HomeMy WebLinkAbout020-1346-90-000 ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
Owner �✓'1 ff 1 /, /
Property Address L t �ree.,.
City /State 14 y ( s G
Legal Description:
Lot Block -- - Subdivision/CSM # 9 n M F-
' /a '/a, Sec. L, T 7 N -R./�< Town of H l-'Ds PIN #
EPTIC TANK.- DOSE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer WE F de-- Size ST/PC ra -- Setback from: House Well L ` P/L D
Pump manufacturer Model
Alarm location --�°
(HOLDING TANKS ONLY)
Setbacks: Service road _ Vent to fresh air intake Water Line
Meter location
Alarm location
t
SOIL ABSORPTION SYSTEM
Type of system: �. eAo -r Width Length 3�, 2 ' Number of Trenches
Setback from: House Z "t Well q PAL 5`6 " Vent to fresh air intake
ELEVATIONS
Description of benchmark I Z,T ` ;P/Pe -- & 41 C) , "4 9 Af' X �' 0 S Elevation ° o 0
Description of alternate benchmark t6.* 2710G,< 3"c3 uNGs17 /oA" 'Z. , Ste' Elevation 1*; 19
z o0
Building Sewer '� ST/HT Inlet - 7. 7s " I ST Outlet PC Inlet
PC Bottom Header/Manifold Top of ST/PC Manhole Cover C,- D "
Distribution Lines P: '= IT / 9,
Bottom of System () 3 , l ° - I& , () � ', a - "'e; ,
Final Grade O 9, /,9
Date of installation X / 7 , f Permit number 2 7 3 State plan number
Plumber's si natur W `[r'tric License number /'�� J a�sa3 Date -?/ - ' -',/ /
g _
GU �.t
Inspector
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.
3 M - 1 ToP
PLAN VIEW " LoT 5 T kf Al W,
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INDICATE ;NORTH ARROW
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y'
Count
Safety and Buildings Division I NSPECTION REPORT ST . CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarjy4ni" - :
Personal information you provice may be used for secondary purposes (Privacy L , s.15.04 (1)(m)].
Permit
MILLER er'S a [k fryjillage ❑Town of: State Plan ID No.:
CST BM Elev.: , Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9900009 3/
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic l�� Benchmark
Dosi ng Q ZS/o b 7 j
Aeration Bldg. Sewer
r Holding.-I St/ Inlet b Z.��
TANK SETBACK INFORMATION St94? Outlet 8 Ib
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet -
Air Intake
Septic I NA Dt Bottom
Dosing NA Heacler.AONW6.
Aeration A Dist. Pipe
H41di'ng Bot. System .66)
PUMP/ SIPHON INFORMATION Final Grade 9 /U� �, 65'
Manufacturer Demand
PM
TDH I Lift Fri 'on Syste Ft
ss Fi
Forcemain ngth Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Lengt No. Of Trenche No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS (�-,Z�; - DI MEN
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM IN
INFORMATION Type O /t&- cp CHAMBER mo Number:
System: "' SG, sg - OR UNIT
DISTRIBUTI SYSTEM
Header / Distribution Pipe(s) ^ ,y x Hole Size x Hole ng Vent o Air Intake
-F-
Length —- Dia. Length Dia. ! Spacing r
i
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 E] No
i
COMMENTS: (Include code discrepancies, persons present c.)
LOCATION: HUDSON 11.29.19,SE,SW 736 PACKER DRIVE - HOMESTEAD LOT19
Plan revision required? ❑ Yes No
Use other side for additional information.
SBD -6710 (R.3/97) Date inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
Safety and Buildings Division
Visconsin SANITARY PERMIT APPLICATION 201 B Washington Avenue
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County r / �� 4 5 than 8 1/2 x 11 inches in size. 1 • 110
• See reverse side for instructions for completing this application State sanitary Permit Num
Personal information you provide may be used for secondary purposes ❑ Check if revisio�pievio
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL 1NF RMATION
Propert Owner Nam Property Location
/ ��� SE 1/4 w 1 /4, S/ T Z7 ,N,111 E( W
Property OTner's Mail ng Address Lot Number Block Number
OAN
.i[ i
Cit , State Zip Code Phone Number Subdivision Name or CSM Number
,SD W l VV / 1 (3?(-) 27 o M E STE
I. TYPE OF BUILDING: (check one) ❑ State Owned 3 ❑ It Nearest Road
❑ Village C
Public Z 1 or 2 Famil Dwelling - No_ of bedrooms Town OF DSO
III BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) f ,
1 ❑ Apartment/ Condo d� 1' ` ,
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. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System ---- ------------- _ ______ ______Tank Only ___ __ - __ - __ Existin�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
12FSeepage Trench 22 E] In-Ground Pressure 42 C] Pit Privy
13 Seepage Pit 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Da 2. Absor . Area 3. Absor . Area 4_ Loading Rate 5. Perc. Rate 6. Stem Elev. 7. Final Grade
q y
Requ (sq. ft.) Proposed (sq. ft.) (Gals/day//sq. ft.) (Min. /inch) y Elevation, (e3 5 , Feet /0( Feet
Ca aclt
VII. TANK in gallo Total # of Prefab. Site Fiber- plastic Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Co " Steel glass App.
New Existing structed
Tanks Tanks
Septic Tank mg Tank '�Qlq Lo r I SrpA,,,,_ ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: o Stamps MP /MPRSW No.: Business Phone Number:
IKE o � -' 'KS�3soo 1 - 71f- 314 -8 07L
Plumber's Address (Street, City, State, Zip Code):
?d N TE i D i4 �f✓ Sa A/ w l O
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing ent Signature (No Stamps)
Surcharge Fee) /r
(A Approved []Owner Given Initial /gb
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11197) DISTRIBUTION: Original to county. One copy To: Safety 6 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 a.curate 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 isto 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
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.
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.
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Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3
Division of Safety and Buildings in accord with Comm 83.05, Ws. Adm. Code
Environmental BY Design
Attach complete site plan on paper not less than 8% x 11 inches in size. Man must e County —
kx*x , but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. $t. CLO1X
Parcel f.D.#
APPLICANT INFORMATION - Please print all information. Re Date
Personal information you provide may be rased for secondary purposes (Privacy Law, s. 15.04 (1) (m)). , l
Property Owner Property Location
Miller, Sam Govt Lot SE 1/4 SW 1/4 S 11 T 29 N,R 19 W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
Troutbrook Road 19 Homestead
City State Zip Code PhoneNumber ❑ City ❑ Village ®Town Nearest Road
Hudson WI 54016 Hudson Labarge
® New Construction Use: Residential / Number of bedrooms 3 []Addition to existing building
Replacement [] Public or commercial describe
Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpol(P .8 trench, gpdff
Absorption area required 643 bed, W 563 trench, W Maximum design loading rate .7 bed, gpd/fe .8 tr ench, gPd/lF
Recommended infiltration surface elevabon(s) Primairy 97 Alt. 96.85' - Af S ft (as referred to site plan benchmar
Additional design / site consideration
Parent material loess Over Glacial OutWash Flood plain elevation, if applicable NA It
S= Suitable for system Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank
U= Unsuitable for system N S❑ U ® S U ® S❑ U ❑ S® U EIS ®U ❑ S® U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD/fF
Boring# Horizon in Munsell Qu. Sz. Cont Color Texture Gr. S7_ Sh. Consists Boundary Roots Bed Trench
1 1 0 -12 10yr3/2 - s1 Imsbk mvfr cW 2f .4
2 12 -29 1Oyr4/4 - sl Imsbk mvfr cW if .4
e%ond 3 29 -46 7.5yr6/4 - gs Osg ml cvv - .7
101.85 ft 4 46 -96 7. Syr6 /4 - gs Osg ml - - .7
Depth to
limiting
factor
>96 ygti
Remarks:
2 1 0 -14 1Oyr3/2 - sl lmsbk mvfr cW 217 .4
- 2 14 -27 10yr4 /4 - is Imsbk mvfr cW If .7 i g
Ground 3 27 -96 7.5yr6/4 - s Osg ml - - 7
elev
99.58 It
Depth to
limiting
factor
>96
Remarks:
CST Name (Please Print) Sg ! Telephone No.
Thomas C. Nelson 715- 246 -2454
Address Environmental By Design Date CST Number Ref#
1432 120th Street, New Richmond, Wl 54017 1/6/99 227387 197
PROPERTY OWNER: Miller, Sain SOIL DESCRIPTION REPORT tea Page 2 of 3
PARCEL I.D4 Envitvnmental By Design
Depth Dominant Color Mottles Structure I GPD/fF
[Horizon in Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. nsistence Boundary Roots
Bed Trench
3 1 0 -19 10yr3 /2 - sl lmsbk mvfr cw 2f .4 .5
2 19 -30 10yr4/4 - sil 2msbk mfr cw if .5 .6
Ground
elev 3 3041 10yr5 /6 - sil 2msbk mfr cw - .5 .6
101.68 ft 4 41 -65 7.5yr5/6 - cs Osg nil cw - 7 8
Depth to 5 65 -94 7.5yr6/4 - s Osg ml - - 7 8
limiting
factor
>94
Remarks:
4 1 0 -11 10yr3 /2 - sl lmsbk mvfr cw 2f .4 .5
2 11 -24 10yr4/6 - sl 1 msbk mvfr cw I f .4 .5
Ground
elev 3 24 -35 10yr4 /6 - Is lmsbk mvfr cw - .7 .8
99.42 ft 4 35 -69 7.5yr6/4 _ s Osg ml cw - .7 .8
Depth to 5 69 -80 10yr4 /3 fif5yr6 /4 cl 2fpl mvfl - - np np
limiting
factor
Remarks:
1 0 -31 10yr2 /1 - sl lmsbk mvfr cw 2f .4 .5
2 3140 10yr2 /1 - Is lmsbk mvfr cw if .7 .8
Ground
elev 3 40 -54 7.5yr5/6 - s Osg ml cw - .7 .8
98.35 ft 4 54 -94 7.5yr5/6 - S Osg ml - 7 R
Depth to
limiting
factor
>94
Remarks:
Ground
elev
Depth to
limiting
factor
Remarks:
NV1 0 NTflt BY DE 51GN
1432 120 STR ET, NEW RICHMOND, WISCONSIN
715 - 246 -2454
PROJECT NAME HOMESTEAD PAGE 3
DESCRIPMON SE ! SW Y, SECTION 11 T 29 N, R 19 W
TOWNSHIP Hudson COUNTY St. Croix
20
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SCALE 1"= Tom Nelson
BM1. ) 6f C0(r)e1 100 ,l ✓ 227387,
BM 2.
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer IV � LL CE
Mailing Address
Property Address 7 3
(Verification required from Planning Department for new construction)
City/State k v ).5ct Parcel Identification Number
syd r �
LEGAL DESCRIPTION
Property Location ' /.,'� V 1 /., Sec. , T 2 -5 N -Rjj(,Q,�, Town of 4 Ob's DM
Subdivision H Q M t IF A P Lot # �1
Certified Survey. Map # .? Q //' 3 , Volume Page # -
Warranty Deed # 9 (0S 4 , Volume 1 - 2- Page #
Spec house Of yes ❑ no Lot lines identifiable )< yes ❑ 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 of the three year expiratio t , p
A �_..� Qn'4—
G F APP ICANT 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 perty described above, jxy virtue of a warranty deed recorded in Register of Deeds Office.
SIGNATURE 6F 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
VOL 1?`3FiFACE�:?2
STATE BAR OF WISCONSIN FORM 1 - 1'92
55865 WARRANTY DEED
DOCUMENT NO -
1EGIMR'S OF71.E
Susan R . Ander a single ST CROIX CTY. %Vi
This Deed made between o _
person
APR 3 0 1, ?'
3:25 P. M I
and Sam E. Miller, a single person qt
WIIReSSeth, That the aid Grantor, fix a %aIuahle arLVdrratu o f one _
dollar and other valuable c
conveys to Grantee the following described real estate in S t . Croix Trt-S SPACE RESERVED Fr,a RECJRr.-%G GATA
County State of Wisc ri .,AW AND RETURN A - SJ
Sam E. biller
Sam roller Construction
Trout Brook Road
Hutson WI. 54016
j
032- 2071 -90 -110
- - OACEL ,DENTtttCATION HUMBER
Part of the NE 1/4 of SW 1/4 of Section 1 3,
Township 33 North, Range 20 Ilest, St. Croix
County, Wisconsin described as follows:
Lot 2 of Certified Survey !lap filed August 8, 1985 in Vol. "6 ", Page 1559,
Doc. No. 404156.
�
!;;FER
This is not homestead property. FEE
iu) vis not)
Together with all and singular the hereduaments and appurtenances thereunto
An d Susan R. Anderson
warrants that the title is good, Indefeasible in fee simple and free and clear of encumbra %. ept
easements, covenants and restrictions of reco if any,
and will warrant and defend the same
Dated this day of
r
tSEAL) � _ (SEAL)
t
ii;-disturbance of a survey stake
236.32 of Wisconsin Statutes. Dtilit B �yOne is a violation of Section
the use of ptwlic bodies and orivate elsents as herein set forth are for
serve the area• public utilities Laving the right to
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