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HomeMy WebLinkAbout040-1259-10-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division Coun�t Croix INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitj Sr�itNo.: Personal information you provice may be used for secondary purposes [Privacy Law s.15.04 (1)(m)]. J Permit Holder's Name: ❑ City ❑ gills e_0 Tovgn.of: State Plan ID No.: rdman, June ro� ownship CST BM Elev.: Insp. BM Elev.: BM Descripti Parce o T • a' I � . o' A"ZI ; ti -�� = CSC b4� "1�s9 - - 000 TANK INF RMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION 94 % HI FS ELEV. Septic t,� e.� y�f �p Benchmark Dosing A t. .IS aq.2S� Aeration Bldg. Sewer Holding St /Ht Inlet `.�S loz•9s T SETBACK INFORMATION St/ Ht Outlet ` (o •80 �a2.1v0� TANKTO P/L WELL BLDG. AirI to ntake ROAD Dt Inlet -- Air I Septic y /Up' 3� NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe t 4, O ` 8. $0 ib. &f Holdin Bot. System ' W Z C 11.90 9�• - / SIPHON INFORMATION Final Grade Manufacturer d St cover z D o 4o Model Num GPM TDH Lift L n System TDH t m e I Forcemain Length Dia. ell SOIL ABSORPTION SYSTEM " Ke TRENCH Width L r N . Of renches PIT No. Of Pits Inside Dia. Liquid Depth DIME 5b • 7 1 DIMENSION SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Mau,f��actyy SETBACK INFORMATION Type Of CHAMBER Model Num b r: System: �tt U , >SO >, -�" OR UNIT u it DISTRIBUTION SYSTEM QI Header / ifold d1 Distribution Pipes) x Hole Size x Hole S acing Vent To Air Intake Length Dia. Length Dia. pacing /OD 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. Ins ection #I: nspection Location: 353 Deer Valley Drive, discrepancies, W 54016 (SE 1/4 k 1/4 18 T28N R19W) - 18.28.19.1380 Deer Valley -Lot 1 1.) Alt BM Description = -1p " PBwa..Q 2.) Bldg sewer length= 3 , t.0 - amount of cover = y 8 Plan revision required? []Yes No Use other side for additional inforrKation. VaILAAL. � � l jl( SBD -6710 (R.3/97) Date Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: m=._.._ , e.. E .. . ... . P. ^m^ ^, ^ F �. .... .. ,> .. .... ta m^ m. y5 i � Y x x 1 E i ! x I e f x .. x , r 1 ....... j E i x j [ [ { fi e ^ E ^m ^ea m e x j , E ^ F e e 1 3 i z i E e s i E � E t ? i A ^. ^.�.�:..: i v a 3 . ( } i E E 8 x ; 4 . �, .�- . 3 f" " E r f E a E F. ... : a .. s.,,. a� j 3 s � , ,.., ..e. o , ( c 3. x E x 3 E a i Safety and Buildings Division SANITARY PERMIT APP. 2 01 W. Washington Avenue Vsconsin J- P O Box 7302 Department of Commerce In accord with Comm 83.05, P�irniCode Madison, WI 53707 - 7302 • Attach complete plans (to the county copy only) for the syst on pao =less Cqunt than 8112 x 11 inches in size. • See reverse side for instructions for completing this applicaiior r ,s State �a itary Permit umber Personal information C ou p rovide may be used for second `. r y p y ry purposes � ! � c �"C N' F! Cnec if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State an I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL IN \ 4MATr� � Propert Owner Name prOpertyt gc�tlor, �) � _ t'/4' tZ, t T , N, R r W Property Owner's Maili Address Lot Numf�er Block NUM 4er ILI 10 P, Ci y , S ate Zip Code Phone Number Subdivisio ame or CSM Numbe ELL ID I La II. TYPE BUILDING one) E] State Owned It� Nearest Road (� Ej Public 1 or 2 Famil Dwelling - No. o f bedrooms Town of r0 III. BUILDING SE: (If building type is public, check all that apply) Parcel Tax Number(s) f IS. 2 $. 9 , 13 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. ref New 2. ❑ Replacement 3. E] Replacementof 4. E] Reconnection of S. ❑ Repair of an ---- __System ________ System Tank Only 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 (Seepage Trench 22 E] In-Ground Pressure 42 E] Pit Privy 13 b Seepage Pit 43 ❑ Vault Privy 14 ❑ System -in -Fill NO Q�-6� meAk4&9 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 Req fired (sq. ft.