Loading...
HomeMy WebLinkAbout038-1168-50-000 f Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division Coungi. Croix INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanita ,r.�RactrtitNo.: Personal information you provice may be used for secondary purposes [Privacy Law , p . 15.04 (1)(m)]. UG / b Permit Holder's Name: ❑ City ❑ i To of: State Plan ID No.: leifcher, Jared tat CST BM Elev..- Insp. BM Elev.: BM Description: Parcel.Taac I I I -50 -000 CSH , 0, I � Qwt.� l = hrc5� eke �r n USA 11 I TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. Septic Z,S.p Benchmark g, �0 1a8. D Ba . D Dosing Alt. B Aeration Bldg. Sewers o Z -SZ Holding St/ Ht Inlet ��/ 3 Ib I - Z - + I TANK SETBACK INFORMATION St/ Ht Outlet boo cro gyp' TANK TO P/ L WELL BLDG. Air I to ntake ROAD Dt Inlet i Air Septic ao f+ 3(, ` NA Dt Bottom Dosing NA Header / Man. � o Aeration NA Dist. Pipe 3!`3 . z' Holdin Bot. System PUMP / SIPHON INFORMATION Final Grade Manufac r man St cover 5 G Model Number GPM TDH Lift L fiction stem TDH Ft Forc ain Length Dia. Dist. To II SOIL AB RPTION SYSTEM LZ Bee RENC Width Length _ t No. f Tr ches PIT No. Of Pits Inside Dia. Li i th IMEN N 3 oZ DIMENSION SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING ` L- c rer: SETBACK i � -r INFORMATION Type Of CHAMBER r r Model Number. System: 1a Jr - ( OR UNIT - 0 . 0 DISTRIBUTION SYSTEM Header/Manifold .. Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake t Length Dia. ength Spacing S y 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 ❑ No �p MMENT ln I od d�cre a Iles , oca s r n ns ec ion ^ Ltton: 17 I �F 1�4t Newic�rnon 5�(75�/4 NW 1/4 28 T31N R18W) �8,31�18.815 Red Pine Estates -Lot 23 1.) Alt BM Description= 2.) Bldg sewer length = - amount of cover = 4 "' 2 K Plan revision required? []Yes % Use other side for additional information. o-: J++-H SBD -6710 (R.3/97) Date Inspector's Signature Cert. No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: E w_ . , a F F e _ ..,e �e e s 3 a i s � €, s x � � i" s e s 4 s i � 3 D ; i F 3 S f ? e C e e 3 S � F E i , a F s e k E P P i �,n,mr r J J , a pp Y t 2 � g � e ..., . . e — <. w .,... m,.. m� .. m ....... s € .....�. , , ®e ...... b ,..e x } { t " € E � L gg s ; a w_ F _Q� s I SANITARY PERMIT APPS. N S afety and Washington Division Vis 201 W. Washin ton Avenue t ! � � P O Box 7302 Department of Commerce In accord with Comm 83.05 iw� rrk,coid&. L,/ Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the sy �j, pa r t less`' <; ' C o my than 8112 x 11 inches in size. r? «c -�t'� C� • See reverse side for instructions for completing a I' 1 r �� fxa Sanitary Permit Numb p 9 this pp 9Dn t ' v `''� Personal information you provide may be used for secondary purposes ' k d S� � revision to previous application [Privacy Law, s. 15.04 (1) (m)]. I / j v� 1�,, /� � N to Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL {~ R N , Property O ner Na a ` `e c r ' �, PrV vLett d@U S T 3 , N, R 15R) W Property Owner's Maili Addr s f �� Lot u r Block Number A c_ N Cit ,State Zip Code Phone Number Subdivis N e or CS umber �C ( ) II. TYPE BUILDING: (check one) E] State Owned it Nearest Road 0 Vile Public a 1 or 2 Family Dwelling - No. of bedrooms Town of 1 t III. BUILDING USE (If building type is public, check all that apply) arcel Tax Number(s) 2(' 3 () P IS' t z (S Q h "l - 1...c1� U`- �g _0 U 1 F1 Apartment/ Condo f,s f 4,6'.V s C, "Ay l(; s 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nurs n Flo a 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 _ N{ New 2 E] Replacement 3. E3 Replacement of 4. E] Reconnection of 5. F] Repair of an ' System Tank Only Existing System Existing System B) [ 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 FSeepage Trench 22 ❑ In- Ground Pressure Z � X �� 1 42 [] Pit Privy 13 eepage Pit C J 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 Required (sq. ft.) P a ropose (sq. ft.) (Gals/da Aq. ft.) Min. /inch) Z� Elevation (Q ✓ '730 7 ✓ i V ' --' gPr Feet Qo7S Feet Capacity VII. TANK in Ca gallo s Total # of r Prefab. Site Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel glass App. New Existin structed Tanks Tanks Septic Tan I-H�enlr M,�Q ❑ ❑ ❑ ❑ ❑ Li tuber ❑ I ❑ I ❑ 1 ❑ 1 ❑ VI11. