HomeMy WebLinkAbout026-1038-30-000 ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT RECV ��
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Owner � 1 \ � `� S 2 ' -
JUN 3 1999
Property Address oZ / '`� GY GROX
City /State /UDC R ,c S �/ 1 ? �' COUNlV
� �GtN1llGQFFI�
Legal Description: S '
Lot Block Subdivision/CSM #
) 1 /4 t ' /4, Sec. /A, T N -R W, Town of I PIN # Q
SEPTIC TANK -- DOSE CHAMBER -- BOLDING TANK INFORMATION:
Tank manufacturer Size ST/PC l Setback from: House -3 (o Well /CV P/L
Pump manufacturer Model R--
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:1 K 1i I fv o r S Width ` Length 7 Number of Trenches
Setback from: House Well -/' P/L I&v Vent to fresh air intake 'u-'o
ELEVATIONS
Description of benchmark 'S u k Elevation
Description of alternate benchmark / 5 Srt a Elevation
Building Sewer ST/HT Inlet ST Outlet PC Inlet
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PC Bottom Header/Manifold ��� 6 Top of ST/PC Manhole Cover
Distribution Lines (i)
Bottom of System
Final Grade 9 0/,. o
I
Date of installation /�/ Per nu ber 33 X96 ( State plan number
1�4 537
Plumber's signature License number Date to I *4
Inspector 1�
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.
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• Show alternate benchmark, if applicable.
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PLAN VIEW
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INDICATE NORTH ARROW
Wisconsin Department of Commerce Count y PRIVATE SEWAGE SYSTEM
Safety and Buildings Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: ST CR I x
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 338
Permit Holder's Name: []City ❑ Village (Z Town of: State Plan ID No.:
HOPKINS, JOHN RICHMOND
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
O r 026- 1012-1
( T - R NK INFORMATION ELEVATION DATA A9900220
TYPE MANUFACTURER CAPACITY 1 - 7 - 1 1WION BS HI FS ELEV.
Septic Benchmark ` q7
Dosing SA Z jIE /r, ^�
Aeration Bldg. Sewer
Holding,- bHt Inlet
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TANK SETBACK INFORMATION t Ht Outlet '� Z
TANK TO P/ L WELL BLDG. Airl to ntake ROAD et
Air I
Septic ? U Sr I ZS/ NA D om
Dosing Header /Man.
Aeration N Dist. Pipe 5
P - 1 - 2 - 1 13,917-
Holding Bot. System L
PUMP / SIPHON INFORMATION Final Grade O- L2 JU
Manufacturer Demand
Model Number GPM
TDH I Lift Friction System TDH Ft
oss Fi
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED / EN Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIM S Z DIMENSION
SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHING ufacturer:
M �
INFORMATION Type O r CHAMBER Mod I Num er:
System: & �f OOl 7Z S j OR UNIT /� C/
DISTRIBUTION SYSTEM
Header /Manifold Distribution Pipe(s) p x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. � / Length . �� Dia. Spacing o / ��- /(/ > 10 d , � j
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
COMMENTS: (Include code discrepancies, persons present, etc.)
LO�C�ATION: RICHMOND 12.30.18.176B,NW,SW 1621 140TH STREET 1
3u j 81
gaj` e;(Z'(461" tire
Plan revision require g Yes ❑ No
Use other side for additional information. 1 23 �p
SBD -6710 (R.3/97) Date nspector's Si ure Cert No
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ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
Visconsin SANITARY PERMIT APPLICATION 201 B. Washington Avenue
Department of Commerce In 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 y
than 8 112 x 11 inches in size. S 1 - � C11"O
• See reverse side for instructions for completing this application State sanitary Permit Number
Personal information you provide may be used for secondary purposes ❑ Ch gsiolno revlo us application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Ornir Name Property Location
tVW1/4 5w,1/4, S T , N, R (orY%]I
r's Prop rtyOwner's Mailing Add�res Lot Number Block Number
pal CA , State \ \ Zip Code Phone Number Subdivision Na
aar_
6 a or CSM Number
mo S O (`I a4t, IV
PE F ILDING: (check one) ❑ State Owned ❑ C it y Nearest Road
p Village `p(,` El Public 1 or 2 Family Dwelling - No. of bedrooms -3 town O F 0 gr
111 BUILDING SE: (If building type is public, check all that apply) Parcel Tax Number(s) 12.-So. 1$- 1
1 ❑ Apartment/ Condo c) (.0` 1 0 ` 30 — ADD
