HomeMy WebLinkAbout040-1263-90-000 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.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 370290
Permit Holder's Name: []City ❑ Village ❑ TOwn of: State Plan ID No.:
Miller, Sam I Troy Township
CST BM Elev.:. Insp. BM Elev.: BM Description: Parcel Tax No.:
ld - f_ to 6 7 1 + 040- 1263 -90 -000
TANK INFORMATION ELEVATION DATA
i
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic �J I < < Z �� Benchmark f ?0
- - .
osmg Alt BM � ___ _.,
Aeratier5 Bldg. Sewer f 17
Holding gY Ht Inlet d z
TANK SETBACK INFORMATION gY Ht Outlet
TANK TO P/ L WELL BLDG. Air i to ntake ROAD
Air
Septic ± 7 r NA
- - - --IA Header/ Man.
IS.q //3-0
Aeratrcfri NA Dist. Pipe it 2 2 q
Holding Bot. System �'
PUMP / SIPHON INFORMATION Final Grade °
1 19
a rer Demand St cover 3.5'0 /ZS. Y//
Model Numb M + O joa 2
TD Lift Friction tem TDH Ft 0-1 2_ 12
L oss e Forcemain Length Dia. Dist. T u
SOIL ABSORPTION SYSTEM ( -?
BED / T ENCH width r Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN 3 Z DIMENSION
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM L CHAMB Ma acturer: ,
INFORMATION TypeO 'r
Mo e Nun
er:
System: Ceti. Z 2 / 3 NIT
DISTRIBUTION SYSTEM ��os�sf pd/„�
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia - Lengt r Dia. Spacing ! V N 7 �O
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: In I de code discrepancies, persons present, etc.)
Inspection #1: 9 11 Inspection #2: / /
Location: 411 New Century Drive, Hudson, Wl 54016 (NW 1/4 SW 1/4 5 T28N R19W) - 05.28.19.1427 Frontier -Lot 19
1.) Alt BM Description= t•p o fok�� "��� well
2.) Bldg sewer length = (8` Y) sr sfci— e�V, cwaS
- amount of cover =7YZtl
Plan revision required? []Yes No
Use other side for additional informa ion. I Z v d wn
SBD -6710 (R.3/97) Dat Inspector's S ature Cert. No.
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ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
V iscons in SANITARY PERMIT APPLICATION 201 W Washington Avenue
-- P O Box 7162
Department of Commerce In accord with Comm 83.0 , i Aprtl. (yo)ie� Madison, WI 53707 -7162
• Attach complete plans (to the county copy only) for the on paner noiaws County S� �!
than 8 1/2 x 11 inches in size. `y'' 1' ii
• See reverse side for instructions for completing this a pi ation `` F`= tate Sanitary Perm't Number
t t �If►'��J ^/
3 1 " Z ? O
Personal information you provide may be used for secondary purpose
4 00 Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. �', 3T OIX tate Plan Review Transaction Number
1. APPLICATION INFORMATION - PLEASE PRINT L �u N Q
Property Owner Name Poe VO3 n s ot *\ IY\%LLF tt►. / p 5 5 T Zj ,N,R19 E(or
Property Owner's Mai Iin Address u b Block Number
D = / S - 7
Cit , State Zip Code Phone Number Subdi ision Name or CSM Number
v A 81~ otL (�k,) Z76
11. TYPE OF BUILDING: (check one) ❑ State Owned it Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms G Iow OF 7 C) y AGV �RerOXV
III. BUILDING USE: (If building type is public, check all that apply) Parcel TaxN 5 S . 1 9 , 1 42- 7 1
L
1 ❑ Apartment/ Condo 0 i � Z`4 ? ?
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 teNew 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 WSeepage Trench LE#4GEI° 22 ❑ In- Ground Pressure ^ 1� 42 ❑ Pit Privy
13'❑ Seepage Pit is tVtC co,L.., C 43 ❑ Vault Privy
14 ❑ System -In -Fill CD y 3 Sol Fr CA C, �{
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
Q Req ' ed (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) 10 Elevo
`j " '� 3 J/1 t Feet ati Feet
VII. TANK Cap s Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App
New Existin strutted
Tanks Tanks
Septic Tank r Holding Tank t t W EI E0 --- ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ 1 111131 ❑ ❑ I ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print2 Plumber's Signature�(Namps&l MP /MPRSW No.: Business Phone Number: Z y
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
`❑ Disapproved S3p itary Permit Fee (Includ Groundwater D ate Issued Agent Signature (No Stamps)
f�l roved
Pp f Owner Given Initial Surcharge Fee)
�
Adverse Determination ��0D
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
l
SBD -6398 (R.12199) 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 Administratjve 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 arvd 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 isto 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.
