Loading...
HomeMy WebLinkAbout040-1259-20-000 e Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Coun Safety and Buildings Division INSPECTION REPORT �'t. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitiy��jcrrait No.: 2 Personal information you provice may be used for secondary purposes [Privacy Law .15.04 (1)(m)]. /JJ Permit Holder's Name: ❑City ❑ \LillageJ l Tow n.of: State Plan ID No.: 1 7 . rdman, June t roy h 0 ownsllip CST BM Elev.: E .... nsp. BM Elev.: BM Description: Parce T . o W . Z) ' Cs -r �►u�� : Q vc, . b 4� 59 -20 -000 TANK INFORMATION LOLEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosi ng Alt. Aeration Bldg. Sewer Holding St /Ht Inlet (o. O 10-5-.86 r TANK SETBACK INFORMATION St/ Ht Outlet 1 1, 30 t 57 TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet - Air Intake Septic r Z — NA Dt Bottom --- Dosing NA Header / Man. Aeration NA Dist. Pipe /3 SO era �3•S •ZL Holding Bot. System Z' �. o PUMP / HON INFORMATION _ fi nal Grade Manufacturer Demand St cover 8 f D`I• Model Number GPM TDH Lift Fr' n S stem TDH Ft Forcemai ength Dia. Dist. To SOIL SORPTION SYSTEM BMATZENCH Width Length No Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION 3 S(o• 2 DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacl red r: INFORMATION Type Of ` CHAMBER Mo e -r er r System: (°.0vol. 50 f SO > 1 S - a OR UNIT 14 k – DISTRIBUTION SYSTEM Header/Manifold r Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake r , Length�� Dia. 4f Spacing } Zoo 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: 05 1.2 Cy nspection Location: 361 Deer Valley Drive Huds n, WI 54016 (SE 1/4 N s E 1/4 18 T28N R19W) - 18.28.19.1381 Deer Valley -Lot 2 1.) Alt BM Description ='(�� �lncnSide�, 2.) Bldg sewer length = 8 - amount of cover = > 42 ". AA. a,�a is ups�s� 'cw2cQ SY t.t . Plan revision required? ❑ Yes XNo Use other side for additional information. IX SBD -6710 (R.3/97) Date Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: s 2 .. e .. ,e e q a t E } F , t S N£ ,gym z ..._.. p 4 E rv� ........_ .m e . . ,, e ...A ,m .., , a a �.m ,.... 5 ...._. .:.....4 Z _ ..., ... s ..,. ...a.. -. a ` _ e .... e, ` a ... s .. E .«..{ I L a a� w. ..... u ee" ...... ..m ® ...... .......,, F m - .........,. t.......... a ....... , , �.. ... ._. _.. _. t s 4 _, S e e a 1 t o .. 3 1 � E t g i e e e a E z Y � 4 9 3 a b S ➢ a w »� s_ a ? t e P e 3 S y a t S s � � g r m y i 3 t 4 i [ F s i � F e.A m i rz i a _, _..�.,.. m.e... .,. .. a a i E t Safety and Buildings Division NVisconsin SANITARY PERMIT APP P o B w3o2ngton Avenue Department of Commerce In accord with Comm 83.05, W t/ , ode " "" Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the syste , pap�'cl ess u than 8 v2 x 11 inches in size. [� �-�- ;='> t • See reverse side for instructions for completing this applica in� tt � Sta Sa itary�P Number Personal information ou provide may be used for seconds p Y P Y secondary purposes -y G [Privacy Law, s. 15.04 (1) (m)]. Z F! If revision to previous application ti 0 �7 e P Stat an I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF MATT 11 Owner Pro a Ow Nam ` Property i-0c2tl n p f�L t—d t4 Y . ti 4Y T ,N,R L9 r4mW