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min. /inch) 1 77, 5 Elevation 123 573 Feet 1 Feet Cap acit y VII. INFORMATION in ga llons Total # of M Name Prefab. Con- steel Fiber- Exper. Manufacturer's Gallons Tanks Concrete glass Plastic App New Existing structed Tanks Tanks eptic Tan r H*kh"gftff 1 Oco t p� r ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber 1 10 1 ❑ 1 01 ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Prin PI b 's Sign tur : (N tamps) /MPRSW No.: Business Phone Number: La C63 7 _7 (o SI Plumber's Address (Street, City, State, Zi Cod - �K U WQ. i b' IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved nit Surcharge Fee) ary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Approved ❑Owner Given Initial c- - Adverse Determination QD-' . � X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: I SBD -6398 (R. 4/99) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS I 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 prior to installation 5. Onsite sewage systems must be properly maintained. `fhe septic tank(s) must be pumped alicerised pumper wheriever 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 andZuildings Division, -608 -266 -3151. - - A 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. 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. `cmpjete plans tkecifications 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 vvith comple dimensions, lbcation of holding tank(sT,10ptic 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 iequired by the county; Er 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. Q� PLC, Lo C) 000 R eV- ct _ l Js t C,o 2-a0 s 3 a hl. h - Q _ 1 l� 1 j �1 r 'Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Human Relations Division of `Z,afety & Buildings in accord with ILHR 83.05, Wis. Adm. Code • COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but St. Croix not limited to vertical and horizontal reference point ( irtipri'a?td. °� of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and dicta fbp he`arest road. 6 -- Aq 4 4 APPLICANT INFORMATION PLEASE P N ILL I -`�' R VIEWED BY DATE PROPERTY OWNER: -_ " `" ;PFr ERTY LOCATION Derrick Construction Inca � l u l l h �Q LOT SE 1/4 NE 1/4,S18 T 28 N,R 19 if (or) W PROPERTY OWNER':S MAILING ADDRESS — 5r '? 'LOT BLOCK # SUED. NAME OR CSM # 1505 HY. #65 • ^'� �'k na Deer VAlley CITY, STATE ZIP CODE PHQ ITY OVILLAGE ®TOWN NEAREST ROAD New Richmond, WI. 54017 (7 246— - ,f Troy E. Coe Rd. ] New Construction Use [x] Residential / Numbe 4 [ ] Addition to existing building (] Replacement [ ] Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd /ft trench, gpd /ft Absorption area required 858 bed, ft 750 trench, ft Maximum design loading rate .7 bed, gpd /ft .8 trench, gpd /ft Recommended infiltration surface elevation(s) area A= 96.5 —B =97.50 ft (as referred to site plan benchmark) Additional design / site considerations na Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem @ S ❑ U [R S ❑ U [R S ❑ U ER S ❑ U CR S ❑ U ❑ S 13;U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft .................. in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trerlcfl ................. .................. ................. .................. 1 1 0 -10 10yr3 /3 none sl 2mgr mfr gw 2f .5 .6 2 10 -84 7.5yr4/6 none cos Osg ml na na .7 .8 Ground elev. 9 9.5 ft. Depth to limiting factor 96 s + 84" 3&/ Z Remarks: Boring # 1 0 -18 1Cry2 /2 none 1 lcsbk mfr cs 2f .4 .5 j 2 'jj`j 2 18 -36 10yr4 /4 none sil 2csbk mfr gw if .5 .6 3 36 -84 7.5yr4/6 none co s Osg ml na na .7 .8 Ground elev. j 99.O Depth to limiting - z 3. z fact Remarks: CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200 Address: 1554 200th. ve. New Richm9nd, WI 54017 Signature: Date: 6 - - CST Number: m02298 PROPERTY OWNER Derrick Const. Inc SOIL DESCRIPTION REPORT Page? of 2 PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ftie .................. in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed jTirench ................. .................. ................. .................. 