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HomeMy WebLinkAbout026-1118-14-000 ST. CROIX COUNTY ZONING DEPARTMEN AS BUILT SANITARY REPORT � �� Y =° ,;� owner 9!�g ; - - -- Property Address f City /State /l� Q L) ,� • ��r-_ 0: /1j Legal Description: ) `` Lot Block Subdivision/CSM # yi ._, Sec., T N -R / W, Town of IN # SEPTIC TANK — DOSE CHAMBER — HOLDING TANK INFORMATION: 3 Tank manufacturer Size ST/M a� Setback from: House �> Well�/I Pump manufacturer Model ?j Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake `dater Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: &ac Width /°Z Length 7 a Number of Trenches Well Vent to fresh air intake /,0 a Setback from: House _� L ELEVATI Description ,of benchmark 510 Elevation /!h7 Description of alternate benchmark Elevation. Building Sewer g / ST/HT Inlet /a o 6 7 ST Outlet 99e s PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover Distribution Lines (} q 9 () ( ) Bottom of System Final Grade Date of installation 11, 9 $er u ber" 3 8 State plan number -44 ��DS3 -7 Plumber's signature License number Date -00 Inspector R Od Complete plot plan �+ ' I 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 )y, 1 �I y INDICATE NORTH ARROW so, )� Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No... CIR A O IX Personal information you provice may be used for secondary purposes [Privacy Law s.15.04 (1)(m)]. 338842 Per rpjt Lioltfp� plam� ONSTRUCTION ❑ Cit R Y VHacme Town of: State Plan ID No.: CST BBM�EEllevv.h !C Insp. BM Elev.: BM Description: l( I Parcel Tax No.: r L TANK INFORMATION ELEVATION DATA YPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic G2C5D Benchmark �, jjy� la g,v ? pf') Dosing 4IA-0M r - �.Zf C�S'•� Aeration Bldg. Sewer Holding St Inlet TANK SETBACK INFORMATION eki 4 Outlet q. to TANK TO P/ L WELL BLDG. A Intake ROAD Dt Inlet Sep is ? 'Z ^ 3'& NA Dt Bottom Dosing NA Header / Man. a q.Sq a ! g. Aeration NA Dist. Pipe .(p 9`�•/� Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer nd S ( Z Model N er GPM TDH ift Friction em TDH Ft e ad Forcemain Length Dia. Dist. To well SOIL ABSORPTION SYSTEM TRENCH width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS I� �a DIMENSION SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHI Manufacturer: SETBACK CHAMB INFORMATION Typeo Model Number ` i p r � r �---- OR UNIT Syste �trei DISTRIBUTION SYSTEM Header / Man ifold Distribution Pipe(s) � x Hole Size x Hole Spacing Vent To Air Intake � Length t! Dia. Length Dia. Spacing A; Z Z4 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 I COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: RICHMOND 1.30.18,NW,SW 1420 174TH AVE— WILLOW VALLEY LOT 14 0 0 P. 6� u' (viol Plan revision required? ❑ Yes !!{ No R , 9 , / 3 Use other side for additional information. / SBD -6710 (R.3/97) Date Inspector's Si ature ert. i ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: e . e. i s , . � sm e f z i ..{...nm_ s f i i A 3 % i 3 i E 3 � m m.0 w '. ._.._._. e..._ .�.. .ems ......... .... t ......._ .�F_.. .. ....,........'. .... .. �... ,.� _,.. .. .�.. _g. 7 m a 3 s i i 4 E I i t 1 � � ae F f a � p.. ..e ....... . ».,.....: eae �.«._.., _ �m m.. ._.�.... �e.... ». �.. .r...= .. _ .» ,a .... e ., .... ,_.. Fe..F -e. ..., f t g 4 . ....... v ....» ... .. Pam >, em f £ 4 € Y ......... ...._ e y . ..... . �...... e ..... m�..., t . ..... .. «. ..,. _. .. , m... ,�. .j.w.e. ..... �... a sm E i a e S € t SANITARY PERMIT APPLICATION Safety and hingt n Avenue n 201 W. Washin If iscons i n I P O Box 7302 Department of Commerce I n accord with ILHR 83.05, Wis. Adm. Code 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. • See reverse side for instructions for completing this application State Sanitary Per Num �-- TV Personal information you provide may be used for secondary purposes []Check if revisiorlYo previous ap hcacion IPrivacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N Property Owrwr Name y` Propert Location ,�� l sd n �pc.