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HomeMy WebLinkAbout040-1262-60-000 W scon`sin Department of Commerce Count y- t' Safety and Buildings Division PRIVATE SEWAGE SYSTEM St. Croix INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanitarxQ�rTVo.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 33 // LLbb Permit Holder's Name: ❑ City ❑ Village q Town of: State Plan ID No.: Miller, Sam Troy "Township CST BM Elev.:. Insp. BM Elev.: BM Description: Parcel Tax No.: Ion p' CSU . D ' o c� = (C T i3vu 040 - 1262 -60 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. Septic `� Benchmark q,cp l o o t- S Dosing Alt. BM .66 JoL( - $S ' Aeration Bldg. Sewer [ Holding St / Ht Inlet �j,g0 9°l - po TANK SETBACK INFORMATION St/ Ht Outlet to -Z 9q.zS� TANK TO P/ L WELL BLDG. Air I ntake ROAD Dt Inlet - — Air Septic a > 40 a0 � NA Dt Bottom Dosing NA Header /Man. Aeration NA Dist. Pipe. (, 30 $.2o , Holding Bot. System Z,5D q -. -co' PUMP/ SIPHON INFORMATION Final Grade ,C70 Man tur D St cover er (o -Zo 03.3 D Model Number GPM TDH Lift i Fricti Y H Ft ead Force Length Dia. H Dist. To well SOIL ABSORPTION SYSTEM .�., IM TRENCH Width Len th No Qf Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMNI N SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING ��o� SETBACK CHAMBER INFORMATION Type Of I M del Num er: System: CPPV, OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. T - 1 '7 SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed/ Trench Center Bed /Trench Edges J Topsoil ❑ Yes ❑ No ❑ Yes ❑ No C I L D CILde c dd dis anti p tt e ��LL ns ec ion inspection Location: 349 fulgren �treet, u�so�n VI! i!9/4 W 1/4 5 T28N Rl9W) - 05.28.19.1414 Frontier -Lot 6 1.) Alt BM Description – - 'rop °'F bk 2.) Bldg sewer length = Zo' u - amount of cover = Plan revision required? ❑ Yes 1, No Z Use other side for additional information. O$ 2 M pl>- ��g�l� N SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. N I ADDITIONAL COMMENTS AND SKETCH 3 SANITARY PERMIT NUMBER: �.,. < sLq gg yy _m -- _._.. e { 3 , = e SCALE j j j g} g �e i p ct ' �9tiN p �TcET: �o, ZS i ��,2 `To 1° o� 131 oc,lc _ orAoP s i B o b o *+Av sc� 7S M � eti A-5 -(4 Safety and Buildings Division Vi scons i n SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue P O Box 7162 Department of Commerce In accord with Comm 83.05, C: <� Madison, WI 53707 -7162 • Attach complete plans (to the county copy only) for the sy te n pape&ot less..- I?punty �- than 81/2 x 11 inches in size. ^. R fC�IVEC� �,T • See reverse side for instructions for completing this appl on ll s Sanitary Permit Number JUR ci 3 Z Personal information you provide may be used fol secondary purposes '.', QC ack if revision to previous application [Privacy law, s. 15.04 (t) (m)1. i 7� X K Staf Plan Review Transaction Number 1. APPLICATION INFORMATION -PLEASE PRINT AL 0 Property Owner Name �� L Propert L ;i �� 7 TL ,N,R E(or Property Owner's Mailing Address u Block Number .— City, State Zi Co Phone Nu er Subdi on Name orC I I Number . TYPE F B ILD NG: (check one) ❑ State Owned 't Nearest Road il ,CIO Si Public 1 or 2 Famil Dwelling - No. of bedrooms ow of l``�V Ill. BUILDING SE: (If building type is public, check all that apply) Parcel TaxNumber(s) o 6 YO_ /z ,& z - -�o 1 ❑ 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. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an - ______ystem ........ 