HomeMy WebLinkAbout020-1319-70-000 ST. CROIX COUNTY ZONING DEPARTMENT F
AS BUILT SANITARY
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Owner e�•ti. ✓ ����
Property Address e �r
City /State S q o
Legal Description:
Lot 2 r Block Subdivision/CSM #�
t /4 fj t /4, Sec. — a TAN -RAW, Town of P Q # - ! y_ 7
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer �JQeA5 (, f Size(g?PC 1ZJ01 Setback from: House ZS Well P/L 100'
Pump manufacturer Model
Alarm location
(HOLDING TANKS ONLY) �/
Setbacks: Service road / V 4 Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of system: ft e tc 4 Width 3 Length 7 5 Number of Trenches Z
Setback from: House /h/ Well 4b3 P/L /l Vent to fresh air intake /vo'
ELEVATIONS
Description of benchmark — 76 / ' 1 t ✓dH 4 SE Ga►� 6rA�- v Elevation /G
Description of alternate benchmark 6)gjk o uJ Oao e Elevation L 3 - <. 2 -
Building Sewer ST/HT Inlet 0 ST Outlet / v /, PC Inlet
PC Bottom Header/Manifold Top of ST/PC Manhole Cover O v
Distribution Lines O Fr O ( )
Bottom of System O 9 7 S z O 9 6 v O
Final Grade
Date of installation / 1100y Permit number �/�/6 State plan number
Plumber's signature License number -- 2- - z- 6 4 ZY Date
Inspector
Complete plot plan
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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
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INDICATE NORTH ARROW
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Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM 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.15.04 (1)(m)]. 344688
Permit Holder's Name: ❑ City ❑ Village g Town of: State Plan ID No.:
Town of Hudson
CST Bb RT. Insp. BM Elev.: BM Description: Parcel Tax No.:
I - 0 , SE 1 020-1319-70-000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ,
�pp Benchmar �3 L 7. tam_- • 0'
Dosing Alt. BM 3 3, 4, 3•io2'
Aeration Bldg. Sewer
Holding St /Ht Inlet 5, �u
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Air to
I ntake ROAD Dt Inlet --
ir
Septic IUD NA Dt Bottom -
Dosing NA Header / Man.
Aeration NA i Dist. Pipe
Holding Bot. System ,I ,ye 9• �� q;. n ,
$
PUMP/ SIPHON INFORMATION Final Grade 5/ .a
Manufacturer Demand St cover k Z( 03.08
Model Number GPM
TDH i Lift Friction System TDH Ft
L oss
Forcemain Length Dia. m e ad Dist. ToWeu
SOIL ABSORPTION SYSTEM tZ,
IM BENCH Width r Len th No. Of Tenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN N S DIMENSION
SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type Of Model Number:
System: mv ( U I 6 OR UNIT C
DISTRIBUTION SYSTEM
Header/Manifold u Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
r
Length Dia - Length Dia Spacing
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: 1 /9 /0V Inspection #2:
Location: 729 Peter Lane, Hudson, WI (NW1 /4, SW1 /4, Section 28 T29N -R19W) - 28.29.19.1633
1� ��•�. � ' �"6r sal � os0.� -K.eu�
Z) "28' b Wi .
Plan revision required? ❑ Yes [5S No
Use other side for additional information. `� 1 Ajf,&e
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
x
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
Visionsin SANITARY PERMIT APPLI Q 201 W. Washin Avenue
In accord with ILHR 83.05, Wis. P O Box 7302
Department of Commerce �� Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the syster>�, on'pap@�
u
than 8 112 x 11 inches in size. !'
• See reverse side for instructions for completing this applicat on-;� Stat n taryPermit u mber
IS i~ P ? 199 3 y `f 69g
Personal information you provide may used for secondary purpose r;'ti ST Cf10lX [I C revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. IN CMNTY St PI n I.D. Number
I. APPLI ATI N INFOR A - PLEA E P IN LL IN ��
Property Owner Name O
04-4 A
�cc u C✓ �`� 2/ Z$ T 2_-9 , N, R 1c1 (or)
Property Owner's M ilingAodress L u K-S Lot Nu B / Block Number
-7 2 r
City, State // Zip Code Phone Number Subd ion Name or CSM Nu ber
( 71 ) - 4 Cr6 JA g5 f @S
II. TYPE OF BUILDING: (check one) ❑ State Owned V ❑ cit Nearest Road
C] Village
Public E@ 1 or 2 Family Dwelling - No. of bedrooms Town OF / we
III BUILDING USE: (If building type is public, check all that apply) Parcel TaxNumber(s) pQ ��. f9 // �2
1 ❑ Apartment/ Condo 0 2_,0 -. 1 / _ - {� J
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 Q Restaurant /Bar /Dining
4 ❑ Church/ School 8 []Mobile Home Park 12 Q Service Station/ Car Wash
5 ❑ Hotel/ Motel 9 Q 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. N New 2, ❑ Replacement 3, ❑ Replacement of 4 Q Reconnection of 5. ❑ Repair of an
System 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 Q Seepage Bed 21 ❑ Mound 30 ❑ Specif Type 41 []Holding Tank
121 Seepage Trench 22 E] In- Ground Pressure ' —� 42 Q Pit Privy
13 ❑ Seepage Pit - 3 r` 7 � 01 r °0 �OS 43 ❑ Vault Privy
14 Q System -In -Fill
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
64) 4Q 7 4 3 � Z . 78 ,? • 7 Feet /44 7 Feet
Capacity VII. FORMATION. in allo s Total # of r Prefab. Site Fiber- Exper.
