HomeMy WebLinkAbout042-1059-50-200 bepartment of Commerce PRIVATE SEWAGE SYSTEM Count y:
,id Buildings Division
INSPECTION REPORT St. Croix
. INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 ( 363981
Permit Holder's Name: ❑City ❑ Village ❑ T6wn of: State Plan ID No.:
Luedtke, Bart Warren Township
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
(O Z • S3 c 042- 1059 -50 -200 ) — I
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic S O v d Benchmark � U Q .5-
/Q z S3
Do ' Alt. BM I/Z 0
Aeration Bldg. Sewer
Hold g St /Ht Inlet 03 3
TANK SETBACK INFORMATION St/ Ht Outlet li_G S
TANKTO P/L WELL BLDG. Ventto ROAD Qt Inl
Air Intake
Septic � / �`/ S' NA
NA Header /Man.
Aeration N Dist. Pipe
Holdin f /to
Bot. System
Cam) 8 .
PUMP / SIPHON INFORMATION Final Grade
Mbfw f lacturer and St coyer
Model Nu r G
TD Lift Friction stem TDH F
oss
Forcemain Length Dia. Dist. To
SOIL A SORPTION SYSTEM 15
t <a
BED TRENC Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DI MENSKYNS DIMENSI
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING �nu cturer:
SETBACK CH BE
INFORMATION TypeO 3 Z T Moe umber:
System: 3 {
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length �• S Dia. y,t Length Dia. 11LL Spacing - S 3 �
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.) S
C7
Inspection #1: // l i q / 00 Inspection #2: / /
Location: 809 110th Street, Roberts, W1 54023 (SW 1/4 SE 1/41 T,29N R18W) - 212918331C -Lot 3
1.) Alt BM Description
2.) Bldg sewer length = _6 /w,v4«
- amount of cover= ' f'l P
ikti Ca,G� C�uf �9. S -5 {!nom C�P.��:py. �BWC /C�� �if`�/ U/r`1"�i1.. /Ir►(r`�$ 0`P Stlt
Plan revision require ? 0 Yes No
Use other side for additional information. / p G
x SBD -6710 (R.3/97) Date Inspector's ignature Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Sanitary Permit Application Safety & Buildings Division
N4 in accord with Comm 83.2 1, Wis. Adm. Code 201 W. Washington Ave.
1scon See reverse side for Instructions for completing this application PO Box 7302
Department of Commerce Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302
(Privacy Law, s. 15.04(1)(m (Submit completed form to county if not
state owned.
Attach com lete tans to the coup co only) for r s than 8 -1/2 x 11 inches in size.
Cou»ty _ State Sanitary Permit Number Ion to pre l on State Plan 1. D. Number
C¢ '
I. Application Information - Please Print all Information Location:
Property Owner Name Property Location
B A ?_� C Q
t( le SW 1 /4W 1 /4Qi To7TN EorW
Property Owner's Mailing Address ST CA( ✓iX Lot Number Block Number
� \
Cit , State Zip Code Subdivision Name or CSM (o O 3
f`r�
II. Type of Building: (check one) ❑ City
T% ( or 2 Family Dwelling - No. of Bedrooms : _ [Nearest Village
• Public/Commercial (describe use):_ ATown o
• State - Owned KR u
Road ( �
r Parcel Tax Number( �
9 3 .— 4'q2 _
III. T e of Permit: Check only one box on line A. Check box on line B if applicable) 2 t Via. 1F- 3 i G
A) 1. I&Ncw 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to
System System Tank Only Existing System
B) Permit Number Date Issued ,
❑ A Sani tary Permit was previously issued
IV. Type of POWT System: (Check all that apply)
!&.INon- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
• Pressurized In - ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
• At- de ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other:
V. Dispersal/Treatment Area Information: 9 r
l . Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed Rate (Cr4Jday/sq. ft.) (MWinch) Elevation
VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
Tanks Tanks
_ Ion 1 peeks -M ❑ ❑ ❑ ❑
❑ ❑ ❑ 1` ❑
VIII. Responsibility Statement
I the undersigned, assume responsibility for installation of the POWTS shown on the attached plans .
