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HomeMy WebLinkAbout020-1353-55-000 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)]. 353125 Permit Holder's Name: ❑ City ❑ Village EkTown of: State Plan ID No.: Nelson Mike I Town of Hudson - CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.: eA. 1� •�" a i i►1Y 020 - 1353 -55 -000 TANK INFORMATION ELEVATION DATA • Z9 , [ aosS TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic t., Z [� Benchmark t05%a 5 100.0 Dosi ng Alt. BM Aeration Bldg. Sewer 7 0,7? ' r 91F39 , IF Holding St /Ht Inlet S`f 6 `13.63 TA SETBACK INFORMATION St/ Ht Outlet - f 7 91 YO TANK TO P / L WELL BLDG. Air I to ntake ROAD Dt Inlet = —T Air Septic q0 7?5� � �_ NA Dt Bottom _ �--- Dosing NA Header / Man. /2, o2 -73 Aeration NA Dist. Pipe IZ. cr2,8Z Holding Bot. System PUM / SIPHON INFORMATION Final Grade 5e _ Manufact Zr De nd St cover .3 Model Numbe GP TDH Lift L ction Syestem TDH t no Force Length He Dist. I SOIL ABSORPTION SYSTEM (I BED/TRENCH Width Le No. Of enches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS r � DIMENSIONS Manufacturer. 4 SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING _ S� INFORMATION Type of f CHAMBER Model Number• System: VW, (7 I > 112 OR UNIT DISTRIBUTION SYSTEM Header Wanifold I , Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. ng (p (7 SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over k Depth Over xx Depth Of xx Seeded / Sodded xx Mulched Bed /Trench Center �3�0 Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: 1 / 67 SOInspection #2: 4 — t - Location: 637 Hillary Farm Road, Hudson, WI(NE1 /�4, SW1/4, Section 36 T29N -R19W) - 36.29.19.2055 • J Plan revision required? ❑ Yes 51 No Use other side for additional information. Of 0 �b K SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. _ 1 ADDITIONAL COMMENTS AND SKETCH i SANITARY PERMIT NUMBER: m� € �ee S t 3 E � ..... e + 3 i F o fl , t � � 3 y £ t t E € x + d _ e , y + t e s s E s i € t E . ....... .. .. . . e...... .. a .. ... ...... � . ..... .. . �. _ _ .,,... ... e ... _ . .....e ...... .. ,.,.. .... .. � ... ,.. ,. .... .,,, .. . . E $ � � 3 I . m € ? n # t p i € . 1 a f + + �. Y G. ., ....... e .. -. .,.N ea.. . ,.�...�- ... �.m� mem s,.. em m„ ... .m ...e p ....e k..,.... ,.,,, a �. ... .�.... .. , ea...._ ,.e . e« m ms,e, e e E 9 € + € e i y r • , Safety and Buildings Division 201 W. Washi n gton Avenue SANITARY PERM APPLICATION g Asconsin RM P O Box 7302 Department of Commerce In accord with Comm 83.05, Wis. _ Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the systee , oh paper not less County than 8 1/2 x 1 I inches in size. r ,S j C k Q I • See reverse side for instructions for completing this appl c n JCL.; LD State Sanitary Permit Number Personal information you provide may be used for secondary purposes p [ eck if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. / - r Sta a Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT A' R Property Owner Name 0fd#jt C6c0w 7 n K� �i1 - SGij 1/4 51 jC� T r N,R �QE(or Property Owner's Mailing Address �f�Nu�mts �� j Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number i p A UL, �/ / 'F 1 ((.251 )70a2 C)& C_d 7��6 /0 II. TYPE OF B ILD NG: (check one) ❑ State Owned P Cit Nearest Road L L Public or 2 Family Dwelling S E] Village - No. of bedroom U a Town OF �-� �l.r' �! /�� ��iQn) Ill BUILDING USE (If building type is public, check all that apply)S�wv� Parcel Tax Number(s) r(s� '� �'G'0 Ic:rC > C rS � -C 1 ❑ Apartment/ Condo 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, 0-5ew 2. (] Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. O 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 ❑ Se age Bed 21 E] Mound 30 ❑ Specify Type 41 [_ Tank 12 eepage Trench 22 ❑ In- Ground Pressure A 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vau Privy 14 ❑ System -In -Fill a k 14 4or. 31 . _ - 5 •r? VI. ABSORPTION SYSTEM INFORMATION:763.Z 1. II n Per Ga o s e Da 2 Absor .Area 3. Absor . Ar 4. L in R t 5. Perc. Rate 6. S stem Elev. .Final Grade ea oad a e Y p p 9 Y e Require! sq. ft.) P poq. ft.) (Galsldayq. ft.) ' Win./inch) c � � Elevation 1j C�` m 7 eet -OFeet Capacit VII. TANK in Ca allo Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks eptic T k ® (� [/ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamberl I I ❑ I ❑ I ❑ I ❑ 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 Si ture p MP /MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, ip Code): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issue Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) 1 1A Adverse Determination 2 S u - X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: +1v,k .P"s o* ld Vuj 9q 61 12.4 . SBD -6398 (R. 4/99) 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 Bw�clings 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. 11. 