Propert Owner's Maili g Address Lot Number Block Nyrnty�r Cal _ St to ip Code Phone Number Subdivisio ame or CSM Num er �J/-t 0,0 ( ( > S U-T-t 11. TYPE F ILDING: (check one) ❑ State Owned kPaCrcel It( t acl Public 1 or 2 Family Dwelling - No. of bedrooms ovvn of , 2 1Q III BUILDING USE (If building type is public, check all that apply) Tax Number(s) 0 cf O — t2Sq --20 — CmD 1❑ Apartment/ Condo 28, t g. 391 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. ry 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 Q Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 F1 In-Ground Pressure 42 ❑ Pit Privy 13 Seepage Pit � S �`� 43 ❑Vault Privy 14 ❑ System -In -Fill ' VI. ABSORPTION SYSTEM INFORMATION: 0 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade 5� Required (q ft.) Proposed . ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation • Feet 162 #7 Feet VII TANK Cap acit in a llons Total # of Prefab. Site Fiber- Plastic Exper. INFORMATION New -Existing Gallons Tanks Manufacturer's Name Concrete st Con ed Steel glass App. Tanks Tanks ep (is Tan or Mr�h#irtgfiztnie+- El El 11 ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ 1 ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for irutkilation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) PI tier's Si nature (N tamps) MP /MPRSW No.: N ness Phone Number: CA I s 0a�s a 5/a-5 Plu er's Address (Street, City, State, Zip C de): � � (� 1 IX. COUNTY / DEPARTMENT USE ONLY Q Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signat re (No Stamps) Approved ❑ Owner Given Initial r� Surcharge Fee) 1 4 — Adverse Determination O � } 2 � `)) .CO1:�Nr DITION$ OF APPROVAL EASO�I� DISAPPR AL:2)'e cam- 'tcz be-- �( �,,,'.� U Ut 19 r6 SBD -6398 (R. 4199) 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 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 insfalled. 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. `.;tfxL l,ete plans a.44 cifications 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. cc)" P� O-Q Q r X\ 19-� �OT - D, A,�Sc, S�qoly - T� 00'aA 2 CO DIO- �Q O-A 1 6rfI i 1 � 1 � 902. tj '- �r �r d u w ✓ 4 - P ® u ,`�O-Q- Wisconsin Department of Industry SOIL AND SITE EVALUATION REPO Page 1 of 3 Labor and Human Relations Division of Safety &Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x rtitilr injrsize. Plan must include, but St. Croix not limited to vertical and horizontal reference point ( i and "fq of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distanc t ad ('� �" �0 7 "f APPLICANT INFORMATION- PLEASE PRI T, L IN N ~\ REVIEWED BY DATE PROPERTY OWNER: �,f r , PROPERTY LOCATION rtt R or W 9 GOVT. OT Sg Derrick Construction 1/4 NE 1/4,S 18 T 28 N, 19 INc. O , 1 PROPERTY OWNERS MAILING ADDRESS LOT, #'; BLOCK # I SU BID. NAME OR CSM # 1505 Hy. #65 ANN - 2 Deer Valley CITY, STATE ZIP CODE �NUMB Cf= []VILLAGE EYOWN NEAREST ROAD New Richmond, WI. 54017 (7 32Q,.. .' Troy E. Cave [ New Construction Use [x] Residential/ Number of be ar s 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 /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= 97.80 —B =99.60 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 MOUND IN- GROUND PRESSURE AT -GRADE 7 j SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem ® S ❑ U ®S ❑ U ® S El ER S ❑ U 2 S ❑ U ❑ S aU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft Q M u in. M nsell u. Sz. Cont. Color Gr. Sz. Sh. Bed Trench .................. ................. .................. ................. 