Plumber's Name (print) Plumber's S' cure (no ps): MP/MP" No. Business Phone Number
m �itauln a �a 4
1% - 0
Plumbers Address (Street, City, State, Zip Coo
IX. County/ Departmen se Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps)
�Approved ❑ Owner Given Initial Adverse � Fee)
Determination S - CD - 3 /" ZBDiI UAm
X. Conditions of Approval /Reasons � f q r p ro t 4
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Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page
Labor and Human Relations
Division of'Safety &Buildings in accord with ILHR 83.05 V1fi5, Ad1Tt "'
COUNTY
•
, Attach complete site plan on paper not less than 8 1/2 x 11 inches in size Ptar must i9 ut r?
not limited to vertical and horizontal reference point (BM), direction and °° o f slope, scaI6 of r�� P GEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. �! �,. -� 10,5q -- 6
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMAT ON I E BY OA�
PROPS OWNS ii1� RGi �i ON �1�
d�brp� J GOu?. LO 1/a - �4,S ?I T 0 )9 N,R /S W W
PROPERTY OWNER':S MAILING ADD SS T ' . NAME OR CSM #
CITY-STATE ZIP CODE PHONE NUMBER ❑CITY ILLAGE (MOWN NEAREST ROAD
.- 5 LUi:sG SY623 t N H 3s s z
[)j New Construction Use jkJ Residential / Number of bedrooms [ J Addition to existing building
j J Replacement (J Public or commercial describe
Code derived daily flow ed, Recommended design loading rate S b gpd/ft gpolft
Absorption area required c = bed, ft ?Sb trench, ft fvla)dmum design loading rate ,S bed, gpd/ft gpd/ft
Recommended infiltration surface elevations ii +, i i 2) -ij_Se 98. It (as referred to site plan benchmark)
Additional design / site considerations
Parent material eUz rz tr%! rer ✓�CFf plain elevation, If applicable a,h ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= unsuitable fors stem )9 S U U JX S D U cgs O U 3 S D U ❑ S ®U D S A U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft
Boring # Horizon in. Munsell Clu. Sz. Cont Color Gr. Sz. Sh. Bed rirerch
T .tiv�:� : n asty.
m} - O n .2 /a 5"` i m sbk pp, C S 3 M , -15'
I .
�" }
a.
Ground 3 - r� >e �' .� s f �'�' fs
/el� ev " 60 - .5 'c/�( Q 0 i�C S r
Depth to 3 -j'V ? 5 5 / 4 -,14 5c t' j ( 117
limiting
factor
? l Zb �v $
Remarks: c o c, in . c, rc -Lx
Boring #
m 12 ( f • __Tjk M F 57 1 i t ;S
Ground
elev _ s 6 vcr 1'h
l
Depth to
limiting
factor
---NIR
Remarks:
CST Name: — Please Pyai--- l 1 t * V( Phone: �,�
Address: � t V • 01� . 4 CJ6JC- 5 2
Signature: Date CST Number
4 _ _
PROPERTY OWNER ALAaal 30110 _ SOIL DESCRIPTION REPORT Page „Lof
PARCEL I.D. # 0 `yC2 — /0-1 — Sy
Depth Dominant Color Mottles Texture Structure Consistence Barry .
Roots GPD /ft
Boring # Horizon in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed rer
M Y:..
v
;...: 3 a l 51 / s k rq Piz G s
Ground 3 36
elev.
/ Q , ft. c� -1 ,� .5 Q a s rn �- --- ,
Depth to
limiting
factor i v
Remarks:
Boring # �. ' m ,.
. 211 Ground
-�
/ oo?, ft
Depth to
limiting f`
.fac .
�t21
Remarks:,
Boring # Y1� � C �fYI �•
,x 1 d- 4 Lle �w1 rn s
Ground
1 - o 4 c k rn �R s 1 V� - s s
elev Jd S
i_
/ ft
Depth to '
limiting
factor
?tu
Remarks:
Boring #
:iW . tt
Ground
elev. _
ft,
Depth to
limiting
factor
Remarks:
Robert Heise -
N4769 430th St.
Menomonie, WI 54751
1(715)-235 -8369
April 24, 1999
Lot #3
Recommendations
1. Designer may choose to use the turtle - shells for both systems, which
would allow the system to be designed a greater depth and would take
advantage of a higher loading rate.
My recommendation of system elevation did not take the turtle shell into
account nor the loading rate.
2. Some- excavation may have to occur over the system, do not to exceed
maximum depth over system.
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer _ for �Ic'p
Mailing Address P 05- 1 10 +\ 5+- rtes &P r 6 Lo t --S ,
Property Address Qq 1 to {,t Pe Q0 6 (; �
(Verification required from Planning Department for new construction)
City /State &q 9(5 L,U ly Parcel Identification Number a 4ok — 1069
LEGAL DESCRIPTION
Property Location h, 5 '/,, Sec. _ j, T Ldg N -R Town of Q
Subdivision PQf � p �_- L-o i ► g o 1. 1 i i , f 30 ,3 R , Lot # _
Certified Survey Map # 1 6 3 �j (p Volume 1 L t . Page # 4 10
Warranty Deed # 620 4 5` DO Volume 1 Lt3-- , Page #
Spec house )a yes ❑ no Lot lines identifiable ❑ yes ❑ no
_SX =M MAV ANCE
Improper use and maintenanceof 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
masterplumber, journeyman plumber, restrictedplumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal 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.
