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HomeMy WebLinkAbout026-1117-30-000 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner ` V �• 4J�9 . wz ve � o`► Property Addres w S' City /State Mew 427 - Traorvi - Legal-Description: Lot —L Block Subdivision/CSM # 4 w 1 /4 Nw 1 /4, Sec. J-, T,3 N -R�W, Town of 9 ` PIN # fL, - l If 7 - 30 -0 p c� SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer bu` .ems to ✓ s Size ST/PC lc Setback from: House Well PAL Pump manufacturer Model Alarm location (HOLDING TAN ONLY) Setbacks: Service roa Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPT ON SYSTEM Type of system: Width - Z- Length 7 Z Number of Trenches Setback from: House & Well >S IT — 1-5 6) Vent to fresh air intake 69 ELEVATIONS Description of benchmark �`�' ' ` > 7 Elevation Description of alternate benchmark Elevation Building Sewer ST/HT Inlet ' 3 ST Outlet -�g•� PC Inlet PC Bottom Header/Manifold S51 Z Top of ST/PC Manhole Cover Distribution Lines () 5, () ( ) Bottom of System () 8 () ( ) Final Grade Date of installation 5/ cM Per number 33 q State plan number 1 Plumber's signature License number X05'3 7 Date Inspector Complete plot plan � • a 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 15' 7.2 u,0l�� Qk-i /S• INDICATE NORTH ARROW c G f Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: ST CR I Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 338997 ❑ City []Village Town of: State Plan ID No.: " Per evf VER JOINT VENTURE RICHMOND CST BM Elev.: Insp. BM Eley.: BM Descri tion: Parcel Tax No.: eiO. C I 1cro, C fl- - D 026 - 1117 -30 -000 TANK INFORMATION ELF ATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark $ 1p2, (o jt30, � a (cU. $ Dosing / Quit^ �j• / 3. Aeration Bldg. Sewer L Holding St / Ht Inlet Z , y} 10, 13 TANK SETBACK INFORMATION St / Ht Outlet 6 2-00 $q. TANK TO P/ L WELL BLDG. Ventto ROAD Air Intake Septic Spy SD (� -- NA Dosing NA Header / Man. IL 0% Aeration NA Dist. Pipe (p Holding Bot. System PUMP / SIPHON INFORMATION Final Grade f�.`f, SSG IZ. Manufacturer Demand -ter, ,� 'r. I �, SD Mode er GPM T Lift Friction yst TDH Ft Forcemainj Length Dia. H Dist. well SOIL ABSORPTION SYSTEM / c l r 'f 3'O= �j= Width Length i No. Of PIT No. Of Pits Inside Dia. Liquid Depth D IMENSIONS 2 1-1 DIMENSION SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type Of t D OR UNIT Model Number: System: �,pbl�1� jS DISTRIBUTION SYSTEM Header / M ifold Distribution Pipe(s)f t, a u x Hole Size x Hole Spacing Vent To Air Intake Length Dia - Length Dia. T Spacing r 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 E] No E] Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCAT ,,,, t ,ION: RICHMO D 01.30.18.683,N ,NW 175 144TH STREET �,� • D � fie/ �" > t�" �.�. c.� /� . 2(f -I �i , XS - '"#" Plan revision required? ❑ Yes No pq I S Use other side for additional information. zZ; SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. � I ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: e T E e a:� e e F i w 3 4 I I M. t r P e. E t 3 I I 9 ¢ e i E � z s e S e. am . a a r F e i t & 7 5 t L,emm, ee s ? s c F e .. e s i T t - � 1 j s b E d g s s a E s s Safety and Buildings Division Viscon SANITARY PERMIT APPLICATION 2 1 Box Washington Avenue In accord with ILHR 83.05, Wis. Adm. Code Department of Commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8112 x 11 inches in size. t-o • See reverse side for instructions for completing this application State Sanitary Permit Number . 3S — 7 Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Prope x Owner ne Property Location �,� 1 �Q w e ` V ,.F �l� A it �S v01 i4, S ( T , N, R [ (or1lWJ Pr(Aerty Owner's Mailing Address Lot Nu b�r Block Numb. lr City, Stat Zip Code Phone Number Subdivision N e or CSM ber N4 �d �" ot C ,.y ( as `tow K MSOCAOW II. TYPE OF BUILDING: (check one) ❑ State Owned It Nearest Road Public or 2 Family Dwelling - No. of bedrooms C] Town of I t1A_ 111. BUILDING SE: (If building type is public, check all that apply) Parcel Tax Number(s) 1,30 • t V% 683 1[]Apartment/ Condo 0 a lo I - 7 _ a 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 if 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. r /New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an __``_TT_``_�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 Seepage Bed 21 ❑ Mound 30 [] Specify Type 41 E] Holding Tank 12 RSeepage Trench 22 ❑ In- Ground Pressure ( 42 ❑ Pit Privy 13 ❑ Seepage Pit �Z X 43 ❑ Vault Privy 14 ❑ System -ln -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 Re uired sq. ft.) Proposed (sq.-ft.) (Gals/day /sq. ft.) (Min. /inch) dd� Elevation d Q S1 960 107 Feet 9�9' Z Feet Capacit VII. TANK in Ca ga llo ns Total # of r Prefab. Site Fiber- Exper INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App New Existing structed Tanks Tank eptic T 1@ Al L an I + - W z P <S. ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 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: (Pri P umber's Sig atu (No Stamps) MP /MPRSW No.: Business Phone Number: rs S 3 `7 [ 5 :mil � jG Plumber's Address (Stree I tv, t te,_Code): IX. COUNTY/ DEPARTMENT USE ON X I ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate I ssued Issuing Agent Signature (No Stamps) Approved [] Owner Given Initial ✓],�- Surcharge fee) Adverse Determination X. COND TION g APPROVAL / REASONS FOR DISAPPROVAL: (` ( *T 61 <�1-f f SBD- 6398 IRA 1/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber t 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 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 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. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE I 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. PIOT PIC, ry ua S 3 N � c �� 7 �l cam; v.�✓� Y11�os �-T.3 ! J d 1G ( l�r r i �I grw 3� 0� r IkC 4 t6 fl I r c � cro ` ern � j0 •� 7 WO .�, rr ego V-eo\ %t/``C. • C r vSS S .:c u , Y- � NE S ee � 1' 3� �111Q l� �••� 'v A.: r ► And ODee Frelh Air Inlet ' rratfon pip . Illnlmwe COP 12•Apove �APPrerta Y,ri, i� • i 20. 42v Above PIP? Te fJnal OrO S C aO -- �• C °,1 Iron Y,nl PIP, • �. L-1 Ile Or nlMlk e.•rin DI, Ov,12PIP, p ° r, T, e A pOI, blDvllon PIP 9 ° 6• ! O,n„Ih PIP, ° P,I'' o Yo - " P o pltnp TOrwJn°11np As O,IIOm 01 Sj�l,m 8 � t00 / DI, STRIBUT101.1 PIPE SOIL F!1_l- 2 of l1GGRl;Gr11E /' - APPROvt;o SYNPaE7tG covctt OR 9" OF STRAW ~` OR ARSu L OFEXL... y f . '' oFiZ - 2 I lk AGGRCGAT OISTRIDUTIO" PJFt: T. AVL AT U' 0E AT �EAS'f !,� 4 1 LCAS7Lp tIJCF{C� BUT I,IO MORC TH I�CtiCS BCLOW p+�j 42 IUt1iE5 OCLOW FINAL GRApE GitAOE r'LtXU1uM D>± P. rH or E c V D , 7'UNIr1(/ T- IoN X OF �xcA "AIWAL 6RADF- W ILL aE ,8 M o �P n� Ff�oM ���It1q ��� +>JCHes GROY- WILL, ©c Itj S I G ►� C 0: LIGCQSC LJUMBEIZ: Ito . Wisconsih Department of Commerce SOIL AND SITE EVALUATION J Division of Safety and Buildings Page - f— of BLreau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach coml5lete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and : 0, percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel 1. D. # 0 a - <11 - 30 -a©� APPLICANT INFORMATION - Please print all information Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Prope Owner Property Location (� ; Govt. Lot pj IF 1/4 Nwi /4,S T 3 0,N,R E (or Property Owner's Mailing Address Lot # Block# I Subd. Name or CSM# City State Zip Code Phone Number Nearest Road ❑ C Village � Town of ( _7ts )a ko. - Gds C ?� New Construction Use: Residential / Number of bedrooms Addition to existing building ❑ Replacement Public or commercial - Describe: Code derived daily flow a0_0 gpd Recommended design loading rate bed, gpd /ft t trench, gpd /ft Absorption area required '3 _ bed, ft " ?S� 6 trench, ft 2 g g �Z bed, gpd /fie Ifs trench, gpd /ft Maximum design loading rate Recommended infiltration surface elevation(s) � �, , ft (as referred to site plan benchmark) Additional design /site considerations Parent material o►(, I 1 Flood plain elevation, if applicable q ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system S❑ U XS ❑ U ®S ❑ U ❑ S QA U ❑ S [25 U ❑ S 9 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench .2 -3' W% S r Ground 3 s J 1 A R ft' 7 Y 10 Depth to limiting 4OZ factor in. Remarks: Boring # low SbK LS >� 5 Ground 4 7 -110 v. ft. ; Depth to limiting A actor in. Remarks: FAddress T Name (Please Pri Si ture Telephone No. s 5 S LIS . Date CST Number q Ss N �� �r - l- 0�� _ Q � SOIL DESCRIPTION REPORT PROPERTY OWNER C t� .r.�ti,�� E Page a of 3 PARCEL I.D.# Boring Horizon Depth Dominant Color Mottles Structure 2 g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed .Trench - /0 5,1 K C S X.-- t ; , L Ground /. ✓r' M S C S elev. p S1 eft. IDY I I Qom^ �s 5L 7Y1( r 13 Depth to limiting factor [LI > in. Remarks: Boring # / 0-V 7 A o- -JO /,O Q M CS A Ground 'y.? `� l D 6 .S �n S rn 2 7 elev. Depth to limiting factor 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 # h r C S ra Ground �— elev. Depth to limiting Pli in. Remarks: Boring # E3 Ground elev. ft. ' Depth to limiting factor in ' Remarks: SBD -8330 (R. 07/96) NE y At ��� S mac: � - 1-30 lu P© y c klc- vMDAd Naila� 'E 1 r c4`. Afl % :# 4 eJ ),so. 7`� I Bnn �a3,�o �C N ti _ ja�� g ,^^�►1 1 3 .1to 4 3 II�---• ST CROIX COUNTY j SEPTIC TANK MAINTENANCE AGREEMENT I AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Q.. V S / \"VL - W - 0VV S c t *-►T' 1 j rzz �� t�1,1 Mailing Address _ �� X s Property Address - t5 ( 14 4 (Verification required from Planning Department for new