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HomeMy WebLinkAbout040-1242-80-000 Wiscofisin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety 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)]. 370210 Permit Holder's Name: ❑ City ❑ Village ❑ ) Jown of: State Plan ID No.: Hartne Shawn Troy Townshi CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: l a S /7 S 040- 1242 -80 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic p r l vvd Benchmark p os n Alt. BM S I'd 7. Aeration - Bldg. Sewer 2 • Z C'0 2S' Holding Ht Inlet Z (� /0� S' TANK SETBACK INFORMATION Q/ Ht Outlet Z, / TANK TO P/ L WELL BLDG. Air I to ntake ROAD aubm Air Septic fi s 2 i 3 Z NA NA Header/ Man. T/ 4, oZ• Aeratio N Dist. Pipe r5' 102. 3 olding Bot. System 60 t ( 1. jOU. PUMP/ SIPHON INFORMATION Final Grade k anu _ mand St cover G r Model Number GP TDH I Li Friction Syst TDH Ft H For main Length Dia. Dist. To Well SOIL ABSO PTION SYSTEM P G� BED / ENCH Width Le th No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIME 3 . Z I DIMENSION SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manuf ctur INFORMATION Type of BE odel umber: System: o Z y t / = NIT IT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length —;ice Dia Length S� Dia. /1 11 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 /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: jp /flee) Inspection #2: Location: 526 Trillium Lane, Hudson, WI 54016 (SW I/4 SE 1/4 3 T28N R19W) - 03.28.19.1237 Countrywood Addn. II - Lot 79 y( / 1.) Alt BM Description= LS& deer 2.) Bldg sewer length = z P ' - amount of cover = > / e" 3�)1 . � el 4 � /li 11111 41e Plan revision required? ❑ Yes E No Use other side for additional information. 1 (d y , SBD -6710 (R.3/97) Dat Inspec 's Signature Cert. No. k r ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: a t e e � C � e _ . r E 3 3 _. ..__. �. ___� ....... ... E e E E e E °s — 3 Safety and Buildings Division NVisconsin SANITARY PERMIT APP t A TION 201 W. Washington Avenue P O Box 7302 Department of Commerce In accord with Comm 83.05, *is. Adm. Cod*? Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on_ papier npt less- ; county , than 8 1/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number y ou p rovide may be used for seconds p v 3� u O Personal information Y P Y second purposes ; S heck if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. x)uNT , .' ate Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF ON i "l Property Owner Name Prope NEV11i C, /�/�.� n eft S T 2 f' , N, R / �j 0 (or)W 4, Property Owner's Mailing Address Block Number 6 � rd Lcc 7 -� City, tate Zip Code Phone Number Subdivision Name or CSM Number / a5r: $ V (q25 ) 2 o -S�q U 44 J12 rn Lt/do cl :� 4dd�► II. TYPE OF BUILDING. (check one) ❑ State Owned 0 ✓ It Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms Z Town OF o t (� r`4C 1 4, 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) O3, o2Q, / , 7. 1 ;2-3 7 1 ❑ Apartment/ Condo L "') q , /2y 0 _00C, 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 8, if applicable) A) 1. M 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 E4 Seepage Trench 22 In- Ground Pressure 42 ❑ Pit Privy 13 F Seepage Pit �/ 43 ❑ Vault Privy 14 E] System In - Fil l 1 ?l L . i , Hv L A u j, c , 5 — ?2 -:2 �( 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 /sq. ft.) (Min. /inch) Elevat'on `l 6L 3 5 ? 2 .41 1 11 l Feetl loq Feet Capacit VII. TANK in Ca gallons Total # of Prefab Steel A Site . Fiber- Plastic p INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- glass A New Existin structed Tanks Tanks Septic Tank or Holding Tank j & ett c wt C9 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamberl I ❑ 1 ❑ 1 ❑ I ❑ 1 ❑ 1 ❑ Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plu er's Signs u : (No Stamps) /MPRSW No.: Business Phone Number: Plumber's Address (Stre ity, State, Zip Code . w , I G 4i j) h G �V 1 t {s' 5 (G L cl IX. COUNTY / DEPARTME USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issu'ng Agent Sign ure (No Stamps) Approved C] Owner Given Initial Surcharge Fee) / Adverse Determination E - 2_wD X. C�O�NDIT NTOF APPR AL / REA ONS F,911 DISAPL: ROV n^ a(�f''L camas - u cis SBA -6398 (R. 4199) Ols IBUTION: original to County, One copy To: Safety & Buildings Division, Owner, Plumber t 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 aSanitary 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 onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, -608- 266 - 3451. 