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HomeMy WebLinkAbout040-1263-10-000 f � Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division Coungi Croix INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanityll5rotNo.: Personal information you provice may be used for secondary purposes [Privacy Law .15.04 (1)(m)1. Permit Holder's Name: ❑ City ❑ a/511aage To lgf: State Plan ID No.: M iller, Sam 1 . Y wa 1i CST BM Elev.; Insp. BM Elev.: BM Description: ' 0 Parcel Tax No.: tT0 •a' Csp -Z) — C TANK INFORMATION ELEVATION DATA S; f g, 11. / ` 4 `j TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic BeAdiiBMk r 16 - Y 0 116. o /� , a Dosi ng A- . ,mil 3 • Aeration Bldg. Sewer Holdin St /Ht Inlet �• 3s o9.aS' TANK SETBACK INFORMATION St /Ht Outlet �, �� �p8•!oS' TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet —, Air Intake Septic >q I ( ' ( Z' NA Dt Bottom Dosing NA Header / Man. (3 SS 102 Z SS I Aeration NA Dist. Pipe .o �d�•�S Holding Bot. System 1�• 30 C;D , o ` PUMP/ SIPHON INFORMATION FiiMl e Manufac `�T_ C.mAlr 3.912 11 •5 Model Number GPM TDH Lift L oss Iction System TDH Ft ad Forcemain Length Dia. To well SOIL AB PTION SYSTEM WO TRENCH Width r Lengt r No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN 1 3 `j DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING M anufacturer: INFORMATION Type Of CHAMBER Model Ny er: System: > I'm >75 OR UNIT 13,,c* r DISTRIBUTION SYSTEM Head nifolcl a� Distribution Pipe(s) Hole S I x Hole SDac Vent To Air Intake Lengt A_ej Dia. t' I Sb SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over u Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center 3 + Bed /Trench Edges � Topso i l Iris eC Ori 1Y.es /n do Insvetcling #2 1 0WHOM1 'u�� ���� �4, 2i q s40Aetit, &I SW 1/4 5 T29N RVW) - Frontier -Lot I I 1 1.) Alt BM Description= S l ( L>� 2.) Bldg sewer length= Io - amount of cover = c{. 2 4 . Plan revision required? ❑ Yes ErNo -{— Use other side for additional information. O8 23 � l �P SBD -6710 (R.3/97) Date Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: _ �.. w 3 " I r E E d 3 t ie® € 3 e 3 e e d a ( 1 E o E a........ .,......, s ........... .. .,,_. .. ..... ...., . _ _ .. . ... m. .. € a` .... -w.0 "m.. .- ..� s.. v .....,. �... rem ........ . ,_........ ... ... ...... ......_.. d ...... ........ .... 5......... ..,. .,. .. _. .. _ s o E t E " �i 6 t -- m E a " �m o € y _ e a_ rv��e m E f 3 � s i _ i € ; r i .W " i 30 / O"T/2� AZ. Safe and Build s Division !_ Vi sconsin SANITARY PERMIT ARP -K-ATION 201 W. Washington Avenue ,-' � ; P o Box 7162 Department of Commerce In accord with Comm 8;4k,Aj..Adm. Code Madison, WI 53707 -7162 r • Attach complete plans (to the county copy only) forth less "\ County .fe than 81/2 x 11 inches in size. �._ ` i �ot !S-F. Carl • See reverse side for instructions for comp leting this a p� l ati � to Sanitary Permit Number Ff e ,5 35 36 Personal information you provide may be used for secondary purposes ST C AOiX J Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. c�IiNTV fate Plan Review Transaction Number I. APPLICATION INFORMATION - PLEASE PRINT A Property Owner Name L c ton LL / 4,S T,N,R 1q E(o W PA erty Owner ai ing Address Lo u " er ' Block Number J City, State Zip Code Phhoaq um er Subdivision Name or CS u er If PE F Bill PILDING: (check one) ❑ State Owned a it Nearest Road Village ( n J Public 1 or 2 Family Dwelling - No. of bedrooms Town OF �1` C VN 111 BUILDIN SE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartmentttondo PerADItJ 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 Q Mobile Home Park 12 ❑ Service