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HomeMy WebLinkAbout004-1071-10-100 ST. CROIX COUNTY ZONING DEPARTMENT" AS BUILT SANITARY REPORT , Owner R u /4 Property Address I � City /State 'Za e Legal Description: Lot Block Subdivision/CSM # N L '/4 L '/4, Sec. 3, T 2?1 -R W, Town of PIN SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC , /6W Setback from: House 2 Well N14 P/L Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: 7 Width S` Length 5 Number of Trenches Setback from: House S5 Well (v P/L 1 5TH Vent to fresh air intake ELEVATIONS Description of benchmark N Elevation G Q Description of alternate benchmark L.I, /k o a 16o e - Elevation G s" Building Sewer G to ST/HT Inlet ST Outlet �U/ y� PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover Distribution Lines () qK, 5 — b () /00 ,G3 ( ) Bottom of System () � , 7 3 ( ) I ) . ( ) Final Grade O 0 3,q O O Date of installation /? 0 Permit umber ''rState plan number Plumber's signature License number Date L I /o/ _. ,.. Inspector 1l �� �1 Complete plot plan p' NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW 1 3 L S� w� ✓Z I I d a go INDICATE NORTH ARROW i Wisconsin Department of Commerce Safet)C.and Buildings Division PRIVATE SEWAGE SYSTEM County: INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 353155 Permit Holder's Name: ❑ City ❑ Village ® Town of: State Plan ID No.: n Paula Town of Cady CST Elev.; Insp. BM Elev.: BM Description: Parcel Tax No.: 1 1 CSO, t7 Igo •,a yj 0,Z ,h �, Ce ending TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic (� Benchmark v' Dosing Alt. BM 1 o_ , 5 -,1 1 ,1 Aeratio Bldg. Sewer �D D(p Holding St/ Ht Inlet O5 OZ, TANK SETBACK INFORMATION St/ Ht Outlet ( , 65 /D /, g/ TANK TO P/ L WELL BLDG. Air I to ntake ROAD Air Septic >5-0 Q_5 NA Dosing A Header / Man. ` 1. r,o 7D.0 6 3 /00.x;3 Aeration NA Dist. Pipe o.ZO V. Holding Bot. System 6. 4-3 I f 17. 73 I.o'f- -7, PUMP/ SIPHON INFORMATION Final Grade C See u ) Man emand St cover �.SZ / of 6 Model Number GPM TDH Lift F 'on SY TDH Ft oss Force Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM jw&ALREN Width Length No. f enches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS S DIMENSION SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type Of I r CHAMBER Model Number: System: > I� D OR UNIT DISTRIBUTION SYSTEM Header / Manifold � Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake LengtK // Dia. Length 15—' Dia. Spacing — /Ufa SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over ^ � i� Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center 3 Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #l: 11 aq Inspection #2: Location: 180 County Road NN, Woodville, WI (NE1 /4, NE1 /4, Section 30 T28N -R15W) - 30.28.15.___ u�eW c1� 11 9 rJC ' Plan revision required? [:]Yes 0 No Use other side for additional information. 0 3 22 01 S SBD -6710 (R.3/97) Date Inspector's Signature Cert. No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: # x r . # # # # s i d # ° a r b i v r i [ 3 c a i i F _ 1 ¢ g � 4 + 7 } �m A- J—. _ t � i , E a 3 , i 8 ; 9 i r...,..... , o mm. m e �...»......... , . , , . .., a .:. e,.. ....., .«„ ,,... .. , ... I , ....... � ,...... ¢�. . . r F g s f . t a f , a me � r C , .. 4, .... ..{...., e....#.,s...- ,....>f r e 9p . .. . ..... . . . ........ .., .. .-� !' I 17 ®� x � r r � � m �•. S a 0 r 0. F [ € � 3 r ; a e a 3 i # .. c ; w 4 3 i # I r E r i # ; �e. so - z , a � i a r . Safety and Buildings Division Vi sconsin S AN[ MIT APPLIC l�l _�.:g� 201 W. Washington Avenue `` .