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. I 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 manufactureG.D)..cross section of the soil absorption system if required by the county; E) soil test data dri a - 115 form; a - nd 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. G� Al 5 v '1 IL N,J) o' G a � �9 o � �c N � C- L sRr i Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in accordance Mw f )LHR,E 109 Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inc l s u, size. Pin m*, ` • County a include, but not limited to: vertical and horizontal reference pol (aM), direction and,,. percent slope, scale or dimensions, north arrow, and location,rad,distance to nearest foad. arcel LD. # t I t APPLICANT INFORMATION - Please print all i�foimation} A °` a 'awed by Date Personal information you provide may be used for secondary purposes (Primacy Laovr ,r`��,,,` '� - 7 q7 Property Owner �, Prop l o atio Pkc �E, r 9v • �' 1/4 S(,J 1/4,S 3 T 2 ,N,R E (or) (@ Property Owner's Mailing Address Block# Subd. Name or CSM# l 5" > e r . 1 515 c4 City State Zip Code Phone Number ❑ City ❑ Vill ".Town Nearest Road Y1 Cat F 1 ),5 _ l 3 a e Cc4- c,n w o a ok +r-. �] New Construction Use: Residential / Number of bedrooms I Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 000 gpd Recommended design loading rate • bed, gpd /ft trench, gpd /ft Absorption area required _ bed, ft 750 trench, ft Maximum design loading rate • 7 bed, gpd /ft L trench, gpd /ft Recommended infiltration surface elevation(s) q/• 5 ft (as referred to site plan benchmark) Additional design /site considerations t G t . 9 / 3 , • 3 o � I Parent material Q C� C:kc, �A1��� Flood plain elevation, if applicable I-1 qo7. d ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system ® S ❑ U ® S ❑ U �Z S❑ U ® S ❑ U ❑ S © U ❑ S 4 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench ,r CS IV- 1 4 5 Ground 3 1g- 11 r 414P fY°t O q C 8 elev. To � Depth to limiting factor i 11 l� in. ' Remarks: Boring # 3 2-6-111Z 1 r 4 6 YY) 3 ffIQ M Ground elev. f Depth to limiting factor M, in. Remarks: CST Name (Please Print) Signature Telephone No. iqdarn 5ch r (11� 2 7_ 00 Address Date CST Number D er 4-1 - 1 5- 9 253 0 5 -A Dru SOIL DESCRIPTION REPORT PROPERTY OWNER Page of PARCEL I.D.# Boring Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench 3 �-1 z n4 -r 2 IZ -1 S 1 rnscll M1 c C, Ground elev. Q s7y n. Depth to limiting factor , Remarks: Boring # 1 o-ts U r 312- �' vL L 4 5 LA 2 IS °Zl 1 4 LS 1 3 ZI-41 I r ti (0 W) 1 C°S Ground elev. Depth to limiting V* f ctor t in. 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 # 1 b-I kC 51 K. SL C, v ' S J 2 II -2 1p 14 _ LS Ground elev. T. ZQ ft. XP Depth to limiting factor 11L Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) s f�U+ L sr v o ,� cJOQ z zd o hut' I ( { - I tab .o ,eta,,( 1z''nti6Lpcc elm t 0 c) N ( ae- � ti �f f OIK , 43! 13 a � az �z 44.r I ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address c ( 1� Property Address _ O (Verification required from Planning Department for new construction) 1 -5 9- 3 - -5-s - vclkJ City /State e Parcel Identification Number LEGAL DESCRIPTION Property Location 1 /a, (-e) `/,, Sec. W, Town of c Subdivision � 1 04 " t,J ©n& `6�el < , Lot # 5 . Certified Survey Map # Volume . . Page # Warranty Deed # , Volume " - Page # a Spec house ❑ yes no Lot lines identifiable Edges ❑ 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 masterplumber, journeymanplumber, restrictedplumber or a licensedpumper verifying that (1) the on-site wastewaterdisposal 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. n agree to maintain the above requirements a d Uwe, the undersigned have read the gr 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 a it tion date. SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION a re the owners) of I (we) certify that all statements on this form are true to the best of my (our) knowledge. g I (we) am (are) t � property y descn above, by virtue of a warranty deed recorded in Register of Deeds Office. 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 I STATE BAR OF WISCONSIN FORM 2 - 1998 �EsO'9608 WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS ���_ 1453PAGf2`76 ST. CROIX CO., WI Document Number RECEIVED FOR RECORD This Deed, made between 09 -01 -1999 9:00 AM RICHARD O STOUT and JANET P -qTO husb WARRANTY DEED and —wife , EXEMPT I Grantor, COPY FEE FEE: and MTCHAP- M NFI„RnN and NICOLE M NELSON -; TRANSFER FEE: 140.70 husband and wife RECORDING FEE: 10.00 PAGES: 1 Grantee. Grantor, for a valuable consideration,. conveys and warrants to Grantee the following described real estate in e � — cll nix County, State of Wisconsin: Recording Area Lot 55, Plat of Cottonwood Ridge, Town of Name and Return Address Hudson, St. Croix County, Wisconsin. R u14r (99 -/, 39 D 020- 1110 -20 -000 Parcel Identification Number (PIN) This i a noi~ homestead property. (is) (is not) Exceptions to warranties: easements, restrictions, rights -of -way and covenants of record. Dated this day of 1999 Richard O Stout (SEAL) janet - y ST01-1-t (SEAL) SbnA (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. St. Cr County. authenticated this day of Personally came before me this th day of AuguS 1 q99 the above named Richa - 0. Stout and JanetP . TITLE: MEMBER STATE BAR OF WISCONSIN Boo a 4° to (If not, *�w to be the person .�_ who executed the foregoing authorized by §706.06, Wis. Stats.) State instrumen d acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Janet p. Stout 1353 Awafukee Tr Hudson, Wi . 54016 Notary lic, State of Wisconsin My co mission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not November 19 2_.) 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. WARRANTY DEED FORM No. 2 - 1998 Milwaukee, Wis. 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