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HomeMy WebLinkAbout026-1061-20-112 ' f Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: ST. CR IX Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j. 344557 Permit H Id is Name: ❑ City []Village Town of: State Plan ID No.: SCREIDER, DON RICHMOND i CST BM Elev.; Insp. BM Elev.: BM Description: Parcel Tax No.: QO . a � oS� 021(0-10(0 — ! ! Z TANK INFORMATION ELEVATION DATA .o, 30, 1& so 319/ Z TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark of )00 or /63.D � Dosing v"5 /• Ty U." Aeration Bldg. Sewer 14.q2- Holding St / Ht Inlet . - 7D C14. 3' TANK SETBACK INFORMATION St/ Ht Outlet S:S c1 .24 TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet Air I Septic NA Dt Bottom Dosing NA Header / Man. 743 qz qir� Aeration NA Dist. Pipe } � 9 � • } •� 2.3 Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade 5-5 S;T3 Manufacturer Demand Model Number GPM rForc emainFriction Syste TDH Ft ead H a Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM - 3`x r.�c c $� BENCH Width ' Length f No f Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS D DIMENSION SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manu c# e� — •�.� SETBACK CHAMBER INFORMATION Type O � M el umber: r System: C.Orit [ O OR UNIT cqo& u DISTRIBUTION SYSTEM 3 Header / Manifold (l Distribution x Hole Size x Hole Spacing Vent To A)r Intake Length Dia - Length Dia. Spacing 7� 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.) —L OCATION: RICHMOND 0.18 , SE , NW 1443 COUNTY ROAD A - LOT 4 A eU =4-f I Dom-.. > r 8" 5,:S t Plan revision required? E] Yes T% No F q ��F I? �� —�, Use other side for additional information. R:F] SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: E .... �...,, ... � ,..,, ems_ ... °. �. <. . .. .. _ .. .. .... ,...... ...,.. ...... ..,.,.. ..... f ° 3 E � S ' 4 c " t 1 ° ° E f E t 1 mm# f € e m ° °s.F °.: y e °°.., ,... .... °.< e °mad ,. d,..,..,, a .. ' . .. ............ ..... ....... mse :..... .e ,.... �.. ,.°. ,.....,.a- p °e..e { ° S { .gi f ea , { s i N a �. 8 ¢ k t .', _ u s g ` a � r � " .a. . { a ° B a q E ° 4 a�. ,.. . ,� :-- F , ....: :..d,..... .. , a pm.N. .,,.. ... .. i __ _...... ,,,,,. L _ 3 _ ....✓e..mam s m ° °E .. e ,e m F E { q i s s Safety and Buildings Division SANITARY PERMIT APPLICATION 2 01 E. Washington Ave. Visconsin In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Department of Commerce 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. 5 - r C IX • See reverse side for instructions for completing this application State sanitary Permit Number 3 y ss�-- The information you provide may be used by other government agency programs ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property O Name Property Location m �C.ti*Se Se 1/4 N W 1/4, S 20 * T 3d , N, R Ig E (o W Property Owner's Mailin ddre s Lot Numb Block Number 1445 Cvuw -r•r �n x 5L C S Zi Code Phone Number Subdivision Name or CSM Number f1 l ictFrvbNV t 3 c > 0 13 l � to � II. TYPE OF BUILDING: (check one) ❑ State Owned L �t tt Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms 5 Town OF I Yl A vrH ~� S`h� - To �Sr III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 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. 0 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 AAr-K alwrtct -4 22 ❑ In- Ground Pressure 42 ❑ Pit Privy IfvFit.'rKMdL 13 E] Seepage Pit 1 43 ❑ Vault Privy 14 ❑ System -In -Fill X = 10 C - VI. ABSORPTION SYSTEM 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.) Propose�d / (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation 6 13� 9 5`t � � , I Feet 'v q5. D Feet VII. TANK Capacity Site INFORMATION in gallons Total # Of Name Prefab. Fiber- Plastic Exper. Gallons Tanks manufacturer's Concrete Con- Steel glass App. New Existing strutted Tanks Tanks 0 El El 1:1 1:1 Lift Pump Tank /Siphon Chamber Su*Alp e1cG 1 W k ❑ ❑ ❑ I ❑ ❑ ❑ VLII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plu ignature: (No Stamps) MP /MPRSW No.: Business Phone Number: �u wJ1l _ _ 2z�91 z 7 t 7 3S Plumber's