- //Q P O Box 7302 Department of Commerce (� c odd nryF�l F} 05, Wis. Ad �g i /, - J Madison, WI 53707 -7302 • Attach complete plans (to the cou X o`py an l ta c�Fthe sy3 won apr not I � ty ; -� than 8 1/2 x 11 inches in size. Y �' ( r` �C - Sta Itar � • See reverse side for instructions f �>rmmpleting this ap atibn mit Numbe - ' p', 1 1 4 3 2, 57 7 > 15 Personal information you provide may be use secondary gfr : ^ , GO k if ro - g"?4 to previous application [Privacy Law, s. 15.04 (1) (m)). \� I Y ?'CJ 4tNC tate Ptah I umber # . I. APPLICATION INFORMATION - - A I � LL 1 F RMA - e° -` Pr Owner Nam \ ` ' Prope ocation ✓� VaLA. GL. t��X'r� ` _ �V�1/4 NE. "na;� `3D T a$ r N,R IS E(or)v Property O wner's Moiling Address Lot Number I Block Number C LO (P Sta a Zip Code Phone Number Subdivision Name or CSM Numb r / 3 _ . 3? 3 Z r�1 5(jbbo� oj5) &fry -3�3� �� 1l1 2 2 II. TYPE F BUI DING: (check one) ❑ State Owned ity N� rest Road Public 1 or 2 Family Dwelling - No. of bedrooms U Town OF Qcu l� 111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo d Oq -,I tyl 1 — I D 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) qj 1 ig New 2. ❑ Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an _ Sysstem ________System _____________ Tank Only______________ ExistingSyst -- __ 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 fj4.Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 E] Vault Privy 14 E] System -In -Fill � 7 x :: �S VI. ABSORPTION SYSTEM INFORMATION: L Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min. /inch) Elevation q5 d - I 7 5D C). 0 Q7. Feet 101 Feet VII. TANK Capacity in gallons Total # Of r Prefab. Site Fiber- Ex per. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Exist in str Tanks Tanks Septic Tank or Holding Tank -. 1 1000 I Y Jwe af e_r n1 1 ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber I 1 ❑ ❑ ❑ ❑ ❑ ❑ VIIL RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility f r installatiogoi the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumb 's Signature: (N S ps) MP /MPRSW No.: Business Phone Number: JoC 5�0_n 0 1 4 Q 3y - 75 915 _ (D9 - a94alo Plumber's Address (Street, ity, Sate, Zip Code): 561 Lv�llcx� �. W odvJ1e W3- S40,99 IX. COUNTY / DEPARTMENT USE ONLY E] Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Agent Signat re (No Stamps) Surcharge Fee) Approved E] Owner Given Initial 2� Adverse Determination � X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) 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 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. 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 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 D1LHR. 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. Complete plans and specifications 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. 3 Z Z n Z U b I I � Z � S i4 J ca O v K S cr c l— a C- 3 r a J s cn J ti Q � M DM" of Sa and Buildings svlL ANU 51TE EVALUATION Bureau of Integrated services in accordance with s. ILHR 83.09, Wis. Adm. Code Page , of Attach complete site plan on paper not less than 8 1/2 x 11 Inches in size. Plan must County Include, but not limited to: vertical and horizontal reference point (BM), direction and �! , C� 0 rx percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # qq1 ►►,,pp - O ' APPLICANT INFORMATION -Plea �jf-aH rtfrett►i�t O©5l -/07/ Reviewed by Date Personal InrorrneUon you Provide may be used for ry P��S®I�I(P►cY [ a}v; "s_ 1 (1) (m)). // /f t Prix Owner i.. ' 1 - - 1 7 1 VIE �. " ' Prope /7 rty Location GC Lot E 1/4 - 0 ncim,S 3a T ,N.R /� VAW w Owners Ma ng Address -- , _ of # :� Block# Subd. Name or CSM# �'d. C, �T CROIX ; �. �— -- city State Zip etwr lj)7, , 0 city O Village [Town Nearest Road M40w Construction Use: residential / Number of bedrooms 3 Addition to existing building O Replacement O Public or commercial - Describe: Code derived daily flow V5 gpd Recommended design loading rate Q -- bed, a. 6 trend Absorption area required gi bed, ft 2 gPd1 • gp 2 _ 7SD trench, ft Maximwn design loading rate D.S bed, gpd* 12. (. trench, goo Recommended infiltration surface elevation $ r 81 r !J'3 ° � y�e 6�c It (as referred to site plan benchmark) Additional desi n/site considerations 2Q F�t.