HomeMy WebLinkAbout040-1262-30-000 Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Per sonal inf ormation you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 353342
Permit Holder's Name: ❑ City ❑ Village ❑ >wn of: State Plan ID No.:
Troy Township
CST B Elev.:- Insp. BM Elev -: BM Description: Parcel Tax No.:
r�0 . Z) T m Z) 6k S��CsZ = CST g "\&*- pending
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark '
p 1 ZS� .0 1 10.0Z I CRD,0
Dosing Alt. BM L- .90 Imo. { Z
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet
Air I
Septic t z `� , NA Dt Bottom
Dosing NA Header / Man. 10-
Aeration NA i Ipe — j' u ps p 9'$.3 }
Holding Bot. System 12.x.{ fl. e `�� �
PUMP / SIPHON INFORMATION Final Grade S te' 103. s
Manufactur 2 and r
St cover 6 I o3
Model Number G M
DH Lift L oss ric ' n System TDH Ft ead
Forcemai Length Dia. Fi Est. To welt
SOIL ABSORPTION SYSTEM
VfO TRENCH Width r Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN 3 _Sl .wj 2 DIMENSION
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
CHAMBER DI (.J (L
INFORMATION Type Of Mode Number:
System: V, S� > T OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold t_( Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length QQ— Dia. L Dia, Spacing 40 +
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 E] No E] Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1:Q'P 19 /00 Inspection #2: -- - - t
Location: 424 New Century Drive, Hudson, )VI 54016 (NW 1/4 SW 1 /4 5 T28N R1 9W) - 5.28.19. Frontier -Lot 3
1.) Alt BM Description = 7 h(.-J, 1011
2.) Bldg sewer length= Z q
u
- amount of cover
i Plan revision required? ❑Yes � No H+tt -�l
Use other side for additional information. 01' IBS oci f `S
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
qZ X� CEC�c b 2
Safety and Bui;dings Division
Vi sconsin SANITARY PERMIT APPLICATION 201 W. Washington Avenue
P O Box 7162
Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7162
• Attach complete plans (to the county copy only) for the syste ci*,paper'iipt s County
than 8 1/2 x 11 inches in size.
• See reverse side for instructions for completing this appl alion � tate Sanitary Permit Number
35
Personal information you provide may be used for secondary purposes ( OlCheck if revision to previous application i
[Privacy Law, s. 15.04 (1) (m)]. I F a R
. r n State Plan Review Transaction Number
1. APPLICATION INFORMATION -PLEASE PRINT ,INS R . N 1
Pro erty Owner NA,me , y Locat n
0� T , N, R E (or)
PLOperl y Chiv J's �ng Address j � ,. t Number \ Block Number
C , State Zip Code Phone Number me or CSM Number
0 > Z7 46 iilt4 N ti 4&
I. TYPE OF BUILDING: (check one) ❑ State Owned c ity [ Near . , st Road
❑
Vi
Public 1 or 2"Famil Dwelling - No. of bedrooms T OF t'U D ;a
III. BUILDIN USE: (If building type is public, check all that apply) Parcel ax Number(s)
1 ❑ Apartment/ Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Ho 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 Q 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. bgNew 2. Q Replacement 3. Q Replacement of 4. E] Reconnection of 5. E] Repair of an
System _______
System Tank Only______________ Existing System ________ ExistibgSystem
_____________
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
I M Seepage Trench At µ 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit ,% J;L IN fL 7`�t.�'� a2 X 75' 43 ❑ Vault Privy
14 Q System -In -Fill 3 a$ � T 2 Y -C R s
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate System Elev. 2. Final Grade
r Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
`Q 0® �� `.."""` 4 ?7� eet Feet
VII. TANK Capacity Site
INFORMATION in gallons Total # of Manufacturer's Name Prefab. Con Fiber- Pla ktic Exper.
Gallons Tanks Concrete Steel glass App.
New Exist in structed
T nks Tank
Septic Tank or Holding Tank El El
Lift Pump Tank /Siphon Chamber 1 ❑ 1 ❑ ci I ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans
Plumber's Name: (Print) Plumbers Signature: ( o Stam MP /MPRSW No.: Business Phone Number:
I k / x =2 3 Sal 49
Plumber's Address (Street, City, State, zip Code): a t'
IX. COUNTY / DEPARTMENT USE ONLY
Q Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
Qpp ❑Owner Given Initial
A roved Surcharge Fee)
��^^ ,,—
Adverse Determination o I ZB —Z60D
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -6398 (R.12/99) DISTRIBUTION: Original to County, One copy To: Safety & 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 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 -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.
