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HomeMy WebLinkAbout026-1118-11-000 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SAM[TARY REPORT Owner � l -err Property Address City /State LLL y . Legal Description: ` I Lot 41 Block Subdivision/CSM # © Q Nt"! ' 4 5e�S 1 /a, Sec. �, T 3 O N -M W, Town of PIN # d SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer ,J"L ^-- Size ST/PC 1 -- Setback from: House a � Well 6-L P/L 0 Pump manufacturer Model Alarm location -- (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: r1 fi r, �t jlr AWidth Length Number of Trenches Setback from: House ,52 Well 9C P/L Vent to fresh air intake 7O ELEVATIONS Description of benchmark /1J Elevation 9/ A0 Description of alternate benchmark Elevation Building Sewer ST/HT Inlet ST Outlet J 7, PC Inlet PC Bottom '! Header/Manifold 94 Top of ST/PC Manhole Cover Distribution Lines Bottom of System (() Final Grade (�) �`�'� (�) 9 ( ) Date of installation L / — /y — / 3 9P er number - ? - ?M State plan number Plumber's signature License number �z -:� o - J 7 Date - - /'— Inspector 41kkA& Complete plot plan 1 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. P AN W I i I t I INDICATE NORTH ARROW 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 IX P er so nal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)), 338946 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: DERRICK CONSTRUCTION RICHMOND CST BM Elev.; Insp. BM Elev.: BM Description: Parcel Tax No.: 1 00.0 1 lat-0 tt) bt S 026- 1118 -11 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. i Septic Benchmark � hmark C0 •0 I CID.0 Dosing 417 46 10S. Aeration Bldg. Sewer * t .+1 Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet ,o df 7,�/ TANK TO P / L WELL BLDG. Air I to ntake ROAD �t-hrtlCE�- Air Septic Q ` oZ ` — NA om Dosing NA Header / Man. $• q(� �a �/' t6 SIG • 2- Aeration NA Dist. Pi e AOP 4e•Sb Holding Bot. System 47 /a. 3y S a 9 o PUMP/ SIPHON INFORMATION Final Grade �.b 8, / Manufact mand ( (o, 3G q�J, Mo I Number GPM TD Lift Friction em Ft L oss ea Forcemain Length Dia. Dist. To Well SOIL A PTION SYSTEM RENCH Width I Len th / N Of renches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN I 'S DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING rer• ` INFORMATION Type O Q� t O r OR UNIT CHAMBER ' N m ac , System: l.C�'v" ' U DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing "~ > s� SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only x Seeded/ Sodded xx Mulched Depth Over Depth Over xx Depth Of x Bed /Trench Center Bed /Trench Edges Topsoil E] Yes ❑ No C] Yes E] No COMMENTS (Include code discrepancies, persons present, etc.) P-M LOCATION: RICHMOND 1.30. 1411 174TH AVENUE – LOT 11 ©.24 � D � • i� a� 7 �d " �,;,Q Ge„�r o� (.'s Pet,•ev, , C va�� w�►e e�.. r4 -401 T - Plan revision required? E] Yes No Use other side for additional inforn{at - ion_ l Z 21 99 SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: T A f - vt 1 1 - t E f I 117111:r 4 „ . .. . KA 1- A A ITT T d w _. 