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for in ion of the onsite sewage system shown on the attached plans. PI tier's Name: (P In P I er's Sign ture: 0 Stamps) MP /MPRSW No.: Business Phone Number: - 1 1 S -. - 5145 Plum Ws Address (Stree City S ate, .p Code): J ' S N O IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Agent Signature (No Stamps) 'Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination Z �� D 9 04 X. CONDITIONS OF ,L APPROVAL / REA FOR DISAPPROVAL: yC [ 5 laver S !yule S l [7C f G- SBD -6398 (R. 4/99) 9 Y Y PY . �j, 0 l6 t� q •�`w t DISTRIBUTION: Original to County, One co To: Safet & Buildings Division, Owner, Plumber INSTRUCTIONS ' 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 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 naibe encimailing 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 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. J,cLreA. t �A, Ch 2�^ T yr �I� v� at 4i ti U isd= �' r r e., ST C�;Ic 72 �. Pao c 4 Z n-44 a1 ay C �t a mb>z �t Q 7.4 / 0 S7 A13 A �3 n\ \ • t ( {_ ` o 7 eat l o ,o i c 9' o J C S t .1 l G a�anu� — cti a : c E o n n E - o ,-- cr) L C > C x (0 i O CL . g V D t Co E�ac. x 0) ro 3 - 0 L N CU c U co r >,cn3� oc o t 0 ) Tu . 2 ! D 0 o c v 0 WV — j2 i " o� rocn -- r E `° x ro O.Ocd�c� U LL a) v V) L �� Z a • • • • ;. C 1 I a.. N 1 rn co E r L.. D v i —° ZZ cu C3 0 N LL LL CCS v O) N N T) , 3 WisconsinDepartment of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3 -Labor and Human 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. Cro'X 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. Cn B k `sd APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION rMi BY DATE //' & PROPERTY OWNER: PROPERTY LOCATION Mike B allard GOVT. LOT SW 1/4 Nod 1/4,528 T 31 N,R 18 Nor) W PROPERTY OWNERS MAILING ADDRESS LOT # I BLOCK # I SUBD. NAME OR CSM # 1050 Curtis St. #1 23 na Red Pine Estates CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE JgOWN NEAREST ROAD Baldwin, WI. 54002 (71-9 684 -5423 Star Prarie I 104th. sT. [x] New Construction Use [x] Residential / Number of bedrooms 4 [ ] Addition to existing building I ) Replacement [ ] Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate • 7 bed, gpd /ft trench, gpd /ft Absorption area required 858 bed, ft 750 trench, ft Maximum design loading rate • 7 bed, gpd /ft - 8 trench, gpd/ft Recommended infiltration surface elevation(s) 98.72 , ft (as referred to site plan benchmark) Additional design / site considerations alt. area system el.= 97.95' Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem 1 ®S El ®S ❑U 1 ®S El [2S El ®S ❑U ❑S ZU SOIL DESCRIPTION REPORT Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft .................. in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Twich ................. ......._........... ................. ...' 1 0 -6 10yr 4/3 none 1 2msbk mfr gw 2f .5 .6 2 6 -24 10yr 4/4 none sicl lcsbk mfr 9w if .2 .3 Ground 3 24 -88 7.5 r 4/6 none ms osg ml na na .7 .8 elev. 10 3.05 ft. Depth to limiting factor +88" �� u Remarks: Boring # 1 0 -11 10 r 3/2 none 1 2msbk mfr gw 2f .5 .6 "? 2 2 11 -30 l0yr 4/4 none sicl lcsbk mfr gw if .2 .3 Ground 3 30 -84 7.5 r 4/6 none cos osg ml na na .7 .8 elev. 10 1.95 ft. ` rry Depth to , limiting ou " f f a c tor +84" Remarks: st c Nil E CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200 Address: 1554 200th. Aye., New Ric mo I 5 / Signature: Date: 11 - - CST 8 ti' PROPERTY OWNER Mike Ballard SOIL DESCRIPTION REPORT Page 2 of 3 PARCELI.D. Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 4...3.... 