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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. se PLAN VIEW I� i INDICATE NORTH ARROW f 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. t ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: E a t a �m. e 7 � ,....,�. .W.a.. .. _..A ., .. .._.w ...... .. ...... .... . u...... .. ., ... .._. _. _,, 5. �, _ w _ .w. 1 i E E x € .... q i F i j E � E � e.M x i [ 3 � --• �._ ..., ,, ,,..s ... v,._. �mm a... ...: .� .eamm. . .. ,. a ... ............... e x E � 3 3 i 2 e.emm ... W ,.. E F } � x t i i . i s i - x € .. m ,a .... �. f [ t s 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. . `�� � ��'- s.� y - ,!/,�/y- �s c.67 � y��o�✓ � /pub �o � eo 9' �a ?s� a ." 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 ��� 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 I O 0 (n I 00i o W Ol 00 < w LU •I �I In (DI (7 Vii �-i .� 0-i Q I �i N �i ni m •I O u J Z I I I •I O OI I H I —1 I U; Ji Zi �i a I~ Z 3m I Z): Di O I Ui Ji L�acn 0(0 I c�� �1 >I N C)I OI OI w 0 co z� I z� = O X, I X; I SON LLJ ,ZS *LO9 M„ OZ,8Z.00S-- - - - - -- - - -- �; - -� — _ — �3W3� 1 �� . ¢/ f f l� Sb'3 ( nun ,Zlt I' $ I � / t ' ►- ° 1 to f\ f f y y ` f z 71 w ! I � rt .�... +.......� .�. ..� / .. ....�.........� ................ ........• . I i I f • I r / �..,p� S � � •� I 4 1 tt' LZ.iI I i t I f! !, I 114aaaiiii t f D i 3 \ 1 4 I f ~ d ! �' i // / '�� ~ �I 1. I I I I I I W O i ! J ; / � 1 ~�4. 1 r / j I ! � I � 1 i i ( ! J / J r /� i� i / �' /��•�' �' 'I �' I �� �„ �. r!/ i I i i I tl i i � 1 rf � // % / /'/ r / ���/ /r` ,. / , // �� ,•l�'"•.... ".. f J ` �� I i f t I+ � 1 ( of ,r ,�� 'f. J' /r /r r ,' r/ / / / F �/ // /� -- �� ��` •- L O c6 I I 1 I / / / / / // .� lV� - .....• 1 / / J I+ / / r/ I / l // // rte/ � / i ,' �/ f / ig �j6 f I � J / ,/ `- C e o o Ar ,•• .. 4lfF" ;Q I. te r' / f/ / r / L44 L'i ! III V al v v 13 I t I ' �\ \\ \\ % �� �\ �\ `\ \\ \�\ �� + IE1 lb � ; � 1 I I \\ \ \, �- �,- \, \� �\ '.� •\ 'r i + � M i I i + f i ft rr r., 01 + 1 f r r ' IC l 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