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
S ❑ 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 S ❑ Repair of an
- _____System________System_____ __Tank Only______________ Existing System _________Ex - -stem
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 C] In-Ground Pressure , 42 ❑ Pit Privy
13U] Seepage Pit G 3 x7S- 43 ❑ Vault Privy
14 ❑ System-in-Fill c, ��e w i (• S
VI. ABSORPTION SYSTEM INFORMATI
1. Gallons Per Day 2. Absorp. Area 3. Absorp`A�e 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
S � Required (sq. ft.) Proposed ft. (Gals/day/sq. ft.) (Min./inch) S? 5, Z� Feet Elevation Feet I 7_5D
Capacit
VII. TANK in Ca g Total # Of Prefab. Site Fiber- Exper
INFORMATION Gallons Tanks Manufacturer's Name concrete Con- steel g{ass Plastic App
New Existin structed
Tanks Tanks
A) ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber - ❑ I ❑ I ❑ 1 ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plu bet's Name: (Prin PI bet "s Signa Stamps) MP /MPRSW No.: Business Phone Number:
10 Plum er's A ress (Street, City, State, Zi pde): ? q _Z:)Il d t .1
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuin nt Signature (No Stamps)
(Approved E] Owner Given Initial Surcharge Fee)
Adverse Determination i1�
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVA
SBD- 6398 (RA 1197) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
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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.
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ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
.This is to certify
t -y11 that I have inspected the septic tank presently
serving the ._14ri�n �I1hs residence located at:
_ 1/4, 5 1/4, Sec. T 36 N, R /4 W, Town of
R ►��+ Upon inspection, I certify that I have found the
tank and baffles to be in good condition, and it appears to be
functioning properly.
Last time serviced
Did flow back occur from absorption system? Yes No_�L(if no, skip
next line)
Approximate volume or length of time: gallons minutes
Capacity: 1600
Construction: Prefab Concrete _ Steel Other
Manufacurer (if known): /1 /A
Age of Ta if known): �� f
C Q.�Q\ � z u9 er .
(Signature) U
(Name) Please Print
1,�-'. •- � "'� r � �`�o' ( � /fit � � z �, ri 53 7
(Title) (License Number)
( Date)
Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes)
or Licensed Disposer (NR 113 Wisconsin Administrative Code)
— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
condition, I certify that the tank to the best of my knowledge will
conform to the requirements of ILHR -83, Adm. Code (except for
inspection opening over outlet baffle).
Name (UI1ARLJt Signature MPRS el ����37
5/88
'Mitcons n Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor'and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but St. Croix
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned north arrow and location and distance to nearest road. oz6 — 103 -3v -400
APPLICANT INFORMATION - PLEASE P LE �N9RMATION REVIEWED BY DATE
R. E�xiwU�t s• i�•9
PROPERTY OWNER: , PROPERTY LOCATION
John Ho kins GOVT. LOT NW 1/4 SW 1/4,S 12 T 30 ,N,R 18 fir) W
PROPERTY OWNERS MAILING ADDRESS _ `% W LOT # BLOCK # I SUBD. NAME OR CSM #
1621 140th. st. °'')" na na na
CITY, STATE ZIP PH NU B °s �r�CITY VILLAGE ®TOWN NEAREST ROAD
New Richmond, WI. 5401 (7 ?p h Richmond 140th. st.
[ ] New Construction Usetc j Reside aY /7�tymber o t�ioms ` . 3 [ j Addition to existing building
[] Replacement [ ] Public or or a r1rf
Code derived daily flow 450 g pd ecommended design loading rate • 5 bed, gpd /ft2 *6 trench, gpd /ft
Absorption area required 900 bed, ft 750 trench, ft Maximum design loading rate • 5 bed, gpd /ft - 6 trench, gpd /ft
Recommended infiltration surface elevation(s) 85.85 trench system It (as referred to site plan benchmark)
Additional design/ site considerations trenches 3.25 below surface el. spaced to code
Parent material pitted glacial drift Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem I FEI S ❑ U EIS ®U CAS ❑ U EIS ®U ❑ S ® U ❑ S ® U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell CQu. Sz. Cont. Color Gr. Sz. Sh. 1 Bed jTrench
<' 1 0 -8 10yr4/3 none sl 2msbk mfr gw 2f .5 1.6
2 8 -84 7.5yr4/6 none sl 2mgr mvfr na if
Ground
elev.
89 ft.
