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HomeMy WebLinkAbout032-2116-60-000 r ST. CROIX COUNTY ZONING DEPAR,� AS BUILT SANITARY REPOR �'��� l ll Owner tai'' --er S I ^> ' move Property Addres -' City/State .a�'��•�', taws 1' Legal Description: Lot Block Subdivision/CSM # ,2� S ' /4. '/4 Sec. lC T I N -R '? W Town of f.�sr' SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: �� I Tank manufacturer Zh Size ST/PC' / Setback from: House � Well P/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 f'-1'-0-1"c )l Width 3 Length 5 Number of Trenches Setback from: House Well P/L Vent to fresh air intake 8 7 ELEVATIONS Description of benchmark Elevation �' Z- Description of alternate benchmark Elevation .3 - 0_ Building Sewer '�� ` ST/HT Inlet ` (P - / 3 ST Outlet of • 9 Z-- PC Inlet 9 Y • ° 9y. Zd PC Bottom 93• v 7 - Header/Manifold Top of ST/PC Manhole Cover C/( Distribution Lines ( j) W ( ) Bottom of System (1) Final Grade Date of installation 71L71 f �Permit number .336 State plan number Plumber's signature License number 87 Z Date i2 9 Inspector A t N Complete plot plan Or 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. i i 1 5� 2 t lVed 14 e , INDICATE NORTH ARROW Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanitaryPerm IX Personal information you provice may be used for secondary purposes [Privacy Law s.15.04 (1)(m)). 33 8 9 58 Per C m eCOREY El City a Villa . % E 9 Town of: State Plan ID No.: CST BM Elev.:- Insp. BM Elev.: BM Description: OM Parcel Tax No.: 00 I m � TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. Septic �� �� Benchmark Q. ';1, (02- 1� 2. Dosing /, .4M Aeration Bldg. Sewer Holding St /Ht Inlet G --2f 46,1 TANK SETBACK INFORMATION St /Ht Outlet G - gS. 9Z TANK TO P/ L WELL BLDG. Air i to ntake ROAD Dt Inlet Air Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System g ' / 6 1. It a 93. oz PUMP/ SIPHON INFORMATION Final Grade 3 b/Z Manufacturer --Demand 96, k'Z. Model Number GPM TDH Li Friction Syste Ft L oss e Forcemain Length Did. Dist. To Well SOIL ABSORPTION SYSTEM LZ) 3' x S� t�,.u,,�s eA•-L• BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING anJ�f� ure : _ St INFORMATION Type O CHAMBER M del Number- System:� ��O 3 OR UNIT Aer — /O DISTRIBUTION SYSTEM Header /Manifold Distribution Pipes) x Hole Spacing Vent To Air Intake Length "19-- 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 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: SOMERSET 15.31.19,SW,NE 575 217TH AVE — SHADOW PINES LOT 9 t D W� � �1 A4, b Plan revision required? ❑ Yes No n Use other side for additional information. T et.� ° � ° l s Z SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. Safety and Buildings Division Visconsin SANITARY PERMIT APPLICATION 201 Box Washington Avenue 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 Sanita Number Personal information you provide may be used for secondary purposes ❑ Check it r evision tprevious - application IPrivacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Owner Name � ro�erty LDC 1�4 - S /5 T � � , N R f � E (or)� C o t e Rec l S© A- N Property Own s Ma ing Addre s i Lot Number Block Number Ci Sta a Zip Code Phone Number Subdivision ame o CSM Numbe S O �✓YJ7 r / �l 1 (4.r/ ) t�'.S'�ol d d b II. TY PE OF TDING: (check one) E] State Owned [I it Nearest Roadd,, Village �-.�.