SIGNATURE 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNATURE OF APPLICANT 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
01.1432fAGE 329
State Bar of Wisconsin Form 16 - 1982 604`„s' 20
KATHLEEN H. WALSH
TRUST'EE'S DEED REGISTER OF DEEDS
DOCUMENT NO. ST CROIX CO ., WI
RECEIVED FOR RECORD
........ ...... 06-07-1999 11:15 AN
Dary.1..L.. Jones.. . ...... ... as Trustee of DEED
L. Newel Jones -and Dorothy M. Jones.Family Trust EXEMPT it
CERT COPY FEE:
.. COPY FEE:
_....... .. TRIDISFER FEE: 93.00
RECORDING FEE: 10,00
for a valuable consideration conveys without warranty to ,Bart J. Luedtke, Pas: I
a single person,. ,.. ,.
...... ............................... ... ..... ........ ........ TMS SPACE RESERVED FOR RECORDIND DATA
.... ............. ............................. NAME AND RETURN ADDRESS:
,Granite,
the following described real estate in St. Croix
County, State of Wisconsin:
042 - 1059 -50 -200
PARCEL IDENTIRCATION NUMBER
Part of the Southwest Quarter of the Southwest Quarter (SW} of SW}), Section
Twenty -one (21,), Township Twenty -nine (29) North, Range Eighteen (18) West
described as follows: Lot Three (3) of C ertified Survey Map filed May 26, 1999
in Volume 13, Page 3648, Doc. No. 603786
Dated this ..... ... . ......... .. .... .. day of ... . June............ , . _ _ ................ 199.9...
(SEAL) C q vn, _
(SEAL)
• s Daryl L. Jones
Trustee Trustee
AUTHENTICATION ACKNOWI*WMENT R
Signature (s) ............................ .. .. .. ........ STATE OF WISCONSIN
I�
..... .. .. .__.. _. .. ._ St...C.roix.........
ss.
C� •Y, �
authenticated this ...... day of .......... ........ . 19 ... Personally came before the�,�, ,�'. "`:..... day of
.,June. ............ a9 .99 the above named
.....
..Daryl
........................................... ................ Jones..and- Dorot.hy..M.. J.ones.. Family. Trust
TITLE: MEMBER STATE BAR OF WISCONSIN
................. .. .......... ...............................
(If not, ..... , ... _ ....... ... _ . .
_ ........................ .. ... _ _ . .. ....
authorized by Section 106.06, Wisconsin Statutes) to me known to be the person .............. who executed the
foreg / y ' ng� In a ���}��)p a the same.
THIS INSTRUMENT WAS DRAFTED BY < 4 V 15-".^ . `... '..`. �...Y. �.C� . !.V ...
Attorney Michael H. Forecki ....
" "` "' """"' "" - - r Kathleen R. Videen
................ Po ........ ..... ... .......... ... ..
Eau Claire Wisconsin Notary Public ....Polk ... County, Wis.
(Signatures may be authenticated or acknowledged. Both are not necessary) My commission is permanent. (If not, state expiration date:
•
Nam of persons aItning in any r —ley dboutd be typod or pthuod below rheit sijium— June 24 , T¢ 2001)
OF bUI..1431 PAGE_ -'
b 1999 ►
WSW( 01
ICO3'786 //0 54-
CER TIFIED SUR VEY MAP
L. Newel and Dorothy Af. Jones FaInil�l Trust
Part of the Southwest 1/4 af,the Sauthwest,1 /4, and - the Southeast 1/4 of the Southwest t
Township 29 North, Range 18 W,cst, "I'uwn f � 14 of`Section 21,
that certified survey map recorded in Vol, 11, Pale 3p3c of �;t� ah Cdunty Sri ear of Lot 1 of
y Maps.
Da'ted; March 10, 1998 "Revised this 19th day of
�
'►� vp+1 D NS' ' i. P AR T 0P May, 1999..
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LEGEND- k Murphy o a.
0 Indicate 1" iron pipe found, fi a y
o Indicates I" x 24" iron pipe a a y y
weighing 1.13 lbs. /lin ft. set. M
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