HomeMy WebLinkAbout040-1263-20-000 r
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division Count
St. Croix
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanit 33370 Ne:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: ❑ City ❑ Village ❑ own of: State Plan ID No.:
filler, Sam Troy Township
CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.:
•C) p' CST gw� 1 040- 1263 -20 -000
TANK INFORMATION ELEVATION DATA -'' 2 ' /,g, /`/Z -,0
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic � �cS�fL f -� Benchmark #1 ZSS' 11 .85 1 .
Dosing Alt. BM
Aeration Bldg. Sewer
Holding St/ Ht Inlet to o s' ,�►
TANK SETBACK INFORMATION St/ Ht Outlet $, �$ o , -.-.f
TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet
Air I
Septic S S � r - 3 ( NA Dt Bottom
Dosing NA Header / Man. 112-% oo • 39
.AI
Aeration NA Dist. Pipe 13.35- ►3.Z} `
Holding Bot. System
.kt8 C lio .3:f
PUMP/ SIPHON INFORMATION Final Grade 9.0' 03A TT I
Manufactu er Demand St cover �� I&W 52
Model Numb PM
TDH I Lift ric System TDH Ft
Forcemain ength If TOwell
SOIL AB PTION SYSTEM 15' &m
TREN H Width If Length UO. f Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIME 3 CZ DIMENSION
SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manuffac`u
INFORMATION Type O f f CHAMBER Model Numb
System: D OR UNIT (
DISTRIBUTION SYSTEM
Header/ anifold �j, u Distribution Pipes) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia- l
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: O* / 18 /ft Inspection #2: - 4 --f --
Location: 440 New Century Drive, �Huddson, WI n54`.0,116 (NE 1/4 SW 1/4 5 T28N R1 9W) - 05.28.19.1420 Frontier -Lot 12
-�
1.) Alt BM Description = t�g:!4
2.) Bldg sewer length= > 4?- k 54- � r
- amount of cover -`� f •
Plan revision required? ❑ Yes ' No
Use other side for additional information. � R—
SBD -6710 (R.3/97) Date Inspector's Signature Cert No.
t
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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- 1 10 Safety and Buildings Division
V SCO►1S %11 SANITARY PE ) f _�_ _`�.ATION %' - -,," 01 W. Washington Avenue
!J P O Box 7162
Department of Commerce In accord wi �e ,�Vts: frl5 Co '(1 adison, WI 53707 -7162
• Attach complete plans (to the county copy only for pap ` vo lessf` Cou y I
than 8 1/2 x 11 inches in size. j. X0 *3 ' ,
• See reverse side for instructions for completin s aetom. �`�, , t S e �n mit Nu e
Personal information you provide may be used for secondary L s C to v application
[Privacy Law, s. 15.04 (1) (m)]. yYa Al e Csrt,L 1 - o A13a3� I - / `
�/u,�� ` •�, t S Ian Review I Number
I. APPLICATION INFORMATION PLEASE P L II� R `F N 1
Propert Owner Nam �` operty Location
I. - .mot /a W1 /4, S T 2'9 , N, R E ( W
Property Own is Mailing Address Lot Number Block Number
//
City, State N I I Zip Coe Phone Number Subdivision Name or CSM Number
II. 1TOPMEOF BUILDING: (check one) ❑ State Owned [j Cit Nearest Road
Village ,p t
Public " 1 or 2 Family Dwelling- No. of bedrooms Town OF� /�-o DR•
III BUILDIN USE: (if building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo 0 4 0 — 122 3 ?,u — •?s in - 1 k 4 — za
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor R 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 V New 2 ❑ Replacement 3. ❑ Replacement of 4. Q Reconnection of 5 Q 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 C] Specify Type 41 [:]Holding Tank
12 Seepage Seepage Trench Pit W ��N 22 In Ground Pressure 42 E] Pit Privy
13 PIS OZ 3
❑ � 1 l T Q �ht�� �. 43 ❑ Vault Privy
14 ❑ System -In -Fill 3 1 , LA B Q„ IOL. Ey4c 0 a 00
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
equired (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) in. /inch) Elevation
400 �r $ �S t / D /
Cap
VII. TANK in Ca allo s Total # of Prefab. Site Fiber- Exper-
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing strutted
T nks Tanks
Septic Tank Z . 7 T A. S Z ❑ ❑ ❑ ❑ ❑
L hon Chamber ❑ ❑ 111 1 ❑ 1 ❑ ❑
VIII. RESPONSIBILITY TATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: o Sta MP /MPRSW No.: Business Phone Number:
Lot — 9
Plumber's Address (Street, Cit , Sta Zip Code):
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue j lssuingAgentS1 nature (No Stamps)
Approved ❑ Owner Given Initial surcharge Fee)
Adverse Determination >Z Z 0< �0
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL ���
I SBD -6398 (R.12I99) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS t
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.