IL Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
Ill. 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.
V Responsibility tatem nt. installing lumber into fill in name license number with appropriate refix e. . MP etc.
111. s a g p p ( q ),
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 follawi'ng' 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 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 ff t
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
Ill = too. ' Sccx 1, : L -
d — rk 5..1XyS
y 13F0kOd,4
*
q Y NE
L OT
#
Lo '� Z
6� .1
SG ��D
3 �,
1Nisconsin Department ofCommerce SOIL AND SITE EVALUATION Page 1 of 3
Division of Safety and Buildings in accord with Comm 83.05, W is. Adm. Code
AC.E. Sod Bc Site Evaluations
Attach complete site plan on paper not less than 8'A x 11 incites in size. Plan must minty
include, but not limited to. vertu and honzor W reference pant (BM), direction and St. Croix
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D.#
7 Prt of 040 - 1022 -10 & 040 - 1021 -90
APPLICANT INFORMATION - �` `
e>�se a�tformation. viewed gy Date
Personal information you provide may ~ secondary purposes (Privacy Law. s. 15.04 (1) (m)). _ , Z OVp
Property Owner 7 r^. 'o Property Location
Miller Sam 7 Govt. Lot NW 1/4 SW 1/4 S 5 T 28 N,R 19 W
Property Owner's Mailing Addr r -? i Lot # Block # Subd. Name or CSI#
P.O. Box 151 — 1 ' -" 3 Plat Of Frontier
City to Zips neNumbec;; ❑ City ❑ Village ®Town Nearest Road
Hudson 38b2 69 Troy Tower Road
® New Construction '
=rl- tialuht of bedrooms 4 ❑Addition to existing building
Use:
Replacement ' c!i raal describe
Code Derived daily flow 600 gpd Recommended design loading rate .7 bed, gpdff .8 trench, gpd/ft
Ab_sc QW area required 857 bed, fl? 750 trench, ft= Maximum design loading rate .7 bed, gpolffz .8 trench, gpdffl
Recommended infiltration surface elevation(s) 97.25' ft (as referred to site plan benchmark)
Additional design 1 site Considerations Site has been cut to provide fill for road construction. Install trenches using high capacity infiltrators.
Parent material Glacial outwash Flood plai n elevation, if applicable NA ft
S- - Suitable for system Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank
U= Unsuitable for system ®S E] U ® S❑ u ® S❑ U ®S ❑ U El S M U El S® U
SOIL DESCRIPTION REPORT
Horizon
Depth Dominant Color Mottles T exture Consisten Boundary Roots Structure GPD/ft
;
Boring# in. Munseil Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 1 0 -12 10yr3 /2 None A fill NA NA as - NA i NA
2 12 -50 10yr5 /4 None s 0 sg dl gw - 0.7 0.8
Gro 3 50 -125 10yr6/4 None s & gr 0 sg dl - - 0.7 0.8
103.68 ft
Depth to
limiting
factor ar 4l.Zc-
>125' AA - A AR t s a{
Remarks:
2 1 0 -10 10yr3/2 None A fill NA NA as - NA NA
2 10 -46 10yr5 /4 None s 0 sg dl gw - 0.7 0.8
Ground 3 46 -122 10yr6/4 None s & gr 0 sg dl - - 0.7 0.8
elev
101.98 ft
Depth to
limiting
factor 5 6 . . WG
>122'
Remarks: _
CST Name (Please Print) Signature: Telephone No.
