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HomeMy WebLinkAbout026-1014-20-000 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner Property Addre ' s City/State / /� Legal Description: ` oF Lot � Block Subdivision/CSM # 3 1 1 /a ski ' /4, Sec., ' -RAW, Town of PIN SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer hL Size ST/PC Setback from: House Well PAL, 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: Zy Width 1-,; Length �A- -V Number of Trenches Setback from: House Well P/L Vent to fresh air intake ELEVATIONS Description of benchmark Elevation -— Description of alternate benchmark Elevation Building Sewer ` ' - ST/HT Inlet 9l ST Outlet 2/, l PC Inlet PC Bottom Header/Manifold 2 Top of ST/PC Manhole Cover 2Y,17 Distribution Lines () -z () ( ) Bottom of System Final Grade Date of installation I P number �3�. 2 J State plan number Plumber's signature rmit License number �/S Date Inspector Complete plot plan Or -fi 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 ,� <,J,e,✓,� well 4 9 Z INDICATE NORTH ARROW ` Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM co ty: Safety and Buildings Divisiont. Croix INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanjjyjjritNo.: Personal information you provice maybe used for secondary purposes [Privacy Law, s.15.04 (1)( m . s Permit Holder's Name: [I City Village Town of: State Plan ID No.: M & G Inc, ichmon CST BM Elev.: T lnsp.BMElev.: BM Description: Par el Tax N 66- 10 ?4 -20 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS - ELEV. Septic Benchmark , 0' Do ' A BM lt. S, o . Z 1 Aer Bldg. Sewer l Q} Holding / Ht Inlet Z ` 1G TANK SETBACK INFORMATION 1 Ht Outlet Hof %,loo TANK TO P/ L WELL BLDG. Ventto ROAD Air Intake Septic > so � -� : f alb r NA Dosing NA Header / Man. Aeration NA Dist. Pipe i Ct. Tcf 35 Hol Bot. System to, PUMP / SIPHON INFORMATION Final Grade Manufacturer mand St cover Mode GPM TDH L' Lricti S stem TDH Ft rcemain Length Dia. To Well SOIL ABSORPTION SYSTEM BED AW4w 41 Width Length r Nn f PIT No. Of Pits Inside th DrME NSION5 __ Z- 102- DIMENSION SYSTEM TO P / L B DG WELL LAKE/STREAM LEACH Manufacturer: SETBACK CHA ER INFORMATION Type O , s 3' )g D ' O NIT Moe er: System: i DISTRIBUTION SYSTEM Header / Mani old • / a Distribution Pipe(s) x Hole Size x Hole Spacing I Vent To Air Intake Length-fig. Dia. T Length M Dia. Spacing i 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 COMMENT (( Intl de cod �1i crep n s s t tc. inspection : 8 op spec on . Location: 11 9 173r�, Ne)y >icl �r4 T�30N R1 8W) - 4.30.18. f' 1.) Alt BM Description 2.) Bldg sewer length = n a1 r _ - amount of cover = > 1$ " c o��e r , Cs�W �.10 S n 6a iko. L& a t p4 ec +-kt I c� `C�.•►� 5 a.�,d ) hn- ura..� tn�` .,,l,eM.� ,,l•c�. otle/ S� �-�' W�++�� hs'�er2 -�-� Plan revision required? ❑ Yes X No Z Use other side for additional information. 1 0-3 1 ou of SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: I I Safety and Buildings Division Vi scons i n SANITARY PERMIT TON 2 01 W. Washington Avenue In accord with ILHR 83 �. ' P O Box 7302 Department of Commerce' y ` Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) forth y m, Q','R�r(11tot less bounty than 8.t /2 x 11 inches in size. • See reverse side for instructions for completing this a ISW tion '3tate Sanitary Permit Number Personal information you provide may be used for secondary purposes ST CAOt)( i" , Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. �n� COUNTY FF1� / 1` tate Plan I.D. Number