HomeMy WebLinkAbout040-1261-20-000 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division Coun�t_ Croix
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitjfx yVNo.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(
Permit Holder's Name: ❑ City ❑ Village fl ovKn.of: State Plan ID No.:
rdman, June roy owns 1p �_..
CST BM Elev.:. Insp. BM Elev.: BM Description: Parcel T
o' csU . ' T `` CI `� -61 -20 -000
TANK INFORMATION V ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic l Benchmark 77 .6 Z i 3,e
Dosing Alt. BM
Aeration Bldg. Sewer
Holding St /Ht Inlet �.$' jeo, p f
TANK SETBACK INFORMATION St/ Ht Outlet „ qZ �,+Z,'
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet r---
Air Intake
Septic >Sa r a NA Dt Bottom
Dosing Header / Man. �O. S'o 97. IZ�
Aeration N Dist. Pipe ID • q 1
Holding Bot.System 11' 9� qS -:Gg,
PUMP/ SIPHON INFORMATION Final Grade g, I I ct . S Z
Man cturer , St cover 6- 2-3
Model Number GPM
TDH Lift L oss Io System TDH Ft
Forc In Length Dia. H st. TO Well
SOIL ABS PTION SYSTEM
0@0 T RENCH Width r Length No. f Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION 3 %. ZS I DIMENSION
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufac ur
SETBACK r CHAMBER 1- W
INFORMATION Type Of ModelNumber:
System: COV0J. 0 25 OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length \`-- Dia. ia. Spacing a6 't
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: 10 /03 /M Inspection :
Location: 381 Whitetail Lane tt �Hud�son, WI 5 016 (NE 1/4 NE 1/4 18 T28N R19W) - 18.28.19.1401 Deer Valley -Lot 22
1.) Alt BM Description =wart :FAQ � '
2.) Bldg sewer length= Zle , 0 0 ,
- amount of cover = 7 ts' S0a
Plan revision required? ❑ Yes M No
Use other side for additional information. lb ( Z
'BD 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
14S ANITARY SCO/1S %11 PERMIT APPLICATION 2 1 Box Washington Avenue
Department of Commerce In accord with Comm 83.05, Wis. A \h I 9/ Madison, WI 53707 -7302
l D j
'I .
• Attach complete plans (to the county copy only) for the syste i on aper n t less,, ty
than 8 vi x 11 inches in size.
• See reverse side for instructions for completing this applica ItJ[l% St nitary Permit Number
Personal information you provide may be used for secondary purposes '- i (' €� ' t ` if revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
ST CR04x St n I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL I
Propert Owner Name y oca low`,
1/4 C_ 114 T aJ�, N, R Fes) W
Property Owner's Mailing Addres umber ! Block Number
pcx
I City, State Zip Code Phone Number Subd on Name or CSM Nu ber
ll. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cit I Nearest Road n
Public 1 or 2 Family Dwelling - No. of bedrooms , K Villag OF � � 06, -0- R
III. BUILDING USE (If building type is public, check all that apply) arcel Tax Number(s)
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. R( New 2_ ❑ Replacement 3. ❑ Replacement of 4 ❑ Reconnection of 5. ❑ Repair of an
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 rNmeepage Trench 22 E] In-Ground Pressure 42 [3 Pit Privy
13 nSeepage Pit 43 ❑ Vault Privy
14 ❑ System -In -Fill 1 fnllSlAk - �&J,- b e►1S
VI. ABSORPTION S S EM INFORMATION: L � 44• } 7
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. Syst E v. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
5� S %p 3 S T Feet / Av Feet
acct
VII. TANK in Ca allon Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete con Steel glass Plastic App
New Existing structed
Tanks Tanks
eptic Tank or f 1 , ❑ ❑ ❑ ❑ ❑
1 ump Tank /Siphon Cha berl I I ❑ 1 ❑ 1 Eli ❑ I ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for in ion of the onsite sewage system shown on the attached plans.
Plumber's Name: (Prin PI ber's Sig ture: ( mps) MP /MPRSW No.: Business Phone Number:
S �3 '71s (o X1
Plumber'sAddress(Street Cit ,mat Zip Code): ) y - NIOL-N.) RIAMnA U_'�X Iq L09 Ot
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate ssue Issuing Agent Signature (No Stamps)
"(Approved []Owner Given Initial Surcharge Fee) a�s
Adverse Determination `f - ��a
X. CONDITIONS 9F APP A VA , L / REASO FOR I
I ��j'ven�r� t �,�-�Y C ,�(,..',,,.. � • S � f
61J1'1k3 = t'°`-r- ���t�w �'�ItMQ. l 1Je.✓L L.VL R-'�a -atU
_;1 50 �p,�(y(���R , 9y ' DIS�RIB:TION: Original to Count ne copy o: Safety & Buildings Division, Ow , Plu ber
U • v `t4N� a �- C�dt.�,
INSTRUCTIONS
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. �he septic tank(s) must be pumped by a 1 'icensed 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 Buddwings Dwision,•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 e fir b slaTred' ' '
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.