Ac dress (Street, City, State, Zip Code): Z 1O5S3 �. StW ` tA-0 ACA -,j IX. COUNTY / DEPARTMENT USE ONLY E] Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Iss IngAg tSignature (No Stamps) �� �. I S urcharge Fee) pproved ❑ Owner Given Initial 02 Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6396 (R 11/96) 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 maybe 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 8 1/2 x 11 inches must be submitted to the county. The plans must include the P following: A) lot Ian, drawn to scale or with complete dimensions, location of holding tank(s), septic p 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. z 0 G P T � it � � T -4 I G 1 G = �y �l Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of safety and Buildings Page of Bureau of Integrated Services in accordance with S. JL-Fff}8309,- Wis. Adm. Code 'County Attach complete site plan on paper not less than 8 1/2 x 11 inches' Plan m st 1 I include, but not limited to: vertical and horizontal reference poirec �F�d. percent slope, sc ale or dimensions, north arrow, and location ce t p el I.D. # APPLICANT INFORMATION - Please print all in �� i Rw wed by Date Personal information you provide may be used for secondary purposes (, s. 1 f� • 3c) /Aq Property Owner n r T atibrn;�� S > Govt. L4L / 1 /4J /4,S T3®,N,R E( 0 W Property Owner's Mailing Address t t ck# Subd. Name or CSM# City tate Zip Code VPhone Number ❑ City ❑ V Town Nearest Road I j 5" )-16_ ,) C' -0 _ New Construction Use: , <Flesidential /Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 6 00 gpd Recommended design loading rate - J bed, gpd /ti trench, gpd/ft Absorption area required -S. bed, ft ft 2 Maximum design loading rate t_ 2 bed, gpd /ft � t rench, gpd /ft Recommended infiltration surface elevation(s) ZZ . Z ft (as referred to site plan benchmark) Additional design /site conside ations Parent material ^. Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system S El `�S ❑ U ❑ U S ❑ U ❑ S ❑ S SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /ft . g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench ...... f � °V -�/ Ground _3 ' �` ! �i'Y)S l i'�)l ` �' •V elev. ; Depth to limiting facto 0 Remarks: Boring # . S y Ground Depth to limiting factor Remarks: [Addr Fss Please Print) Signature Telephone No. ZZ Date CST Number �' � �(/ 62 7 ' Q OIL DESCRIPTION REPORT PROPERTY OWNER D Z 3 tS - 301 � — OI Page ; of PARCEL I.D.# Boris # Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Ground 54' l 9 elev. Depth to limiting �� . Ell I I t I I I I �z Remarks: Boring # lz 1621 f �7 Ground Depth to limiting factoy d Remarks: Horizon Depth Dominant Color Mottles Structure GPD /ft Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # ii:Di fit ' K it 1 Ground el v � / . 7 , Depth to limiting factor - /� �' Remarks: Boring # L) Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) i Soil Test Plot Plan Project Name Don Schneider Byron ird Jr. Address 1445 County Road A -� New Ri Wi 54017 C #220527 Lot 2 Subdivision ---- - ------ Date 10/15/98 SE 1 /4NW 1/4820 T 30 N/R i8 W Township Richmond ❑ Boring Q Well PL Property Line County S T. CROIX BM or VRP Assume Elevation 100 ft. T op of Fence Post System Elevation 9 1.1 * H R p Sa a s Benchmark Alternate Benchmark Top of Fence Post @ 99.7 County Road A A B. 50' B -5 B -2 30' a ep A Pri A 100' B -3 ►d 2% r' Slope Pro 4 Bedroom 50' House B. B -1 30 ' 30' B -4 25' 25' 366' Property 5' Line ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM / e Owner/Buyer inr� l !� Q • o� Mailing Address / �� �o R� /�` �.lrz i� �� o Ldr g ©/ 7 Property Address (Verification required from Planning Department for new construction) City /State /v eA� k� a M Parcel Identification Number LEGAL DESCRIPTION Property Location `s E %+, AR110 V4 Sec. ;Z 0 T a N -R Town of ` Subdivision �POJ ©� `7 . Lot # . Certified Survey Map # `3�fa 9'3 ---5 , Volume I , Page # 3 Warranty Deed # 6 - 0 - 6 3 6 � , Volume / , Page # S / Spec house ❑ yes 19 no Lot lines identifiable Z 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, journeyman 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. 