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.
N. 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 segion
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.
�r• APP7
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Wisconsm Department ofCommeme SOIL AND SITE EVALUATION Page 1 of 3
' Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
AC.E. Soil &Site Evaluatioa5
Attach complete site plan on paper not kiss than 8'/: x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal re0arence point (BM), direction and St. Croix
percent slope, scale or dimensions, north —
arrow, and l cation to nearest road. Parcel I.D.#
APPLICANT INFORMATION - please p ' � �riformatrain. oao- 1021 - 90
Personal information you provide maybe used for ry�punposes (Pr Law s. 15:04(1) (m)). BY Date
�! 3 1 } -2ea0
Property Owner c J I „' Prope�ocation
Miller, Sam ! Govt. Lot { , NE 1/4 SW 1/4 S 5 T 28 N,R 19 W
Property owners Mailing Address+ a " V"' Block # Subd. Name or CSM#
P.O. Box 151 - O( Plat Of Frontier
City State Zip C e PhoneNumbbutJy E] Village ®Town Nearest Road
Hudson WI 5401 715 3WbVWi Tower Road
® New Construction Use: ❑ Residentia ufttbet gflt 4 ❑Addition to existing building
❑ Replacement El Public or commel'taal
Code Derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd/ft .8 trench, gpd1ft
Absorption area required 857 bed, ftz 750 trench, f 2 Maximum design loading rate .7 bed, gpdr •8 trench, gpd/ft
Recommended infiltration surface elevation(s) 98.50'. ft (as referred to site plan benchmark)
Additional design 1 site considerations Install trenches using high capacity infiltrato Increase trench length if silt inclusion is found at system elev. while
Parent material Glacial outwash 1* en C.J Flood plai n elevation, if appi cable NA ft
S - - Suitable for system Conventional Mound In - Ground Pressure AT - Grade System in Fill Holding Tank
U Unsuitable for sy ten S ❑ u e S ❑ u ■ S u ® ❑
U S U S® U ■ S
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD�
BMW ri Horizon in. Munsell Qu. Sz, Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench
1 0 -10 1 3/2 None A 2msbk mvfr as 2f 0.5 0.6
1 �
2 10 -17 1Oyr4/4 None A 2msbk mvfr aw if 0.5 0.6
Ground is Os ml cw - 0.7 0.8
3 17 -25 10 4/6 None
elev
yr g
106.03 It 4 25 -63 10yr5 /4 None s Osg dl gs - 0.7 0.8
Depth to _
5 63-127
1 6/4 None s Osg g dl - 0.7 0.8
limiting
factor
>127' o• 36 .36
Y 26
I
Remarks:
2
1 0 -14 IOyr2 /1 None 1 2fcr mvfr cs 2f &m 0.5 0.6
mfr s 2 lm 0.5 0.6
1 4 4 None
sil 2msbk f
2 14 33 Oyr / 8
Ground 3 39 -46 10yr5 /4 f2d7.5yr5/8 sil lmsbk mfr cw If 0.2 0.3
elev
103.08 ft 4 46 -70 10yr5/4 None s &gr Osg dl aw - 0.7 0.8
Depth to 5 70 -120 10yr6/4 None s Osg di - - 0.7 0.8
limiting
factor
>120' �(' Y o • ro
Remarks: On foot rule appUed disregard redox. features found in H #3.