� r� -f+ Public or 2 Family Dwelling - No. of bedrooms Town OF III BUILDING USE (If building type is public, check all that apply) Panel Tax Numbers) 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 Q Hotel /Motel 9 Q 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 E3 Replacement 3 [] Replacement of 4_ E] Reconnection of 5 [3 Repair of an System ____ ___System _ ______ ______Tank Only_ ____________ Existing System ________�Existinc�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 Xseepage Trench / // l 22 E] In- Ground Pressure 42 [] Pit Privy 13 Q Seepage Pit In 4 ` -4 �i� � 43� Vault Privy 14 E] System-In-Fill ,S�'�� W , ,� c/�,.L uA, TS 31. cS lt,v VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc_ Rate 6. SysteT Elev. 7. Final Grade Required (sq_ ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) 9Y. 3/ �, p Elev�ti n 6 s� �o� T 7 Z- / 9 Feet J'� y' ,9J`'eeet act VII TANK in Ca pact s Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete con Steel glass Plastic App New Existin structed Tanks Tanks l ptic Ing an X /4 0� d�..1 Q�_ ❑ ❑ ❑ 1 ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sew stem shown on the attached plans. Plumber's Name: (Prink P �Sjgnature '(No Stam ps) M PRSW o.: Business Phone Number: Plumbers Address (Street, City, State, Zip Code): &/ S G & © - . 1 " 1 1 ve, 4LIr & r` IX. COUNTY / DEPARTMENT USE ONLY Q Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Age ignature (No Stamps) Approved []Owner Given Initial ` t0 Surcharge Fee) Adverse Determination ��.J �� / �< X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVA • I�PiJ . • U 1 2a. 5 . SBD- 6398 (R.11197) 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. 111. 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. G � o *` '05 c �� T a a 1IC £d / ` r " �i'11 OL 1 ec 4e ?dam �� � �t / D,�, -r► �'tJ i 1 ,/�,,�/. ASS / /� -5� - iv f it t I l 3� I' a C P 3 3 x S� a + 9 3. v z z J`7 Z Wisconsin Department of Commerce SOIL AND SITE EVALUATION 1 3 Division of safety and Buildings Page of Bureau Irftegrated Services in accordance with s. A9,_Wis. Adm. Code *ty Attach complete site plan on paper not less than 8 1/2 x 11 inches in siz Rl�prtiust include, but not limited to: vertical and horizontal reference point (BM) on a Croix L .: i`�,rr r' ri percent slope, scale or dimensions, north arrow, and location and dist ,fo near Parcel I.D. # APPLICANT INFORMATION - Please print all inform tig. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy 15.04 (1) R OIX Property Owner PiiOF�ti6 Richard Stout v Lot SWj < °' :,ii NE 1/4,s 1 5 T 31 N,R 1 9 E (or) W Property Owner's Mailing Address # • i 1353 Awatukee Trail Ibckfa� ubd. Name or CSM# 9 � Shadow Pines City State Zip Code Phone Number ci ty ❑ Village f] Town Nearest Road Hudson Wi 4016 f15 149 -6731 ❑ Somerset 160th Street ® 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 85 bed, ft 0 trench, ft 2 Maximum design loading rate . 7 bed, gpd/ft . 8 trench, gpd /ft Recommended infiltration surface elevation(s) SPe — n 1 of I 1 an ft (as referred to site plan benchmark) Additional design /site considerations Parent material CoC2 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 ❑ U Ex S ❑ u O s ❑ U 1 0 s ❑ U I ❑ s FRI u ❑ S Q U SOIL DESCRIPTION REPORT Boris # Horizon Depth Dominant Color Mottles Structure GPD /ft 9 Texture Consistence Boundary Roots in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 1 0 -6 10yr2/1 -- sil Imabk mfr cs 1f .5'.6 2 6-80 10yr4/6 -- ms osg ml - .7 - .8 Ground elev. 94 60 ft. Depth to limiting , f18 II JJ in. Remarks: Boring # 1 0-14 1 0yr2 /1 -- sil Imabk mfr cs if .5 .6 2 2 14 -72 10yr4/6 m s osg ml -- -- .7 ;.8 Ground elev. 97 ft. 37 Depth to limiting factor 7 2 in. Remarks: CST Name (Please Print) Signature Telephone No. �' f ct, r- +' �i ,cam• vt-z �( ��r'' �_-� � ��� -- 3 l Z Address Date CST Number Richard Stout SOIL DESCRIPTION REPORT , PROPERTY OWNER — Page � o� 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 0 -6 10yr2/1 -- sil mabk mfr cs 1f .5 '.6 2 6 -80 10yr4/6 -- s osg ml -- -- .7 '.8 Ground elev. 95 tt Depth to limiting 'G factor 8 0 in. Remarks: Boring # 1 0 -6 10 r2 1 sil mabk mfr cs 1f ,. y / -- 4 2 6 -8 10yr4/6 -- ms oscf ml -- - Nu Ground elev. 92. ft, Depth to limiting factor 8 0 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 -6 1 Oyr2/ 1 -- sil mabk mfr cs 1 f .5 ' . 