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 eepage Trench l 1 E] 22 In- Ground Pressure X 3 %/ 42 ❑ Pit Privy 13 Seepage Pit 0 /*Pi I- Tit A'"6 s 43 ❑ Vault Privy 14 ❑ System -In -Fill .7, �/ — 1 / s Q 1EAG VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Galstday /sq. ft.) (Min. /inch) ✓ Elevation ®a 7 $" 0 -- 9 7- 0,0 Feet / COI. 00 Feet VII. TANK Capacity in allons Total # of Prefab. Site Fiber- Ex per- INFORMATION g Gallons Tanks Manufacturers Name Concrete con Steel glass Plastic A p p New Exist strutted Tanks Tanksl Tanks K c Tank oldi C FA,,,,. ❑ 11 13 ❑ ❑ tuber ❑ 1 ❑ 1 ❑ 1 ❑ ❑ ❑ Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) I Plumber's ignature: tamps) MP /MPRSW No.: Business Phone Number: ft\t-;-: jy�ajtFtL )OZiL V Plumber's Address (Street, City, State, Zi Code): o Iv cJD A0 k.) 4 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate I ssued Issuing Agent Signature (No Stamps) CApproved ❑ Owner Given Initial Surcharge Fee) /- Adverse Determination 4 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 maybe 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 priorto 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 oe 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. SIST F-/),1 97, ' se^Lf � �sAo f /kA oav l�T ' '�, . • z Z S CJ 3 G C.T, 7a? � v, rrt PFP 9f ° B, & ' pP © F loo, 00 A LAND r � z- fAcN Tkt��'U 3 9 � t ti^ i . q _ BEo c. -sPtir 14 Lo y ST Y B -y z s • n � N ! C N N zo:-_ — _ N N O , co M N O N t0 X N N CL fd E r (D E � o c0 e cu o o a � � ►'— c E O V a NL O fl % GCi O! ` CD cC _ y 7 C. C O 7 �C N > o O ; J co lL 0 = V '0 In C (n 3: Q. • • • • p Cl • 4 y � �---- zo ►� ; m v ° �l• a a cl p s R W a co 1 050 F = CD " Wisconsin Department of Commerce SOIL AND SIT AL4AT N ,~'` Page 1 of 3 Division of Safety and Buildings in accord with Comm 3.Qt3, Wis ode \ 6 r ;- A.C.E. Soil & Site Evaluations Attach cornplete site plan on paper not less than 8 x 11 inches in sine. P t Include, but not limited to. vertical and ho iz ital reference pant (BK, direcUb St. Croix percent slope, scale or dimensions, north arrow, and location and distance t t p APPLICANT INFORMATION - Please Tint all ~'* S7 cp °0X ' Prt of 040-1021-90 P r CO(1NTW By Date Personal information you provide may be used for secondary purposes (Privacy Law. s \4,04,,P )W ING 3 - (6 —.2 ev0 Pr n °. Mille Sam ef Govt. L j __ `L.. , SW 1/4 S 5 T 28 N,R 19 W Property Owners Mailing Address Lot # Subd. Name or CSM# P.O. Box 151 6 Plat Of Frontier Cit State Zip Code PhoneNumber ❑ City ❑Village ®Town Nearest Road Hudson WI 54016 715 386 -2769 Troy Tower Road ® New Construction Use: ❑ Residential / Number of bedrooms 4 ❑Addition to existing building ❑ Replacement ❑ Public or commercial describe Code Derived daily flow 600 gpd Recommended design loading rate •7 bed, gpd/ft .8 trench, gpd/RZ Absorption area required 857 bed, ft' 750 trench, W Maximum design loading rate •7 bed, gpd/fP .8 trench, gpdff Recommended infiltration surface elevation(s) 97.00. ft (as referred to site plan benchmark) Additional design / site considerations Install trenches using high capacity infiltrators. Parent material Glacial outwash Flood plai n elevation, ff applicable NA ft S= Suitable for system Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank U= Unsuitable for system ®S El N S O U N S O U ® S❑ U EIS ®U ❑ S L U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPDffF Boring# Horizon In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench 1 1 0 -8 10yr2 /1 None sil lthinpl mvfr as 2f NP 0.3 We 2 8 -20 10yr4/4 None sil 2msbk