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 da of the a year expiration date. 7 /$/ SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the b est of my ( our ) knowledge. I (we am ( are ) the owns ( s) of O wne r (s) owled e. g ( the perty described above, by virtue of a warranty deed recorded in Register of Deeds Office. 7 /7/ 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 i POCUW�NT NO. ST.kTE BAR OF WISCONSIN FORM I — ISW ` r►us ra. s ae3saysa ►� ax:o.a;Na oars I WAROA: = j This Dead, made 1 Awfta ..... ...... . ........... .................. a Craig A. Hali aM 0< -)ra J. Ha,ns� a :, hi�s aM ar..c g } N - . . ---- -• - - -• I Recd Tier t .................... ...._..--- ............. ........... •-- - - - - -- - •- •- -..... 11 •. -- ......... ..................... .............. , Gra,: tor, ' S 2 1 { and. A4fAd cd.T! hi d _.aazd..?�i a..;t,.. 3u i .. t..hush nd_.... �' � -- ............. -- -• -- ... ----------------- ._. .._.._... 4� �t 12:5 �R if f * ••, ._� -- -- ........ ....... Granter, i f witt18 seth, Tbat the said Grantor, for a valuable wasideration.... i� �veH ro it z ,i conveys to Grantee the following deserraed renal estate in _ -_$ -.. O X ............. �+ County, State of Wiseonsln. jl i n.. f Tax Paz-eel No 3 (� All that part of SEI /4 of NWI /4 of Section 20, Township 30 North, Range 18 West, 5 ` St. Croix County, Wisconsin lying Soutlieasterly of County Trunk Highway "A" i j EXCEPT part to Virgil Becker and Marti.,a Becker in Vol. 415, Fage 171. Is i .ir j j i M r This ........ is -- - ------------- homestead property. (is) (is not) r Together with all and sLiaar the he editaments and appurtenancz°. thereunto belongir • And G> aig -- ..Hanse n a i -- D J----- �---�- - goo y wa rrants that the title to indefeasible in fee simple and free and --- clear o! encumbrances ex- e .t 1: easements, restrictions and rights -of -gray of record, if any. a;.d will warrazat and defevJ the same. fated this Z� -- Se tuber 18 ....... ..; - day of - --- -- ------- - -------- , � _...... - �' ---- -- ....... - (SEAL) ----- �` Craig A. Han , n Debra J. - -- - - - - - - -- - -(SEAL) -------------- -- ------ (gib AL) --- I� AUTHNNTI CATION ACKNOWLBDGMBNT i j� 4 j} 3ignaiure(e) Crax� A Pnnsen, Debra c'ramr rho x a o� 2 FILED F JUN 1 S 19 ► 99 3 [� ry KATHLEEN H. WALSH V ©J�1 ! S y isIg 4� SL Croix Co., Nfl g CERTIF]" I URVEY MAP Located in part of the Southeast Quarter of the Northwest Quarter of Section 20, Township 30 North, Range 18 West, Town of Richmond, St. Croix County, Wisconsin. Prepared for and at the request of: OWNER: Don Schneider 1445 County Trunk Highway "A" -4&f — NORTH 114 CORNER New Richmond, WI 54017 � SEC. 20 .TO - 18 (fND. 2" IRON PIPE) Drafted by. Kristi A. Eylandt I �\ 1 \ I It TOTAL AREA LOT 3• NOTE: AREA EAST AND AREA SOUTH OF of \ I FENCE ARE AREAS.POSSESSED BY OTHERS. t 134, 263 S0. FT. CONSULT ADJOINING LAND OWNER(S) OR i 3.08 3.08 ACRES AN ATTORNEY BEFORE REMOVING SAID rn AREA EXCLUDING R.O.W.: FENCE. m 113,502 SQ. FT. . AV,' ,. 2.61 ACRES �,�t►� "° O ° � +t jz o / > LOT 1 LOT 2 I ID -4 TOTAL AREA LOT 4: y !L5�9S I I C 113,904 SO. FT. 'Cl RONALD F. � •� CERTIFIED SURVEY MAP j j I O 2.61 ACRES JOHNSON VOLUME 8 PAGE 2214 II i 9 S DOC. NO. 458732 l0 I u`• I I AREA EXCLUDING R.O.W.: AMER' 90,899 SQ. FT. 1 WI C, ' I .P, 2.09 ACRES % < 1 pQ, I `� / G x , LINE TABLE: ° ° "• °w °..U* �''! \ rn cn C LINE DIRECTION DISTANCE ° * Gii' I j /C6� �'�'r �` N 0 ^Zi Lt N37'54'55 "W 55.08' ��,' / gab R= S32'52'E 56' °+ � L2 S52 6 "W 72.20' o Z, ��' / 9-ya ,' '' o m a R= N52'10'E 72.2' �,P�i' � / ,O, h i' °� I L3 S89'59'42 "W 74.76 ,`Q`i y j� g y ��� S NEO I oo w l 0 0 Jai t e� ��'4 JX m m 'z h /R LOT ip ,��' 3 I EAST 114 CORNER W£ST 1/4 CORNER / 5 ��� Jig s� x� o C. 20 -JO -18 / p x SEC. . CO. SE MO (ALUM. CO. MON.) �� /� �' LOT 4 , O' P ��• I (ALUM. CO. MoA!) ' / \,`L % \ $89'59'42 "W N89'59'42 "E \ i - L1 - 1862.83' - X I - ' . x — x 547.50' I _ 1 