HomeMy WebLinkAbout032-2121-60-000 A �
ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
Owner
Property Address kb
City /State
Legal Description:
Lo Block — Subdivision/CSM #
,;f4 1 /4 44/L ' /a, Sec. ,a, T_ N -RaW, Town of PIN 4
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer - Size ST/P / Setback from: House _/l Well r/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: 17;5Q Wid �, � Length _ Number of Trenches
Setback from: House,,�>2,cl Well 44g P/L ,7S` Vent to fresh air intake _,A-21
ELEVATIONS
Description of benchmark 7 ; Elevation
Description of alternate benchmark Elevation
Building Sewer ST/HT Inlet ST Outlet PC Inlet
PC Bottom Header/Manifold Top of ST/PC Manhole Cover
Distribution Lines O Y9 2Z O ( )
Bottom of System () 6 5�9G () ( )
Final Grade
Date of installation / v / Pe it numb r State plan number
Plumber's signatur License numbe 421.3 Date /Z/
Inspector -J az
Complete plot plan a
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.
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PLAN VIEW
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INDICATE NORTH ARROW
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Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 344698
Permit Holder's Name: ❑ City ❑ Village ❑ of: State Plan ID No.:
Town of Somerset
CST BM Elev.: [ Insp. BM Elev.: BM Descriptio : Parcel Tax No.:
O(1 O
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ZU� Benchmark ' . 6 Z O U
Dos Alt. BM .
Aer � Bldg. Sewer
Holding / Ht Inlet 6 ?/
TANK SETBACK INFORMATION ®/ Ht Outlet G, 9 L
TANK TO P/ L WELL BLDG.
t ROAD e
Septic } //A I NA
ing NA Header /Man. �L q(�
Aer on NA Dist. Pipe : y. ,
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade G, y
cturer nd St cover 93 3
Model Number GP
TDH Lift Friction System TDH F
L oss Forcemain I Length Dia. Di .
SOIL ABSORPTION SYSTEM
BED / RENCH width Length No. Of ches P T No. Of Pits Inside Dia. Liquid Depth
N I N f Tre ra DIM
SYSTEM TO P/ L BLDG WELL L A K E I S TREAM LEA -
SETBACK
INFORMATION Type O G /� CHA ER Mo mber: u
System: �� 0 Nh] �— OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold I/ Distribution Pipes) / 'r x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length _It= Dia. Sparing � Z� q Z Z 7 O0
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.) Inspection #1: If / 11 / 9 ? Inspection #2:
Location: 1680 85th Street, Somerset, WI (SE1 /4, NW1 /4, Section 12 T30N -R19W) - 12.30.19.1098
All BN d
z,) zo' of U.4 ewe✓
W a F co
3� Kq 11 0' �,,VA
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. (�
SBD -6710 (R.3/97) Date( spector's Si na re Cert. No.
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ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
S ANITARY PERMIT APPLICATION 2 01 W. Washington Avenue
Vi sconsin
to accord with ILHR 83.05, Wis. Adm. Code P O Box 7302
Department of Commerce Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the y of less county
than 8112 x 11 inches in size. /Q
0 See reverse side for instructions for completing thi cati o State Sanitary Pe i i Number
l� O
Personal information you provide may be used for secondary purp $as ❑ Check it revis' to previous application
[Privacy Law, s. 15.04 (1) (m)). y 9 I '� State Plan I.D. Number
1 APPLICATION INFORMATION - PLEASE PR LL 1 ! f
Property Owner Name _ � NT1+Pr e 5 T N, R E (Or�
�� /4,
Property Owner's Mailing Addr ss x Lot Nup:ij5 t Block Numb
L O � oZ
City, to Zip Code Phone Number ion ame or ber
. T p VII BUILDING: (check one) ❑ State Owned 't� age Nearest Road
./'
Public Ea 1 or 2 Family Dwelling - No. of bedrooms & LownOF r S
111 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 ( New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only
_____ _____________ ______________ Existing System ExlstingSystem
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 t 43 ❑ Vault Privy
14 E] System-In-Fill 12 ,<
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.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /i h) Elevation
�-� , Feet Feet
Capacit V11. TANK in Ca allons Total # Of r Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App
New Existin structed
Tanks Tanks
Septic Tank or Holding Tank ® ❑ ❑ 11 1:1 - ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
Vill. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for ins llation of the onsite sewage system shown on the attached plans.