C,I -rAete plans andjpecifications 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 scal"e'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 REPORT Page 1 of 3
Labor and Human Relations
DMsion 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 11 inches in size. Plan must include, but S Crnix
not limited to vertical and horizontal reference point (BM ion and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance�fp eareat roacf : , 040- 107 -10
' ,' R VIEWED Y DATE
APPLICANT INFORMATION- PLEASE PR�N ' ,, INFORMATI `J
PROPERTY OWNER: ROPERTY LOCATION
Derrick Construction, Inc / l,, VT. LOT NE 1/4 NE 1v4,S 18 T 28 N,R 19 R(or) W
PROPERTY OWNER':S MAILING ADDRESS f'* T # BLOCK # SUBD. NAME OR CSM #
1505 Hwy #65 sr 1 2 na Deer Valley
CITY, STATE ZIP COD - P ; CITY ❑VILLAGE ZWOWN NEAREST ROAD
New Richmond, WI. 54017 �; >; 303 / Troy E. Cove Rd.
(x] New Construction Use [x ] Residential / Nun bOr mf Addition to existing building
(] Replacement [ ] Public or commercial`
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 • trench, gpd /ft
Recommended infiltration surface elevation(s) 99.60 ft (as referred to site plan benchmark)
Additional design / site considerationg ma trenches spaced to code 3.50' below grade
Parent material outwash Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem EIS ❑ U ®S ❑ U ® S El )m S El ®S ❑ U El 1 9U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPDJft
..................
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trey ch
.................
..................
.................
..................
1 0 -12 10 r 3/3 none sl 2mgr mvfr gw 2f .5 .6
1
2 12 -84 7.5yr 4/4 none cos osg ml na na .7 .8
Ground
elev.
103 ft.
Depth to
limiting
factor
Remarks:
Boring #
1 0 - 10 r 3/3 none sl 2mgr mvfr gw 2f .5 .6
2 2 12 -84 7.5yr 4/4 none cos osg ml na na .7 ' .8
Ground
elev.
10 ft.
Depth to
limiting
factor
+
Remarks:
CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200
Address: 1554 200th. Av . New Richmond W 54017
Signature: Date: 6 -9 -99 CST Number: m02298
OKI
PROPERTYOWNER Derrick Constructio SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D. # 040 - 1070 -10
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ITrench
3 .. 1 0 -8 mvfr .5 .6
2 8 -84 7.5 r 4/4 none cos 0SCf ml na na .7 .8
Ground
elev.
1 00. ? 1t.
Depth to
limiting
factor
+84
Remarks:
Boring #
1 0 -12 10 r 3/3 none sl 2mgr mvfr gw 2c .5 .6
La 2 12 -18 10 r 4/4 none sl 2mgr mvfr gw lc .5 ' .6
Ground 3 18 -84 7.5 r 4/6 none cos os ml na na .7 .8
elev.
98.00 ft.
Depth to -
limiting
factor
+84"
Remarks:
Boring #
1 0 10 r 3/3 none sl 2mgr mvfr 9w 2c .5 ` .6
2 16 -20 10 r 4/4 none sl 2mgr mvfr gw lc .5 .6
3 20 -84 7.5yr 4/6 none cos osg ml na na .7i .8
Ground
elev.
9 8.0 ft.
Depth to
limiting
factor
+84"
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
1 '
STEEL'S SOIL SERVICE
Gary L. Steel Derrick Construction, Inc. 1554 200th Ave.