1: .. �, , T - t r , , e E f _ _._. _. _ w _.... _ _ , Ad 1 -- 1 -4— kum r E t t 3 ,i n 3 3 4 $ e 9 i E e e t F 4 S I S k € y e .. f^ € s 3 e ➢ . r _.tee s �„ ,�. ..... .. . ....... w t 0 t V is con si n Safety and Buildings Division SANITARY PERMIT APPLICATION p 201 W. O BoW shington Avenue Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code p Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanit P ermit 4 1 4 r Personal information you provide may be used for secondary purposes ❑ Check irrevi §ion to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Pro Owner Na Propert Location in n 1 rte.. ��ia1/a, S T , N, R t E (o P rty O ner's Ma' ing Addr ss Lot Num Block Number w 1 N Crt , State Zip Code Phone Number Subdivision N� or CSM Numb r ` s - ©i ( W II. TYPE 0 BUILDING: (check one) ❑ State Owned ❑ ityy Ne rest Road ❑ Vlliage ` 't '\- Public 1 or 2 Famil Dwellin - No. of bedrooms own OF JAJQ 111. BUILDING SE: (If building type is public, check all that apply) Parcel Tax Number(s) n/ / / 9 A 1 ❑ Apartment/ Condo "¢ � -�19 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. New 2. Replacement 3 Replacement of 4_ ❑ ❑ 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) dv 4�z 11615 - Pressurized Distribution Pressurized Distribution ental Other 11 Seepage Bed 21 ❑ Mound 30 [] ❑ Specify Type 41 Holding Tank 12 fISeepage Trench 22 ❑ In- Ground Pressure ( 1 42 ❑ Pit Privy 13 ❑ Seepage Pit a * ( C 4 x 4:3T Vault Privy 14 [] System -In -Fill l pli 44 ji Y d fit Y! rl VI. ABSORPTION SYSTEM INFORMATI N: I If 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5_ Perc. Rate 6. System Elev. 17. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min-/inch) v tion 0 - 3 �_ ���r5 Feet r5 Feet Capacrt VII. TANK in allons Total # Of r Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New 1 E structed Tans Tanks Septic T r Meldir +T-ow c -�it�O ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 1 Ell ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Pri t Plumber's Sig ure Stamps) MP /MPRSW No.: Business Phone Number: t Irss ps 71 s f Plum is Address (Street, Ci to Zip Cod R(ag IX. WUNTY /DEPARTMENT USE ONLY E] Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing A t Si ature (No Stamps) A roved Surcharge Fee) pp ❑Owner Given Initial / Adverse Determination � �(�f X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: i SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, plumber I 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, fist 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. ---------------------------------------------------------------------------------------------- - - - - -- 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. f Y a luo ell" of — rre r_" 70L j r, 5.. T-t 15 �S L a cr, I _p a� c76 Al an S • tv' D jC r $m n A m 1 3 // Z Z . --� w� v rn g � 3 � w o QWQ • cr M $ Yv w r« CD Luj o i rn o rrnn 0 CL g _ a O w • ` � m Z n -- f � mw lJ N_ IE o Q �g w p R w O N _ -- b K X A ( m V lu: . . . . . . . . . . . . P011 a ll .11 r« cn r r o (D � � o �. a cs =37 (D 0 = cQ a m x �' CD =) m r n =NVac� c x N a ` � —� Em- t7 n. p '07 r !n n � R O n 3 � Z Z: cu 9 0 N O �° �' w an o- g.. N ? a CD ca cQ x �' 5� = 3 s � 3 m ► o z3 0 C� C& Q CD cn 0) X 4 � a? ° 0 COL o 0) 0 E co = is o W 3 Y :3 (D ca�3� �C m 3 �-- invert 11" --� a C 5 . (D oC Y j D 4� Wisconsin Department of Commerce SOIL AND SITE EVALUATION Pap 1 of 3 Division of Safety and Buildings in accord with Comm 83.05, Wis:,Adm. Code Environineutal By Design c o u nty Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must � t, include, but not limited to: vertical and horizontal reference point (BM), direction arty ` Coun St. Croix percent slope, scale or dimemsions, north arrow, and location and distance to neatest road. Panel I.D.