L APPLICATION INFORMATION -PLEASE PRINT A A►II "\ " Property Owner Name o on 1 4 1 1/4, S T , N, R E (or '114 1/9 Property Owner's Mailing Add re Lot um er Block Number city, ate Zip Code 711 ne Number S divi ion Name or CS r 190 ) 11. TYPE OF BUILDING: (check one) ❑ State Owned y o iitr Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms m Town o III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo .", — 1614 — 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 ® 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) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 ® Seepage Bed 21 [:]Mound 30 ❑ Specify Type 41 []Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground ssure . 42 ❑ Pit Privy 13 ❑ Seepage Pit I , 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSQEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (MinA h) Elevation 7 r S' Feet Feet aclt VII. TANK in Ca g llons Total # of r Prefab. Site Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete . Con- Steel glass App. New Existing structed Tanks Tanks Septic Tank or Holding Tank tiz; I ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ 1 ❑ ❑ ❑ Vill. RESPONSIBILITY STATEMENT I, the ndersigned, assume responsibility for irr allation of the onsite sewage system shown on the attached pla Plum _ ame: rint) Plumb r' nat : (No ps MP /MPRSW No.: Business Phone Number: Plumber's ddress (Street, ity, State 'p Code): p IX. COUNTY /DEPARTMENT USE ONLY Disapproved Sani ryPermit Fee (IncludesGroundwater ate SSUe Issuin Agent Signat re (No Stamps) � pproved E] Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: $BD 6398 (8.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber e 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 Admhinistrative 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: 1. 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. it Aye "�°ScJ ?;G' 3 - o a lob' 7© �cr195k4 ideal .3 e 8� ys'� Wisconsin Department of commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of BuredhQf Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 81/2 x 11 inc fdi.. baust Coun ty 1 , include, but not limited to: vertical and horizontal reference po and percent slope, scale or dimensions, north arrow, and location 'I I.D. # APPLICANT INFORMATION - Please print all in - Rlevie�ved y Date Personal information you provide may be used for seconda ury fwd ( T ( TAD)( Property Owner , P ' lion J v /l . �/4��1/4,S T �D ,N,R / E (o V 4 Property Owners Mailing Address 'Li?t ubd. Name gr CSM# 1/ �- City to Tip Code Phone Number ❑ City ❑ Village Town Nearest Road N R ` rna i 5 /7 (71s G New Construction Use: j6esidential / Number of bedrooms Addition to existing building ❑ Replacement / El Public or commercial - Describe: Code derived daily flow �!1� gpd Recommended design loading rate bed, gpdffF ' � trench, gpd/fl Absorption area required bed, ft ©© nch, It' Maximum design loading rate %7 bed, gpd/fi _ trench, gpd/ft Recommended infiltration surface elevation(s) Al 2 1 F -- ft ft (as referred to site plan benchmark) Additional desigrt/site considerations Parent material I Flood plain elevation, if applicabl //, ft S = Suitable for system Conventional Mound In- Ground Pressure I AT -Grade System in Fill Holding T k U = Unsuitable for system S❑ u s❑ u 9S El u S❑ u ❑ S ,,emu [- . I u SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 13 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 0 ? 