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HomeMy WebLinkAbout032-2116-30-000 ST. CROIX COUNTY ZONING DEPARTMENT,.. y ,`-'-'-., AS BUII. SANTrARY REPORT Owner A&C & r r� Property Address City /State ��,'o���,� U s �� .2 - so ��rx 99 i d o Legal Description- Lot / Block � Subdivision/CSM # S' n . 7 , ; ),fs '/a &' /a, Sec. /6', T -R)� - W, Town of ,�kzasAJ- ____ PIN # SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer ' ` Size ST/PC / Setback from: House �,� Well, P/L � 2 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: Wid - e 6;� Length Y9 Number of Trenches Setback from: House 7 Well P/L f sD Vent to fresh air intake ELEVATIONS / Description of benchmark :, �r� ,��' c Elevation ) Description of alternate benchmark o ; 41 Elevation 9s. Building Sewer ST/HT Inlet �s _7.sr ST Outlet PC Inlet PC Bottom Header/Manifold 9_?, 1 7 Top of ST/PC Manhole Cover 9 ,e, 7� Distribution Lines O ,r?,g y O ( ) Bottom of System Final Grade O 4 s © O ( ) Date of installation 2. Fermit number SY State plan number Plumber's s re D License number L a-;2 1 /� /2 Date Inspector Complete plot plan � 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 applic le.) I r PLAN VIEW ' 93 I 9' I I "Q t eus,Z I INDICATE N RTH ARROW Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: ST CR IX P er so nal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 338841 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: M & G INC. SOMERSET CST BM Elev.:- Insp. BM Elev.: 777 tion: Parcel Tax No.: TANK INFORMATION ELEVATION DATA 00292 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic utlt� Benchmark /, D a /,D a8 Dosing .910 o2. Aeration Bldg. Sewer S: D 1 Holding *9inlet ,6 6 5 TANK SETBACK INFORMATION &D19 Outlet 0 TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic r f NA Dt Bottom Dosing NA Header / Man. �(3, L Z q \ Aeration NA Dist. Pipe ��� Ste• -1 J Holdin Bot. System 9 2 / PUMP / SIPHON INFORMATION Final Grade s $ 44 /g' Manufacturer- Demand Y- z s 0f Model Number GPM TDH I Lift Los, He s TDH Ft Forcemain Length Dia. Dist. To well SOIL ABSORPTION SYSTEM BE �I�H Width Lengt i No. Of s PIT No. Of Pits Inside Dia. Liquid Depth EN I N ) 2 . 4� DIMENSION SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type O r �1 model Number: System: COP- � OR UNIT DISTRIBUTION SYSTEM Header / Ma fold Distribution Pipes ! v x Hole Size x Hole Spacing Vent To Air Intake Length —&- Dia. Length �_ Dia. _� Spacing _c— �> 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.) LOCATION: SOMERSET 15.31.19,SE,NE 589 217TH AVE — SHADOW P � ,Q p �� , 0/�(= 6 � (M6 �•�t- ca�+r-) D�T�;.d'^ C•� •- - `� U e 14 � 43.19 qg.o 1 ❑ Plan revision re fired Yes No I s �u ❑ e � - h.�.• Use other side for additional information. 1 /0 1 p I g �- Ry SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. Safety and Buildings Division 201 W. Washington Avenue NVL consin SANITARY PERMIT APPLICATION P O Box 7302 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 Sam ry rmit Num �application Personal information ou rovide ma be used for seconds �3w Y P Y ry purposes ❑Check if revision to prevlou (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 - 1/4 - 1/4, S T 3 , N, R (or& R Property Owner's Mailing Address Lot Number Block Number Cit tate Zip Code Phone Number Subdivision Nam or CSM Numb tZ:: II. P F B IL V II age DING- (check one) ❑ State Owned ! Nearest Road ❑ Public 1 or 2 Family Dwelling - No. of bedrooms Town OF 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. �& New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ______Syrstem 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 22 ❑ In- Ground Pressure 42 [] Pit Privy 13 ❑ Seepage Pit /s X 55/ 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION:GA /B 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 15. Perc. to 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /i h) W,10 Elevation Feet Feet VII. TANK Capacity in gallons Total # of Prefab. Site 9 Plastic ass App INFORMATION Gallons Tanks Manufacturer s Name Concrete con- steel New Existin