Station/ Car Wash 5 Hotel /Motel 9 Office / Factor y Factor 13 Other: s pecif y ❑ ❑ Y ❑ p y IV. TYPE OF PERMIT (Check only one box on line A. Check box on line B, if applicable) A) 1,' New 2 Replacement Replacement of Reconnection of Repair of an ­7` 73ystem _____❑ System _________ __________ Tank Only ❑ 5 Existing System ____ ❑ ExstinqSystem 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 1715pecify Type 41 Q Holding Tank 12�dSeepage Trench L� A 22 ❑ In- Ground Pressure, 42 ❑ Pit Privy 1 eepage Pit r Nt L"I L r a �""""` ' 3 X S 3❑ Vault Privy 14 E] System-In-Fill ` A e- NK E MS Z . '_, q •T`Q�`� VI. ABSORPTION SY EM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sg Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation � Q -) i I 0"D . et Feet VII. TANK Cap acit in g allons Total # Of Prefab. Site Fiber- Exper. INFORMATION Tanks Tanks Gallons Tanks Manufacturers Name concrete Con- Steel glass Plastic App New Existin structed Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ID 1 ❑ 1 ❑ I ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Prin Plum (No Sta s) MP /MPRSW No.: Busine s Phone umber: k t e 6' Z Plumber's Addre�eet a e , Zip Code): Vb4A115 ey 1 41 M A I NTY / DEPARTMENT USE'ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date I ssued Issuing Agent Signature (No Stamps) Approved []Owner Given Initial Surcharge Fee) Adverse Determination , csb - - X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: '� SBD -6398 (R.12/99) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber f INSTRUCTIO) S 1 . A s a nitary 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 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. 11. 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. SAM rM lLtE IL FRW M E-k � 316 NEW clewol. T)(Jivc.: Gvt, d Ra ✓Y57'E j + . To p F LOT` 1p ik Y Q P f'� A .� R 1 �� a r , Y r WoconsinDepaMlentofCommeme SOIL AND SITE EVALUATION Page 1 of 3 Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code A.C.E. Soil & Site Evaluations Attach complete site plan on paper not less than 8'/: x 11 inches in size. Plan must F County include, twt not lim ited to: vertical and honzorrtal reference point (13M ), direction and St. Croix n percent slope, scale or dimesions, north arrow, and { n t�nce to nearest road. rt of 040 - 1021 AO APPLICANT INFORMATION - Please nt kWormatidA- D Personal information you provide may be used for rposes jqriacy Law, s. 15.04 (1) (m)). Property Owner a Property Location Miller, Sam Govt `'ot NE 1/4 SW 1/4 S 5 T 28 N,R 19 W Property Owners Mailing Address — I` E e ", Lot # Block # Subd. Name or CSM# P.O. Box 151 `�' Ll Plat Of Frontier City State Zi a PhoneNtnlbef' Y City E] Village ®Town Nearest Road Hudson WI 54 - 71' �� Troy Tower Road ® N ew Construction Use: Res id Ml of beds 4 ❑Addition to existing building [] Replacement Public or co be Code Derived daily flow 600 gpd Recommended design loading rate •7 bed, gP • Bch gP Absorption rea required 857 bed, flz 750 trench, ftz Max mum d sign loading rate .7 bed, gpd/fP . trenc gPd/ft Recommended infiltration surface elevations) 100.0' ft (as referred to site plan benchmark) S Z Additional design / site considerations .J-K�" [ of 0,,+ �Z 1, � LP U naren suitabSuitable t material Glacial outwash Flood lain vation, If applicable NA ft for System Conventional Mound In - Gro und Pressure AT - Grade System in Fill Holding Tank le for system M S❑ u ®S ❑ u ® S❑ u ® S U ❑ s ®U El S® U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consisten Boundary Roots GPD/ft2 Boring# Horizon in. Munseil Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 1 0 -27 1Oyr2 /1 None sl 2fsbk mvfr as 2f &m 0.5 0.6 2 27 -48 10yr4/4 None sl 2msbk mfr gw 2f 0.5 0.6 Ground 3 48 -56 1 Oyr4 /4 f2f10yr6 /3 scl Om dsh aw - NP 0 i� 2 elev 107.31 ft 4 56 -66 1Oyr4/6 None is Osg dl gs - 0.7 0.8 Depth to 5 66 -125 10yr5/6 None s Osg dl - - 0.7 0.8 limiting factor >125' 87- t 23.6 Remarks: One foot rule apphed to disregard m*x. features found in H #3. 