`'rO Pn /1/Lj /4 l j 1 /4, S � T :33,,N, R � E (ot J Pr erty Owner's MaiUnq Address Lot Number Block Nu b r CAtr, State ` Zip Code Phone Number Subdivision Name r CSM Number' r Iv�Q �GL�MO S O 1 ( '7 , - � if II. TYPE F BUILDING: (check one) ❑ State Owned ❑ Cit Near st Road ❑ Village th Public 1 or 2 Family Dwelling - No. of bedrooms Q aownOF 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo �d ` t oo — '00 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 Onl�r_____-- ___ -___ Exist 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 E] Mound 30 E] Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit X �a 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: $6 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade (DO© Required (sq. ft.) Proposed (s ft.) (Gals/day /sq. ft_) (Min. /inch) b Elevation S , �'� ` �� Feet IJK Feet Cap acity VII TANK in Ca gallo s Total # of Prefab. Site Fi b er- ss Plastic APpr. INFORMATION Gallons Tanks Manufacturers Name Concrete con Steel New Existin structed Tan Tanks eptic Tan I I .QS FS ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ I ❑ I ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for instakation of the onsite sewage system shown on the attached plans. P mber's Name: (P t) PI be 's Sig ture: Stamps) MP /NIPRSW No.: Business Phone Number: 91 S is a 5 1� � Plumb e 's Adds (Street, Cit , M S�tP,Zip de): 1 s V U IX. COUNTY/ DEPARTMENT USE ON ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuin e t Si n ure (No Stamps) App roved ] Surcharge fee) pp ❑ Owner Given Initial 90 Sf� r Cl Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (11.11/97) 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 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. ---------------------------------------------------------------------------------------------------- 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. iy sue;� S 17 Lo rZ) K � t y W, W o Li uoJ -Q / 1U•e {�`, �hw.o , (e> 5 c(o/ 7 L�w\OAl a - 05- 7 nChrfic, V �, 1 1 41. 8 , C� Y� 0 7 h r� Q i � i CroSS S `c�IOn o� 1�, ti7 S•fs�c� • DO rr G P o 'q I y sv fresh Alt Intel► Ana OD►sfrollon Pipe ;1v� =�5�� �.� q' s i 30 A; f2��►c) .,� Ntnfmwn 12'AOo.► • Fln el .Gte i 20. 4V Apo.e Plpp 4* Cost Iron To flnel area• Vent PIP$ ► WIN tiff Of SfnlMlk Ce.fulny ' Lin 2' Apynpote .. Of•t PIP• DI&IM.119n See e 1i. AOyteOate o PetloteUe PINS ttelor OeA441k PIP• o ' 'Ce.ptlnj Te.enlnellne At + Oollene Of Sjetem P���n)Ep �I�'- c�rnc�< � • V"j "'n SOIL FILL OISTRIBUTIOM PIPE-' APPROVED Sy1,1�'1ILTIC COVCtt 11 Olc 9" OF s-rRAW 2" of AGGRE Al I- -- � :' .— OK /AAKSN lAA'j 1.''0F%t t /� AGGItCGATE. E of FEY r7 OIS,T1115UTIOM PIPE TO INC AT LEAs'? INCHES BELOW ORIGIMAL G RAOC AQU AT LEAST LO IUCHCS BUT 1.10 MORC THAIJ 42 IUCIICS CCLOW FINAL GRADE M MMUM DaR.tH OF 1�XEAVATIoIJ rXOM ORIWAL 6AI\Da WILL BE �_ IuCHEs 111t1It1 MPni o f E r GIkI�IWAL GR49f- WILL BC INCHES f . ,t sIGUED: LIC CI.! SC j1uM5C It: OATC:_ _.. _.__.. 110 Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3 Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code Environnxenta113y Design Attach complete site plan on paper not less than 8'h x 11 inches in size. Plan must „ County include, but not limited to: vertical and horizontal reference point (BM), direction and" nd St. Croix percent slope, scale or dimensions, north arrow, and location and distance to nearegt road. Pamel l.D.