3 1 0 -12 10yr4 /3 none sl 2msbk mfr gw 2f .5 .6 2 12 -98 7.5yr4/6 none co s Osg ml na na .7 .8 Ground elev. 1 Depth to limiting factor Remarks: Boring # 1 0 - 10yr4 /3 none sl 2csbk mfr gw 2f .5 .6 4 2 14 -84 7.5yr4/6 none cos Osg ml na na .7 .8 Ground elev. 100, t. - Depth to - limiting factor +8411 39•x/ s:b Remarks: Boring # _......_... 1 0 -10 10yr4 /3 none sl 2csbk mfr cs 2f .5 .6 5 2 10 -24 10yr4 /4 none sit 2msbk mfr gw 1f .5 .6 3 24 -94 7.5yr4/6 none co s Osg ml na na .7 .8 Ground elev. 10 ft. Depth to limiting factor 9 �� �4— Remarks: Boring # Ground elev. j ft. Depth to limiting factor Remarks: j SBD- 8330(8.05/92) e STEEL'S SOIL SERVICE Gary L. Steel Derrick Sonstruction, Inc. 1554 200th Ave. CSTM2298 SE4NE4 S18- T28N -R19w New Richmond, WI 54017 MPRSW -3254 town of Troy (715) 246 -6200 lot #1 -Deer VAlley N' .,1" =40' , BM.= nail in Pine tree C el. 100.00 Alt. BM.= nail in Pine tree C el. 99.00 �n 2 4 AO 2� 90, i �06 0cvaz:L �C Gary L. Steel 6 -1 -99 ' r 15 � T^ n. � rf M m w CO x 3 c7 n m P N m s' S � P - i f .. f 0 i (D 0 o G .L CD X 7 CD 71 ? =3- CD CJ -- CL (a c R _ 0 - - (( p D 4 _ � n n 4 O (D fn cn Cl N IO 3 I N ? w ` -�°n - cxn 3 cD 0-0 c o G �X (D D�'`•a Hfir'' a CO = -! ch � 6 = n ]D ro G 1 o 3 } m c ° A� Invert c W C) i ' ST CROIX COUNTY ��1��� S SEPTIC TANK MAINTENANCE AGREEME b' AND OWNERSHIP CE IFICATION FO l - r 1- uxv Owner/Bu er "L4 � U - 1'll _cs i Y yv Mailing Address S0$4 t b FVUoS a" \Aft 54� ► t Property Address (Verification required from Planning Department for new c nstruction) City/State t Parcel Identification Num er LEGAL DESCRIPTION ( I, l � - Z Property Location 5 %4, We 1 /4, Sec. , T 'Lb N -R q W, Town of Subdivision -''ti �a �-��/ Lot # Certified Survey Map # . Volume , Page # Warranty Deed # n-SIR 1 C Volume /7Zcc3® Page # G (01 - 433 ryg 36� Spec house ❑ yes )<no Lot lines identifiableXyes ❑ no 1 � . ze'� r � . (3 ?0 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 master plumber, journeymanpldmber, 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 s of the thr year expiration date. SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION A pro we) certi fy t 1 statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of y described e, virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE O /Z "i O � F PLICANT 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 e 4 •tiarva Q 117 E p d pN { a WOO P 4P Z 8 O g a0 N Iq s O ' �S+ 00 oozz C X co up- a ' L IN ol ° d 004 P*4 CDrolo 10 In CD o cc N 01. �1 d�fN� O O � it 00 09) 4 Ott O OD 0 G7 a z� F N ,. F. Ej W P O ©.0.+1+ ,p .� 0 0 x 3 N '•� ' T.. 0 E t o �p 4 JN ~ a°a a�{I-oco ° m° '� W3 � oar «� ca { nz � W °: x z a I r�u7aon O a oti.�rt ° .O cc ca WWQ D 0 M 2N lot- wo 0 f c wo 4D >W o lt S F- U a z >-"►, zin ,. �qx Xw° o a zee WOV40 v N V { 1... Fy d [t'01 Ir! t..1'� ► E' E H ON M E'd GT+frL- 9BE -SiG sJORWId S'O'S RZTiOT 66 0a 400 DEER VALLEY Located in the NE1 /4 of the NE1 /4, Part of the SE1 /4 of the NE1 /4,.Part of the SWIM of the NE1 /4, and part of the NW1 /4 of the NE1 /4, of Section 18, T28N, R19W, TOWN OF TROY, ST. CROIX COUNTY, WISCONSIN LOT 12 2.3 Acres LOT 11 2.7 Acres LOT 13 N 4.8 Acres O Q 2 J LOT 10 ILI 2.7 Acres LOT 14 C 3.2 Acres IL I LOT 9 3.3 Acres D LOT 15 Z LOT 16 UNPLATTED LANDS 2.3 Acres LOT 8 Qtu Acres 3.4 Acres J a LOT 17 2.4 Acres LOT 18 LOT 23 LOT 7 2.5 Acres 2.6 4.7 Acres LOT 28 LOT 22 Acres 2.9 Acres 2.7 LOT 29 Acres ILI 6.8 Acres LOT LOT 6 v LOT 19 2.4 2.7 Acres u 2.3 Acres Acres LOT 24 x LOT 20 3.4 Acres 3.4 Acres LOT 5 0 2.7 Acres LOT 4 4.8 Acres LOT 25 2.3 Acres LOT 3 LOT 2 3.7 Acres 2.8 Acres LOT 26 3.3 Acres LOT 27 2.7 Acres LOT 1 2.3 Acres Existing House East Cove Road