2 1 0 -26 1Oyr2/1 None sit mvfr cs 2f NP 0.3` 2 26 -54 10yr5/4 None sil 2msbk mfr aw if 0.5 0.6 Ground 3 54- 5 10yr4/6 None is Osg dl cw - 0.7 0.8 eiev 104.51 ft 4 5 -97 10yr5/4 None s Osg dl gs - 0.7 0.8 Depth to 5 97 -122 1Oyr6/4 None s Osg dl - - 0.7 0.8 limiting factor >122' 117, o,rZ Remarks: _ , CST Name (Please Print) Signature: - -- Telephone No. James K. Thompson 715- 248 -7767 Address A.C.E. Soil & Site Evaluations Date CST Number Ref # 340 Paulson hake Lane, Osceola, 54020 12/31/1999 3602 1160 PROPERTY OWNER: Miller, Sam SOIL DESCRIPTION REPORT tteo Page 2 of 3 PARCEL I.D.e Prt of040- 1021 -90 AC.E. Soil & Site Evaluations Horim Depth Dominant Color Mottles Texture Structure sistence Boundary Roots C41W in. Munsell Qu. St. Cont. Color Gr. Sz Sh. Bed Trench 3 1 0 -15 10yr3/2 None A 2fsbk mvfr cs 2f &m 0.5 0.6 2 15 -27 10yr5 /4 None sil 2msbk mfr aw 20m 0.5 0.6 Ground elev 3 27 -41 10yr4 /4 None Sl 2msbk dl cw - 0.5 0.6 104.60 ft 4 41 -49 10yr5 /6 None is Osg dl cw - 0.7 0.8 Depth to 5 49 -119 10yr6 /4 None s Osg dl - - 0.7 0.8 limiting factor >11 Remarks: 4 1 0 -12 10yr3 /2 None sl 2msbk mvfr as 2f 0.5 0.6 2 12 -21 1Oyr4/4 None is Osg ml gw 1f 0.7 0.8 Ground elev 3 21 -53 10yr5 /4 None s Osg dl gs - 0.7 0.8 103.35 ft 4 53 -123 10yr6 /4 None s Osg dl gs - 0.7 0.8 Depth to limiting factor >123" Remarks: 5 1 0 -12 10yr3 /2 None sl 2msbk mvfr as 2f 0.5 0.6 2 12 -24 10yr4 /4 None Is Osg ml gw if 0.7 0.8 Ground elev 3 24 -71 10yr5 /4 None S Osg dl gs - 0.7 0.8 106.43 It - 71 -121 10yr6 /4 None s Osg dl gs - 0.7 0.8 Depth to limiting factor >121' Remarks: Ground elev Depth to limiting factor Remarks: ? Pig 3 &P3 r"tAA r t -Eowr► road ■ for 1 Obsu'd c c h a r 7 o - A/L ..B nf. T .F A c0. /oca.;ee d !L � Lot 11 82 ■ ■ dam �, � 84 IV = ■ ■� Ae —� `S /O we P Q ■ ■� b/ � 81 h s SOW 'Jcvn ell 7e M dsc o r ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 51 MA JA 14 t- Mailing Address O X �* 15 Property Address 3 X E w 4CE AI T V Q2 y 2 1 V (Verification required from Planning Department for new construction) City /State y 0,5 y N W Parcel Identification Number LEGAL DESCRIPTION Property Location J� %,a m2 Y., Sec. , T N -R Town of Subdivision F P-0 KT 1 r A--- , Lot # Certified Survey Map # 57S . Volume , Page # y Warranty Deed # APO q ( , Volume Page # 41 Z 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 mastor 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. 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 the ear expire 'o date. A F APP ANT 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 rty desc 'bed above, y virtue of a warranty deed recorded in Register of Deeds Office. 3 ,zq, o A O APPLICANT DATE being revoked b the Department.""" Any information that is mis- represented may result in the sanitary permit Y ��g �P� •• 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 I • s J E E Z c C l X CD _ N! c� N O �0 N y N ! �-- CD E o N o zap- _ = co v y� c c v o > o a X n °' r�a�`�° o a n aci Wit`'= a�i v` v 4 X m a) 0 a0C 3 r °' t c c t o ? ED � me m N >0 % 3 2E0:.2�v CL F c a v �J zo gg w � ► `• 'ti E d . • VVV �� a 1• © E •=� I R U t s� it W. � M � � c � � �Z �• a Z g 00 �� W a x� w0�� h Z vo1.1442PAGE 42 STATE BAR OF WISCONSIN FORM 2. 