HomeMy WebLinkAbout032-2115-10-000 ST. CROIX COUNTY ZONING DEPARTMENT,,
AS BUILT SANITARY REPORT f
Owner
Property Address
City/State r
Legal Description:
Lot Block Subdivision/CSM # -
T�� S I
Y4 Sv ' / 4, Sec. , TAN -R _aW, Town of _7755 ��2sz1� 1?IN
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer Size ST/P CI,2.Qo / Setback from: House Well jc, P/L :�'
Pump manufacturer Model
Alarm location
DING TANKS ONLY)
) ,
Setbacks: Service road Vent to fresh Water L
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of system: Width Length �7 S Number of Trenches
Setback from: House " Well Z c �2 P/L Vent to fresh air intake
ELEVATIONS
Description of benchmark f Elevation
k Elevation 9/ 7
' nchmar
)cscnrh of alternate be
�
Building Sewer 3 ST/HT Inlet 9a, ST Outlet PC Inlet
PC Bottom Header/Manifold Top of ST/PC Manhole Cover
Distribution Lines () 9/ () ( )
Bottom of System O 9 s�" O ( )
Final Grade () () ( )
Date of installation / / P rmit nu ber yD State plan number
Plumber's signature License number � Date / /
Inspector � A)
Complete plot plan or
y
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
a3 3
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I
INDICATE NORTH ARROW
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count y
Safety and Buildings Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: IX
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 338840
Permit Holder's Name: j ❑ City ❑ Village 3 Town of: State Plan ID No.:
M & G INC. SOMERSET
CST BM Ele nsp. BM Elev.: c q( BM Description: Parcel Tax No.:
2
}� 3 � y. 032-2115-10-000
TANK INFORMATION Q OLEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Z Benchmark S y, Z 1
Dosing 1 41�4, 8PLA-
Aeration Bldg. Sewer _,�:2( RZ. 31
Holding St /Ht Inlet 7�.3� Z, 0
TANK SETBACK INFORMATION St/ Ht Outlet q j0
TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet
irl
Septic Z� 5�i �, NA Dt Bottom •"
Dosing NA Header /Man.
Aeration NA Dist. Pipe 0
Holding Bot. System p5 0• r�
PUMP/ SIPHON INFORMATWIN Final Grade a 6-, Y' kc�, Lp
Manufacturer Demand '!�TCave/ f9 3, 35�
Model Number GPM
TDH Lift Lric n System TDH Ft
ost Fi
Forcemain Leng a. Dist. To well
S BSORPTION SYSTEM
( BEDkTRENCH Width / Lent 1 No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
EN I N �- 3 DIMEN I N
SETBACK
SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING Manufacturer:
INFORMATION Type Of CHAMBER Mode Num er:
System: � • oZ ( ��o � OR UNIT
DISTRIBUTION SYSTEM
Header / Manif Distribution Pipes) , x Hole Size x Hole Spacing Vent To Air Intake
LengthDia. I' Length Dia. Spacing 6
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
/ , Co M ENTS: (Include code discrepancies, persons present, etc.)
Az f
OCATIO SOMERSET 3.31 19 NE,SW 232 53RD SIRE T — MEADOWOODS LOT 11
amp
Plan revision required? ❑ Yes ❑ No V L
Use other side for additional information. �� Atk, — �— , ` ( 2
SBD -6710 (R.3/97) Date Inspector's Signature Cert No.
Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 Box Washington Avenue
`i sconsin
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
than 8 112 x 11 inches in size.
• See reverse side for instructions for completing this application state sanitary Permit Number
3 7 :3 , T<&qo
Personal information you provide may be used for secondary purposes ❑ Check it revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N Property ,Owner Name Property Location
_ 114 1/4, S T , N, R E (or&
Property Owner's Mailing Address lot Number e' Block Number
1 Y e Zip Code Phone Number Subdivision Name or CSM Number
..r (
II. TYPE OF BUILDING: (check one) ❑ State Owned It Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms ° Town of �a
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo 1 d 3 - � »S -1 �O q I os
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____ _________TankOnly______________ 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 JRJ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 73 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION: c 6 - (
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. ate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min /i ch) Eleva 'on
0 �- Q Feet Feet
acct
VII. TANK in Ca gallo Total # Of r s Name Prefab. Site Fiber- Exper
INFORMATION Gallons Tanks Manufacturer Concrete Con - steel glass Plastic App
New Existing structed
Tanks Tanks
eptic Tank mg ® ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the Tclersigned, assume responsibility for i stallation of the onsite sewage system shown on the attached plans.