strutted Tanks Tanks epti Tan r FT8T�1TflJ1'lanh ❑ ❑ ❑ 1 ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for ins0illation of the onsite sewage system shown on the attached plans. Plu er' Name: Prin Plumber's Si to St MP /MPRSW No.: Business Phone Number: �3l P umber's ress (3treet, Cit , State, i ode)° a S t IX. `COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D atelssued Issuing ent Signature (No Stamps) ,Approved C] Owner Given Initial q Surcharge Fee) Advers Determination 9,P,5 dD 6 �� X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL. SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber lee, 0 4r6 y0 s� 1S ���,e /..&lam l�J,�/z� /`�FO��/ � �- �` _ a 2 � 3 we �x 11 Qfi� r Wisconsin Department of Commerce SOIL AND SITE EVALUATION 1 3 ' Divi*lrof Safety and Buildings Page of Bureau of Integrated Services in accordance wit$3 69, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches 4 Plan mull. 'Iounty include, but not limited to: vertical and horizontal reference point directieilC frn St. Croix percent slope, scale or dimensions, north arrow, and location an nce to neatestrb' Panel I.D. # APPLICANT INFORMATION - Please print all inf V btion. ; f ,, ~' Reviewed by Date Personal information you provide may be used for secondary purposes (Pri l w, s. 15. &Nffli W. 4 Property Owner r Property LoceNotl- ,� Richard Stout ` -�' revt: f 5' 1/4 NE 1/4 15 T 31 N,R 19 E (or* Property Owner's Mailing Address LGtu_ ock# Subd. Name or CSM# -7 � 1353 Awatukee Trail 6 Shadow Pines City State Zip Code Phone Number Wi 54016 71 5 49 -6731 ❑City ❑Village ® Town Nearest Road Hudson ( � Somerset 60th Street ® New Construction Use: Residential / Number of bedrooms 4 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 600 gpd Recommended design loading rate • 7 bed, gpdO • 8 trench, gpd /ft Absorption area required 858 bed, ft2 7 5 0 trench, ft Maximum design loading rate ' 7 bed, gpd /fie • 8 trenc d/ft Recommended infiltration surface elevation(s) See p lot plan .rte ft (as referred to site plan benchmark) 4.� Additional design /site considerations 14 L."I S i �/l #J C Ld� / Parent material COC Flood plain elevation, if applicable S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system [NS ❑ U I ®S ❑ U ® S ❑ U ®S ❑ U ❑ S in U ❑ S :E] U 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 1 1 0 -6 1 0yr2 /1 none sil 1 m{):J.K mfr cs 1 f 4 2 6-30 10yr3/6 none sil 1 'rfieoK mfr cs -- ' Ground 3 30- 0 10yr4/6 none ms osg ml -- -- .7 .8 elev. 1 95 .1 11 ft. Depth to limiting factor rf 8 0 in. Remarks Boring # , 1 0 -6 10yr2/1 none sil 1 MA (X mfr cs if ". / 2 2 6 -36 1 0yr3 /6 none sil 1 m�K mfr cs -- �.6 3 36 -84 10 r4/6 none ms osq ml - -- .7 '.8 Ground elev. 92 .e ft. Depth to limiting Barr �y in. Remarks: CST Name (Please Print) Signature / Telephone No. Address Date CST Number _ Sz -14- P «'i �'C '� CAL PROPERTY OWNER Richard Stout _ SOIL DESCRIPTION REPORT Page 2 t PARCEL I.D.# Boren # Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3 1 -6 1 0 r2/1 -- it 1 rn CS if 5 .6' r 2 - 3 6 10yr3/6 hil 1m,(4 mfr cs r . Ground 3 6 -9 ) 10yr4/6 ins osg ml cs -- .7 -.8 elev. 95. ft. Depth to limiting factor 9 in. emar�ts: Boring # 1 0 -3 �Oy 2 / 1 -- it 1 mjvO& mfr cs 1 f ' .,:. - -- ma , 2 3 5 re osg ml cs -- .7 :8 - -- s Ground elev. 95. ft. Depth to r, limiting factor 8 in. '7?i •Z� Remarks: F2 Depth Dominant Color Mottles Structure GPD /ft Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench Boring# 0 -3 10yr2/1 -- it 1,MA mfr cs 1f y 5 -24 10yr3/6 sil 1 M mfr cs -- .5 '. 3 24 -84 10yr4/5 -- s osg ml cs -- Ground elev. 92. ft. Depth to limiting 17(0 factor 8 4Z in. Remarks: Boring # i3 Ground elev. ft. ' Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) PROPERTY Richard Stout _ SOIL DESCRIPTION REPORT Page 2 PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed . Trench 3 1 -6 1 0 r2 1 -- it 1 MAb nf.i r; cs if . 26' 3 2 - 36 10yr3 /6 -- it 1riIAL mfr cs -- ;.6 Ground 3 6 -9 10yr4 /6 ins osg ml cs -- .7 '.8 elev. f5. 