Plumb r' ame• P t)L Plumber's Si t No ps) MP /MPRSW No.: Business Phone Number:
Plu ber's Address (Stre t, City, tate, Zip e):
7. o
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps)
Surcharge Fee) �
pproved [:]Owner Given Initial
Adverse Determination aoZS • ����
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11 /97) DISTRIBUTION: Original to county, One copy To: Safety & Buildings Division, Owner, Plumber
[ a
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.
11. 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
i 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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." Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page of
Labor and Human Relations
D iv i sio n of Safety �& (Buildings in accord with ILHR 83.05, Wis. Adm. Code
Attach compete site plan on paper not�than 8 1/2 x/2 x 1� in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or r RCEL .
dimensioned, north arrow, and location and distance to nearest road. endi
APPLICANT I F RM TI
ON -PL ASE PRINT ALL INFORMATION ��, REV BY E
cp
i k - ZO-
PROPERTY OWNER: 19 PROPERTY LOCATION
Gerald Smith GOVT. LOT SE 1/4 1VGf6" ,N for) W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. !�M
na na na � 1. i
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE]&OWN I tEARSS - T ROAD
Elk River, MN. 55330 ( )
(�] New Construction Use [ .4 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, gpd /ft gpolft
Absorption area required 643 bed, ft 563 trench, ft Maximum design loading rate —_ bed, gpd /ft gpolft
Recommended infiltration surface elevation(s) 89.00 ft (as referred to site plan benchmark)
Additional design / site considerations na
Parent material oL wash Flood plain elevation, if applicable —na ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRES AT -GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem [a E] U CRS ❑ U CA ❑ SURE U 0 S ❑ U El S ❑ U ❑ S �7 U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Mfr CS 9f -6
1 0 -16 10 r4 3 none 1
2 16 -39 10yr4 /4 none sicl lcsbk mfr gw if .2 .3
Ground 3 39 -84 7.5yr4/6 none co s Osg ml na na .7 .8
elev.
9 3.00 ft.
Depth to
limiting
factor
+84
Remarks:
Boring #
1 -14 10yr3 /3 none 1 2msbk mfr gw 2f .5 .6
2€ 2 14 -32 10yr4 /4 none sicl lcsbk mfr gw if .2`: .3
3 2 -86 7.5yr4/6 none co s Osg ml na na .7 .8
Ground
elev.
93 ft.
N o .
Depth to
limiting
factor
+86"
Remarks:
CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200
Address: 1554 200th. Ave. New chmond WI 54017
Signature: Date: 12 - - CST Number: m02298
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t. 1
PROPERTY OWNER Gerald Smith SOIL DESCRIPTION REPORT Page 2 d;2„• '
PARCEL I.D. # pin-ndi ng
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourclary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 0 -14 10 r3/3 none 1 2msbk mfr gw 2f .5 .6
------------- 2 14 -30 10yr4 /4 none sicl 2msbk mfr gw if
Ground 3 30 -84 7.5yr4/6 none co s Osg ml na na .7 .8
elev.
9 2.20 ft.
Depth to
limiting
factor
+84"
Remarks:
Boring #
1 0 -11 10yr3 /3 none 1 2msbk mfr gw 2f .5 .6
<4 2 11 -28 10yr4 /4 none sicl 2msbk mfr gw if .4 .5
3 28 -84 7.5yr4/6 none cos Osg ml na na .7
.8
Ground
elev.
9 1.80 ft.
Depth to
limiting
factor
+84 11
F - 1 I
Remarks:
Boring #
1 0 -11 10yr3 /3 none 1 2msbbk mfr cs 2f .5 .6
5 €< 2 11 -36 10yr5 /4 none sici lcsbk mfr gw if .2 .3
3 36 -80 7.5yr4/6 none co s Osg ml na na .7 .8
Ground
elev.
9 2.00 ft.
Depth to
limiting
factor
+Rn
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel rald Smith 1554 200th Ave.