James K. Thompson
715- 248 -7767
Address A.C.E. Soil & Site Evahtations Date CST Number Ref #
340 Paulson Lake Lane, Osceola, 54020 12/31/1999 3602 1151
PROPERTiOWNER: Miller Sam SOIL DESCRIPTION REPORT 115 Page 2 of 3
'PARC17- LDJ Pit of040- 1022 -10 & 040- 1021 -90 A.C.E. Soil & Site Evaluations
Depth Dominant Color Mottles Texture Structure sistenoe Boundary Roots GPD&
Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz Sh. Bed Trench
3 1 0 -6 10yr3/2 None A fill NA NA as - NA NA
2 6 -50 10yr5 /4 None s 0 Sg dl gw - 0.7 i 0.8
Ground
elev 3 50 -118 10yr6 /4 None s & gr 0 Sg dl - - 0.7 0.8
102.25 ft
Depth to
limiting
>118* R�
Remarks:
4 1 0 -10 10yr3 /2 None Sl fill NA NA as - NA NA
2 10 -51 10yr5 /4 None s 0 Sg dl gw - 0.7 0.8
Ground
elev 3 51 -82 10yr6/4 None s & gr 0 sg dl cw - 0.7 0.8
98.05 ft 4 82 -119 10yr6 /4 None s 0 Sg dl - - 0.7 0.8
Depth b
limiting
factor
>119"
Remarks:
5 1 0 -12 10yr3 /2 None Sl fill NA NA as - NA NA
2 12 -62 10yr5 /4 None s 0 Sg dl gw - 0.7 0.8
Ground
elev 3 62 -116 10yr6 /4 None s & gr 0 Sg dl - - 0.7 0.8
101.67 It
Depth to
limiting
factor
>116"
Remarks.
Ground
elev
Depth to
limiting
factor
Remarks:
P . 34 - 3
• �i�o�Dbsed ,�
• 31767 -
t
A656coled a /eV = /oa. 4Z
� ■ \ ■ � ♦ E /evE�; ors
IQC/�
5y Area
Az
.A Syo /6
ei ■
v
• D
■
ey ■
8Z
1 (� �P. /9�•, Tn.
,C.e E 3 � . p /�f ��'�r►+E: u� � � � � • .B. _ 7 0�' /off
/IcAV 500- 5 ee..5 T..284t, 1(. /9640. a eo�nero�'
-1 o,( Tray, St fir (. W/•
FA I I i
V1 'o Ci E
w. X W to N L
d V 0 T M V O 0
w. X m N C\l E E
o cd
F- ca
o
v, �g0o� >o-rn
U U X a C L N �'N O
4 4 J d N 01� >•- t« C UZ'
n .- L N
1 X c R CO U C O C U C- 2
l` , �i • O t � � t � � E N C �
v O O N_ cq 01 c 7 d O ._ 0 7
Rf N > O O : ` .J c0 lL E O = U
U cn c (n • • • •
C j
rE
zu
4
y � 4
;'. V e jai
V 0'
rl _
` W E O � a!
1 z. z 6 0 n
e i t�
W ; ,� f :
u, L1 co
i- rn U = "
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer--500-21-1
Mailing Address 4� /,r -
Property Address
-44- C P,, kL)
(Verification required from Planning Department for new construction)
City/State
# s ox It.- Parcel Identification Number
LEGAL DESCRIPTION
property Location 2YL/ %4, S k� V4, Sec. . T � N -R Town of MaO SO A/
subdivision 6 OA/T/ *�- . Lot # 3
Certified Survey Map # Co S 5 0 . Volume Page #
Warranty Deed #
�. C� ! o'� , Volume I y L A Z , Page # Z
Spec house 0 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
What u
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper . you pu t into the syste
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..lo�rwymanplumber, restrictedp�mber 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
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 Natura 1 Resources, State of Wisconsin. certification
within 30
maintained must be s t a ti n g that your septic system has been com and returned to the St. Croix County Zoning offi tmg
e ear
e iration date.
of the xP 3 � 7 / �O
ATURE O 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 owners) of
th roperty described above, by virtue of a warranty deed recorded in Register of Deeds Office.
S ATURE CANT 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
e in the warrant deed
of the certified curve ma if reference is mad ty
copy Y P
Vol.1442PAGE 42
STATE BAR OF WISCONSIN FORM 2.1998 606841
n—m-t N—hrr WARRANTY DEED KATHLEEN H. WALSH
REGISTER OF DEEDS
This Deed, made between Katbrvn B. Tuleren, and Ferris — ST. CROIX CO., WI
R 1\1lgran .i fa n .: t, ,ah- .4 RECEIVED FOR RECORD
Grantor, conveys and warrants to 07 -14-1999 11:00 RM
Sam E Miller, a s' ale person WARAWY DEED
EMPT I
Grantee. CERT COPT FEE:
Grantor, fora valuable consideration, conveys and warrants to Grantee C OPY TERFEE: 2228.10
the following described real estate in St. Croix County, State of S IN6 FEE: 22.