gall Tanks Manufacturer s Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks I 1 Septic Tank or Holding Tank /Z106 / ZOO 1 �.4 C , r D • ® ❑ ❑ ❑ ❑ ❑
Lift Pump ank /Siphon Chamber El 11 El 11 11 11 p P
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plum er's Name: (Print) Plumb e 's Signature: (No S mps) MP /MPRSW No. Business Phone Number:
,. 'j r 7 t �j - 7 74 - 32
Plumbe 's Address (Street, City, State, I Code):
a1 2 �V r � 5f �7
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate Issued IssRM gnature (No Stamps)
DtApproved []Owner Given Initial V�5 � Surcharge Fee)
g _ _9t .
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 e
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
DILHR.
VIII. Responsibility statement. Installing plumber isto 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.
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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.
• JOB
TIMM EXCAVATING
Route 1 Box 192 SHEET NO. of
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• WILSON, WISCONSIN 54027 CALCULATED BY Z i ^° DATE � - 7 1 9
(715) 772 -3214 (715) 386 -5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
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PRODUCT 2115-1® Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE 1- 800.225.6380
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
COUNTY
Attacii complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan mu St. Croix
not limited to vertical and horizontal reference point (BM), direction and % of slo CEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. pe ing
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION O tt iji I ED [3Y DATE
CID - >�
PROPERTY OWNER: PERTYQCA(IOtV 'a, tai
Brid eland Dev. Company . L04 f.' ` i(4, SW 1/ 8 T 29 N,R 19 A or) W
PROPERTY OWNER':S MAILING ADDRESS Q;F BLOB 1BD. NA CSM # .
11736 117th St. I r_} t ' of ''Fxtates first addn.
CITY, STATE ZIP CODE PHONE NUMBER V =1 L GE ) NEAREST ROAD
Lakeville, MN. 55044 (512) 985 -5000 Crosbv Dr.
[ New Construction Use [x] Residential 1 Number of bedrooms 3 [ j Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate • 7 bed, gpd/ft2 .8 trench, gpd/ft
Absorption area required 643 bed, ft2 563 trench, ft Maximum design loading rate • 7 bed, gpd /ft trench, gpd/ft
Recommended infiltration surface elevation(s) 98.52 ft (as referred to site plan benchmark)
Additional design / site considerations na
Parent material outwash Flood plain elevation, if applicable na= It
S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable for s stem ®S ❑ U ®S ❑ U ® S ❑ U C3S ❑ U (3 s ❑ U [IS MU
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
....1 1 0 -13 10 r2 2 none 51 2m r mfr cs 2f .5 .6
2 13 -19 10 r4 4 none 2msbk mfr CjW if .4 .5
Ground 3 19 -30 10 r4 4 none S1 2mar mvfr crw if -9 -6
elev.
101 ft. 4 30 -82 7.5 r4 6 none s oscr ml na na .7 �.8
Depth to
limiting
factor .
+ 82"
Remarks:
Boring #
1 0 -17 10 r2 2 non
>' 2 17 -29 10 r4/4 none scl 2msbk mvfr ctw 2 .4 i.5
3 29 -82 7.5 r4 6 none s osa mvf
Ground
elev.
102 ft.
Depth to
limiting
factor
+ 82"
Remarks:
CST Name:— Please Print Phone:
Gary L. Steel — —
Address: 1554 200 h Ve. , Ney Ri ond, WI. 54017 m02298
Si 9 nature:
Date: CST Number:
6 -25 -96
PROPERTY OWNER BridcTeland Dev. CO. SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D. # pend
Lot #21
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed iiench
.,:3.:,.:. 1 0 -18 10 r2/2 none 1 2msbk mfr qw 2f .5 .6
2 18 -30 10yr4 /4 none scl 2msbk mfr gw if .4 .5
Ground 3 30 -38 10 r4/4 none sl 2mcfr mvfr 9w if .5 .6
elev.