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Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3
Division of Safety and Buildings in accord with Comm 83.05, W is. 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 County
include, tit not limited to: vertical and horizontal reference point (BM), direction and St. Croix
percent slope, scale or dimemsions, north arrow _ and distance to nearest road. Parcel I.D.#
Prt of 040 - 1022 -10
APPLICANT INFORMATION - /4alse print all Information. R viewed B Date
Personal information you provide may be - secondary purposes (Privacy Law, s. 15.04 (1) (m)). — 4. M-D
Property Owner ° Property Location
c,,
Miller, Sam Govt. Lot NW 1/4 SW 1/4 S 5 T 28 N,R 19 W
Property Owners Mailing Addressl _. ; ^ Lot # Block # Subd. Name or CSM#
P.O. Box 151 19 Plat Of Frontier
City State Zip Codes iFluxreNumber City E] village ®Town Nearest Road
Hudson WI 54046 ,7.1c 038 6 =27 Troy Tower Road.
® New Construction Use: X Residential'tNll41 bedrooms 4 ❑Addition to existing building
Replacement ❑ Publie o - ot-06 il describe
Code Derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd/ft .8 french, gpd/ft2
Abso hon area required 857 bed, ft 750 trench, ft Maximum design loading rate .7 bed, g pd/ft2 .8 trench, gpd/ft
Recommended infiltration surface elevation(s) 111.00. ft (as referred to site plan benchmark)
Additional design 1 site considerations hiscan trenches using high capacity infiltrators. .=p
Parent material Glacial outwash FLA plain 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 El ® S❑ U ® S❑ u M S U ❑ S ®u ❑ S® u
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Sere Consistence Boundary Roots GPD1f12
Boring# Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ; Trench
1 1 0 -6 10yr2 /1 None sl 2fcr mvfr cs 2f &m 0.5 i 0.6
2 6 -10 10yr4 /2 None sil 2msbk mfr gw 2fm,lc 0.5 0.6
Ground 3 10 -25 10yr5 /4 None sil 2msbk mfr aw 2fm,lc 0.5 0.6
elev
117.05 It 4 2032 7.5yr4/6 None is Osg dl gw - 0.7 0.8
Depth to 5 32 -125 10yr5 /4 None s &gr Osg dl - - 0.7 0.8
liming
factor
>125" (4 0 8 6
Remarks:
2 1 0 -4 10yr3 /2 None A 2msbk mvfr cs 2f 0.5 0.6
2 4 -12 10yr3 /3 None sl 2msbk mfr cw 2f &m 0.5 0.6
Ground 3 12- 0 7.5yr4/6 None is Osg ml cw 1f &m 0.7 0.8
elev
116.65 ft 4 O 74 10yr5 /4 None s Osg dl gs - 0.7 0.8
Depth to 5 74 -119 10yr6 /4 None s Osg dl - - 0.7 0.8
limiting
factor
>119"
Remarks:
CST Name (Please Print) Signature: - Telephone No.
James K. Thompson _ � �� > S " — 715- 248 -7767
Address A.C.E. Soil & Site Evaluations Date CST Number Ref #
12/31/1999 3602 1168
340 Paulson Lake Lane, Osceola, 54020
PROPERTY OWNER- Miller Sam SOIL DESCRIPTION REPORT 1188 Page 2 of 3
PARCEL LD.0 Prt of 040- 1022 -10 A.C.E. Soil & Site Evaluations
Depth Dominant Color Mottles Terre structure Boundary Boundary Roots GPDM2
won in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
3 1 0 -6 10yr3/2 None A 2msbk mvfr cs 2f 0.5 0.6
2 6 -14 10yr3/3 None sl 2msbk mfr cw 2f &m 0.5 0.6
Ground
elev 3 1 23 7.5yr4/6 None Is Osg ml cw if &m 0.7 0.8
113.341t 4 23 -59 10yr5/4 None s Osg dl gs - 0.7 0.8
Depth to 5 59 -124 1Oyr6/4 None s Osg dl - - 0.7 0.8
limiting
factor
>124" .tom 4.
Remarks: I-TA"t
4 1 0 -4 10yr3 /2 None Sl 2msbk mvfr cs 2f 0.5 0.6
2 4 -12 10yr3/3 None Sl 2msbk mfr cw 2f &m 0.5 i 0.6
Ground
elev 3 12 -20 7.5yr4/6 None is Osg ml cw if &m 0.7 0.8
109.92 ft 4 20 -74 10yr5/4 None s Osg dl gs - 0.7 0.8
Depth to 5 74 -119 10yr6/4 None S Osg dl - - 0.7 0.8
limiting
factor
>119"
Remarks:
5 1 0 -6 10yr3/2 None sl 2msbk mvfr cs 2f 0.5 0.6
2 6 -19 10yr3/3 None A 2msbk mfr cw 2f &m 0.5 0.6
Ground
elev 3 19 -27 7.5yr4/6 None is Osg ml cw 1 f &m 0.7 0.8
110.91 It 4 27 -65 10yr5/4 None s Osg dl gs - 0.7 0.8
Depth to 5 65 -127 10yr6/4 None s Osg dl - - 0.7 0.8
limiting
factor
>119'
Remarks:
6 1 0 -25 10yr2 /1 None sl lthinpl mvfr cs 2f &m NP 0.3
2 25 -34 1 4/2 None sil 2fsbk mfr gw 20m 0.5 0.6
Ground 6
elev 3 34 -51 10yr5 /4 None stl
2fsbk mfr
aw
1 f &m
0.5 0
105.77 it 4 51 -58 7.5yr4/6 None is Osg dl gw If 0.7 0.8
i
Depth to 5 58 -120 10yr5 /4 None s &gr Osg dl - - 0.7 0.8
limiting
factor
>120'
Remarks:
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer G 4 IYI M IG 42"
Mailing Address
Property Address
(Verification required from Planning Department for new construction)
Cit y /State # (/ ,0S0q V Parcel Identification Number 4yQ` Z 3" 9 U - < 5 "> 0
LEGAL DESCRIPTION
Property Location At a) 1/4, Lo '/•, Sec. S . T Z$ N -R Town of �• o
Lot #
Subdivision �' � �''��f '�`'2 -- .