2621.18' ------ SB9'59'42 "W 649.17' - - - - -- y < \` I 1.4 {, I 25.5' 5299 ---- - - - - - -- ---- N89'59'42 "E .44'�f x� - a -- / II I I bt�' � � to � ST- *EST 114 LINE OF SEC710N 20 °j I I / JOQP °- • ---- - LANDS oI r NOTE: The parcel(s) shown on this map is /are subject to State, County and Township laws, rules and regulations ( i.e. wetlands, minimum lot size, access I to parcel, etc.). Before purchasing or developing any parcel, contact the St. Croix County Zoning Office and the appropriate Town Board for advice. LFGFND County Section Corner Monument of Record • Set 1" x 24" Iron Pipe weighing I i a minimum of 1.13 pounds per I linear foot. / SOUTH 114 CORNER ® Septic S£C. 20- .30 -18 • • • • • • • • •Building Setback (100' from R.O.W.) (ALUM. CO. MON.) — —x —Fence (SEE NOTE) R= Recorded As JOB #98247 2a _ 0 2 00 N T-{ Prepared by. ' A & E GRAPHIC SCALE LAND SURVEYING do CIVIL ENGINEERING SCALE IN FEET: 1 inch = 200 feet Phone No. (715) 246 -4319 BEARINGS ARE REFERENCED TO THE EAST -WEST 1/4 109 East Third Street, P.O. Box 325 LINE OF SECTION 20, TOWNSHIP 30 N., RANGE 18 W. New Richmond, WI 54017 WHICH IS ASSUMED TO BEAR N89'59'42E. Sheet 1 of 2 Vo1.13 Page 3665 a.. CERTIFIED SURVEY MAP Located in part of the Southeast Quarter of the Northwest Quarter of Section 20, Township 30 North, Rarge 18 West, Town of Richmond, St. Croix County, Wisconsin. SURVEYOR'S CERTIFICATE I, Ronald F. Johnson, a Registered Wisconsin Land Surveyor, hereby certify that by the direction of Don Schneider, I have surveyed, divided and mapped a parcel of land located in part of the Southeast Quarter of the Northwest Quarter in Section 20, Township 30 North, Range 18 West, Town of Richmond, St. Croix County, Wisconsin described as follows: Commencing at the West Quarter Corner of said Section 20; thence, on an assumed bearing along the east /west Quarter line of said Section 20, North 89 degrees 59 minutes 42 seconds East a distance of 1862.83 feet to the point of beginning of the parcel to be described; thence, along the approximate center line of County Trunk Highway "A ", North 52 degrees 59 minutes 16 seconds East a distance of 1019.34 feet to the north /south Quarter line of said Section 20; thence, along last said Quarter line, South 00 degrees 08 minutes 16 seconds East a distance of 613.56 feet to the said east /west Quarter line; thence, along last said Quarter line, South 89 degrees 59 minutes 42 seconds West a distance of 649.17 feet; thence, along the northeasterly line of that property described in Volume 415 page 171 of Deeds recorded in the Register of Deeds Office in said County, North 37 degrees 54 minutes 55 seconds West a distance of•55.08 feet; thence, along the northwesterly line of last said property, this also being on the southeasterly right -of -way of County Trunk Highway "A ", South 52 degrees 59 minutes 16 seconds West a distance of 72.20 feet to said east /west Quarter line; thence, along last said Quarter line, South 89 degrees 59 minutes 42 seconds West a distance of 74.76 feet to the point of beginning. Containing 248,167 square feet (5.697 acres). Subject to right -of. -way for County Trunk Highway "A" along the most northwesterly line of the above described property, also subject to all easements, restrictions and covenants of record. I also certify that this Certified Survey Map is a correct representation to scale of the exterior boundaries surveyed and described; that I have complied with the provisions of Chapter 236.34 of the Wisconsin Statutes and the Subdivision Ordinance of the County of St. Croix and the Town of Richmond in surveying and mapping the same. Ronald F. JAffinson Reg. No 1186 Date — � A & E Land Surveying Telephone # (715) 246 -4319 P. 0. Box 325 New Richmond, WI 54017 >�r RONALD F. Q JOHNSON AMERY, Wis. ♦j Qr < +��-- ic c-Sm� o z+ sr�^ 0 SUR R D �,♦�� z'cm-,asm r-.mmm v cm r ep 9 v Co- nc--�i �+ mmc+ •+ µ m omm 'n c�i as m t�'t . ` r-4;0 Z y X Y n m n cn o Vol. 13 Page 3665 m;^ m � � M0_2 a ° o c d tiN o a b £Mr r+ rn S Sheet 2 of 2 