10 ft, Depth to limiting factor 9 0 in. Remarks: Boring # .Z 3 L 1 0 -3 10 r2/1 -- it 1 mfr C 1f -- mg g osg ml cs -- .7 '8 -- s .3 14 -oLt IVYL /10 Ground ' elev. 9 5 .2�ft. Depth to limiting factor 8 4 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 # 1 0 -3 1 Oyr2/ 1 -- it 1.ry1«} mfr cs 1 f E � 2 3 -24 10yr3/6 sil 1 MA mfr cs -- ".5 iaw 3 24 -84 10yr4/5 -- s osg ml cs -- .7�.8 Ground elev. 9 2 . Depth to limiting factor 8 in. Remarks: Boring # Ground elev. ft. , Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) ele ')• iod ��OLte Efre 4) it �6 ,14447 . 13 Cv o IJ L q s 43 i , 13�i1 • I . ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERS141P CERTIFICATION FORM OwnerBuyer �`I� TA Mailing Address P-)S "fr. )4kp3Q" Property Address t q (q AN E (Verification required from Planning Department for new construction) City /State 5( mt f - 5 c� Parcel Identification Number LEGAL DESCRIPTION Property Location s5.6� ' /,, �� '/,, Sec. � , T,,?/ _N - R 9� W, Town of s�i/e � • Subdivision Lot # s �• %,eruuea aurvey Map # , Volume , Page # Warranty Deed # /,ZA Z Volume , Page Spec house yes 0 no Lot lines identifiable �J yes 0 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 masterplumber, jourrrcyman 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. 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. - A ­ Ln� - �/ / q SIG14ATURE O 1 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. 9///9 SIG14ATURE 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 - UL 1- �l.urAGt14_I STATE BAR OF WISCONSIN FORM 2 — 1982 601 0631 WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS DOCUMENT NO. ST. CROIX CO., WI RECEIVED FOR RECORD RICHARD n STAILT and TANPT P STOUT hushanci 04 -05 -1999 9:30 AM and wi fa IORRANTY DEED EXEMPT N CERT COPY FEE: conveys and warrants to M P . C� , T Nr _ COPY FEE: TRANSFER FEE: 133.80 RECORDING FEE: 10.00 PAGES: 1 THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in S t Croix County, ��� Q v ev Ham-' %w State of Wisconsin: Lot 6, Plat of Shadow Pines, Town of Somerset, St. Croix County, Wisconsin. 032- 1042 -10 -000 PARCEL IDENTIFICATION NUMBER 032- 1042 -30 -000 032- 1042 -30 -000 032 - 1042 -50 -000 032- 1042 -70 -000 This i S riAt homestead property. (is) (is not) Exception to warranties: easements, restrictions, rights -of -way and covenants of record. Dated this end day of Apr i 1 A.D., 19 9 9 (SEAL) Janet P. Stout (SEAL) (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. St. Cr oix County authenticated this day of 19 Personally came before me this grid day of April , 19 9 9 , the above named Richard O Stout and Janet P Stout TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Stats.) to me known to be the pe on F xecuted the foregoing instrument and acknowle pCOB THIS NS UM TWA DRAFTED BY (fib S Jane'tou Of �r h s c 1 Awatukaa Tr Soh hudson, Wi. 54016 Notary Public, County, Wis. (Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not statyxpiration necessary.) — i . Names of persons signing in any capacity should by typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Bla Form No. 2 — 1982 Mm. . w i w � N UNPLATTED LANDS OF OWNER J 175 W Z --------- S89'26'46 "E 1271.82' -- - - - - -- ---------- 1238.82'----- - - - - -- DEDICATED THE PUBUC TO R C - -- - - -- 232.01' - - -- - -------- N89'26'46 "W 1239.60'------- - to Lo 1 3,3' - +-- - --�,. :'`�•�'T % ti--- - - - - -- — — - - - -- -- I 1 1 rn rn � . 'QO ,� �,�.. M �.•�a 239.27' 12' UTVTY I N EASEMENT \! 1 ........ o: � ...1. . • .. .....�� �.SJ� . ^"' . .................... ... N ... . W C '4 �, 4 / N7 � N o 131.304 SQ. FT. io 131,940 SO. FT. 3.01 ACRES Z 3.03 ACRES z 6 131,150 SQ. FT. 3.01 ACRES S89.26'46 "E 91_17_ �P ,% i r x I N89' lLl M �x x Z a� , / xx x� x N � Ij) W M U) , PO: � iN cMD 25 YR H W,L. Y > Q� 0061 hlxrYy z� �, yXs2sJlsv'n� X�< to "� N CERTI VOLU !a 778.42' O N89'26'46 "W � 169.59' - Z o N 0 I 1 208.00' 211.57' N89'.' - - -- ----- N89 2115.60'----- -- R= N89'38'55 "E - ---- - --(TO WEST 1/4 CORNER) N8726 -46 "W 5331.35' - � L /NE OF THE SE 114 OF R= N89'38'55 "E T "yE NE l/4 (EAST —WEST 114 L /NE) UNPLATTED LANDS __ -