Certified Survey Map # Cvl 9 S5"o , Volume Page #
Warranty Deed #
Co 0 �7 $ `f l , Volume � �., Page # ` l - Z
Spec house �f 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
lumber, restricted lumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system
master p lourneymanP , P
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.
1,
require agree I/we, the undersigned have read the
above meats and a 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 maintampd must be completed and returned to the St. Croix County Zoning Office within 30
days of the three year expiration date.
/ Z7 /t2C
SIGRATURE OF APPLIbUqT 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 owaet{s) of
the property described above, b virtue of a warranty deed recorded in Register of Deeds Office.
AURE T dPPLICANT 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 copy of the certified survey map if reference is made in the warranty deed
Vill.1442PAGE 42
STATE BAR OF WISCONSIN FORM 2 - 1998 1606841
WARRANTY DFFD
KATHLEEN H. NALSH
+ * This and Ferris Deed, made between Kathrvn B. Tulgren, ST. CR O
OIX. WI
Co., -
R - T1tl g ran . wi fa nr l ► �bys RECEIVED FOR RECORD
Grantor, conveys and warrants to 07-14 -1999 11:00 U
Sam E. Miller, a single person. WARRANTY DES
EXEMPT 1
Grantee. CERT COPY FEE.
Grantor for a valuable consideration conveys and war COPY FEE:
co y rants to Grantee
the iRraNSF ER FEE. 2228.10
following tng ducrtbed real estate to St. Croix County, State of RECORDING FEES 12.00
Wisconsin (Tbe "Property'): PAGES. 2
Recording Area
Name and Rewm Address )
040.1022 -10: 001=•30; 040- IMI -90;
040 1029-20-.040-1023-70
Parcel Identifkadon Number (PIN)
This is not homestesd 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. Tlilgren
A LURENTICATION ACKNOWLEDGMENT
Signuurc(s) STATE OF WISCONSIN )
) u.
authenticated this _ day of St. Croix County )
Personally came before me this 13 day
• of July, 1999, the above named Kathryn f. 1Llaren.
TITLE: MEMBER STATE BAR OF WISCONSIN B� Ferris T}:--� greii, rife -m,�— I
(If not, me UMnt the per s) who executed the foregoing
autltoriud by 4 706.06, Wis. Stan.) instru and ackno I � t }e tlx sane.
THIS INSTRUMENT WAS DRAFTED BY
Attorney KrIstiva Ogland
Hudson, WI 54016 N blic, State of Wisconsin
(SIFutuies may be authemicated or acknowledged. Bush are rwi My Cum mi 10 sfpe d e f not. state expiration date:
nCGe3S " )
Breads Poulin ((
Notary Public
State of Wisconsin
'Names of person sion8 In any capacity should be typed or printed below their mgmituu
WARRANTY DUO RAS W Or w6Caw
roam rr. s . tar
a1rORAMMN PAOFE8401M1 I COWANY FONDOVRAC.VA 8004WWMI
1442M.1 43
EXHIBIT "A„
ed in the NE' /. of SE' /. of section 8 Nor h! Range
That That certain parcel of land local described as tollows:
ALL in Town
St Croix County, �Nlsconsin more f lhle Ce N87 °51'08 "E
of SAN' /• and the S• of SW '/` °t Section Section 5; distance of
West, Town of T Y
Beginning at the West quarter comer u said
quarter line o
the East -West qu °151 08 'E288 00 feet to a said S6c
(recorded bearing on 854 feet, thence Said East line,
2342.24 feet'. thence S00 °13'24 "E, thence along the
E corner of said NE /• of SN / ;�� of SW '/•
thence along
point on the East line ofEt to he S' of SW ' / lin of 5210 ° 4
Soo 13 466.08 fe 170 48 feet-, thence S87 said
of SAN' /• and the South ► � thence along
South Ilne of s 237 41 thence N00 °30'28'E,
7°54'5 ted West tine of Bald NW 41 26 feet • thence E ,�•
S8 01 °), 9
273 91 feet to the monumecorded a5 N 3238 E ° " recorded as
line N00 3 0 28 E (r ecor ded 458.40 feet to the t E ( line of sa
id f
West , to the Point o
N64 °57'47 "W (recorded as N6 said North line, N88 2 25 /• rods)
of SEA of Section 6; 210 4g 6 6g feet (recorde
a d as
S88 °40'19 "E nd N 89 ° "E)
Beginning.
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NORDT,C_ HEIGHTS_ ADQQN.
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