Wisconsin (The "Property "):
Recordina Area
Name and Return Address 1
0404022.10: 040-1022-30:040-1021-90'.
040 - 1029 -30: 040-1028 -70
Parcel Identification Number (PIM
This is not homestead property.
(Sce Attached Exhibit "A ")
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any
Dated this 13th day of July, 1999.
+ + athryn B. ulgren
• Ferris R. Tulgren
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
) ss.
authenticated this _ day of St. Croix County )
Personally came before me this _ 1 T daY
+ of July, 1999, the above named Kathryn B. Tu eren.
and Ferris to
TITLE: MEMBER STATE BAR OF WISCONSIN
(If mt me crow '(Obc the pe s) who executed the foregoing
authorized by 5 706.0 Wis. Stats.) instru and ackno ge the sane.
THIS INSTRUMENT WAS DRAFTED BY
Attorney Kristin Deland '
Hudson, WI 54016 N blic, Sate of Wisconsin
(Signatures may he authenticated or acknowledged. Both are not My Commissio is �pc rent. If not, state expiration date:
new) !r r r Ac
Breads. Poulin
Notary Public
State of Wisconsin
•Nunn of persons signing In ►ny capacity should be typed or punted below their ►igmttua
WAaaANn DaND ETAT19 BAR OF W16CQNM
rt'" Nw 1 • IaM
INF~TION►ROFE1131ONMaCOWANY FON00 AC -M &00666.2021
7
1442PAGE 43
. EXHIBIT "A"
That certain parcel of land located in the NE' /• of SE' /, of Section 6 and in the NW 1 /4
of SW % and the NE' /. of SW 1/ of Section 5, ALL in Township 28 North, Range 19
West, Town of Troy, St. Croix County, Wisconsin more fully described as follows'
Beginning at the West quarter comer of said Section 5; thence N87 1 08"E
(recorded bearing on the East -West quarter line of said Section 5) a distance of
2342.24 feet; thence S00 0 13'24 "E, 854.00 feet', thence N87 0 51'08 0 E, 288.00 beet to a
point on the East line of said NE' /4 of SW' /.; thence along said East line,
S00 °13'24 "E, 466.08 feet to the SE corner of said NE % of SW %; thence along the
South line of said NE' /4 of SW % and the South line ,/54'54 "W,
S87 0 54'54 "W, 2372.41 feet; thence N00030'28'E, 170.48 feet; ence S
273.91 feet to the monumented West line of said NW 1 /4 of SW' / thence along said
thence
N00 °30'28 "E (recorded as N01 032 "E), 941.26 feet;
West line, ,. 458.40 /•
N64 0 57'47 "W (recorded as N63 °54'50 W), feet to the North line of said NE N88 °20'13 "E (recorded as
of SE' /4 of Section 6; thence along said North line,
S88 9"E and N89 0 24'42 "E), 416.69 feet (recorded as 25'/4 rods) to the Point of
Beginning.
W.-
• if �
NORDIC HEIGHTS_ ADDMON. ra 1 i fJ�j A�
_ / $ OR I
heel Ue d Vie NN I -SN I// Saow (Sa Sn�rys't Ak $
I N 0 1 94! 76' )� ,
Sj
-09
I MAN
Mr
ff �
� t
i I ' ��� �. '' s � \�• �, \ 100' � � "1 � 1
sp 1
1 ,� i '4 x /l !s•vlasr>« -�. .... 497r..?!! ...........:....__.... _..
34 i Ali J! f " ) F
..
.._....
i. I t
Ji• l
IF uleai MNI
V #
cl m b. • • t i �� 1.�� - 1Sw1
d�c3 •. -r� 5 4 F 1
cl
r ik ?�� ! I
la
or
f 10
lit,
n F ;�� �„ a , N w 3J pl � � � `C11 ;(�,[•��,, �V� i' e�
4 a _ ` r 101 .%
Ii (
C Z
IL
f f
1� •^ '4L41r 157.ff n I w
-a m II
r i al l"I p
1
1 91—
�j -'�o'�.ti•)1'I amour -- �.: