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HomeMy WebLinkAbout020-1357-19-000 • Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y: Safety and Buildings Division Count 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.o4 (1)(m)]. 353258 Permit Holder's Name: y [] Village ❑ of: State Plan ID No.: ❑Cit n Town of Hudson CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: •�f tso •o� 2 vL 2 cg aM 020- 1357 -19 -000 - I L / TANK INFORMATION ELEVATION DATA Z/1 �9 ,z Q3 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 1.2&0 Benchmark I g 03• Ofl • p / Dosing Alt. BM /02-01 �9 Aeration Bldg. Sewer Zy cb •T� Holding St / Ht Inlet • $ 9• if TANK SETBACK INFORMATION St/ Ht Outlet 1 KC 0 98 9 P TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic f NA Dt Bottom Dosing NA Header / Man. 1%A -S • r Aeration NA Dist. Pipe of s �' UP Holding Bot. System qs %- PUMP/ SIPHON INFORMATION Final Grade A 5 A 4 e6 5_ I g p r Manufacturer Demand St cover 3-4 100 Model Number G TDH Lift n System TDH F Loss Force m Length Dia. m ead _ SOIL ABSORPTION SYSTEM T41IN01 Width Lenath Of T ench s PIT No. Of Pits Inside Dia uid Depth DIMENSIONS Z DIM EN I SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEAC anuacturer: INFORMATION TypeO r ( C B Mo a Num er: System: CAM. OR UNIT DISTRIBUTION SYSTEM •"� Header/Manifold V Distribution Pipes) x Hole Size x Hole Spacing Vent To Air Intake 1 Length 6A Dia. Length ' C� Dia. Spacing • 7 100 SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over 7Bed th Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed ! Trench Center / T rench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #l:1 0 3r�Inspection #2: �_1__�.. . Location: 853 Waldrof Farm Road Hudson W1 54016 NW 1/4 SW 1/4 3 T29N - 23.29.19.2093 1.) Alt BM Description loam or" 5•' � � b 2.) Bldg sewer length = 02 amount of cover = &ALM r . tti1 c s Plan revision required? ❑ Yes o Us other d atio for additional informn. C SB 6� 3197) �' °'- Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ! s I f • i { ­� 3 [ ; _L'_ � � t • 77 g 7 f t ? 2 a e 6 t f s E E s t _ • I v Safety , ,. W i � Safety and Buildings Division SANITARY PER AP TION 201 W. Washington Avenue Visconsin In accord with t , g�Q; Wis. Ade P O Box 7302 Department of Commerce 7. ., Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) fo system, on o0ir not less., County than 8112 x 11 inches in size. 49 p,,�, • See reverse side for instructions for completing th � plidAtion " State Sanitary Permit Number Personal information you provide may be used for secondary purpo ? E] Check if revision to previous application �:� ; [Privacy Law, s. 15.04 (1) (m)]. a'(. ;tNCiJ> -S -I is State Plan I.D. Number .% 1. APPLICATION INFORMATION - PLEASE PRINT Tl .p., Property Owner Name C ; lFr p Location OA-- . 57 w 1/4, zg T 9 ,N,R E(ordv Property Owner's�Vlaili ddress A Lot Number Block Number q t �/ r.� City, State Zip Code Phone Number Subdivision Name oP01i 1tamber .r/ us a/� (_rfi ,' ,� v �T.� ,ear II. E OF BUILDING: (check one) ❑ State Owned its Nearest Road Public 1 or 2 Family Dwelling To - No. of bedrooms wn of k GvAV— A III BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo ®Zoe 7 — Ill f —000 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. 0 New 2. ❑ Replacement 3. ❑ Replacement of 4 ❑ Reconnection of 5 ❑ Repair of an - _____System ________ System _ ____________Tank Only Existing System ________ Existing ---- 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 ❑ Seepage Trench 22 ❑ In- Ground Pressure l� 42 ❑ Pit Privy 13 ❑ Seepage Pit /.2 CZ4 r = f`'� 43 ❑ Vault Privy 14 ❑ System -In -Fill le VI. ABSORPTION SYSTEM INFORMATION: 1. 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/day /sq. ft.) (Min. /inch) Elevation God Feet Feet VII. TANK Capacit gall Total # of r Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber 11 El 11 1:1 1:1 13 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of a onsite sewage system shown on the attached plans. PI ber's Name: (Print) Plumber's Signature: (No St ps) A424MPRSW No.: Business Phone Number: f- � 0 7 — er's Address (Street, City, State, Zip ode): mar l3O 9Mff&M Wt 42 IX. COUNTY/ EPARTMENTUSEONLY E] Disapproved Sar)itary Permit Fee (Includes Groundwater D ate Issued tssuin AgentSignat re(NoStamps) ,� Surcharge Fee) / Approved ❑Owner Given Initial. i Adverse Determination -- f ` y lkv 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 -3451. 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. =,i V. Type of system. Check appropriate box depending on system type. 3 �. 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. MPetc.) 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 81/2 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,1 15 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. 7Y9-3�sG �•iidv 1 777,S � Cy ,r3�Rr� syrr e.�� �i So . , ` �p -4 N 4 ° ,P V -44 -2 a Td, N may✓ ,t�f/ �J� X m _ cvArr c O /2 X 72� I - • Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code FPARCEL Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but St. Croix not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance a(tlr� '~. \ 020— — APPLICANT INFORMATION— PLEASE PR T (NFORMATI RE IEWED BY DATE PROPERTY OWNER: , y i111R - PFi PERTY LOCATION Kern on - - -- G0 . LOT NW v4 SW 1 /4 23 T 29 N,R 19 :R(or) W PROPERTY OWNER':S MAILING ADDRESS 4 2 LOT BLOCK # SUBD. NAME OR CSM # 948 LaBAr a Rd. s� 1 na Evergreen Estates II CITY, STATE ZIP CODE `A N © TY ❑VILLAGE [3'OWN NEAREST ROAD Hu W 16 Hudson aldroff Fm. Rd. [x] New Construction Use [x J Residential / Nu r,'A obfis ' ` [ ]Addition to existing building [ J Replacement [ ] Public or commercial Code derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd /ft gpd /11 Absorption area required 858 bed, ft 750 trench, ft Maximum design loading rate _,L bed, gpd /ft gpd /ft Recommended infiltration surface elevation(s) 95.90 ft (as referred to site plan benchmark) Additional design / site considerations _ na Parent material pitted 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 ® S ❑ U ® S ❑ U ® S ❑ U NS ❑ U N S ❑ U [:]S SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ITImench 1 — 17 10yr2 /2 none 1 2msbk mfr gW 2f .5 ( .6 2 7 - 36 10yr4j4 none sit 2msbk mfr gW 2f .5 l.6 Ground 3 6 -84 7.5yr4/4 none Co s Osg mvfr na na .7 .8 elev. 9 9.6 ft. Depth to limiting factor Y +8 Remarks: Boring # 1 -11 10yr3 /3 none 1 2msbk mfr gW 2f .5 .6 2 1 -28 10yr4 /4 none sil 2msbk mfr gw 2f .5 .6 OEM 3 8 -86 7.5yr4/4 none is Osg mvfr na na .7 .8 Ground elev. 1 10 ft. Depth to Z/ ` limiting factor Remarks: CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200 Address: 1554 200t e. New Richmoo, WI 54 17 Signature: Date: 6 -17 -99 CST Number: m02298 PROPERTY OWNER Kernon BAst SOIL DESCRIPTION REPORT Page? of 3 PARCEL I.D. # 020 - 1020 -90 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft .................. in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed !Tw& ................. 