101 ft. 4 38 -84 7.5 r4 4 none s osa mvfr na na .7 ':.8
Depth to
limiting
factor
+84"
Remarks:
Boring #
1 1 0-16 10 r2/2 none 1 2msbk mfr gw 2f .5 .6
.4:
4 <' 2 16 -32 10 r4 4 none scl 2msbk mfr a if .4 .5
3 1 32-80 , 7.5 r4/6 none s OSQ mvfr na na .7 .8
Ground
io - ft.
Depth to
limiting
factor
+ 80"
Remarks:
Boring #
1 1 0-16 10 r2 2 none 1 2msbk mfr qw 2f .5 .6
5 2 1 16-28 10 r4/4 none scl 2msbk mfr qw if .4 '.5
3 28 -37 10 r4/4 none sl 2msbk mvfr qw na
.5 .6
Ground
I 6�% ft. 4 37 -84 7.5 r4/6 none s Oscf mvfr na na .7 i.8
Depth to
limiting
+8
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
l
STEEL'S SOIL SERVICE
Gary L. Steel Bridgeland Dev. Co. 1 200th Ave.
CSTM2298 NW4SW4 S28- T29N -R18w New Richmond, WI 54017
MPRSW 3254 town of Hudson (715) 246 -6200
lot #21 -St. croix Estates First Addn.
N
1 =40'
BM.= top of SE lot stake C el. 100
�I
-Ac
2V
Z�
L10 ` ( P oll
Gary L \ Steel
5 -25 -96
' STEEL'S SOIL SERVICE
Gary L. Steel 1554 200th Ave.
CSTM2298 New Richmond, W 54017
MPRSW 3254 (715) 246 -6200
To whom it may concern;
This soil evaluation was conducted to satisfy a zoning requirement,
it may or may not be satisfactory for your use. The location of the
system may or may not be as shown, as permanent lot lines had not
been established at the time of the test.
Gary L. Steel
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address
Property Address
(Verification required from Planning Department for new construction)
City/State 14" IL�z Parcel Identification Number 70
LEGAL DESCRIPTION
Property Location %a, %,, Sec. �� T N -R_Z±_W, Town of Ate
Subdivision �1, �yx Lot # l
Certified Survey Map # . Volume . Page #
Warranty Deed # 5ef 2 Volume 13 �7 . Page # 9
Spec house O yes no Lot lines identifiable / El yes O no
SYSTEM MARMNArNCE
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
'y set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
y 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 exp' on date.
q,
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 operty describ ov by virtue of a warranty deed recorded in Register of Deeds Office. qil
/?i C/
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
5 X ts
KAT4LEEN H. WASH
Rtt;ISTER UF DEEDS
J. CROIX CO., U1
DOCUNIENT NO STATE BAR OF" WISCONSIN FOR RECEIVED FOR RECORD
WARRANTY DFV.D
01-20-I994 2:00 PM
ORRANTY DIED
EXEMPT #
CERT COPY FEE:
COPY FEE:
TRANSFEF FEE: 131.70
RECORDING FEE: 10.00
comcys and %%arrant,to
Daniel P. Bauer a d ne K. Pauer. husband and wife PAGES: I
Di: -
the foIIo%%ingdmribcdreal estate in St. Croix Comm StaWofWiscionsin Return to: First Nat] Ba rk of Hudson
P.I.N. 020-1319-70
Lot 21 St Croix Estates First Addition in the Fo%%aof Hudson, St Croix County. Wisconsin.
-,-is tit -- homestead prop-crt%
is nA)
Exceptions to Warranties�
Dated this 6th day of jamau. 19 99
__(SEAL)
L)
-(SEAL) _(SEA
AUTHENTICATION ACKNOWLEDGMENT
Signatures authenticated this --dav of STATF OF MINNESOTA
.19
County
,
day of
Personally came before me, this 6th
LujuaD 19 the above named
TITLE: MEMBER STATE BAR OF WISCONSIN
(If n,
authorized by 706.06. Wis. Slats.)
This instrument was drailed by
to nic k►io%%n to be the person who executed the
BridacliInd Elcyclopmcill Company foregoing instrument and acknowl ged the same.
2014 i Icenic Tr_Suite BLakcvill , MN 55044
(Signatures may be authenticated or acknowledged- 1
Both arc not necessary.)
Notary P Dak
ublic ota County. MN
My co expires JanuarN 1, 2000.
"'ALA J. 8ZER
NOMV A
- A ITY
COUN
jj
*N%vics of p,;rsoris signing in 1 l c apacity should be tN or printed below Ilicir signature 5112 NIT uo.' I
WARRANTY DEED S1. xTE RAR OF WISCONSIN. F� %I N-j- 2-1982
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