SYSTEM Safety PRIVATE ,and. Buildings Division County: INSPECTION REPORT S'f. C,& 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 T D Z $- Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: ?. c- Co L L -OVA `3u.� ��E2 s i P�F, PP.14 -IR-tE CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: tso .o do . S C C51 R 0 039 -- - - c1t3� TANK INFORMATION U ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 6 l b *;5AJ 0 I OD. p f Dosing BwL. *:t Z 1 D• TS7 ItO •'15' 1 co .0 1 Aeration Bldg. Sewer // 2.10 J oI8 .16 SS' Holding St/ Ht Inlet l� Z.3T IOga.`{Or TANK SETBACK INFORMATION St /Ht Outlet Z.'FS oOo• 30 TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet Air I Septic >'40 ' Z1 — NA Dt Bottom Dosing NA Header/ Man. lb-So qZ• 7 0 , .S � Aeration NA Dist. Pipe 1b C'2.$5 Holding Bot. System 103.g0 ] 4 1 x°0 PUMP/ SIPHON INFORMATION Final Grade Manu er Demand �j"r�e�t 1O. 0 � 1 O`I.aS Model Number GPM AIf.g� L° 9 tt0.$ 3.51 r TDH Lift Lriction m TDH Ft F emain Length Dia. Dist. To Well SOIL AB O RPTION SYSTEM s pj j _6 t4,4 BSB / Width r Length N renches PIT No. Of Pits Inside Dia. Liquid Depth D IMENSIONS 3 (o•Z l DIMENSION SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Man SETBACK f = - ( an , INFORMATION Type O j r _ CHAMBER odel Number System: Co�v 0 + 7 I0D OR UNIT Q DISTRIBUTION SYSTEM Header / Manifold Distribute e(s) x Ho ze x Hole Spacing Vent To Air Intake Length - ke Dia. Length Dia. Spacing / 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/Tr nch Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (include code discrepancl s, persons - present, etc.) T "�&'^ " 5(1 " �) A, . g °"^ Ywtta� S toj • *Wlelr, Z S� tk�r'0� c9tle" � � ( cf �SY Iy� � � �s�� L S� 14-i � n U 3 Wka u uu �v �Crs t1tiSPec[m++ Oc. Pin revision required? * 4G� Use other side for additional Inform tion. e3 0 0 ( ds - L2 11 SBD -6710 (R.3197) %jw or 's r `/ 1 �� / In ect's Si Cert. No. e O l AS l�T pX� 1C , ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: �. f t �.m 4- S €«. S fl i e m ° E I ' .- 1 T i z � � T_ �� � I r << P -aa0 35 x lob 7 Wi o a f ,. IN o ac' 3 c� s -r y Wicconsir, Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division Count St. Croix ' INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary tNo.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 370256 Permit Holder's Name: ❑ City ❑ Village p T n of: State Plan ID No.: P.C. Collova Builders Inc., Star Prairie Township CST BM Elev.:. Insp. BM Elev.: BM Description: Parcel Tax No.: 038- 1166 -70 -000 TANK INFOR ATION ELEVATION DATA TYPE ANUFACTURER CAPACITY STATION BS HI S ELEV. Septic Benchmark Dosing �` Alt. BM it Aeration l Bldg. Sewer 2 , Holding St /Ht Inlet a•3S TANK SETBACK INFORMATION St/ Ht Outlet 2 •� TANK TO P/ L WELL BLDG. '\ Intake ROAD Dt Inlet Septic y 0 a f r NA Dt Bottom Dosing NA Header an. Aeration A Dist i p ,{ p" Holding t. Syste 3 PUMP/ SIPHON INFORMATION Final Grad Manufactu Deman St cove X 9 0 Model Number PM T Lift Lriction S�r TD Ft F o We ain Length Dia. Dist. To e SOIL ABSORPTION SYSTEM ADIMENSI EN Width r Lengt No.Of renches No.Of Pits i e Dia. Liquid Depth DIMEN I N 3 SYSTEM TO / L BLDG WELL LAKE / STREA LEACHING ! 'n�?f��tur r: SETBACK CHAMBER INFORMATION Type O r odel Number: System: O ? 'L /�S r RUNIT _C' C4. ' C- DISTRIBUTION SYSTEM Header / nifolcl tribution Pi e(s) ole Size x Hole Spacing Vent To Air Intake Length x- Dia. th Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Syste Only / S� Depth Over Depth Over xx Depth Of xx Seeded / So ed xx Mulched Bed/ Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ N ❑ Yes ❑ No COMM/IN (Include code discrepancies, pe s pr nt,�t ) ns ect>on : D O ns ection Loca 1.) AlDescription 2 104th Street, New Richmond, 1 ' 5M 7 (N� 1/4 SW 1/4 28 T3IN R18W) - 28.31.18.799 Red Pine Estates - Lot 7 2.) Bl length - amount of cover = > I Plan revision required? _�K Yes ❑ No Use other side for additional information. SBD -6710 (8.3197) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: A £ E £ £ _ E £ s - -- - -- .� ro ,. � ..� ,� ...... � ��... w, . ...... ... �.a a f ( t s t i s i 6' .,� L' ,D ALE -- Safety and Buildings Division SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue Ais P O Box 7162 Department of Commerce In accord with Co fLAff �1 C Madison, WI 53707 -7162 Attach complete plans (to the county copy only) for thpater not iess.