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM C ounty: Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: ST CH IX Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 344557 Per t H Id r' Name: ❑ City ❑ Village Town of: State Plan ID No.: 79 EMR, DON RICHMOND CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift L oss riction PDi System TDH Ft ead Forcemain Length F i Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth D IMENSIONS DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type O CHAMBER Moe Number: System: OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length 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 I Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: RICHMOND 20.30.18,SE,NW 1443 COUNTY ROAD A — LOT 4 Plan revision required? ❑ Yes ❑ No Use other side for additional information. _ can_a n ro iio7N Date Inspector's Signature Cert. No. SANITARY PERMIT APPLICATION 20 1 e E.W and ashington Ave N" Asconsin In accord with ILHR 83.05; Wis. Adm. Code P.O. Box 7969 Department of Commerce Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less county than 8 112 x 1.1 inches in size. S-r C ]X • See reverse side for instructions for completing this application State sanitary Permit Number 3 1 — The information you provide may be used by other government agency programs ❑ Check it revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLI ATION INFORMATION -PLEASE PRINT ALL INF RMATION Property O Name Property Location 1 N �c ti�l�n 1/4 N w 1/4, S U ' T So r N, R 1j E (o W Property Owner's'Maiiin ddre s Lot Numb Block Number 1445 �orr n ( Ci y , SCa�e ZI Code Phone Number Subdivision Name or CSM Number M ((I lj i -7 1 1 ( ] PE OF BUILDING: (check one) ❑ State Owned It Nearest Road Public 0 1 or 2 Family Dwelling - No. of bedrooms J� Town of 4 14 � l urt - 4 ' - S"^. -T° III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 3 A 1 E] Apartment/ Condo Mile 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 N 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) No Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 []Holding Tank 12 ® Seepage Trench Wr,14 Wdct 22 ❑ In- Ground Pressure 42 ❑ Pit Privy - Vault Privy 13 ❑Seepage Pit 43 � � ❑ y 14 ❑ System -In -Fill $ c 10 VI. ABSORPTION SYSTEM INFORMATION: = 3o ws 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.) (Min. /inch) Elevation _15 13 954 Feet ti QS•v Feet Capacity VII. T ANK NFORMATION in g Total # of Prefab. Site Fiber- Exper g Gallons Tanks Manufacturers Name Concrete co Steel glass Plastic App New lExisting strutted Tanks Tanks t; k - >- 15bU -.. 0 El El 1:1 ❑ 1:1 Li Pump Tank /Siphon Chamber Su+wP ©CC. IrY VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Ptu ignature: (No Stamps) r S,09 (MPRS W No.: Business Phone Number. � v wJ1 01" IZ Plumber's Ac dress (Street, City, State, Zip—Code): " Z (615 {S . _ tA-0 C(A' orw l.� �. IX. COUNTY / DEPARTMENT USE ONLY ❑Disapproved Sanitary Permit Fee (includes Groundwater I Late lue Iss IngAg tSignature(NoStamps) pproved ❑ Owner Given Initial Adverse Determination 2 ,�S 11// r� «harge Pee) Z, r•'L 1 X. CONDITIONS OF APPROVAL f REASONS FOR DISAPPROVAL: r.,....... n..e r..• cainh. it Nrrildin« ni.,iainn. owner. Plumber ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer J�tAa-1 Q / Mailing Address ALV n 'e °(d We , ©/ 7 Property Address ( y-'J A (Verification required from Planning Department for new construction) City /State Parcel Identification Number LEGAL DESCRIPTION Property Location ' /., ` /•, Sec. C�. T 3 I N -R Town of ©� Lot # J Subdivision Certified Survey Map # , Volume / , Page # 3 lrJ!oS . Warranty Deed # 606 Volume / 03 7 , Page # Spec house ❑ yes A no Lot lines identifiable WL 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, journeyman 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 day of the thiSe year expiration date. SIGNATURE 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 described above, by virtue of a warranty deed recorded in Register of Deeds Office. 7 /7/ 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 l