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. 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 practiceswhich can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. S� Q w'n 14;rtneti 1�2e� �3 ��z Sz4"► /'YI►' 223�1 1x 193 St L 4rt Hcj MN �s U3 3 v Cogor2y d 2 1 ) ; toL' 7 C tc, wh G t R V Y 3 - r3,d 1'('��w. u -lokf = qoo d�1 �'E Ib' F.V/'A* c 44'nAc�s : 3►,� -��� : s"�2.24i Ira. /7 a '" r 3 fvf�U bat W► crrti� SG,pt�'c Laa k u�L s s, El la! G 3 4614 � yo , 1 r c 0v f ���� S4 i' r _J r f3 `� 13 s �i� ill ►' u �► L:N, . _ .�_.� __ _ Wisconsin Depart SOIL AND SITE EVALUATION REPORT Page I of 3 Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY St. Croix Attach complete site plan on paper not less than 8 1/2 x 11 inches in size a�i'Y ti *616:6, Wt , ; not limited to vertical and horizontal reference point (BM), direction and pe sale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. < 1 / *` r ' pendin APPLICANT INFORMATION- PLEASE PRINT ALL INFORM VIEWED BY DATE PROPERTY OWNER: PAIJOERTY LOCATION Richard Stout �� GOVT.;L ©T 1/4 ` 1i4,S 3 T 28 ,N,R 19 1 (or) W PROPERTY OWNERS MAILING ADDRESS ` S LOT # C CK #• S ',NAME OR CSM # 1353 Awatukee Trl. 7g na ;do try Wood Second Addn. CITY, STATE ZIP CODE PHONE NUMBER O)TY [] ' � � VILLA OWN NEAREST ROAD Hudson, WI. 54016 (715) 549 -6731 F !'tmy Tower Rd. New Construction Use �c ] Residential I Number of bedrooms 3 [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate • 7 bed, gpd /ft2 - 8 trench, gpd/ft Absorption area required 643 bed, ft2 563 trench, ft Maximum design loading rate • 7 bed, gpd /ft •8 trench, gpd/ft Recommended infiltration surface elevation(s) 101.10 ft (as referred to site plan benchmark) Additional design / site considerations alt site system el. = 100.27' Parent material pitted outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem ®S ❑U ❑S 13U ®S ❑U 0 ElU ®S El ❑S flU 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 Tmr& 1 -12 l.0 r3 3 none 1 fill -- -- -- -- -- ' 2 12 -27 10 r4 4 none sicl m na ~w I na ,2 . Ground 3 27 - 84 7.5 r4/6 none cos OSC4 mvfr na na 1-7 .8 105 ft. Depth to limiting 'tor 01. 0 Remarks: Boring # -> 1 -6 10 r2 2 none 1 fill -- -- -- -- -- `' 2 -13 10 r2/2 none 1 lmsbk mfr QW if .2 .3 Ground 3 13 -22 10 r4/4 none Sicl lmsbk mfr Aw na -rt .3 103 e le v. it. 4 2 -80 7.5yr4/4 none cos os mvfr na na .7 .8 Depth to limiting B factor +80 Remarks: CST Name: Please Print Phone: Gary L. Steel 715 - 246 - 6200 Address: 1554 200th. Av . , New Richmond WI. 54017 m02298 Signature: p Date: 8 -13 -96 CST Number: �Z". PROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Page 2 of 3 PARCEL I.D. # pending Lot #79 Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench U 1 0 -16 10 r2 2 none 1 fill -- -- -- - -- 2 1 16-24, 7.5 r4/4 none scl 2m r mvfr QV if .4 .5 Ground 3 124 7.5 r4 6 none co elev. 104 ft. Depth to limiting factor Remarks: Boring # 1 10-28 10 r2/2 none 1 fill -- -- -- -- -- 4 2 1 28-50 10Zr4 4 none sil 1 Ground 3 1 50-96 7.5 r4 4 none cos os mvfr na na .7 i.8 10 e5�1 ft. Depth to limiting factor +96" Remarks: Boring # 1 1 0-16 10 r2/2 none 1 fill -- -- -- -- ' -- 2 1 16-27 10 r2 2 none 1 lcsbk mfr Uw if .2 :.3 Ground 1 27-40 10 r4 4 none sicl lfsbk mfr n .2 .3 elev. 4 7.5 r4/4 none cos 0Sq mvfr na na .7 .8 10 ft. Depth to limiting factor +801, may( Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(R.05/92) STEEL'S SOIL SERVICE Gary L. Steel Richard Stout 1554 200th Ave. CSTM2298 SW4SE4 S3- T28N -R19W New Richmond, WI 54017 MPRSW 3254 town of Troy (715) 246 -6200 lot #79- Country Wood Second Addn. ✓N ✓BM.