HomeMy WebLinkAbout026-1118-16-000 ST. CROIX COUNTY ZONING DEPART
AS BUILT SANITARY REPORT
Owner I ►� r`
Property Address IS a.S .11.! -
City /State 42&j, S
Legal Description:
Lot Block -- Subdivision/CSM #
' /a, Sec. Town of PIN # D Q (.
SEPTIC TANK — DOSE CHAMBER — HOLDING TANK INFORMATION:
Tank manufacturer U)U;w- Size ST/PC /a' Setback from: House c-V Well r 4 P/L
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: 16, Width
/vZ Length a Number of Trenches
Setback from: House �Z 5 Well ALA P/L 54 Vent to fresh air intake 75"
ELEVATIONS O
Description of benchmark Elevation i t�
Description of alternate benchmark Elevation
Building Sewer ST/HT Inlet 9? 73 _ ST Outlet 2 PC Inlet
PC Bottom Header/Manifold �� _ Top of ST/PC Manhole Cover
Distribution Lines
Bottom of System O C /51 O ( )
Final Grade O ! C/.- Z O ( )
Date of installation 40 /9 Permit numbe 7` d State plan number
Plumber's signature FA License number a- b537 Date X1
Inspector 6,V
Complete plot plan �
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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
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INDICATE NORTH ARROW
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Wisonsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
Safety and Buildings Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit IX
Personal information you provice may be used for secondary purposes [Privacy Law s.15.04 (1)(m)). �a1�7(nQ
Permit Holder's Name: ❑ cit pp Vil Town of: State Plan ID No.:
DERRICK CONSTRUCTION, INC. y FtIC [W)
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No
oa �tsE car
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic j Zsp Benchmark /00. 1a� 3
Dosing ��, 0. ? 0 11, 6:F
Aeration Bldg. Sewer -�
Holding 6)1++t- In 5;6Z �.1�
TANK SETBACK INFORMATION 0/ HT Outlet
TANKTO P/L WELL BLDG. Ventto ROAD ®t - et
Air Intake
Septic 0 9.1- / — NA Dt B o ttom
Dosing NA Header / Man. � r q p 0
i 1, t�
i Aeration NA Dist. Pipe " .e.
�.6z qr�2.
Holding Bot. System , S` •S
PUMP/ SIPHON INFORMATION Final Grade 3• tr 99
Manufacturer Demand C,,�,.� ,
Model Number GPM
TDH Lift Friction stem TDH Ft
oss
Forcemain L gth Dia. F D, — ,t — T, - W , 91
SOIL ABSORPTION SYSTEM
B D 'fF{ Width r Length r s PIT No. Of Pits Inside Dia. Liquid Depth
MEN I N z 2 t I DIMENSION
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O CHAMBER Model Number:
System: C� 5O� �{� OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold u Distribution Pipe(s) r �, x Hole Size x Hole Spacing Vent To Air Intake
r , - t
Length � Dia. ( Length � 2 Dia. � Spacing � � °
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 El Yes ❑ No ❑ Yes E3 No
/ COMMENTS: (Include code discrepancies, persons present, etc.)
�(JCATION: RICHMOND 1.30.18,NW,SW 1410 174TH AVENUE
(9 aill�a
® Cam) ,,,ett � t .&,
Plan revision required? ❑ Yes Q� No _ r I 2
Use other side for additional information. �" (3 `� ` %dw_
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No
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ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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SANITARY PERMIT APPLICATION Saf ety E w W ashington Buildings
Vis co ns in P.O. Box 7969
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 1/2 x 11 inches in size. _%
`
• See reverse side for instructions for completing this application State sanitary Permit
The information you provide may be used by other government agency programs ❑ Check if revision to previous ap Ication
(Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N
Property Owner Name Property Location
I ( ✓ l < <
N01/4 S u31 /4, S l T 3( N, R 1 jelE (orCl
Property Owner's Mailing Ad ress Lot Num er Bloc�k Ifumber
City, State Zip Code Phone Number Subdivisi Name or CS N mber •`
iV (� ! S)
II.