mfr aw 1f 0.5 0.6 Ground 3 20 -24 10yr4/6 None Is Osg dl cw - 0.7 0.8 elev 102.35 ft 4 24 -54 10yr5 /4 None s & gr. Osg dl gs - 0.7 0.8 Depth to 5 54 10yr6 /4 None s Osg dl - - 0.7 0.8 limiting factor 4 ;•0 >121" ' •7- Remarks: 2 1 0 -10 10yr3 /2 None sil 2fcr mvfr as 2f 0.5 0.6 2 10 -24 10yr4 /4 None sil 2msbk mfr aw if 0.5 0.6 Ground 3 24 -34 10yr4 /6 None is Osg dl cw if 0.7 0.8 elev 103.89 it 4 34 -67 10yr5 /4 None s Osg dl gs - 0.7 0.8 Depth to 5 67 -126 1 Oyr6 /4 None s Osg dl - - 0.7 0.8 limiting factor >126" Remarks: CST Name (Please Print) Signature: J Telephone No. 1 - 715- 248 -7767 James K. Thompson " Adder A.C.E. Soil & Site Evaluations Date CST Number Ref # 340 Paulson Lake Lane, Osceola, 54020 12/31/1999 3602 1154 PROPE Miller, Sam SOIL DESCRIPTION REPORT Page 2 of 3 t >ARM LDJ Prt of 040- 1021 -90 A-C.E. Soil & site Evaluations pepi�h Dominant Color Mottles Texture Structure sistence Boundary Roots C4)W Horizon in. Munsell Qu. Sz. Cont Cola Gr. Sz. Sl1. Bed Trench 3 1 0 -13 10yr3 /2 None sl 2msbk mvfr as 2f 0.5 0.6 2 13 -28 10yr4 /4 None sil 2msbk mfr aw if 0.5 0.6 Ground elev 3 28 -33 10yr4 /6 None Is Osg dl cw if 0.7 0.8 103.28 it 4 33 -71 10yr5 /4 None s & gr. Osg dl gs - 0.7 0.8 Depth to 5 71 -119 1Oyr6/4 None s Osg dl - - 0.7 0.8 limiting factor >119 / 7S; 3b tfl - 3 Remarks: 4 1 0 -14 10yr3 /2 None sl 2msbk mvfr as 2f 0.5 0.6 2 14 -27 10yr4 /4 None A 2msbk mfr aw if 0.5 0.6 Ground elev 3 27 -34 10yr4 /6 None is Osg dl cw - 0.7 0.8 103.76 It 4 34 -80 10yr5 /4 None s & gr. Osg dl gs - 0.7 0.8 Depth to 5 80 -122 10yr6/4 None s Osg dl - - 0.7 0.8 limiting factor >1 Remarks: pre 5 1 0 -10 10yr3/2 None sil 2thinpl mvfr as 2f NP 0.3 2 10 -19 10yr5 /4 None sil 2msbk mfr gw if 0.5 i 0.6 Ground elev 3 19 -30 10yr5 /4 None sil 2msbk mfr aw if 0.5 0.6 101.74 ft 4 30 -78 10yr5/4 None s Osg dl gs - 0.7 0.8 Depth g 5 78 -116 10yr6 /4 None s Osg dl - - 0.7 0.8 limiting factor >116' t. 0 Remarks: Ground elev Depth to limiting favor Remarks: '--- 1. 3.x`3 L� • `op off' eLee. 42insAwr rkc .Cee 't' wo gasc( QSB Q �CaY'/IL!' o�'�d'�S 5��•' -�. �G1r % �UD.(o0� IS7 70 & ncl+ Top a /o1� . ./ ^w/ � y < <o edor Y) Owner: p 5Q•m 11; 116f - i .o..,6 /s/ � P � 0 s�or6 • � o� !o, A pr 7G' �'. ���-� o•f' moo» e'er, �/s�9 z9 , n e*.5 wyy, See . S, T. ?if /9a), 7 , or T e y, .St • Croix Cc, w V) NJ d " Qt 64 � d ST CROIX COUNT SEPTIC TAN. MAINTLI ANCL AGREEMENT j AND OWNERSHIP CERTIFICA`T`ION FORM Owner/Buyer Mailing Address X r Property Address L (ail (Verification required from planning Department for new construction) City /State 14LJ Y) - N i Parcel Identification Number 0 3 LEGAL DESCRIPTION Property Location I& r/s, � .1' /�, Sec. -�'. T N -R � W Town of Subdivision , --� �� , Lot # Certified Survey Map # 4 1 SS Z) , Volume , Page # Warranty Deed # 1'0 0 40 y . Volume I Z- Page # _ . _• 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 P umping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system e tic tank as a treatment stage in the waste disposal system. can affect the function of the septic g 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 wastewaterdisposal 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. j Uwe, 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 I of the three year a lion date. NATURE OF 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 owner(s) of rty described abov , b virtue of a warranty deed recorded in Register of Deeds Office. �j I / AN, Aaua�— SIGNATURE OF PLICANT DATE « « « « «« A 