# APPLICANT INFORMATION - Please print all information ' By �' Personal information you Provide may be used for secondary Purposes (Privacy Law, s, (1) (m)) Re Date 11 Property Owner . Property L•ocatioh Derrick Construction Inc. Go*t. Lot r , ; 1/4 W /4 S l T 30 N,R IS W Property Owners Mailing Address i of if Subd..N or CSM# 1505 Hwy 65 " "lA . ` ' g '` Willow Vall City State Zip Code PhoneNumber City ❑.ViUa [kbwn Nearest Road New Richmond W1 54017 idhilioh& -" ` 140Th St. ❑ New Construction Use: N Residential / Number of bedrooms 3 ❑Addition to existing building ❑ Replacement ❑ Public or commercial describe Code Derived daily flow 450 gpd Recommended design loading rate 7 bed, gpdW •8 trench, gpd/fl! Absorption area required 643 bed, ft' 563 trench, fl? Maximum design loading rate .7 bed, gpd/f 2 .8 tr ench, gpd/ft Recommended infiltration surface elevation(s) 98.20 ft (as referred to site plan benchmar Additional design / site consideration 1 ,2,3, 6 s it e to b g r a ded so as to meet code requirements for maximum depths Parent material Loess Over Glacial OutWash Flood lain elevation, if applicable NA ft S= Suitable for system Conventional Mound In Ground Pressure AT - Grade System in Fill Holding Tank U= Unsuitable for system M S❑ U M S❑ u El S U E ❑ U EIS ®U ❑ S® U L SOIL DESCRIPTION REPORT Horizon Depth Dominant Color Mottles Texture Structure Consistent Boundary Roots GPD/fF Boring# in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ; Trench 1 1 0 -21 10yr3/3 - sil 2msbk mfr as 2f .5 i .6 2 21 -58 10yr4/6 - sit 2msbk mfr as if .5 .6 Ground 3 58 -64 5yr5/8 - is 2msbk mvfr cw elev 103.21 ft 4 64 -110 7.5yr5/6 - s Ogg ml - - .7 .8 tom• Ct— Depth to limiting factor >110 Remarks: 2 1 0 -12 10yr3/3 - sil 2msbk mfr as 2f .5 .6 2 12 -30 10yr4/6 - sil 2msbk mfr as if .5 .6 Ground 3 30 -53 7.5yr5/6 - ifs 0m mfi cw - .4 .5 elev 103.69 ft 4 53 -110 7.5yr5/6 - s Osg ml - - .7 .8 Depth to limiting factor >110 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 ENVIgONMENTHL BY DE51GN 1432120th STREET, NEW RICHMOND, WISCONSIN Last saved by Thomas Nelson 715- 246 -2454 0 1 1 ,211, W!Uo w VaU PAGE 3 , h NW % SW '4, SECTION 1 T 30 N, R 19 W TOWNSHIP Richmond COuNTY St. Croix Wisconsin n� ti 0 ' Q Q.. 13 e�1 ,t o v w 3 or S q� r SCALE 1" =40 Tom Nelson BM I. SE LOT CORNER Top of iron pipe ELEV. 100' 227387 C� BM 2. Ground surface next to lath 104.12 r ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer OZ 1C--V � t� t�N �►JC� 111LM . �"T1 -►�-t �`c.- Mailing Address R® �a X �c1nr �tc..�w�o t-0, �1 4---a % - I Property Address (Verification required from Planning Department for new construction), City /State V PtL-A AA-< N-O Parcel Identification Number I - 910 - 1 0 a z LEGAL DESCRIPTION Property Location t %a, 'Sw %., Sec. , T *)0 N -R W, Town of Pt c4f%4 4 0 Subdivision ���-��' Yp- L - �-C'y Lot # 9' . Certified Survey Map # . Volume , Page # Warranty Deed # �' a , Volume �s , Page # b Spec house Oyes ❑ no Lot lines identifiable Cylvs ❑ no SYSTEM MAINTENANCE Improper use and maintenance of our septic y p 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, journeymanpl*ber, 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 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 day f the three year xp' ti date r IGNATURE 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 p erty escribed aDqve y virtue 9f 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 W.P.S. COMPANY M<NOMONit FALLS. WISCONSIN 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 qt - rrni 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 11 acer�= 'AA+siet =� er- had that that the undersigned was duly authorized as genera 1 guardian to proceed in said matter; fl me rt i`�peeia+ f-orj 6trrere+�'} 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, fnrmprl y T.oi s Aspl Lnd , as such guardian, was duly authorized by order of Court herein dated on the 16th day of December , 19 -A-6, 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 1 V rfsertr'M tnar _° vr✓'tntrompeten t =�' 1 to said real estate: NOW, THEREFORE, I, the said Lni s Handraban, farrmerl37 T.ni s Aspl and , by authority of the Court above named and in my capacity as such guardian, in consideration of the premises and of ------------------ Sixty hniiaand ($60, 00-00) ------------------ - - - - -- 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. 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