# APPLICANT INFORMATION - Plea s�prin$ all information Personal information you provide may be used for sZ6*ty pixposes (Privacy Law, 8 ( h)). Y X . Date r Property Owner Looatwn ._ 3t Derrick Construction Inc. Govt. Lot NW 1/4 „ S'W ` S I T 30 N,R 18 W Property Owners Mailing Address ( ,� @ r , r ICLI tot_ # 13iodc # Su' b . N T or CSM# 1505 Hwy 65 - I 1 — Willow Valle City State Vp Pho i -City ❑ Village ®Town Nearest Road New Richmond W1 4 , V0N NG0FFtCE Richmond 140Th St. New Construction Use: Res ` lit i / u b�r figed�Oms 3 ❑Addition to existing building El Replacement [� Public or bribe Code Derived daily flow 450 gpd Recommended design loading rate .5 bed, gpolfP 6 trench, gpd/fP Absorption area required 900 bed, fP 750 trench, fr? Maximum design loadin rate .5 bed, gpdf 6 tr ench, gpd/ft� Recommended infiltration surface elevation(s) 95.50 61. -51 ft ft (as referred to site plan benchmar Additional design / site consideration t Parent aterial Loess Ove r Glacial OutWash Flood lain elevation, if licable NA ft e for System Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank able f o r system FI S ❑ U ® S ❑ u ® S ❑ u ® S ❑ u ❑ S ®U E I S M U SOIL DESCRIPTION REPORT Horizon Depth Dominant Color Mottles Texture Structure Co nsistence Boundary Roots GPDfif Boring# in. Munseli Qu. Sz. Cont Color Gr. Sz. Sh. Be ; Trench 1 1 0 -9 10yr3/2 - sil 2msbk mfr cw 2f .5 .6 2 9 -20 1 Oyr4 /4 - sil 2msbk mfr cw 1 f .5 .6 Ground 3 20 -32 7.5yr4/6 - Ifs 2msbk mfi cw - 5 6 elev 97 ft 4 3248 10yr5 /6 - fs Osg ml cw - .5 .6 Depth to 5 48 -80 7.5yr6/4 - s Osg ml - - .7 ! .8 limiting factor >80 Remarks: 2 1 0 -11 1Oyr3/2 - sil 2msbk mfr cw 2f .5 .6 2 11 -23 10yr4/4 - sil 2msbk mfr cw if .5 .6 Ground 3 2347 7.5yr4/6 - sl 2msbk mfi cva - 5 6 elev 9&63 ft 4 47 -88 7.5yr6/4 - s Osg m1 cw - 7 ; 8 Depth to limiting factor >88 Remarks: CST Name (Please Print) Signature: Telephone No. Thomas C. Nelson 715- 246 -2454 Address Environmental BY Design Date CST Number Ref # 1432 120th Street, New Richmond, W1 54017 1/20/99 227387 189 PROPERTY OWNER: Derrick Contraction hie. SOIL DESCRIPTION REPORT Page 2 of 3 PARCEL LD.# Environmental Bv Desian Horizon Depth Dominant Color Mottles Texture Structure onsistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed : Trench 3 1 0 -$ 10yr3/2 - sil 2msbk mfr cw 2f 5 6 2 8 -22 10yr4/4 - sil 2msbk mfr cw if .5 .6 Ground elev 3 22 -37 7.5yr4l6 - gsl 2msbk mfi cw - .5 6 98.26 ft 4 37 -55 7.5yr4/6 - cs Osg ml cw - ? 8 Depth 5 55 -90 7.5yr6/4 - s Osg ml - - 7 8 limiting factor >90 Remarks: 1 0 -10 1Oyr3/2 - sil 2msbk mfr cw 2f .5 .6 2 10 -20 1Oyr4/4 - sit 2msbk mfr cw if .5 .6 Ground elev 3 20 -33 7.5yr4/6 - gs Osg ml cw - .7 .8 97.98 ft 4 33 -80 7.5yr4/6 - gls Osg ml cw - 7 .8 Depth to 5 68 -86 7.5yr6/4 - s Osg ml - - 7 8 limiting factor >86 Remarks: 5 1 0 -9 10yr3l2 - sil 2msbk mfr cw 2f 5 6 2 9 -24 10yr4/4 - s1 2msbk mfr cw 1f .5 6 Ground elev 3 24 -39 7.5yr4/6 - s Osg ml cw - .7 i .8 98.51 ft 4 39 -90 5yr4/6 - s1 2msbk mvfr cw - 5 6 Depth limiting factor >90 Remarks: Ground elev Depth to limiting factor Remarks: • I I Q BY D E 51GN 1��'I � L N1� NT 1432 120`h STREET, NEW RICHMOND, WISCONSIN Last saved by Thomas Nelson 715 -246 -2454 Willow Valley 4 t , ' : rt. �ry PAGE 3 NW 'Y SW %, SECTION 1 T 30 N, R 19 W TowNsHIP Richmond COUNTY