HomeMy WebLinkAbout020-1110-20-000 'Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y
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)l. 353187
Permit Holder's Name: ❑ City ❑ Village Q Town of: State Plan ID No.:
Town of Hudson
Insp. BM Elev.: BM Descriptio Parcel Tax No.:
e a 00 Z" 020 - 1110 -20 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic �C Zdd Benchmark d
i n Alt. BM
Aerati Bldg. Sewer
Holding / Ht Inlet O- K le
TANK SETBACK INFORMATION ! Ht Outlet d
TANK TO P/ L WELL BLDG. Air I ntake ROAD
Air
Septic y 71 t / V Z� ' Z NA Bt Bottom
NA Header / Man.
Aeration NA Dist. Pipe
�z d c
Holding Bot. System ��) -t I. 9/,
PUMP/ SIPHON INFORMATION Final Grade - -7 q Z Z !5'
Manua nd St cover A & O 16s�_0
Model Number GPM l05
TDH Friction stem TDH Ft
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM 5 �,
BED/ T N Width Len th , No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIM N I DIMENSION
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Ma r u Cturer: r
INFORMATION Type O r CH E M0 el Numb
System: c6+lJ Zj > o f
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) ..�- r x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. L/ /f Length �� � Dia. � Spacing A1 1 A
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/Tr nch Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: q /IL//oo Inspection #2:
Location: 630 Hillary Farm Road, Hudson, WI (SW /4, F NW1 /4, Section 36 T29N - R19W) - 36-29 19 2003
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l) Al � guA C SC ri " Si / f d o : o Gloo✓ O
Gtw�oum t a ( Govcr : 7/� — lx ct AAje- pvgo�e
Plan revision required? ❑ Yes f� No
Use other side for additional inforn4ation. µ /}d
SBD -6710 (R.3/97) Da'4 ture Cert. No
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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t Safety and Buildings Division
• SANITARY PERMIT APP N 2 01 W. Washington Avenue
V i sconsin
Department of Commerce In accord with ILHR 83.05, Wi Cnde
P O Box 7302
�,� � Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the syste , pap4R", ,e9- County' t
than 8 1/2 x 11 inches in size. . `'' ` / '
• See reverse side for instructions for completing this appllcatom� state I ary Permit Number
Personal information you provide may �� ST C£t-`
_
Y P Y be used for secondary purposes � ❑Check;- r evisi n t previous application
[Privacy Law, s. 15.04 (1) (m)). 3 �� LL Ale v UN Stati n I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INF R TI ON
`+
Propert*Own r P opertyto ation
�' I 4 f 8lock , N, R f (or) W
Prop Owner's Mailing Add r s � r Lot Numbe� Nu mber
Cit State X / Zi C�o P one Numb r Subdivisio Na a or CSM Number
N S47 &
II. TYPE B IL ING: ( ck e one) ❑ State Owned it Nearest R ad
Public 1 or 2 Family Dwelling - No. of bedrooms Tow o f
I11. BUILDING SE: (If O
type is public, check all that apply) Parcel Tax Number(s) 2-1 19. 20t7 3
1❑ Apartment/ Condo o ` 0 o 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)
A) 1. IMP New 2, ❑ Replacement 3. ❑ Replacement of 4 ❑ Reconnection of 5_ ❑ Repair of an
_- _____ysterrl -------- 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 ❑ Seepage Bed 21 F] Mound 30 E] Specify Type 41 []Holding Tank
12 Ed Seepage Trench S rz ❑ In- Ground Pressure 42 ❑ Pit Privy
13 E] Seepage Pit 43 ❑ V It Privy
14 ❑ System -In -Fill
V ABSORPTION S YSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
600 1 Required (s q. ft.) Proposed (sq. ft.) (Gals/da sq. ft.) (Min. /inch) / Elevatio
S �. �(r Feet / & .110 Feet
Capacity
VII. TANK in Ca allo
g Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks
S tic Tan k Q ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans.
