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:
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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
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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.
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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
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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
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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