Plum is ame: ri Plu er's gn . No ps MP /MPRSW No.: Business Phone Number: bl I � &
Plumber's Address (Street, Ci , State, Zip C ):
IX. COUNTY/ DEPARTMENT USE ONLY
E] Disapproved Sanitary Permit Fee (Includes Groundwater ate I ssued Issuin entSignature (No Stamps)
Surcharge Fee)
Approved ❑Owner Given Initial 500 Ir� n
Adverse Determination /
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
DISTRIBUTION: O to Count One co To: Saf & Buildi Division Owner Plumber
SBD- 6398 (R.11/97) 9 y' copy r 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 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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AF'F'LIGAN I INN -UHMA I IUN - r -tease prnnr an inrarmaruaa - Heyie a Dy uate
i
Personal information you provide may be used for secondary purposes (P vecy`Law, s. 15.(1j C
Property Owner x�11eDfyfl!6ation;';�' �
Richard Stout Govt. Lot ,, ';' 1/4 SW 1 /4,S 3 T N,R 19 E (or) I&
Property Owner's Mailing Address ..`' Ldt i Beek# Subd. Name or CSM#
1353 Awatukee Trail I Meadowoods
City State Zip Code Phone Number nn Ci El illage ® Town Nearest Road
Hudson Wi 54016 `�15 -549 -6731 Do Ave
® New Construction Use: ® Residential / Number of bedrooms 4 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 6 0 0 gpd Recommended design loading rate . 7 bed, gpd /ft . 8 trench, gpd /ft
Absorption area required 858 bed, ft 7 5 0 trench, ft Maximum design loading rate -7 bed, gpd /ft - — 8 trench, gpd /ft
Recommended infiltration surface elevation(s) See plot plan ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material AnR Flood plain elevation, if applicable it
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = unsuitable for system ® S ❑ u IR S El � S El [] S❑ U El S E ❑ s O u
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 1 0-12 10yr4/3 -- sil 1 mfr cs 1f .5 .�6
2 1 12-36 1 Oyr4 /6 -- sicl 2 M444 mf i cs -- .4 .5
Ground 3 36-88 10yr4/4 -- ms Osg ml cs -- .7 .8
elev.
9 4—A f•
Depth to
limiting
factor
in.
g � m
Remarks:
Boring #
1 0 -12 10 r dtbK
2 2 12-48 10yr4/6 -- sicl 2Mwb4 " mfi c --
3 48-98 10yr4/4 Ms osg ml cs -- .7 .8
Ground
elev.
9 3__-9-1at.
Depth to
limiting
f ctor
� 8 in. Remarks:
CST Name (Please Print) Signature Telephone No.
Address Date CST Number
cJ 7 :Sc k
i
PROPERTY OWNER Richard Stout _ SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D.#
Boren # Horizon Depth Dominant Color Mottles Structure 2
Boring Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
3 1 0-1C 10yr4/3 -- sil 1 q"d�w . mfr cs if .5 .6
..........................
...........................
..........................
...........................
..........................
...........................
2 10-44 10yr4/6 -- sicl 2psa-17k mfi cs -- .4 .5
Ground 3 44-S3 10yr4/4 -- ms osg ml CS -- .7 .8
elev.
9 4 -20-ft.
Depth to
limiting
%6T
n
Remarks:
Boring # Z
1 - -- �bl� .3
2 14-50 10 r4 6 -- icl 2. --
4
mfi
3 0 -1 00 10 r4 4 TIS 0scr ml
Ground
elev.
94 ft.
Depth to
limiting
fa�tf �r
1 U v in.
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 # t ;;
5 1 1 -46 1 0 r4 6 -- icl 2d� mfi --
3 46 -92 10 r4/4 MS osq ml cs -- .7 -.8
Ground
elev.