CST Name (Please Print) Sign re: - I Telephone No.
James IC. Thompson 715 - 248 -7767
� Address
AC.E. Soil &Site Evaluations Dad CST Number Ref #
la'
340 Paulson Lake Lane, Osceo�V 54020
12/31/1999 3602 1161
pRppERTYOWNER. Miller Sam SOIL DESCRIPTION REPORT 1e+ Page 2 of 3
PARCEL LDJ 040-1021 -90 A.C.E. Sod & Site Evaluations
Depth Dominant Color Mottles Structure sistence Bounda Roots GPW
Horizon in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. ry Bed Trench
3 1 0 -10 10yr3/2 None sl 2msbk mvfr as 2f 0.5 0.6
2 10 -21 10yr4/4 None heavy sl 2msbk mvfr aw if 0.5 0.6
Ground
elev 3 21 -30 10yr5/4 None is Osg ml cw - 0.7 0.8
103.75 ft 4 30 -42 1 Oyr4 /6 None is Osg dl gs - 0.7 0.8
Depth to 5 42 -117 10yr5/4 None s Osg dl - - 0.7 0.8
limiting
factor
>117' 63
Remarks:
4 1 0 -12 10yr2/1 None 1 2fcr mvfr cs 2f &m 0.5 0.6
2 12 -22 1Oyr4/4 None sil 2msbk mfr aw 2flm 0.5 0.6
Ground
elev 3 22 -34 10yr5 /4 None is Osg dl aw if 0.7 0.8
102.25ft 4 34 -41 10yr5 /4 f2d7.5yr5/8 sil lmsbk mfr ai - 0.2 0.3
e 9 5 41 -115 10yr5/4 None s Osg dl - -'
factor
>115"
Remarks: One foot rule applied to disregard redox. features found in H #4.
5 0 -10 10yr2/1 None 1 2fcr mvfr cs 2f &m 0.5 0.6
2 10 -25 10yr4 /4 None sil 2msbk mfr gw 2f,lm 0.5 I 0.6
1 6
Ground
elev 3 25 -34 10yr5/4 None sil 2msbk mfr aw if 0.5 0.6
104.94 ft 4 34 -44 10yr5/4 f2d7.5yr5/8 sil lmsbk mfr aw - 0.2 0.3
Depth to 5 44 -118 10yr5/4 None s &gr Osg dl - - 0.7 0.8
limiting
factor
>118'
Remarks: One foot rule applied to disregard redox. features found in H #4.
Ground
elev
Depth to
limiting
factor
Remarks:
Cu( cre - Sae off'
loo, Ile 000 /o -e - +�. Elegy _ /02
fovl 82-5/'
.64 IV
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer m5 &
Mailing Address I N y 5 d ryo f
property Address 4 4 0 N E U-) F - t V
(Verification required from planning Department for new construction)______ _.
City /State , )4 L)I So t4 W ( Parcel Identification Number
LEGAL DESCRIPTION
Properly Location h L r /4, SI�I ' /,, Sec. 5 , 'I L N -R—L10, Town of TA-0 Y ._.
Subdivision F k b � 1 F W -- . Lot # �Z .
Certified Survey Map # d . Volume Page #
Warranty Deed # 60 , Volume Z-- Page # 2 "
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
masborplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system
condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
is in proper operating i
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
e three ear expiratpon date.