1998 tEaOta^a841 WARRANTYMED KATHLEEN H. NALSH REGISTER OF DEEDS This Deed, made between IKathrvn B. Tuleren. and Ferris — ST. CROIX Co., UI R_ 'nilgrpn. wif nad b6sb" RECEIVED FOR REm Grantor, conveys and warrants to 07 -14-1999 11:00 All Sam E. Miller, a sintlenerson. YARRANTY DEEI Grantee. CERT COPY FEE: Grantor, for a valuable consideration, conveys and warrants to Grantee COPY FEE: TRANSFER FEE: 2223.10 the following described real estate in St. Croix County, State of RECORDI116 FEE: 12.00 Wisconsin (Tbe "Property'): PAGES: 2 Recording Area Name and Return Address 040-1022-10.040-1022-30; 0 a- I M I.90. 040 -IM9- 20;040.1028 -70 Parcel Identification Number (Pn4) This is rot 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. Tulgren AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ) as. authenticated this _ day of St. Croix County ) Personally came before me this day • of July, 1999, the above named Kathryn @. TuIrren. and Ferris R. Tulgren, wife mid TITLE: MEMBER STATE BAR OF WISCONSIN to (If rot. ntu yawn t the pe s) who executed the foregoing authorized by 1 706.06, Wis. Slats.) instru and acltno I r Be the $am. THIS INSTRUMENT WAS DRAFTED BY Attorney Krlstina Ogland Hudson, WI 34016 N blic, State of Wisconsin (Signatures may be authenticated or acknowledged. Both are not My Commissici is (If not, state expiration date: necessary.) Breads Poulin f f ► ( JJ((�ill Notary Public State of Wisconsin -Names of persons signing In any capacity should be typed or printed below their signatures wAauxrr DaaD t7ASt6 a" or wrseotm" aOtM N. I • {M 1NFonaaA110N ►11oFEU0NAta C0WANY FOND DV LAC. NA 6004663021 1442PAU 43 EX):BBIT "A" parcel of land located in the NE' /. of L in�T�ownship 28 North That certain P Range 19 , of SW '/• and the NE /• of SW '/• of Section onsin more fully described as follows: West. Town of Troy, St. Croix County, thence IoVE at the West quarter comer of said l neecttiif n ; Sect o N) a distance of Begin (recorded bearing on the East -West quarter 2342.24 feet, thence S00 °13'24 "E, 854.00 feet; th n along sa id NE d East line, 00 f eet to a point on the East line of said of SW /•, then S00 °13 24 466.08 feet to the SE corner of Bald N of said W 1/40f SW ' /•�ng the 41 feet; thence N00 °30'28'E, 170.48 feet; thence the nce alo said South line of said NE /, of SW ' /• and the South one � of SW' /�; thence along S87 °54'54 "W, 2372• 941.26 feet; thence 273.91 feet to the monurn enrded as N01 32'36 "E), , North line of said NE '/. West line, N00 308 E (r ° 458.40 feet to the N N64 057'47 "W (recorded as N63 54 50 W). N88 °20'13 25'h rods) "E (recorded as said North line, to the point of of SE' /•19 -Sect nd N 2 2 "E) , 4 g.69 feet (recorded as ssa °ao Beginning. - NORDIC HEIGHTS_ ADQ�TIQN- ��� I " — Yavmmted IM1 I't a Ik IAr I -511 1/1 Setib" (4e Svvtrnl i 6k) N DI'l771 / I it- r,r, ' •,' �� 7Q AM- F ,� N 0 L ►(,./ �» I i A�j 1 \\` ut sy �._._._.t... -•- -�-•-•- '�'-- -- -•, 11DAA' � d/� � S`1Et1 asl ; f I I i i � j I I ii Syr w t' 7 N E I STREET ... � $$ �, z• + f R X14 p,. t �, \ - -- -•- --- - -- -- - .�t 0)•.RY a e6. fi U-4 WtN111 /15 keren5� y ' �► • I Iq'�� q - Rni Gc IA I%f S•I S,c I'+,n 5 �� I � 0 � Ilrt� r Q) 1-. tiNCP1v � y 4?7 - -- — _ PJ A V7 . • - t - t .1 N D 11'SQ R - I I U 1-a• R �iS . .�,. o � t•1 -, � � - � ..,. -•. �. }i (1 i to n IC la ''•a 'x' J Q I � /�� I a l tv . �. 5c a 19 1 b y ILA st _ I � I I Iz . I, 7S7.A' 2924r �. - "1 �� �� � �� � N p} ► ngt(�v{jd�� '� Il l.i'71" I 11. icln � IV�I np IOAT 371 +7 ,, sc InrE INS 1 s o ls� r 0'.1711 7640 IC J Mt IA 1/1 'df 1/1 kc 9NPlA�TEt SANDS 01WNED BY OTHERS T�' t a„ " I