CSTM2298 NE4NE4 S18- T28N -R19w New Richmond, WI 54017
MPRSW -3254 town of Troy (715) 246 -6200
lot #22 -Deer Valley
This soil evaluation was conducted to satisfy zonin r e qu irement, it may or m
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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
111 =401 -
- BM.= top of 1 pvc pipe C el. 100.00, G
—Alt. BM.= nail in Cherry tree C el. 95.10
1 '�,q0
k 30
2d5
Gary L. Steel
6 -9 -99
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer Ot t WE 0 A-tJ �4t Silo �
t ( Gcs R-toAo 3 S -- wi°►t"f - 1
Mailing Address kkA05,0 4, 54-O►, %a � �-, �E� M � S s � J a
Property Address " vii- ►� . l.A�t� c
(Verification required from Planning Department for new construction)
City /State t V > -, \'-tq t Parcel Identification Number E�2r CI
J 04D - 12(01 -- 20 - oaV
LEGAL DESCRIPTION t 8, Z8. l9. / �
Property Location V�� I4, �-C 1 �4, Sec. . T Ib N -R t q W, Town of
Subdivision Lot #
Certified Survey Map # Volume . Page #
Warranty Deed # '��� Volume -'A . Page #
Spec house ❑ yes )<no Lot lines identifiableXyes ❑ 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
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 r e year expiration date.
'17 �
OGR ATURE OF APPLICANT DATE
OWNER CERTIFI
tATUR I (we certify ents on warranty s form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
O Px"HeAN — ir' rty d scri 1 e deed recorded in Register of Deeds Office.
E s 7 / O Q
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
Oct 20 99 10:13a. S.O.S Players 715- 386 -7447 p.6
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WARRANTY DEED (Fortner statutory Farm). STA ?E OF NVISC(INSIN Mlller•nnvis (:n., Minneapolis, h:inn.
Form No. 9 W. '
25) 9154
ig4is InikPntnre, Mtuin by Archie J. Waxon and Lois 1Yaxon, his wife,.
erantors , of St. Croix County, Wisconsin, hereby convey and warrant to'
Jack J. Erdman and June M. Erdman, husband and wife as joint tenants
granteog , of St. Croix Coi(.nty,
Wisconsin. for the suns. of One dollar and other good and valuable consideration
the following tract of land in St Croix County, State of , Wisconsin:
Northeast quarter of Section Eighteen (18), Township Twenty -eight (28)
North, Range Nineteen (19) West, (NEI 18- 28 -19), i
I
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REGISTL*R.s OFFICE
'ST. CROIX. C O.. Wli.
Pec'd f,- accord this_ 17th
dey0f-_.9u,',ust -. r1. �.:� 59
- A
naiiid Hope
Raylsict Gf _ ___„
Deputy
In 3llitneass MfIrrrof, The snitl <;rru,lorshavehereuntosrt their Itt,utl s.,,ttl „, /s thi,
14th da11 of August 1. 1). 79 59 .�
SIGNED AND SEALED IN PRESENCE DF
�, _ Arc h i �JwY;� n _ __ ( _ • , -J __ .
1 ugh" 1 _ Gwin
Lois Waxon
01'.1
Karol
d lValbrandt
Mate of ; isransin, I
St. Croix l' „t nt,l j
Pe)son,ll,l t•tnor brfurtr nu', this 14th tl"'I 'If August
✓l. n. 19 59 , the „bore. named Archie J. Waxon and Lois Waxon, his wife,
to nne kn.nt n. to br the l,e, ;su)a
it ho eacciitrtl fit furevoins instrument a ackrunvIed_%ed the same.
w liugh_Fin_
Iris.
i,}ty c(In1 nnkston,
• I ypewrite Name tinder each Sionature
DEER VALLEY
Located in the NE1 /4 of the NE1 /4, Part of the SE1 /4 of the NE1 /4,.Part of the SW1 /4 of the NE1 /4,
and part of the NW1 /4 of the NE1 /4, of Section 18, T28N, RI 9W, TOWN OF TROY, ST. CROIX
COUNTY, WISCONSIN
LOT 12
2.3 Acres LOT 11
2.7 Acres
LOT 13
0 4.8 Acres
a
Q Z
J LOT 10
p 2.7 Acres
W
k LOT 14
32 Acres
a LOT 9
Z 3.3 Acres
N �
O LOT 15
z LOT 16
1 UNPLATTEA LANDS 2.3 Ac es LOT 8
3.4 Acres
a Acres
Q W
a
z LOT 17
2.4 Acres
LOT 18 LOT 23 LOT 7
LOT 2.5 Acres Ads 4.7 Acres
LOT 22
2.9 Acres 2.7
LOT 29 Acres
If M 6.8 Acres LOT LOT 6
LOT 19 2.4 2.7 Acres
�
2.3 Acres LOT 20 Acres LOT 24
B. 3.4 Acres 3.4
? Acres LOT 5
0 2.7 Acres
U LOT 4
4.8 Acres
LOT 2S
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