1 0 -12 10r32 n 2 12 -14 10 r 4/4 none sicl lcsbk mfr qw if .2 .3 I Ground 3 14 -88 7.5 r 4/4 none cos osa ml na na .7 .8 elev. 1 Depth to limiting factor 2 +88" Remarks: Boring # 1 0 -12 10 3 4 2 12 -80 7.5yr 4/4 none ms osg ml na na .7 .8 Ground elev. 1 Depth to limiting factor +80" Remarks: Boring # 1 0 -8 10 r 3/ none 1 2msbk mfr Qfw 2f .5 .6 2 8 -30 10 r 4/4 none sicl 2msbk mfr qw if .4 .5 Ground 3 30 -80 7.5 r 4/6 none cos os ml na na .7 .8 elev. 1 Depth to limiting factor +80" Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(8.05/92) STEEL'S SOIL SERVICE Gary L. Steel 1554 200th Ave. CSTM2298 MIke Ballard Now Richmond, WI 54017 MPRSW 3254 SW4NW4 S28- T31N -R18W (715) 246-6200 town of Star Prarie lot #23 -Red Pine Estates I T N 1 BM.= base of elec. transformer % el. 100' Alt. BM.= top of tel. ped. C el. 101.75' .4/ J� �h% , A- I Gary L. Steel 11 -7 -97 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address 1'7 A)ze2 � �mp, Si[ ©!� Property Address AA ,, (Verification required from Planning Department for new construction) City /State IL e,12 IL- IL—Lid Parcel Identification Number g — < < (Og Sy -- -dO LEGAL DESCRIPTION Property Location SLO ' /4, N om ' /, Sec. , T_3LN -R_L!�'_W, Town of = � �irYc'++ Subdivision QUA P Iola_ C�_.5� Lot # �. Certified Survey Map # , Volume , Page # I Warranty Deed # = _� o r� �{ (S �L , Volume ISKO , Page # 3 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 master plumber, journeyman 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. 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 b the Department of Commerce and the a a R esources , State of Wisconsin. Certification Y P Depar tment of Natur R s , 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. S NATURE OF APPLI ANT DATE OWNER CERTIFICATION 1(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. L2 / 131 OZ7 S NATURE OF APPLI ANT 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 DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1 - 1982 WARRANTY DEED 62415 KATHLEEN H. WALSH Vo l. REGISTER OF DEEDS . �� PAC E ST. CROIX CO., WI RECEIVED FOR RECORD This Deed, made between 06 -02 -2000 1:45 PM 7T, �7 WARRANTY DEED Grantor, EXEMPT II and CERT COPY FEE: _ £' I `. �, =- COPY FEE: TRANSFER FEE: 71.70 /� RECORDING FEE: 10.00 Grantee, PAGES: 1 Wit esse l hat the said rancor, f9 r a v able/consider ti n RETURN TO c? < conveys to G ntee win Ve4 log deskbed real estate In c Z l /D t?0 u si re RD G ix County, State of Wisconsin: c L C / I Tax Parcel o: t�3 This �s �� homestead property. (is) .0s r(ot) Together wi all and singu_l r th �}e ereditments and appurtenances thereunto belonging; And ` '/n / rN Z` 1 -1 111 -- warrants that the title is good, indefeasible in fee simple and free and clear o encumbrances except n and will warrant and defend the same. Dated this day of 4 '� `�• (SEAL) – - _r�Y�l�} n - {SE AL) (SEAL) JEANEEN Notary Public St011f Of sim AUTHENTICATION ACKNOWLEDGEMENT Signature(s) STATE OF WISCONSIN ss. o / X - County. S"r Personally came before me this 3 day of authenticated this day of , 19 rn cLL' 00 L' the above named F r rn 1i h 0 t tc-k e-�– TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the person who executed the authorized by § 706.06, Wis. Stats.) foregoing instrument and acknowledge the same. THIS INSTRUMENT AS DRAFTED BY // Notary Public S 6- - C w x County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: – o 'Names of persons signing in any capacity should be typed or printed below their signatures. & A RRANTY DEED STATE BAR OF WISCONSIN WISCONSIN REALTORS@ ASSOCIATION anDRA Aln i - 1 000 Aan1 Wow— P—A LA -Cenn wicr —in r170A 400 440 00 I S 14 q I g I I ti 10 16 807 8060 �.," 13 I 803 802 S"D i I r. R S ae. 17 gE _ � EET_ _S ., s (9 fb NW 4 1 �/ l/4 - N W 1-14 9,_. aa7b. /' 311,3 815 \\ 8 4 801 g 8 � 24 •b i 800 � � ei� 816 G3 �: SOLD 810 1 f 1 ~ 22 / 440 rea le' , 814 SOLD 19• Am 811 21 8 20 812' SOL OLD I 474 a sew uw •4 v. 798 g � 795 N - , � I 2 784 797 i o soe e 4 e 796 7 3 I 91' 4 �. 345.49 3,4b.42 C .. 5. M. VOL. I PAGE I I5 4BP 10 S Ohl 1 1 9 .1 SOLD 9 s dil Lo I LOT 2 1 LOT 3 LOT 4 _ J _ _ - lfl Na - i IQ f \ 3113 C(":Ln Z