> county than 8 t/1 x 11 inches in size. ECE IVEO : 5 See reverse side for instructions for completing this ap to Sanitary Permit Number r Personal information ou rovide ma be used for seconda 2,000 i y p y ry purposes heck if resion to previous application [Privacy Law, s. 15.04 (1) (m)]. T C.4OX to Plan Review Transaction Number L APPLI ATION INFORMATI N - PLEASE PRINT � an Prop y / Owner Name r /" � Propert i Ci / , S g T 3 , N, R or) © Property Owner's Mailing Addres t d Block Number City, tate , Zip tode / Phone Number Subdivisi n N me or CS Number 9 5 Q7 -C- IL TYPE OF BUILDING: (check one) ❑ State Owned - Nearest ROa Public 1 or 2 Family Dwelling No_ of bedrooms Town OF r V 5 111. BUILDING USE (If building type is public, check all that apply) Ok" Parcel Tax Number(s) r1 p �,. 1 p �lyn /p i ,bo 1 E] 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. jM 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 [Z Seepage Trench ;�Q ! _ 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 5-��'' -` / 43 ❑ Vault Privy 14 ❑ System -In -Fill _ ✓��v� X y = 3/, " VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 15. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) ( Elevation © S 7J, Q f 3 Feet Capacit VII. TANK in Ca allo g Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin structed Tanks T nks Septic Tank 100Q ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plum s ame: (Print) Plumb�jgnatur : (N ps) M MPRSW No.: Business Phone Number: ©3 ? 7 /S -a6e Plumber's Address (Street City, 6"t Zip Code): IX. COUNTY / DEPARTMENT USE ONLY ❑Disapproved �Sanitary Permit Fee (includes Groundwater ate Issued ' Iss ntsi nature(NoStamps) ®Approved [ Given Initial Surcharge Fee) Adverse Determination �S 1 E47ZW X. CONDITIONS OF APPROVAL /REASONS FO D ISAPPROVAL: SBD -6398 (R.12/99) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber FNSTRUCTIONS. 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 Admin_istrattive 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 licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsi fe 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 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. Complete plans and specifications not smaller than 8 112 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 siring 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. ST. CROIX COUNTY ZONING DEPARTME AS BUILT SANITARY REPORT Owner C -- TON } Property Address O G � ,�, � City /State �t/�.t�r �`^ �"� 7 \ , Legal Description:. Lot Block E-to Subdivision/CSM # ` N/ '/a �' /a, Sec. d,9 T N -RAW, Town of A4"PIN # SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer , r Size ST/PC /0 Oa — Setback from: House f:L Well NIA P/L t620 Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: ly` / S ` cI?Vidth �_ Length 5 of Trenches 02 Setback from: House ,39 Well `t/ /R P/L -/ CQ Vent to fresh air intake ELEVATIONS Description of benchmark Elevation /DD Description of alternate benc ark Elevation Building Sewer ST/HT Inlet ST Outlet PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover Distribution Lines ( ) ( ) ( ) Bottom of System () () ( ) Final Grade O O ( ) Date of installation `l /O // O CPermit number 74 State plan number Plumber's ig ature License number c)o3S Date.3! / c Inspector Complete plot plan a' NOTICE Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. ,) � q0 VIEW - ` J 3' 13 . It I i INDICATE NORTH ARR a� .4 6� /00 /4 /, i s te-j /'V�j ,v isconsir) Department of Industry SOIL AND SITE EVALUATION Labor ant: Human Relations Page of t�ivisicn of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County 0 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. a., J0 APPLICANT INFORMATION - Please print all information. vi ed by �' - (; ,D Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). „ . (p Property Owner Property Location ..� ~r' rcl Govt. Lot 1/4S Ud 1 /4,S '' fkt,Ilf : R R ;f;r Property Owner's Mailing Add ess Lot # Bloc Subd. me or CS # ®, Ci Stat Zip Code Phone Number Ci Town Nearest Road / (�i ). ❑ � : f New Construction Use: Residential / Number of bedrooms Addition to existing building ❑ Replacement / ❑ Public or commercial - Describe: Code derived daily flow ` gpd Recommended design loading rate bed, gpd/fi gpd/ft Absorption area required <gZe ed, ft , `r � trench, ft Maximum design loading rate -, 7 bed, gpd/ft --,,y — trench, gpd/ft Recommended infiltration surface elevation(s) �, ft (as referred to site plan benchmark) Additional design /site considerations Parent material g ac,tAJ4,5`'/ 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 ® S ❑ s U [ZS O U [As El U ❑ S W U ❑ S f z U 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 f/7 _ C i Ground — — _. elev. �" , Depth to limiting facto in 6 3 Remarks: Boring # 011 FM 02 - Al r> Ground ft. Depth to limiting factor �n. Remarks: 1 17 CST Na a leas Prin I ) Signature Telephone No. Address Date CST Number SOIL DESCRIPTION REPORT PROPERTY OWNER Page of PARCEL I.D.