S ATURE OF " APPLI CANT
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
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
CL Q
SIGNATURE OIF APPLICANT DATE
« « « «s« being revoked b the Depart
« « « « ««
Any information that is mis- represented, may result in the sanitary permit Y ��g
«« 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
V ill.1442PAG E 42
• 1 STATE BAR OF WISCONSIN FORM 2 - 1998
WARRANTY MED 60684 1
KATHLEEN H. WALSH
REGISTER OF DEEDS
This Deed, made between Kathryn B. Tuleren, Md Ferris — ST. CROIX CO., WI
R_ Mi l g ran s wifa nW lis<bZila RECEIVED FOR RECORD
Grantor, conveys and warrants to 07 -14 -1999 11:00 N
Sam E. Miller, a single person. YARRANTY Do
EREIPT
Grantee. CEAT COPY FEE:
Grantor, for a valuable consideration, conveys and warrants to Grantee COPY FEE:
the following described real estate in S1. Croix County, State of TRANSFER FEE: 2228.10 RECORDING FEE: 12.00
Wisconsin (The "Property"): PAGES: 2
Recording Ara
Name and Ream Address
040-1022.10; 010-1022.70; 040- IMI -90:
040. 1029 - 20:001028 -70
Parcel Identification Number (PIM
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.
i
K athryn B. ulgren
X 44 et9 // irLr-,.V
' Ferris R. Tulgren
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
) ss.
authenticated this _ day of St. Croix County )
Personally came before me this 13 day
of July, 1999, the above named Kathryn B. TLlaren,
and TITLE: MEMBER STATE BAR OF WISCONSIN Ferris ,
to
(If rot, rile yawn o the per (s) who executed the foregoing
authorized by 1 706.06, Wis. Stars.) instru and aqua �(ge the sane.
THIS INSTRUMENT WAS DRAFTED BY
Attorney Krlstbu Ogland
Hudson, Will 34016 N 4W%blic, State of Wisconsin
(Sigrutures may be audwrxicated or acknowledged. Both are rot My Commissici i3 pe nent. If not, state expiration date:
necessary.) $re4kda Poulin / ! / ► d Qev
—
Notary Public
State of Wisconsin
•T�arm of persons signing In any capacity should be typed or printed below dwIr signatures
wAtaAIM DBLD aTA7a ana or wascomm
ro"N.r -INS
1Nf0RWn011 PWe$$K*M1 C0WANY FDrrD OV RAC, IAI /004062671
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1442 43
EXHIBIT "A
parcel of land located in the NE' /. of SE % of s cti 28 North, Range 9 ,/4
That certain Pa ,
ALL
County, Wisconsin more f5 08
Beginning at the lows.
Of SW' /• and t TroESt. CSW �'/' ully.describe
of Section 5� •thence N87
West, Town of Y.
West quarter comer of said Section ,
d bearing on the East -West quarter let thence N87 °51'08 "E, 288.00 meet to a
records ° � " 654.00 fe ,
( 24 E, t line,
3 East S00 1 said
2342.24 feet; thence on
thence a g
point on the East line of said NE' /. of SW o o f said NW' /• of thence al
466.08 feet to the SE corner of said eE' /. of SW / thence along the
S00 °13 the S
170.48 feet; thence S87°54'54said
South line of said NE 14fe SW ce N o 28'E n ,/� of SW' /•; thence along
37 W
° W 2 said N
S87 5
a 54 � of
273.91 feet to the monumented West line ° 841.26 feet; thence
30'28 "E (fecorded as N01 32'36"E).
ed as N6"W), 458.40 feet to the North corded as
NE ,/•
West line, N00 ° 3054'50
N64 °57'47 "W (record said North line, N88-2o E
of SE' /. of Section 6; thence , „E� 416.
ng r
Ne9° 69 feet (ecorded as 25'/• rods) to the Point o
888 °40'19 "E and
Beginning.
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I �
NORDIC HEIGHTS ADD
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(R 0 01'52"36•
I'i N WSW 1 91!.16'
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