1 -13 10yr3 /3 none 1 lcsbk mfr cs 2m .4 ( .5 1 2 13 -28 10yr4 /4 none sil 2csbk mfr gw lm Ground 3 8 -80 7.5yr4/6 none co s Osg ml gw na .7 .8 10 ft. 4 ,Q-88 10yr7 /4 none fractured lime tone na na nP nP Depth to limiting factor 9 80" Remarks: Boring # 1 -26 10yr3 /3 none 1 lcsbk mfr cs 2f .4 .5 2 '?> 2 6 -39 10yr4/4 none sil 2csbk mfr 9W if .5 .6 3 9 -82 7.5yr4/6 none co s Osg ml na na .7 .8 . Ground ... elev. 4 2 -88 10 r7 4 none frac ured lime tone na na n 4 n Y /. P A 1 01.4 0 Depth to limiting factor 82 " Remarks: CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200 Address: 1554 200th.Ayf., New Richmond, W54017 Signature: Date: 6 -1 - CST Number: m02298 f 42� f PROPERTYOWNER Derrick Const. SOIL DESCRIPTION REPORT Page 2 of 3 PARCEL I.D. # Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends 3....... 1 0 -12 10yr3 /3 none 1 lmsbk mfr cs 2f .4 .5 2 12 -29 10yr4 /4 none sicl lcsbk mfr gw if .2 .3 Ground 3 29 - 90, 7.5ry4/6 none co s Osg ml na na .7 .8 elev. 1 02.1 ft. Depth to limiting f +6�0 4 . 5l•b �,c Remarks: Boring # 1 0 -10 10yr3 /3 none 1 lmsbk mfr gw 2f 2 10 -15 7.5yr4/4 none s1 2msbk mfr gw if .5 .6 3 15 -96 7.5ry4/6 none co s Osg ml na na .7 .8 Ground elev. 104.4 ft. — Depth to — limiting factor +9611 3 (o Remarks: Boring # 1 0 -10 10yr3 /3 none sl 2mgr mfr gw 2f . .6 5 2 10 -15 7.5yr4/4 none sl 2msbk mfr gw if .5 '.6 3 15 -96 7.5yr4/6 none co s Osg ml na na .7 .8 Ground elev. 1 Depth to limiting factor ( o O +96" Remarks: Boring # Ground elev. i ft. Depth to limiting factor Remarks: SBD- 8330(8.05/92) r STEEL'S SOIL SERVICE Gary L. Steel Derrick Construction, Inc. 1554 200th Ave. CSTM2298 SE4NE4 S18 T28N - New Richmond, WI 54017 MPRSW -3254 town of Troy (715) 246 -6200 lot #2 -Deer Valley This soil evaluation was conducted to satisfy.a zoning requirement, it may or may not be suitable for your use. The location of the test may or may not be as shown as permanent lot lines were not established at the time the test was conducted. �N i " -40' .= top of 1" pvc pipe C el. 100.00' 'Alt. BM.= top of 1" pvc pipe C el. 102.90 150' Gary L. Steel 6 -1 -99 ... ......._: Cd o :E `, t c 0 �E 2� c p C ` x t. ->` 3 ( E x m M ; 3 M r O T ? J+ 0 Q r C 1 O O "' O N --0 �'Q) O N cd , 7. w X i 0)- (U C L X I LL .O U- N 0 ) a) O -C Y C) C = p p� GL�� N O U) -- o n J O = ch cA 0 rte- CL • • • • co ii 1 t'r ul r r. S 0. a a LL CCS U co X - x°°000 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer -� WE lap -V A'" Fu Z k-A1Z :Ji "an t, 4 w Mailing Address ueScx t w j 54-0I `o 6 IAO.