►,c 1l rc ` 9 t oe,o a h•scrnfiav► ana in madwake 5/,,r #,Arcd 5 Lts Parent material I n e-Z — Flood plain elevation, n applicable A _ I ft S = Suitable for system Conventional Mound In-Ground Pressure AT -Grade System in Fill Holding Tank U= Unsuitable for system p s❑ u 2'9 O U l-S O U C-g U ❑ S O s SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure Texture Consistence Boundary Roots Ge In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. , Trench .Bed ,Trench 0-4 /0 /)one 5; i Z er C5 2.1 0 •s o. - If o Vo 17" S z hVl r 5 .2. 0-5 Ground Q i Yl S; S6 NA S �' O. S O. elev. l eft. f �,G 4 S rl mt S; z Wk 66K m r 23 - d. S O.6 Depth to S '$ /� S n ' Ke PK r - 10-Z: . Remarks: # � a.& r1q Boring # 1 0-7 3 /3 ,2 z -sl MS6 r►1 s o.S o. 3 V-'v 4W S: in 54< S 5 - : 0. (0 Ground -G 53 17 5; zn+ S6 5 g • S : O. G elev. /t,.ft. S io s; I C S61C m �'� - - p.2 : Depth t Ong factor >6 I n. Remarks:` CST Name (Please Print) lure Telephone No. so> /S�z 7767 Address Date CST Number 364 el m ©• - �1- L - =FOR . . r mm .:. .• MotUes Ou. Sz. Cont color MIA L , W rAtMM- M . .• ®� Mim MW I • it ■ JOIC /o: E G&✓a. -an seas.: ZZ Upo `- ol 14, P�o�oosed �hoase Abe S;ttd 225 V v /o 7.3 10 �o.L3Z'■ S/ X320''' r Q.3 , = a -S BdylCh mark : 12. " ELwl kree. AssK,ned d ul-V = Sao. 0) '. Owner. k {(amp Locai6;g . ne See. 30, ,�, 284 TV if f _ / ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND (� OWNERSHIP CERTMCATION FORM Owner/Buyer Mailing Address Property Address (Verification required from Planning Department for new construction) city/State Parcel Identification Number L/ jLEGAL AESCRIPTION Property Location N E y,, V '�, Sea. 3 b, T2N -R /-ft—W, Town of C CL 4d Subdivision Lot # Cerhfti ed Survey Map it l l Z Q _ v o l ume � � . Page # 3 ? Y Z Warraaty Deed # C 1 5 G� , volume U , Page # 3 Spec house Q yes no Lot lines identifiable ff yes C3 no cy6 M MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance co nsisas of pumping out the septic tank every three years or sooner, if mceded by a licensed Fu°mr. What you tut into the system c= 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 certifoation form, signed by the owner and by a waster plumber, jowneymanphrmber, restricted phrmlrer or a licensed pin gm venfYmg that (1) the co -site wastewawdispoaat system is in proper erating condition and/or (2} slier inspection and pumping (if necess op ary), the septic teak is less than 1/3 full of sludge. Itwc, the undersigned have read the above regairemeuta 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. Cer if cation stating that your septic system bas been maintained must be completed and returned to the St. Croix County Zoning office within 30 days of the three year cx iratia� date. �. / DATE Sit3NATURE OF AF'PLICAN'!' , OWNER CERTrFICATION I (we) certify that all stat==ts On this form are true to the best of ray (mete) knowledge. I (we) am (an) the owacr(s} of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. I ! SIONATURE OP APPLICANT DATE * +•'• Any inSocma►tion that is misrepresented may result in the sanitary permit being revoked by tho Zoning Department- • "'" r •• Include with this appiicstion; a stamped warranty deed from the Regista