Depth to
limiting
factor
+84"
Remarks:
Boring #
1 0 -13 10yr3 /3 none sl 2msbk mfr gw 2f .5 ' .6
2 13 -45 7.5yr4/4 none sl 2mgr mvfr yw if 5 .6
3 45 -80 7.5yr4/4 none sl 2csbk mvfr na na .5 .6
Grounl
elev. 1
86. .%.
Depth to
limiting
facto
+
Remarks:
CST Name: -- Please Print Gary L. Steel Phone: 715- 246-6200
Address: 1554 200th. New Richmon WI 54017
Signature: Date: 4 -30 -99 CST Number: m02298
f
PROPERTYOWNER John Hopkins SOIL DESCRIPTION REPORT Paget of *3
I
PARCEL I.D. # d 2� 1 O 3 ~' 3CJ' aG 10
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouxxiary Roots GPD /ft
..................
3 21 54 7.5yr4/4 none sl 2csb �
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
.................
..................
.................
1 0 -9 10yr4 /3 none sl 2mgr mfr gw 2f .5 .6
0yr4 /4 none sl 2mgr mfr 9w
Ground if .5 .6
2 9 -21 1
_ k mvfr na .5 .6
elev.
8 6.3 ft. 4 54 -80 7.5yr4/6 none ms Osg ml na na .7 .8
Depth to
limiting
factor
+80
Remarks:
Boring #
Ground
elev.
ft. —
Depth to —
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
13
Ground
elev. j
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(R.05192)
or
STEEL'S SOIL SERVICE
Gary L. Steel John Hopkins 1554 200th Ave.
CSTM2298 NW4SW4 S12- T30N -R18W New Richmond, WI 54017
MPRSW -3254 town of Richmond (715) 246 -6200
N
1 " =40'
BM.= top of 1" steel pipe C el. 100.00
Alt. BM.= top of 1 steel pipe @ el. 97.95'
�t
a
Gary L. Steel
-30 -99
7
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer - Jnk,2 � i K5
Mailing Address Lo a( 1 6 ti t- D e Matta I'��
Property Address
(Verification required from Planning Department for new construction)
City /State [ pVC' OA� Parcel Identification Number
LEGAL DESCRIPTION i
Property Location 1 /4, 1 /a, Sec. , T�1- RR�cTV, Town of ` CL
Subdivision , Lot #
Certified Survey Map # Volume . Page #
Warranty Deed # Q 3 ,A , Volume ki Page #
Spec house ❑ yes 1� 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 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 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.
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S NATUPOft 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
_ ` ra /
SA 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
_ No. 26_0 _W Deed— To _H tnt TananW PuDIfaDW ki Dan Cl B aot k Bg Co.
282221
This Indenture, Made this 9 day of October ,1965
between Leo L. Williams and Anna Mary Williams, his wife,
parti e s of the first part, and
John N. Hopkins and Janet G. Hopkins, '
husband and wife, as joint tenants, parties of the second part.
UMVICOOtty, That the said part ies of the first part, for and in consideration of the sum of
Twenty -one Hundred and no /100ths (,r >2100.00) ------- - - - - -- Dollars,
to them in hand paid by the said parties of the second part, the receipt whereof is hereby
confessed and acknowledged, ha v given, granted, bargained, sold remised, released, aliened, conveyed
and confirmed, and by these presents do give, grant, bargain, sell, remise, release, alien, convey and
confirm unto the said parties of the second part, as joint tenants, the following described real estate
situated in the County of St. Croix , Wisconsin, to -wit:
The North Half of-the Northwest Quarter of the
Southwest Quarter (N4.N"V,SWV ) of Section Twelve
(12) Township Thirty (30) Dl rth of Range Eighteen
(1 1 "Jest, St. Croix County, "Vi sconsin
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ZCOgttPM with all and singular the hereditaments and appurtenances thereunto belonging or in anywise
appertaining; and all the estate, right, title, interest, claim or demand whatsoever, of the said part i e s
of the first part, either in law or equity, either in possession or expectancy of, in and to the above bargained
premises, and their hereditaments and appurtenances.
ZO 120t anb tO t)01O, the said premises as above described with the hereditaments and appurtenances,
unto the said 'parties of the second part, as joint tenants.
Anb tbt oafO, Leo L. Williams and Anna Mary Williams,
part i e.%f the first part, for their heirs, executors and administrators,
do covenant, grant, bargain and agree to and with the said parties of the second part, and to and
with the survivor of them, his or her heirs and assigns, that at the time of the ensealing and delivery of
these presents they are well seized of the premises above described,
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