II. TYPE OF BUILDING: (check one) ❑ State Owned ! t Nearest.Road
Public 1 or 2 Family Dwelling - No_ of bedrooms r- To�ag of R; �� ST
III. BUILDING SE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo I cfl allo — loot _90-000
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 online B, if applicable)
A) 1. [ 4 New 2_ ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an
System ________System __TankOnly______________ Existing System ________ Ex)stin 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 [:]Holding Tank
12 Seepage Trench 22 ❑ In- Ground Pressure / 42 ❑ Pit Privy
13 ❑ Seepage Pit 1a l y 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2_ Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 1 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
(QCD 85Se , 7 Q 5 *y Feet 91. 1 Feet
�apacit
VII. TANK in gallons Exper.
Total # of Prefab. Site Fiber-
INFORMATION g Gallons Tanks Manufacturers Name concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks
eptic Tank / � D , ❑ ❑ El E] 1:1 Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's NameA ) P mber's Sig atur (No Sta ps) l�IMPRSW No.: Business Phone Number:
MILS .0 O 71-'S a Sl,�5
Plumber's Address (Street, City, State, Zi Code):
v�"'t� e,✓ e (7 t
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued I lssuin 3 i. . A gent Signature (No Stamps)
JE Approved ❑ Surcharge Fee) /
Owner Given Initial � �o . 11 /��,�,�
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
WOMBS (R.t 1Aq DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
1
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.
1 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 instal iation
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:
1. Property owner's name and mailing address. Provide the legal description and parcel tai: 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 exiAing 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 8 1/2x 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; Q 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 nu "mber 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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20. 42' ADora Ptpp 4* Cool Iron
To Flnal Grade, Vanl PIP•
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SOIL FILL
DISTRIBUTIOI.I PIPE '
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APPROVED SIVTUETIC COVER
2" O,F AGGREGA1F- ----- o a ' — PIATEMAj- OR 4" OF STAXW
"' - ;• OR MARSH HAS
p� � �
ELEV. OF +~5 EE a Z I: /Z AGGIitGATE � % /�.
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DISTRIP,IUTIOM PIPE TO BE AT LEAST _ I►UCHES BELOW ORIGIUkL GRADE
AUU AT LEAS't•zo iuc-HCS BUT 1.10 MORC THAIJ 42 IuCNES OELOW FILIAL GRADE
1'111XU1uM DaP•rH OF F-XcAV/+TIo0 rXOm OR16 NAL 6�AVR WILL BE _ IIJCHEs
7UKlMVM 05F T11 OF EACAVAT1CN rA 0w\ 0'�1644 WILL 0C _ IAICHE s
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SIGIJED:
LIG EN SC I.IUMBE R: s
DATE : C: 1 0-7 I ;
- - -- - - -- I I o _
.......... .
Wisoonsin'DepartmentofCommerce SOIL AND SITE EVALUATION Page 1 of 3
Division of Safety and Buildings in accord with Comrw 83.1 Wis. Adm.. Code •.
Environmental By Design
Attach complete site plan on paper not less than 8 x 11 inches in sizelaa`Fnust fl County
include, but not limited to: vertical and horizontal reference point (BM), 6etion and i s Lo i ; t St. Croix
percent slope, scale or dimensions, north arrow, and location and distafiae Xo nearest road. Parcel LD.#
r 7
APPLICANT INFORMATION - Please print all informo.06n. " iewed By Date
Personal information you provide may be used for secondary purposes (Privacy L", &' (1) G 99
Property Owner
Derrick Construction Inc. 1< A SW I/4 S r T 30 N,R 19 W
Property Owner's Mailing Address ubd. Name or CSM#
1505 14wy 65 1 b� ' Willow Valle
City State Zip Code PhoneNumber 0 City ❑ Village ®Town Nearest Road
New Richmond Wl 54017 Richmond I 140Th St.
M New Construction Use: ® Residential / Number of bedrooms 3 Addition to existing building
U Replacement LJ Public or commercial describe
Code Derived daily flow 450 gpd Recommended design loading rate 7 bed, gpolfls S trench, gpd/fl?