CSTM2298 SE 4 S12- T30N - x 19w New Richmond, WI 54017
MP 3254 town of Somerset (715) 246 -6200
1
N
1 " =40'
BM.= top of tel. ped @ el. 100'
f
So �`
O
�F
Gary L. Steel
U -3 -96
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address I-F, oo7y " Sy a t to
Property Address
(Verification required from Planning Department for new construction)
City /State Parccl Identification Number 03a
LEGAL DESCRIPTION
� Som -tr�t�
Property Location 6,E ' /<, "A, Sec. _4� T _f,,�� N -R1'W, Town of
Subdivision 00"P 1 9PySS V , 9 1 1fkTV- S , Lot # Q c�
Certified Survey Map # , Volume , Page #
Warranty Deed # (Q to L 46 1 - ,Volume ILI5(p , Page # ?
Spec house M yes ❑ no Lot lines identifiable yes ❑ no
SYSTEM- .MAINTENANCE .
Improper use and mantenanccof 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 wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than I/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 ZoiIi.ng Office within 30
days "' e three year expiration date. L� /)S /
SIG A ^ OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on flits form arc true to the best of my (our) knowledge. I (we) am (are) the o of
the prope descri be above, by virtue ot' a warranty deed recorded in Register of Deeds Office.
SIGN TURE O 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
,09!13198 THU 09;08 FAX 715 383 4687 REGISTER OF DEEDS Z002
W. 145 6 PAGi 4 10
G -1Lod1Loz
STATE BAR OF WISCONSIN FORM 2 - ].948 KATHLEEN H. WALSH
Document xtl mber W Y RCGTSTER OF DEEDS
ST„ CROIX Co., WI
This Deed, made between Forest Oaks Condos Inc. a Minnecotst RECEIVER FOR RECORD
Corporation
09 -15 -1999 10:15 AM
Grantor, conveys and UARRAHTY DEEP
warrants to M & G Inc.. Wisconsin (Corporation EXERPT A
-- — CERT MPY FEE:
- - ----._ CO!?Y FEE:
y RECORDING 10.00
,
Grantee, PAM: 1
Grantor, for a valuable consideration, convigs and warrants to Grantee
the following described real estate in St. C ix County, State of Wisconsin (The
"Property ").
R ecording Area
Dame and Rerun Address 5tfe C. I
L
ozc SF
032- 2121 -60
percel Identification Number (PIN)
This is not hameaxad property.
Lot 29, Nortll Bass Lake Estates First Additiou.
I
Exceptions to warranties: Easernents, restrictions and rights -of -way of record, if any.
Dared this — 14-�' day of September, 1999.
r. liporest k5 C x Inc.. a Minnesota Corporation
ACKNOWLEDGMENT
AUTHENTICATION STATE OF WISCONTSIN )
55,
Signature(s) forest Oaks Condos .InC._, _a_,MinneFnta County }
C orporation
Personally came before me this day of
_authenticated this September , 1999, the above named
day of September, 1999. _ to me
known to.bt the person(s) who executed the foregoing instrumcat
and acknowledge the same.
* I{ristina 0 , d -
*
TITLE: MEMBER STATE BAIL OF WISCONSIN Notary ublic, State of Wisconsin
(If not, rY
authorized by § 706,06, Wis. Scats.) My Commission is permanent_ (If not, state expiration date:
THIS 1>VSTRTJMENT WAS DRAFTED BY
Attorney Kristiina Qgland
Hudson, W1 54016
(Siguarures may be authendcated or ackmwlcdgcd. Roth are nut
necessary.)
*Names of persons signing ul auy capacity should tle typed or printed below their siguatures
WARStANTY IMED STATE DAR OT wISCONSW
FORM No. 2 - 1996
INFORMATION PROFESSIONALS COMPANY FQNO 0U LAC. VYI WO. 465.2021
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ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
a o b o u u non ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016 -7710
(715) 386 -4680
December 14, 1999
REMAX Team 1 Realty
Attn: Jo Hintz
103 Main Street
Somerset, WI 54025
RE: Septic Inspection for M & G Inc. located at 1680 85t Street,
Lot 29 of North Bass Lake Estates, Town of Somerset,
St. Croix County, Wisconsin
Dear Jo:
A septic inspection of the above referenced property was conducted on November 10,
1999. This property is located in the SE' /4 of the NW' /4 of Section 12, T30N -R1 9W, Lot 29
of North Bass Lake Estates, Town of Somerset, St. Croix County, Wisconsin. At the time
of the inspection, this septic system was found to be code compliant for a four (4)
bedroom home.
If you have any questions regarding this, please contact our office at (715) 386 -4680.
Sincerely,
Jon Sonnentag
Zoning Technician
/sm