Plumber' : Prin ) w Plumb Signatu e: ( o P/ PRSW No.: Business Phone Number: J,5 c2
Plumbe s�cJress(Str� � Cit , e,2ipC ): ` '' 9 6
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate I ssued Is Ing n Signature (No Stamps)
Surcharge ree)G 1 /
Approved ❑Owner Given Initial
Adverse Determination � /
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
i h : �O4G C
SBD- 6398 (RA 1/97) DISTRIBUTION: Original to county. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS w
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 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 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 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.
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Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Divi §iori of Safety and Buildings Page -- of
Bureau of Integrated Services in accordance.with s7tTfrt- .09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 ings in size. Plmust / County
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include, but not limited to: vertical and horizontal reference Oint,(BM), d f . rn ; 5 � • e rU
percent slope, scale or dimensions, north arrow, and locatign and distance tb'neaieM road. parcel I.D. #
APPLICANT INFORMATION - Please print all information I R wed by Date
Personal information you provide may be used for secondary purposAs (Privacy Law g�j 44-V) (m)).
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Property Owner ro LQp8it' n
i C- ko f - o V Govt:,Lo .�, & f 1/4 /fjWl /4,S �Z ( Tp q ,N,R E (orb
Property Owner's Mailing Address _ ;Lot Block# Subd. Name or CSM#
City State Zip Code Phone Number Ci ty r_1 Village [Y Town Nearest Road
❑
iN u cl o eN I W i I S' v/ ( 7 / S) Syy -6, 73/ Nods C5 r , (b+Jo rwocj:--( _1_r�
® New Construction Use: ® Residential / Number of bedrooms -3 — 7 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 1 gpd Recommended design loading rate . 7 bed, gpd /ft trench, gpd/ft
Absorption area required _? _ bed, ft 7SC� trench, ft2 Maximum design loading rate • bed, gpd /ft gpd /ft
Recommended infiltration surface elevation(s) ? /. 7 U ft (as referred to site plan benchmark)
Additional design /site considerations jaLl'. 2 /cc 1 ? 0 - go
Parent material 1�r IeLc_ r 0.l U U 4b-j -S (�N Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U= Unsuitable for s ® S El U IX S❑ U
[ZS ❑ u s ❑ u ❑ S lY U ❑ s [�' u
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD /ft
g Texture Consistence Boundary Roots
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
to '/ s. ,tea -c es
Ground _1 D yl
elev.
Depth to
limiting
factor
3 6 in.
Remarks:
Boring #
0- 1Z T S ]
.. t Z 0 I -' s r� ( !n it (� C • S� , . �c
'/ -2t 110 vr 4 116 in Os
Ground
elev.
Depth to
limiting
factor
1 —_in. Remarks:
CST Name (Please Print) Signature Telephone No.
a S - 7 40 a
Address Date CST Number
f PROPERTY OWNER SOIL DESCRIPTION REPORT Page of
PARCEL I.D.#
Boris # Horizon Depth Dominant Color Mottles Structure 2
Boring Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
i -f z a S; a b w1 r- C . (o
Ground
% 7o ft.
Depth to
limiting
fact (?r $
IZI in.
Remarks:
Boring #
`' IZ toy ry S� u -fir — ,� •�o
Ground
elev.
Depth to
limiting
factor
LMin.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Boring # - 11 l0 31 S, r` e ,S
S
II -q.3 v -� S I' b r`
Ground
elev.
9 � ft.
Depth to
limiting S q).&
factor
130 in. Remarks:
Boring #
..........................
Ground
elev.
ft. '
Depth to
limiting
factor
in.
Remarks:
SBD -8330 (R. 07/96)
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Ovu i er/$u) e, - 51W De -w1 q Q rt a( ,/"I" el le s cot
g ,;; 4hvrr 6rMire �U �►�`S� `-�'Sa 74
Mau .in Atld.r. is .3 9 / f/y
Pr4i erty Addx sss to 3 Gafi*nwoo/ Al'e #ve/ T% wl - -'p
(Verification required from Planning Department for new construction)
Cite' 'State j� / / / U-�- L Parcel Identification Number
r.