St. Croix Wisconsin D� %19 �v 2'/o P ope A �ti ro �a �0 T 1 Iy5. /4 SCALE 1" =40 Tom Nelson BM 1. NWLOT CORNER Top of iron pipe ELEV. 100' J 227387 BM 2. Ground surface next to lath w/ ribbon ELEV 97.80' ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer '- �'1� b W AA 1 Axz-,� P- Mailing Address © JOX A & 4-o rl Property Address 4` ��= taa �rv�Ei�c.1D NPl1 (Verification required from Planning Department for new construction q g P ) City /State Parcel Identification Number LEGAL DESCRIPTION Property Location gW '/4, '/4, Sec. , T I"- N -R �� W, Town of V4 t4-HKa W Subdivision ti -mow , Lot # Certified Survey a # Volume Page # Y P g Warranty Deed # 4)-- I ©� , Volume 7�O , Page # Spec house Kyes ❑ no Lot lines identifiable yes ❑ 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, journeymanpliumber, restricted plumber or a licensed pumper 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. 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 that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days the three a 'on date. /f] SI GNATURE OF APPL 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 .desc ' ed ove a of a warranty deed recorded in Register of Deeds Office. /8 S1 NATURE F APPLIC 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 W.P.M. COMPANY :i. MKNOMONtt PALLS. WISCONSIN • 00 . • 4? �oo� i UiJR�iE STATE OF WISCONSIN ST. CROIX COUNTY, CIRCUIT COURT PROBATE BRANCH SALE OF REAL ESTATE OF PERSONS UNDER LEGAL DISABILITY —DEED BY GUARDIAN WHEREAS, On application to the Circuit Court of S-F C ro ii X County, Wisconsin, to sell all right, title and interest of Leo T. Domke, also known as Leo Domke Spendthrift , in and to the real estate hereinafter described, such proceedings were 4�pceFf: �lAiFler = -e.- had that that the undersigned was duly authorized as Jeneral . guardian to proceed in said matter; 44rraert- u9pecia J- aT-j6enere4 and whereas, the undersigned, as such guardian, has done or caused to be done all things necessary and required to be done by law in such cases made and provided, before conveyance of such real estate may be made; and whereas, the undersigned, Lois Handrahan , farmp-rl y T ni G Aap1 Lnd , as such guardian, was duly authorized by order of Court herein dated on the 16th day of December 19 --RE, to execute, acknowledge and deliver to Derrick Construction, Inc. a deed of conveyance of all the right, title and interest of said Spendthrift in and If rtsertr'Minor rn "tntlmtRe[ent =✓'1 to said real estate: NOW, THEREFORE, I, the said —Lai s Haridrahan r fnrmpr1 v T.ai -, Aapl nncl , by authority of the Court above named and in my capacity as such guardian, in consideration of the premises and of ------------------ ,i X�� T hOtlsand (.$60, D(10 )_ 00 - ----------------- - - - - -- Dollars to me in hand paid by the said Derrick Construction, Inc. , do hereby grant and convey unto the said Derrick Construction, Inc. all the right, title and interest of the said Leo T. Domke, also known as Leo Domke SpF±ncl _hri f , in and to the following described real estate in St- ['.-ro4 X County, Wisconsin, to -wit: The Northwest Quarter of the Southwest Quarter (NWI of SA) of Section One (1), Township Thirty (30) North, of Range Eighteen (18) West. rtEC951us C ffia i ST. CROIX 00., WI& 0C 'd, for Record thta 2nd ;a, of � 19? 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