9 - 5. 4 ft.
Depth to
limiting 51 -J
fle ar s:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
SBD -8330 (R. 07/96)
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSi-[IP CERTIFICATION FORM
Owner/Buyer \
Mailing Address N'5'5°,, Pc vs A t C . 'fR H tsasor�
t Property Address ST R Ig K 1
(Verification required from Planning Department for new construction)
City /State S(,AYSI;�_V Parcel Identification Number O9 1 I s ` _ 10
LEGAL DESCRIPTION
3
Property Location &C_ ' /4, _, ,)_ ' /a, Sec. �"' , T N -R W, Town of f
Subdivision it 9.A DID W b ID D , Lot
Certified Survey Map it , Volume , Page #
Warranty Deed # , Volume 1 , Page # /�,T S
Spec house ,yes ❑ no Lot Iines identifiable yes ❑ no
SYSTEM .MAINTEN
ANCE
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 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.
I/-c, 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.
q/ /,1
Sldl4ATURE FAPPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) ant (are) the owner(s) of
the pro described above, by virtue of a warranty deed recorded in Register of Deeds Office.
'L M . — - - y,/ / 99
SIGNA OF PPLICANT DATE
s « « «ss 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
WOL 1416PA0085
Ea00603
STATE BAR OF WISCONSIN FORM 2 - 1982 KATHLEEN H. WALSH
WARRANTY DEED REGISTER OF DEEDS
DOCUMENT NO. ST. CROIX CO., WI
RECEIVED FOR RECORD
i
04- 05-1999 9 :00 AM
RICHARD O- ST0 TT and JANET STO 1Tj i
husband and w i f , YARRANTY DEED
EXEMPT N
CERT COPY FEE:
COPY FEE:
conveys and warrants to _ M & G , TN( TRANSFER FEE: 105.30
RECORDING FEE: 10.00
PAGES: 1
THIS SPACE RESERVED FOR RECORDING DATA
NAME AND RETURN ADDRESS
the following described real estate in St. Croix County, 11 - —
State of Wisconsin: "N G c Y Y� — fa��
Lot 11, Plat of Meadowoods, Town of Somerset, 0>"k
St. Croix County, Wisconsin. 0"
io -c�oc,
PARCEL IDENTIFIC NUMBER
f�
This i nni- homestead property.
(is) (is not)
Exception to warranties: easements restrictions, rights -of -way and covenants
of record.
Dated this 2nd day of April A.D., 19 9 9
R�t-� c s SAS (SEAL) (SEAL)
)
R ichard 0. Stout anet P. Stout
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Wisconsin,
ss.
St. Cro county
authenticated this day of 19 Personally came before me this 2_nd day of
April , 1999, the above named
Richard O S nrnt and Tanaf- p
* Stout
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, _
authorized by §706.06, Wis. Stats.) to me known to be the person S — who executed the foregoing
instrument and acknowledge the s
THIS INSTRUMENT WAS DRAFTED BY HE:RYL J ACOB
Janet P. Stout
to °i Wrsco
— 1353 Awdtukt�e TL.
�
--
Hudson, Wi . 54016
Notary Public, Count , is.
(Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, - staff expiratio
necessary.) y � .
Names of persons signing in any capacity should by typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc.
.
Form No. 2 — 1982 Milwaukee, Wis
II ,
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VLEV AM
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ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
c r b n n u n■ ST. CROIX COUNTY GOVERNMENT CENTER
■���, 1101 Carmichael Road
- Hudson, WI 54016 -7710
_ (715) 386 -4680
November 29, 1999
REMAX Team 1 Realty
Attn: Mike Germain
103 Main Street
Somerset, WI 54025
RE: Septic Inspection for M & G Inc. located at 2321 53' Street,
Lot 11 of Meadowoods, Town of Somerset, St. Croix County,
Wisconsin
Dear Mr. Germain:
A septic inspection of the above referenced property was conducted on July 9, 1999. This
property is located in the NE'/ of the SW' /< of Section 3, T31 N -R1 9W, Lot 11 of
Meadowoods, 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,
&ATV &kWA'
Kevin Grabau
Zoning Technician
�/s