= top of SE lot stake C el. 100' Y` GAry L. Steel 8 -13 -96 •May 19 00 03:26p Hudworth Homes 1 -715- 396 -7996 p•2 ReMhed: WMWOD 12:46 PM fmm: i715asugge To: 42ST905M !�! fame by aMq. FNa. AFSX,asel Page: 2 012 May 19 �0 12:52p Hudworth Hoaws 1-715- 385 - ?996 p_2 S1D = TANK )sRNII�VM4ANM AGR AND OWNUMW (=TIKCRTM FORM / O*nankw T /• M� �'�273 � 1� W* A 3L� 14- P, Add" dsa• (V,mfi aelob aon► ryem>Rnap. "�• cioa� A ed s o _ Bamsl Idea Sftf ea N=W - - — cat r Ces'tl!" girvoy 1bp #1 S�Sr4 33 `( vohm _--- t'!oe M -- q 25 ..nor r Spec bom 0 yu �Xuu Lot UM awt out) ria 13 ro bwapffm ae ywwp& g OVA oemn is la wasaa woe b bsuftwas m, pwpamat 000aa� d die $%* tale slay dales yea. at boa w. it w"by a ticMW Pte. WW Pv r m't'a "W m am aw the s 1, eos va p in dK *am &pow 0" JU pmep q owner R OM* to aaldl b OL Qob Z4069 a ,! a 6M "'a0vdsr.+ by M COW Old W asulwpllYa+ se�e�l a.l pl�a�r °`abiesrhdFrmPerwrityteitMt� )>Ae+�asiu �, Mz�a�e'ecmdk�aa a�c�speednaas Nl � �'� �o rd� et�i+� u.e.'die tiara ieea so � W � w ®aahw tbs pefndeae�ye 1 '�'� fbe waMnb ea rook brleiLesmbysicDgArftO nrolflo== wVWaaddwDspowtofM"Wlusone'w^ Vr so8ymrt yeetaepae :l MtioeR>asrlaarmodmw d+stroed MeEitlebr Z-Mg 10 dw / PAT ssbmr= cr AnWCWr OWN / (we) our* Mee elt oo iDia [arm M au m du boat of MY C00 ��• er i ( � ° >'`` °"""(') above, by vk2w of a vacrmaty deedteeaue$ aeb�°. at Da.d� Odbe. WWA ...y.� ...,..4 pATB r. } vdm iw a aausprd varaoopt doef p am , ltepear et Do etru : oepy d Ibe oati9alawrveX me f it�*lsa°°° b n�ads dwd VOL 1513PAGE 425 STATE BAR OF WISCONSIN FORM 2 - 1998 623624 WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS ST, CROIX CO., WI Document Number RECEIVED FOR RECORD This Deed, made between 05 -25 -2000 9:30 AM RICHARD Q STOUT WARRANTY DEED Grantor, EXEMPT D CERT COPY FEE: and SHAWN T HARTNETT and AMY R- HARTNETT , COPY FEE: hu-hand and wi fe, TRANSFER FEE: 170.70 RECORDING FEE: 10.00 PAGES: 1 Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St: Croix County, State of Wisconsin: Recording Area Lot 79, Plat of Country Wood Second A ddit ion, Name and Return Address Town of Troy, St. Croix County, Wisconsin. EAGLE VALLEY BANK, N.A. 1301 Coulee Rd., Unit 2 Hudson, WI 54016 040 - 1242 -80 -000 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Exceptions to warranties: easements, restrictions, rights -of -way and covenants of record. Dated this 1 s t1. day of May 2 0 0 0 ►�l� • sh � (SEAL) (SEAL) * Richard O. Stout (SEAL) (SEAL) * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. St — 1'roix County. authenticated this day of Personally came before me this 1 8th day of May , 9 0 0 0 the above named Richard-0 Stout * TITLE: MEMBER STATE BAR OF WISCONSIN ^I to (If not, me known to a ted the foregoing authorized by §706.06, Wis. Stats.) instrument and ac�V12�'fh� s"dmt'' THIS INSTRUMENT WAS DRAFTED BY Janet P. Stout 1 353 Awatukee Tr Hudson, WI 54016 Notar Public, State of i consin My ommis is per anent. (If not, state expir tion date: sfo (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. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. WARRANTY DEED FORM No. 2 - 1998 Milwaukee, Wis, Ss o i - / /68 01 ESMT. / T. ®,N M j N j N 3 ' c o /' 83 "— 84 2.01 ACRES o 2.75 ACRES ., \ / /S , 87,639 SO. FT. p N 119,679 SO. FT. / 94 O� J / V / O 1.92 AC. EXC. ESMT / \ / 67, 639 SO. FT. G / S64 8 6 � 2 00, ac 30, 49 /9 v Ic n O 150.00' /� �� / j 25.40' 240.00' 345.40' aN O'/ 230.00' ti /® 2.15 ACRES S85 °25'52 "E 93,866 S0. FT 495.40' 6 . / 2.03 AC. EXC. ESMT. / 88, 381 SO. FT. LU / N, in 78 e ` N M < o O SQ.T. 2.51 ACRES 109,130 SO. FT. Z w IV N62 22, 36S O p 2.13 AC. EXC. ESMT. ID K j 92,758 S0. FT. \ \ O 933 z 3 32 00 0 , \ ii__ 3 ' t4' P � � 6 .36, � HWL = 1041.0 SKETCH , 8 A) 4 �- - --.�- EERWID DR. ^ 041, y 16