-,c ant t 540 �V, Property Address ':�� 1 h, Vch'. T>."Ve (Verification required from Planning Department for new construction) City/State k! 1 Parcel Identification Number LEGAL DESCRIPTION ��� 2g' 1 9 • 1 38 1 Property Location 1 /,, 0 1/4, Sec. , T 'Lb N -R 4 W, Town of Subdivisio - ti ya-I :I / Lot # Z - Certified Survey Map # �^ Volume , Page # Warranty Deed # SIR %I;r Volume _ /77k . Page # (0-- Spec house ❑ yes )<no Lot lines identifiablexyes ❑ no SYSTEM N AEVTENANCE 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, 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. I/we, 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 days of the three year expiration date. SI ATURE 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 the &opedes ribed above, by virtue o a warranty deed recorded in Register of Deeds Office. 0 (3 SIGN F PLICANT DA TE * * * * ** 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 I WARRANTY DF.F;U (F'ormcr Statutory Form). STATF. OF WISCONSIN Miller -Dim., Co.. Minncatxdis, A ;u., Form No. D W. 259154 ights fnbienflire, b11 Archie J. Waxon and Lois Waxon, his wife, grantor , of St. Croix County, Wisconsin, hereby convey and warrant to' Jack J. Erdman and June M. Erdman, husband and wife as joint tenants granted , of St. Croix County, Wisconsin.. for the suns of One dollar and other good and valuable consideration the followings tract of land in St. CT'OiX County, State of lVisconsin: Northeast quarter of Section Eighteen (18), Township Twenty -eight (28) North, Range Nineteen (19) West, (NF.j 18- 28 -19). j . I 1 I REGISTERS OFFICE ST. CROIX. CO.. WIS. K(*C'd for Hocord this 17th dnyof__ 9u�-,u.,t_ A.G.. 59 at__9 0 A* Hope F2..t{Isi _r of Deputy In Witness Mijerraf, The said : ranfnr S haveherrunto art the i hanf! 14th rl trt of August .4. 1). 11) 59 SIGNED AND SEALED IN MUNCE DF • -'.vim farJ 1fugh Chv Lois Waxon Harold ',Valbrandt k amu,unrg yma Japun aw' OJI -adh ! • y 09 - r 1 T .. -r� � n�1 w •. �tnu.a dill7�,� °,p3jnuno)v pun j2�,�miulsut yu.jo;i )jof )III popi,).�yj ni�►t �ns,t��l ,���� ,n1 u� u.ur�u.� :�tu o� '3jZM St L[ Uoxrm slo'j par. UOXT'M 'r ajtjD.ztr /r.rrnMI d.uogo ,)r /{ ' 65 (i/ V T �sn .J nEr rrr fir III i Brut '.,,u .,u>l.— n,,,,. l;..,.,,...•., . J L warr.a tx Lr1 0 . WOst I CD ZOV 8 F � a 0 R a ■' a 00 V4 . - e g azz 7 U r- }� r I tr w N } ro t a N rn � m a E in .... . atd i aPJ M O I- s 0 .•, o 0000c.. ° pi w N�v�� 0 $ 5 n O zad W , O O O pW ix - Ml�lnm . .r F. U 1 Pl 00 -0.,r+ W .+ N OW] ,.. '.•N m ti m 0 O 1 0 0 U O O 0 JN ~ ►- 0 TOM ' 0 "6 W 3 O m Otto MV4 aa �aN� N �Q U � V O UE O� W NS it mIn03k .0 O M�'Oo *+ O .. 1269 A ? aD et O M Z N .. fl' O► !h U y o � W +•+ W .•! H E >WWO ~ a zN 3 .. tG z � ► �-, '� �U a. aV F31�� z o� Omz a }XU�O 0 cc20 F.- 2a a LL � w F' Fr � N 39D NM grog ca rq IL CD X032 aNUUN UO rtX ONLLa aWm E'd G1sbL- 98E -SIL sJOReld S'O`S W21 :01 66 OZ 4 I s � 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 NW of the NE1 /4, of Section 18, T28N, R1 9W, TOWN OF TROY, ST. CROIX COUNTY, WISCONSIN LOT 12 2.3 Acres LOT 11 2.7 Acres LOT 13 N 4.8 Acres O Z LOT 10 W 2.7 Acres LOT 14 J 3.2 Acres n LOT 9 Z 3.3 Acres d) � Z LOT 15 UNPLATTED LANDS LOT T316 Acres LOT 8 Q � Acres 3.4 Acres J a LOT 17 2.4 Acres LOT 18 LOT 23 LOT 7 2-6 4.7 Acres LOT 28 2.5 Acres LOT 22 Acres 2.9 Acres 2.7 LOT 29 Acres 6.8 Acres LOT LOT 6 LOT 19 2.4 2.7 Acres R 2 .3 Acres LOT 20 Acres LOT 24 3.4 Acres 3.4 Acres LOT 5 U 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