I
LL B: Sp�I, ; !RIPTIO v
PM!. Mfiy I1;ac,. «1.I:ion %,, Nom /�, Sec. 3� . T N- R2, ,W, Town of
Subt :ivisiott , Lot #
Cer' "Ifted E'4i i °i ey leap t! /�— � . Volume Page #
Volume V6 3 _, Page #
Spe; house C'.,J ;yes 0 nc Lot lures identifiable 0 yes 0 no
SY ►r : . r
NIEN—AN
Imp; l-r, �( imeandmai: ntenanecofyoursepticsystemcouldresultin faduretohandlewastes ,P::opsrxn-'ua
coa >i As of pvgl lr�Ag out the s- ;;ptie tank every three years or sooner, if needed by a licensed pumper. What you Pat into tR:t, system
can : � i'fect the f i jx.:tion of tixe septic tank as a treatment stage in the waste disposal system.
The ..rty owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owna f Ad by a
mast, ;rplumb, r, J nrneyrnan p :umber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater dispoi 3,11' system
is irk.-, -roper o gem ing condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1.13 full "J;
11we. the unda-ri.:i,s, coed have re,4 the above requirements and agree to maintain, the private sewage disposal system with the! ,::andards
set f o th, herein,, 11 1. set by the Department of Commerce and Department of Natural Resources, State of Wisconsin. Ck� tification
statip -r that yc .ui !c optic system has been maintained must be completed and returned to the St. Croix County Zoninf Office 1c ithin 30
days of the tY're - ,?ear expiration date.
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il-Gi LICAI-T D ATE
OVw;: (, X..' FI'I{ ,ICA7 : 'TO�I
I (wi.l', w* 1ify that all statements on this form are true to the best of my (our) knowledge. I (we) am (aro) the o %ver(s) of
the ,F, aperty f (v is :,ribed above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGCR;ATURLai()f APPLICAI DATE
Any i:a. Cc: ination that is mis represented may result in the sanitary permit being revoked by tho Zoning Departmet. {.
W :lode with I fiils 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
CO 39Vd VC19f L9 6G :60 666Z/8u/60
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1463 496
STATE BAR OF WISCONSIN FORM 2 - 1998 6121 S3
WARRANTY DEED KATHLEEN H. WALSH
REGISTER OF DEEDS
Document Number ST. CROIX CO., WI
RECEIVED FOR RECORD
This Deed, made between RICHARD 0. STOUT an d 10 -18 -1999 9:00 AM
`TA.NFT P_ STOUT, husband a wi WARRANTY DEED
EXEMPT W
Grantor, CERT COPY FEE:
COPY FEE:
and - �cr;�VI+y1V —I�_ L1I�IG �1— I+4TCILLI�,BK TRANSFER FEE: 110.70
RECORDING FEE: 10.00
PAGES: 1
Grantee.
Grantor, for a valuable consideration, 'conveys and warrants to Grantee the following
described real estate in St. County, State of Wisconsin:
Recording Area
Lot 3, Plat of Cottonwood Ridge, Town of Name and Return Address
Hudson, St. Croix County, Wisconsin. 61 #r
This deed is given in full and final satis- ,7- w'2
faction of that unrecorded land contract �'
between Richard 0. Stout and Janet P. Stout
and Steven R. Dewing and Michelle L. Beck
dated May 21, 1999.
Parcel Identification Niger RP
This is not homestead property.
(is) (is not)
Exceptions to warranties: easements, restrictions, rights -of -way and covenants
of record.
Dated this IF
th day of Ontobar
Ri = Stout (SEAL) (SEAL)
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s)
State of Wisconsin,
SS.
St. Croix County.
authenticated this day of Personally came before me this 1 5 f h day of
nctnht -r 1 9 , 99 , the above named
Richard 0. Stout and Janet P.
Stout
TITLE: MEMBER STATE BAR OF WISCONSIN to
(If not, me known to be the person _q executed the foregoing
authorized by §706.06, Wis. Stats.) g IB instrument and ackno a the same.
06 �
THIS INSTRUMENT WAS DRAFTED BY
Janet P. Stout OMIMINSM
1353 Awatukpe Tr
Hudson, Wi . 54016 Notary Public, State of Wisconsin
M commission is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not )
necessary)
Names of persons signing in any capacity must be typed or printed below their signature.
STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc.
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