of Deeds office a copy of the certified swvey rnap if reference is made is the wansixty deed yr�I 1460PAG Es i 1394 KATHLEEN H. WALSH Document Number WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD This Deed, made between Hugh Hampton, a/k/a Hugh H. 10 -01 -1999 12:30 PM Hampton and Mary Hampton, a/k/a Mary L. Hampton, husband and wife and each in their own right, Grantor, and Paula M. Hampton, a WARRANTY DEED single person, Grantee. EXEMPT Ii Witnesseth, That the said Grantor, for a valuable consideration CERT COPY FEE: COPY FEE: 2.00 conveys to Grantee the following described real estate in St. Croix County, TRANSFER FEE: 3.00 State of Wisconsin: RECORDING FEE: 10.00 PAGES: 1 A parcel of land located in the Northeast Quarter of the Northeast Quarter Recording Area (NE% of NE' /.) of Section Thirty (30), Township Twenty -eight (28) North, Name and Return Address Range Fifteen (15) West, described as follows: Richardson Law Office P.O. Box 399 Lot One (1) of Certified Survey Map, recorded September 28, 1999 Spring Valley, WI 54767 in Vol. 13, page 3732, as Document No. 611122. Part of 0041071- 10.000 (Parcel Identification Number) i This is not homestead property. Together with all and singular hereditaments and appurtenances thereunto belonging; And Grantor warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except all easements, restrictions and rights of way of record and will warrant and defend the same. Dated this 30"' day of September, 1999. * *Hu H. Hampton * *Mary L. Hitfnpton AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN PIERCE COUNTY Personally came before me this 30" day of September, 1999, the above named Hugh H. Hampton and Mary L. authenticated this day of Hampton to me known to be the person(s) who executed the foregoing instrument and acknowledge the same. signature signature Sh re &uje type or print name type or print name TITLE: MEMBER STATE BAR OF WISCONSIN Notary Public Pierce County, WI (If not, My commission is permanent. (if not, t " SQ authorized by § 706.06, Wis. Stats.) /J?ar�/� /G, ��3 .) ' % q. V'•. 4- THIS INSTRUMENT WAS DRAFTED BY JENNIFER A. O'NEILL ~Names of persons signing in any capacif Vo41d9 tyk �? Attorney at Law printed below their signatures. Z � Spring Valley, WI 54767 (Signatures may be authenticated or acknowledged. Both are not necessary.) Information Professionals Company Fond du Lac, Wisconsin 800. 855-2021 SEP 2 � 1999 0� w ���N.waa�tt 2tef of DO S CERTIFIED SURVEY MAP L OCA TED IN THE NE 1, OF THE NE 114 OF SECTION 30, T. 28N. , R. 15W., TOWN OF CADY, ST. CROI X COUNTY, WISCONSIN PREPARED FOR PAULA HAMPTON to NORTHEAST CORNER) SECTION 30 - FOUND CO. SURVEY N A I L e O BEARINGS REFERENCED TO THE EAST LINE OF THE NE 114 OF SECT 30. n MEASURED AS S00 10'27'E. (ST. , r H CRO I X COUNTY COORDINATE SYSTEM.) ~ r- a m { a • UNPL ATTED LAN DS I 50 I m C N 89 546.89' Lu 498.69' 48.20' n o, 100 I m O W I c ° LOT 1 x I n 4. 45 ACRES ' Q { I ;C Z Z 193, 918 SO. FT. g �2 D 3.89 ACRES EXC. RIM � :r = y 169, 635 SO. FT. ~ (r N .n m M ro 33,3 A : m � :2 z o { y .z s 1 00' :z LEGEND �TTFo A �9• { s O - SET I* X 24" IRON PIPE WEIGHING tiO�y, s ?, { 1. 13 L BS. PER LINEAR FOOT • • I APPRUVEMS ST. CROIX COUNTY 50• I Planning Zoning and Parks r.,,,,n- S0' I C CJAV SEP 2 81999 I �IZ ,A, JAMES M. If not recorded within 30 days or WEBER �`{ = approval date approval shall be ro e 3 a null and viici I O SPRING VALLEY, wl Q EAST QUARTER CORNER { �y SECT RONO FOUND PIPE P a.suR� � i ulunnl:l :autin�` JAMES M. WEBER S -1804 0 75 150 300 NELSEN -WEBER AND SURVEYING DATED SHEET 1 OF 2 CAD FILE - 99212A Vol. 13 Page 3732 t b , U" —s a J 1 i . o0 0® I r 1 l t -�f