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 l v01. U 42PAU 42 STATE BAR OF WISCONSIN FORM I - 1998 606841 ARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS ` Tlils Deed, made between Kathryn B. Tuleren. and Ferris ST. CROIX CO., NI - - R- Milgrvn. wife aW h RECEIVED FOR RECORD Grantor, conveys and wrtnams to 07-14-1999 11.00 All Sam E. Miller, a sinizic person. YARWY Do Grantee. CERT COPY FEE: Grantor, fora valuable consideration, conveys and warrants to Grantee COPY FEE: the following described real estate in St. Croix County, State of TRANSFER FEE: 2228.10 RECORDING FEE: 12.00 Wisconsin (The "Property"): PAGES: a Recording Ara Name and Rerum Address 1 040-1022-10-.00 040- 010. 1029 -20: 001023.70 Parcel 16tr tificadon Number (PtM This is not homestead property. (See Attached Exhibit "A ") Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any Dated this 13th day of July, 1999. Kathryn B. ulgrcn "Ferris R. Tslgren� AUTHENTICATION: ACKNOWLEDGMENT Signaturc(s) STATE OF WISCONSIN ) ss. authenticated this _day of St. Croix County ) Personally came before me this L3 day • of July, 1999, the above nuned Kathryn B. Tularen. TI LE: MEMBER STATE BAR OF WISCONSIN and Ferris & — �t3are,,; wife — i (If not, me mown t the per s) who executed the foregoing authorized by 1 706.06, Wis. Stan.) irutru and ackno I ge the $ante. THIS INSTRUMENT WAS DRAFTED BY `[�_ ' Attorney Krlstiva Oglaud • ' Hudson, WI 540i6 N blic, Suteof Wisconsin (Slgrutures may be authenticated or acknowledged. Bush are not My Commissio isjic nent. If not, state expiration date: KCe sary Bread& Poulin t f r d D Notary Public State of Wisconsin .Names of persom signing In any capacity should be typed or printed below their sign0tres wAAAAMTy DSLD STAIN a" or wa$eoraare roaM W r•t Nfootw now PROF ESSK MAt 9 COWANY F0N0 0V LAe. hM /0om6-1071 A , fit �r• „� 1442 43 EXH1131T "A„ aced in the NE of SE' /` °f Sec 8 Nor h! Range 19/• That certain Parcel of Iand loc ALL in Tow P Croix County, Wisconsin more fully des cri be d N851'08' Eows. of SW ' / +and the NE' /' of SW '/ of Section 5, West, Town of Troy, St. q uarter line of said Section d 288 c meet to a Inning at the West quaff st West 4 ion 5) f said Section 7 E, I3eg on the Ea (recorded bearing 4 "E 854.00 feet, thence N said East line, 2342.24 feet; thence S00 °13 2 thence along the East Ilse of said NE E corner of Bald NE'/, of S W ;� ° f SAN' /•, n the Eas '/• of SW ' /'�� thence a ong N point o Oa feet to the SE thence S87 °54'54 "W. S00 °13'2 ° E. ,. of SW' /• and the South I�n170.48't�et; South lie of said n said NE N0 / 2372.41 feet; thence 0 °30'28'E, S8 7954'54 -W, e of said N ed West l i n e of 2 then 6 a t'cee along �/� 273 91 feet to the monurrien rth line of said N ° 3 . E (recorded as . e N00'30'28'E (recorded as N01 °3238 E), 9 °54'50 "W), g58�40 feet to the No West Im rded as t g8 20 N64 °57'47 °W (reco said IN Sec as 25'/' rods) to the Point of a l on g of SE '/+ of Section 2 "E), 416.69 feet ,88°40'19 "E and N 89024'4 Beginning. i cd AO b I r It CL! j Ai tj s m 0/1 w ac 1101 —610.0 U All � �h - 11VAW com 1AN)S Y It, WLI sr LU k zt t o Ur I r or 4 it Col .77 p Va' ;U —IOC A J . I. ... a I t . 0 vu sr kA ,,� a; _ = � to ; ; � ��� � �� � � � � � eo � t � e In ;;5 - - - kj ► L 11 ♦ 1. 0 • 60 0 4p sr tQ ------- ------ ...... ------- . S .. ............ ...... al fl, 38 .14 6c, ----- ------ bill 19 t4 I p1l ' JO jz ....... sr L ------- L ------ ....... -------- d I got bt .4o -limp Ald Oslif =C