1 0 -13 10yr3 /2 none 2msbk MFH 2f .5 .6 2 13 -30 10yr4 /4 none sil 2msbk mfr gw 2f .5 .6 Ground 3 30 -88 7.5yr4/4 none Co s Osg ml na na .7 .8 elev. 1 00.3 ft. Depth to limiting factor 8 + 88 1, Remarks: Boring # 1 0 -13 10yr3 /3 none 1 2msbk mfr 9w 2f .5 .6 4 2 13 -30 10yr4 /4 none sil 2msbk mfr gw if .5 .6 3 30 -62 7.5yr4/4 none ms sOg Mvfj gw na .7 .8 Ground elev. 4 62 -65 7.5yr4/6 none is Osg mvfr gw na .7 .8 98.4 ft. — 5 65 -84 7.5yr4/6 none ms Osg ml na na .7 .8 Depth to - limiting factor +8 4 1, Remarks: Boring # 1 0 -10 10yr3 /2 none 1 2msbk mfr gw 2f .5 .6 5? 2 10 -19 10yr4 /4 none sil 2msbk mfr gw if .5 .6 3 19 -84 7.5yr4/4 none Cos Osg mvfr na na .7 .8 .................. Ground elev. JO ft. Depth to limiting factor +84" Remarks: Boring # ................. Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(8.05/92) STEEL'S SOIL SERVICE Gary L. Steel Kernon J. Bast 1554 200th Ave. CSTM2298 WIWI S23- T29N -R19w New Richmond, WI 54017 MPRSW -3254 town of Hudson (715) 246 -6200 lot #19- Evergreen Estates II N / � 1 =40' � M.= top of 2" pvc pipe C el. 100.00 ,Alt. BM.= top of nail in pine tree @ el. 101.40' A ; kk i r 5 E a% Gary L. Steel 6 -17 -99 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner /Boyer X�xyoly A,4-s Mailing ddress F' ,r/ c p g �✓ G l'�/ � ¢r}, u > / / Property Address &'wb&rp- (Verification required from Planning Department for new construction) City/State 4o 0 Q __ ;; qo fA Parcel Identification Number LEGAL DESCRIPTION Property Location, ' /,, S Sri ' /., Sec. >.3 , T Z 1' N -R. 1_W, Town of Subdivision �iya,�,� Tf' , Lot # �. Certified Survey Map # , Volume , Page # Warranty Deed # S� t6QZ Z . Volume /3 7 y , Page # 3� Spec house fW yes O no Lot lines identifiable 0 yes O 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 licensedpumper 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 da)s qf the three y r e "ration date. t'� 11?lg9 SI NATURE OF &PP11CANT 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 th property descri d above-, )by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF PLICANT 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 F vt ,I A4 �.A romm! jj A- 1W A. VOL 1374PAci*354 590962 WARRANTY DEED Document Number REGISTER'S OFFICE Return Address ST. CROIX CO3 1Y1 39 NOV 0 5 1998 /0: so Parcel I.D. Number: 020-1062-80-100 020-1062-50.100 Zane R. Bollom and Deborah L. Bollorn, husband and wife, conveys and warrants to Kernon J. Bast, _arid Donalda J. Speer-Bast, husband and wife the following described real estate in St. Croix County, State of Wisconsin: ti Lot Two (2) of Certified Survey Map filed October 14, 1998, in Volume 13 of Certified Survey Maps, page 3536, as Document No. 589022, located in part of the SWIM of the NWIA and in part of the NWI/4 of the SWIM of Section 23, T29N, R19W, Town of Hudson, St. Croix County, Wisconsin. ti This is not homestead property. Exception to warranties: Easements, restrictions and rights-of-way of record, if any. Dated this day of October, 1998. (SEAL) / —sq- (SEAL) �e R . Bollon, Deborah L. Bollom ACKNOWLEDGMENT STATE OF WISCONSIN TRANSFER ss COUNTY FEE low Personally came before me this day of October, 1998, the above named Zane P_ Bollom and Deborah L. Bollom, husband and wife, to me known to be the person(s) who executed the foregoing ins nt and a:c��owledge the same. Broad& Poulin • Notary Public Notary Public i t C 0, y, WI State if - Ali.iconsin K . Ly My commission expires /j /,I Con THIS INSTRUMENT WAS DRAFTED BY: Attorney Kristina Ogland Hudson, Wl 54016 W r • w Q ON + . . OD LA 1 N i i~ r I J o 1 in ri i +CQ iy + ' W + +rCJ / iGl iN N CA J i / 31 ' Ul US ro 0 �D v o US, N00 "E 364. 0 � ' n�' 283,89 rn 0 ti CD W z US � V �� D '4 w 0 x � 2 < m S 1 "E ... 35.48' 35.48' �1 a 35.48' 35.48' \ / .0� 74.94' / ? I °00'51 "E 160,94' f OR