0, f f-- _3 Ground , j — . ✓ �/�'! `COI" < <j (7 e le v. ft. Depth to limiting ; factor in. Remarks: Boring # fell 0_7� Ground 9 ft. Depth to limiting factor hO in. Remarks: CST Name (Please Print) nature Telephone No. 1S `�� 1 C >� Address , Date CST Number �' of ��� �v> v �oS -� - 6 CFO c %'/Lip/ r n i � f�� SOIL DESCRIPTION REPORT Pag of PROPERTY OWNER L _ 9 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 Ground 3 /— ..� /4 Depth to limiting factor 17.0 in. Remarks: Boring # G� Ground / ft. Depth to limiting f ll �r in. ` r 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 # (9 116 :.: 3 l Ground v. Depth to limiting factor !— J . Remarks: Boring # 13 Ground elev. ft. , Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) a Soil Test Plot Plan Project Name John Kovaleski 5 aun Bird Address 1701 112th St. ��o New Richmond Wi 54017 ZSTM #226900 Lot 3 Subdivision --- -- -- Date 3/3/99 SE 1 /4SW 1/454 T 30 N /R18 W Township Richmond F1 Boring ()Well PL Property Line County S T. CROIX BM or VRP Assume Elevation 100 ft. Top of Wood Fence Post with Orange Ribbon System Elevation 93.5/9 * H R p Same as Al Benchmark Alt. BM Top of Survey Pipe @ 96.6 * Alt. 224' Property Line 5' B -4 30' B -2 5 ' S' ep A Pri A'�, B -3 100' o 100' 0' 6% Sloe CD c� Ji v 30' B -5 15' 15' Pro 4 Bedroom House i 173rd St. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND O W NERS141 P CERTIFICATION FORM OwnerBuyer Mailing Address Avj',P rTL IcY T R- 1 _� � o �,0 Property Address la e ))2,j 7 (Verification required from lanning Department for new construction) "' City /State 11 P, Parcel Identification Number dQ6, - 101V -, LEGAL DESCRIPTION + To wn of i Property Location � 1 A, �In, / <, Sec. f , T 3� N- ��'_W, T• t m&hr Subdivision , Lot # -� Certified Survey Map # f Volume 1 -3 Page # Warranty Deed # Volume , Page # Spec house -0 yes ❑ 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 master plumber, joumeyman plumber, 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. Uwc, 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 Wiscnnsin. 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 expiration date. tt, / 3g /9°t SIG ATURE F 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 property de cribed above, by virtue of a warranty deed recorded in Register of Deeds Office. 10 /ag / jR SIG AT 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 11/05/99 FRI 08;27 FAX 715 388 4887 REGISTER OF DEEDS I�j002 Vol, 14 68 FAGS 2Ut STATE BAR OF vViSCON FORM 1 • IM 61 Wf4LSH ` I NVARRANTY DEEl�1 REGISTER OF DEEDS ST. CROIX CO.,, WI Do�umeet! Nnmtiar Ri Cl:IirFD FOR RECM This Deed, Wrack between Jo C. 1Wvaleski and It -1589 5:30 AM Kim D. Kovaleski, husband and wrifa WARRANTY DEED EXERPT iI Grantor, CERT COPY FEE: and M 4 Q XN C. , a Msaonslt: _Co rporation COP TRANSF FEE: 90.00 RECDOIMG FEE: 10.00 ` — PPAS: l _ Grantee. Grantor, for a valuable oond& ration, conveys to Grantee the fallowing &um - bed real estate in at . Croix County, State of Wisconsin (the "Property"). Part of BE 1/6 of SIN 1/4 of Bection 4, Township 30 north, Range 19 'West, at. Croix County, Wizoonsin' RmwdivgArca described an follows: Loot 3 of Certified svxvey Nwe and Remm AAdrow — raap filed May 21, 1999 in Vol. 13, page 3646, Doc. .Q2X� no. 603574. Pd I88 026 - 1014 -20 Wmal Identification Namba (PM This 19 not hwmtead property. (is) (is not) Together with all appurtenant r410, title and interests. Grantor warrants that the title to the Property is good, indefeasible in .fee simple and flee and clear of encumbrances except