Absorption area required 643 bed, fP 563 trench, W Maximum design loading rate .7 bed, gpd/W .8 tr ench, gpdff
Recommended infiftration surface elevation(s) 95.80 ft (as referred to site plan benchmar
Additional design / site consideration 2, 3, 5
Parent material Loess Over Glacial OutWash Flood pVin eievation, if Iic" na ft
S= Suitable for system Conventional Mound In -Ground Pressure AT -Grade System in F11 Holding Tank
U= Unsuitable for system Fg S El U Z S O U Z S u U C1 S 0 U I EI O U I ❑ S 0 U
SOIL DESC REPORT
Depth Dominant Color I Mottles I Structure I ( I GPD/fF
Borin Horizon Texture Consisten Boundary Roots
9# in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ? Trench
1 1 0 -14 10yr3/2 - sir 2msbk mfr cw 2f 5 6
2 14 -29 10yr4 /4 - sil 2msbk mfr cw If .5 .6
Ground 3 29 -39 7.5yr5/6 - s Osg ml cw - .7 .8
elev
99.17 ft 4 39 -54 7.5yr5/6 - Ifs Osg mfi cw - 5 ; 6
Depth to 5 54 -98 7.5yr5/6 - s Osg ml - - 7 8
limiting
factor
>98
Remarks:
2 1 0 -11 10w3/2 - sil 2msbk mfr cw 2f .5 .6
2 11 -24 10yr4/4 - sir 2msbk mfr cw if .5 .6
Ground 3 24 -34 7.5yr5 /6 - Ifs Osg mfi cvv - .5 .6
elev
99.30 ft 4 34 -96 7.5yr5/6 - s Osg m1 - - .7 .8
Depth to
limiting
factor
>96
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, WI 54017 1/20/99 227387 189
PROPEL BiY OWNER: DercickConsmictionInc. S OIL DESCRIPTION REPORT ,es Page 2 of 3
PARC I.D.# Environmental By Desi
Depth Dominant Color Mottl es Structure GPDIfI�
Horizon in Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. nsistence Boundary Roots
Bed Trench
3 1 0 -12 10yr3/2 - sil 2msbk mfr cw 2f .5 .6
2 12 -20 1Oyr4/4 - sil 2msbk mfr cw if .5 .6
Ground
elev 3 20-45 7.5yr5/6 - Ifs Osg mfi cw - .5 .6
99.68 fL, 4 45 -96 7.5yr5/6 - is 2msbk mvfr - - .7 .8
Depth to
limiting
factor
>96
Remarks:
1 0 -12 10yr3/2 - A I 2msbk mfr cw I 2f .5 .6
2 12 -23 10yr4/4 - sil 2msbk mfr cw if 5 6
Ground
elev 3 23 -34 7.5yr5/6 - ifs Osg mfi cw - 5 6
100.1 ft 4 34 -60 7.5yr5 /6 _ s Osg ml cw - .7 .8
Depth to 5 60 -90 7.5yr4/6 - sil 2msbk mfr - - .5 .6
limiting
factor
>90
Remarks:
5 1 0 -11 10yr3 /2 - sil 2msbk mfr cw 2f .5 .6
2 11 -18 1Oyr4,4 - A 2msbk mfr cw 1f .5 .6
Ground
elev 3 18 -41 7.5yr5/6 - sl 2msbk MA cw - .5 .6
100.28ft 4 41 -90 7.5yr5/6 - s Osg ml - - 7 8
Dept to
limiting
factor
>
I I I I I I I I I
Remarks:
Ground
elev
Depth to
limiting
factor
Remarks:
ENVIgONMENTRI BY DE51GN
1432120 STREET, NEW RICHMOND, WISCONSIN
Last saved by Thomas Nelson
71S-246-24S4
Willow Valley too* PAGE 3
NW '/ SW V/, SECTION 1 T 30 N, R 19 W
TOWNSHIP Richmond COUNTY St. Croix Wisconsin
.1 1 4 7. 55
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- 7 6 acres
SCALE 1" =40 — Fa 0 r (Z o w Tom Nelson
BM 1. SE LOT CORNER Top Of iron pipe ELEV. 100 227387
BM 2 Gound surface next to lath with ribbon ELEV 98.92
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND .
OWNERSHIP CERTIFICATION FORM
Owner/Buyer %4-&v A i c t-!
Mailing Address �� ��k �, — w PtL-4A M o Vy6 4 wx S 4 O 1 "i
Property Address 1 410 `7 q
(Verification required from Planning Department for new construction)
City/State Parcel Identification Number �Ze - t c3c t - 90 - 0 'z z
LEGAL DESCRIPTION
Property Location - t - 1 w '/4, 5vy '/,, Sec. ( , T 3o N -R % W, Town of
Subdivision �t`��`N VAI � y Lot # LIG
Certified Survey Map # , Volume . Page #
Warranty Deed # `+'-1 6 a . Volume b S . Page #
Spec house Kyes' ❑ no Lot lines identifiable O F-1 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, journeymanplgmber, 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
days o e three ar ex irati te.
Z - j Fes y'
SICNATURE OF APPLIC DATE
OWNER CERTIFICATION
I
(we) certify 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 desc 2dd abov virtue of a warranty deed recorded in Register of Deeds Office.
V Y/ 2 /
SIGNATURE OF 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. .0. COMPANY
MSNOMON!{ PALLS. WISCONSIN
'
�.: 420} Boor P OE
STATE OF WISCONSIN ST. CROIk 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 St rr ni Y County, Wisconsin,
to sell all right, title and interest of Leo T. Domke, also known as Leo Domke
I
Spendthrift in and to the real estate hereinafter described, such proceedings were
44aceFt= 'A4+fler= '' =er- kleorfl�e!4:w> = -1 -
had that the undersigned was duly authorized as general guardian to proceed in said matter;
a-I rrae rt j' apt eia+' =er•+ 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 , fn_rmerl y Lois Aspl Lnd , as such guardian, was
duly authorized by order of Court herein dated on the 16th day of December
19 _16 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
( I rrser t . M in ar n ttr tntrontperen cam' 1
to said real estate:
NOW, THEREFORE, I, the said Lai S uanrdrahan, fnrmerl T.ni G Ac;pl and , by authority of the
Court above named and in my capacity as such guardian, in consideration of the premises and of ------------------
Sixty Thousand M60,000 ------------------ - - - - -- 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
Spendthrif , in and to the following described real estate in __ St _ Croj .X
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(Irmmr vrinS(- Tncomp
County, Wisconsin, to -wit:
The Northwest Quarter of the Southwest Quarter (NA of SA) of
Section One (1), Township Thirty (30) North, of Range Eighteen
(18) west.
ao r�ISI CTME
ST. CROIX 00., WAS.
P�
' 'm'd. for Record** 2nd
la of Jan. A. M 19 7
1 7�
a
File No.
No. 75P -SALE OF REAL ESTATE OF PERSONS UNDER L FrAI nISARII ITV- nFFn RV rHAPnI c
IDDP �67
.::. BOG A4� m <' ;
0
WITNESS the hand and seal of said Lois Handrahan, formerly Loi / Asp +Iuardian aforesaid, this
22nd day of December , 19 86
In Presence of
(SEAL)
Lois Handrahan, formerly Lois Asplu d
General Guardian of
(Irrsert-'3peeie0--or G,er,r i-
Leo T. Domke, also known as Leo
Domke, Spendthrift
Hnser� �M4iner == •er +necMtpeten� '=F
STATE OF WISCONSIN,
ss.
St. Croix County.
Personally came before me this 22nd day of December , A D 19 86 ,
the above named Lol: Handrahan, formerl t7 •Asplund uardian,
to me known to be the person who executed the foregoing instrument and ac nowledg7tha G he execL"@rrf2.by
virtue of the authority aforesaid. �. {.�.,. ,��� •.,;
Tanya . Glaser•
�~
Notary Public, St. Croix t Cam► t
My Commission Expires 4--�5
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