# Boring Horizon Depth Dominant Color Mottles Structure 2 g Texture Consistence Boundary Roots - in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground _ elev. ' Depth to limiting 0 factor --- -- . _ 'yLp• 2 n �-� Remarks: Boring # J L7 Ground 1 elev. _ — �Fft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # , a / Ground X L - — — L;t elev. J Depth to limiting L factor- n. Remarks: Boring # Ground C ft. LA �� 9 Depth to limiting factor ' Remarks: SBDW -8330 (R. 08/95) r /� --%�. l ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer P C 00 /1 6 VA b R-0 Mailing Address 70:!� Qj . (ZW j -�,,,i 6 u 4o Property Address ) c (y'a " /d Z- %�''��,� (Verification required from Planning Department for new construction) �. City/State ynp RA Parcel Identification Number LEGAL DESCRIPTION Property Location Sec, o� 8 , T 3 / N -RW, Town of JI U r P,„ r i e . Subdivision _ 1��2 cx �( G _ `� TZi S Lot #_. Certified Survey Map # Volume , Page # Warranty Deed # l Volume 151 , Page # J Spec house ❑ yes )<no Lot lines identifiable' 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 licensed pumper verifying that (1) the on -site wastewaterdisposal system ism 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 birc year expiration date. SI A OF AP LICANT 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 p describ abov , by virtue of a warranty deed recorded in Register of Deeds Office. / 40 S NATURE 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 �O vo..1515 pm 552 62413 7 STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH Document Number WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., WI This Deed, made between Scott D. Thompson RECEIVED FOR RECORD 06 -02 -2000 10:00 AM _r -- - - - - -_ YW07Y DEED Grantor, and CERT COPY FEE: EXEMPT I P C. C011otra Builder Inc. COPY FEE: TRADER FEE 74.70 RECORDING FEE: 10.00 PAGES: 1 Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Lot 7, Red Pine Estates in the Town of Star Prairie, St. Croix County, Recording Area Wisconsin. Name and Return Address 038 - 1166 -70 Parcel Identification Number (PIN) This is not homestead prop". Ok) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this day of May 2000 ` • Scott D. Thompson AUTHENTICATION ACKNOWLEDGMENT Si btu E(s) STATE OF WISCONSIN ) - ) ss. — County ) authenticated this day of May 2000 Personally came before me this day of - . the above named • Kristin Ogland TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the person(s) who executed the foregoing authorized by § 706.06, Wis. StatsJ instrument and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY Attorney Kristin Deland Notary Public, State of Wisconsin Hudson, I S My Commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) Names of persons signing in any capacity must be typed or printed below their signature. Information Professional, company. Fond du tae. WI STATE BAR OF WISCONSIN 800 WARRANTY DEED FORM No. 2 -1999 -- - -- - - -• I1tiL'Iii37aw OF Dams rM t102 it p tea av / a vekd Iof Lclu Wow RUILusuu X$1 puBiq sam"Pod _ _ b T r� UNPLATTED LANOS w�wrww mow• �rw�i � �,�• T I,I0119 OF TINE KJA OF THE SWIM CW SECTION as y r ♦ V � • St r r a ' N/� r USL IC w .. is a. 1 �4I IQ • . � a , cow P R �? ST. CROIX COUNTY �= WISCONSIN ZONING OFFICE 4. 1 ST. CROIX COUNTY GOVERNMENT CENTER IIN IIIIIAII�IN� - - " °Nn� 1101 Carmichael Road • Hudson, WI 54016 -7710 " (715) 386 -4680 Fax (715) 381 -4686 March 8, 2001 P.C.CollovaBuilders Attn: Laurie 705 County Trunk E Hudson, WI 54016 RE: Septic Inspection for P.C. Collova Builders Inc. located at 1942 104th Street, Red Pine Estates (Lot 7), Star Prairie Township, St. Croix County, Wisconsin Dear Laurie: A septic inspection of the above referenced property was conducted on 09/01/00. This property is located in the NE 1/4 SW 1/4 of Section 28, T31 N R1 8W, Red Pine Estates (Lot 7), Star Prairie Township, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a three (3) bedroom home. If you have any questions regarding this, please contact our office at (715) 386 -4680. Sincerely, Kevin Grabau Zoning Technican /sm cc: file