xubloct to xecoxded oaawam sts and restrciti.ons of record I Datedthis 29 dw of October 1999 '� JC);in C. Irova.Y,Crki �' tiC3m D. 1Cova14ski t i AUTHENTICATION ACKNOWLEDGMENT STATB OF WISCONSIN } Signatures) _ ) ss. s& Croirc _ County. ) Personally came before me this 2 day of and mticated this _day of 99tobqpr , 1999 the above named Job C' tiaysleskf _send _ _ TITLE: MEMBM STATE BAIL Cr WISCONSIN to use known to be tlw person _ ss who executed (If root,_ the foregoing instru ien t and ackrwwledged the same. authorized by § 706.06. Wis. Stats.) �-r- TMS INSMUMENT WAS DFAp'rBD BY GjTALD F. HARVIEUX ,., , %- 1 4viaUA 10 Q ;a1d Hasvigux 0111 �1�C 10f V1�r $ l t wisCOgS1n NOW Riah:orrnd, Wi 11My Commission is per77it�. ( if wt am expiration date (Signatures may be authenticated or acknowledged. Botb are d �7 A Y / - ) not necessary.) games of persans sipin3 in sny c9acky must be typed or prloted below their. sivaUm STAT$ BAR OF WiSMINSIN WARRANTY DEWED FORM Na i -]" r+roaarea wdh apwm,*� b,� Vargsoklm 9eo2s FIRee:n k1A. itnaq elkwmTownl,ip 1lfchipn 4atAS. (000) sas.eeo6 i _ • Oct 19 89 11:59a Gerald Harvieux 715- 246 -6070 P.2 Q00 c. CERTIFIED SURVEY MAP Located in port of the Southwest Quarter of the Southwest Uuortcr of Section 4, Township .JU North, Rort9e 113 West, Town of Richmond, St. Croix Co+inty, WitiC011a for and of the r of: Prepared rc NORTH 114 UWeN£R --.- 4A P 4 �� SEC, d - so•• 18 OWNER, 95.692 A 50. FT. % 2.20 ACRES (I Ph' NAIL.) i \� John C. and Kim D. Kovaleskl I{ ` AREA EX 0 I'l R 1. 1701 112th Street 1 1 ` i 15 4 .459 S E1. / 1.94 ACRC�' New Richmond. Wt 54U1 � L i Drefted by Knott A. Eylandt ! J4f3 #98292 (Sta. 1 92.253 SQ. F'T. / 2.12 ACRES I I AREA EX P.- R -Q-W-: j ! 86,409 SQ. FT. / 1.99 ACRES I j UNPLATTED `` UNPL�YXEO { I UN(?LATT I l t�0 T 1 EO - LANDS k-Viga I j I WARfjANTY UEEO I QUIT AIM DE fl C.S.M. { C� _ _ _ �_ W6t2R11N TY DEED ! In ei { �. I vOl 812�Pc: z 69 I VQ•,211 J" } V• -14 7 PG. 4�� ! — — — J 1 L. ?•39 CINrERUNE 17�N AVG. rl { I — .. _ . , • • — -- .1 _ /, off ry unf ,0r , fHf s 29 "4 4 - - - - -• - 1 .16' - -, 1 r1 244.5S, -� �a0.00' - . , 173ra Av , ` 27T N O9 N 1 I !A } ' LOT v ,D a1 LOT m 1,901 SF. S w 9 1< p }� , �o 8 .88 AC. 1 v� v, _ C.M. 'r ( I (.a ka 1 ..; � VOL. b NC. 1306 � $ � r� o W �` ,1x28.51' t V - -� - - -- c� ARj2ArlTY I N ++ r � c tJN r t 1j" �� t N O m f �; $ QQ w r, R .S84'43'00 v m rh Vt7;. 667 N { N ; `i t4.�1 '" �� f�� 3C4-46'29'E 450.00' r ; e>e `p,_ S89 36'04 E 461.51 e N t , PACE 2 ' gofQN : LOT 5 j 1 l ip 10 t� ! I a N "-_335.85' - --• a ' a �\N89'36'04'W 365.00' t 1 1 1 ��� R- S89'32'35'E `S89'36'04'E R= N89'09'E t' i _ - j ^ � t I� y_V3�RAt�TY DEED 96.26 LOT 5 N89't0'OO�E 350.00' - �� iN 111 PG. 586 AUA: ' , t UNPLAT7tiU LANDS 746,361 30. FT. j r = BARN 17.13 ACRES i �,� 1 A ... L ; . O SHED SHORE LINO nS - ! a 1 1 ` +4 L4L1 g L0rAtCO ON ) 03 -02 -99 p� e� 1 + 1 f a+ GREEN t z I 1 �1' I� -4 u $ { r Y-t&. �1`_>. w .5 SMEO \' "O � 1 ► HOUSE 1 L ii. r, ~' HOUSE 1 BUII.OING SET9ACK� `S61 :4, J. C� l LINE (75' FROM 9 1 Ir f� B �d ; Stly;d'04 "E DEC!« : - DRIVEWAY F SHARE I INE) �I f F5 J 190.54' / /1 t -- � $$936 '04 "E 1480.3 ��� ----- N89'36'04 - W 1167.62'... Ila ���� -.-- � � 1 - •' - - - - - .N89 "W 2647.94' - - -__ _.. «.. .. - -... SOfl7H11£ST CORNfk `�� t Jy� R N89'32'35 "W ,SOUTH 1/4 CORNER SEC. I - .SO -1s >v� lovnl u Or retc aw r/-r or SCCAON 4 SCC. 4 .r0 to (ALUM. Ca MON.) �' 4!Y NPl hIL �AfIQ,� LFGFND- (ALUM. CO. MON.) 7..�J:. A rtminty Sortfinn Onmer Monument