construction) City /State �w QiL-++ nn,owb k� ( Parcel Identification Number LEGAL DESCRIPTION Property Location W %4, Al W %4, Sec. , T ')'G N -R NO W, Town of V c 4MC &LO Subdivision P-tv<rZ Lot # Certified Survey Map # . Volume , Page # Warranty Deed # 4S - 2' - I A Volume S Page # 4 S 9 Spec house X yes ❑ no Lot lines identifiablxyes ❑ 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, journeymanplymber, 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. Uwe, 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 t your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 . days o e three yea' te. 6 / ' - 7 S NATURE OF APPLIC DATE OWNER CERTIFICATION (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 pr rty described abov by viu f a warranty deed recorded in Register of Deeds Office. (o 7 1 S NATURE O 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 4.52767 GUARDIAN'S DEED REGISTER'S OFFICE This Deed, made between .......................................................... ST. CROIX CO., WI ...... G ertrude r ...... u.d .... e ... E.-...Sc.hmA.t ... .. by ... Bey.er.iy..Ajjq�;!....... i dia Recd for Record .... .. ...... .... . . .......................................................................................................... ...... OGT218 1989 .......... ............................................................................ , Grantor, at and ..... ..A� ... P1. .......... M. ... Derrick .. ... ........... 8 • ..... ... AqKXj.c.k..and ...... ........... ............. Reg ......... :i � .................................................................................... , Grantee, itnesseth, That the said Grantor, for a valuable consideration ...... Gertrude E. Schmit by„ Hqyqpl ..................................... Conveys to Grantee the following described real estate in ....... 5.t. Q. r. P County, State of Wisconsin Southeast Quarter of Northwest Quarter and Northeast Quarter of Southwest Quarter of Section 1, Township 30 North, Range 18 West. Tax Parcel No: ................................... This deed is given pursuant to the Order to Sell, dated October 16, 1989, and the Confirmation of Agreement and Order, dated October 19, 1989, both duly,authorized by Order of the Court and whereas the undersigned, Beverly Buckner, is authorized to sell the same by Letters of Guardianship certified on October 22, 1989. w � - I'M This ........ not ...... homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And ..... Ger.tr.ude...E.....S.chmit...by..Be.v.er.1y..Buckn.er ...................................... warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except ... easements, restrictions and rights-of-way of record, if any. and will warrant and defend the same. Dated .............. .................. day o f ......... October ........... .............................. .... ... . ..... ..... A ..................................................................... (SEAL) ......... (SEAL) G.ertrude'E. Schmit by Beverly .................................................................. — 'BucImer , "GUardl .................... ..................................................................... (SEAL) .................................................................... (SEAL) AUTHENTICATION AORNOW•EDGMENT Signature(s) ............................. ....... STATE OF WISCONSIN Beverly Buckner ................ October ................... County. authenticated thls ..... day of ........................... 19..�q ........... . ....... ..... Personal I y came before me this ................ day of -; 46— ............................................ 19........ the above named KristinaOgland Lundeen ................................................................................ E T ....... ** ....... ....... ................................................................................ (If not . ................................................... authorized by § 106.06, Wis. Stats.) to me known to be the person ............ who executed the foregoing instrument and acknowledge the same. Kill tTAW"6T1'Kffcf • 4, .. ornp-y ... kt..Lax ....................................... ................................................................................ .......................................................... I ................... ................................................................. ' Notnry Public .... ; ................................ .e e .County"Wis- may he authenticated or acknowledged. Both My Commission is perninnent. (If not, iit nary.) date: ............................................ win. t. —.At� .1—JA A. —1.1.A • 4.1. � M '1••:. ' ' .1.•x•11 • ' 1 � "' 1 �' 1 , . 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