6 5 2 6 -8 10yr4/6 -- ms osg ml -- -- .7'.8 Ground 97.4 tt. v Depth to limiting factor 8 - —in, Remarks: Boring # Ground elev. ft. Depth to limiting factor in ' Remarks: SBD -8330 (R. 07/96) y � J [3� °r�Vt �►,n�k eky, i00' �y "act rye tl ma rk, /()0 j,,.L)L ,i-zr-E r IttAc JK\ 3 ,00 rJ a� �a a ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer a d Mailing Address 9 1 S M Q (+ d M cj /' Av Property Address \5 7 S"" c 2 / � zk (Verification required from Planning Department for new construction) City/State Parcel Identification Number LEGAL DESCRIPTION Property Locatio ' /,, A�C '/4, Sec. T_3 I_N -R W, Town of -50 P-5j Subdivision d o cJ 2t,, Lot # Certified Survey Map # . Volume �y Page # Warranty Deed # 9 (5 :39/ c2 . Volume . Page # Spec house ❑ yes k no Lot lines identifiable )� 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. Itwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your snk y0onylias been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days o e ex ' tion date. S / A LICANT DATE OWNER CERTIFICATION I we) certi a a tements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the prop desc ' ed v , by virtue of a warranty deed recorded in Register of Deeds Office. S A / f 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 x29PAGi: 502 �v STATE BAR OF WISCONSIN FORM 2 - 1982 Es03912 WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS DOCUMENT NO. ST. CROIX CO., WI RECEIVED FOR RECORD RICHARD O STOUT and JANET P STOUT, husband 05 - 1999 9:00 AM and wife WARRANTY DEED EXEMPT N CERT COPY FEE: cones and warrants to COREY R. CARLSON and LINDA M. COPY FEE: Y TRANSFER FEE: 140.70 CARLSON husband and wife RECOR DING FEE: 10.00 PAINTS: 1 THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in St. Croix County, State of Wisconsin: U / •, Lot 9, Plat,of Shadow Pines, Town of Somerset, kTNA64 t St. Croix County, Wisconsin. L' ,f-� c,ad�. �i4Rlso� 032 - 1042 -10 PAACE TtF R 032- 1042 -40 032- 1042- 50 - -.. 032- 1042 -70 This i s not homestead property. (is) (is not) Exception to warranties: easements, restrictions, rights -of -way and covenants of record. Dated this 26th day of May A.D., 19 Richard I I t (SEAL) �A (SEAL) (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. St Croi County authenticated this day of 19 Personally came before me this 6th day of May , 19 -9-9_ , the above named Ri rhard Q, gf-nnt- and Janet P Stntlt TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Stats.) to me known to be thN TA UBLeCuted the foregoing instrument and as C0 NS1N THIS INSTRUMENT WAS DRAFTED BY KERNON J. 6 ST Janet P. Stout _ u Hudson , W i _ 54016 _ _ - Notary ublic, k County, Wis. (Signatures may be authenticated or acknowledged. Both are not My mmission i permanent. (If not, state expiration date: necessary) I A W) " Names of persons signing in any capacity should by typed or printed below their signatures. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc. WARRANTY DEED Form No. 2 — 1992 Milwaukee, Wis. '� J rr �� �--- w r O rn 0 0 I 0 V UNPLATTED LANDS IOF OWNER I t0 I O j I r7 I ---- S89'26'46 "E 12 I _ - - - -- -- 15 R O , / 3'0'20. TOWN _ _ '56!04"E - -- / 578 p - - - - - - -N8926 46 "W 1239. - - - - -- __ _ —__ 0 - Tl B 5 ;- _ _ 1 _ 1 0 I 23.57 /': 246.02' 3 pE0 _ »E 78 — \� 1 -\ �� 3 I 72' UT/L/TY - 2 1 EASEMENT 1 I LP .......... .. .. 1 �• I� � N I 1 6 Ln 1 1 �n I 00 V 131,150 U' �' �1� j 131,150 So. 10 -- 131,028 SO. FT No 1 18 3.01 ACRE: 131,113 SQ. FT N 3.01 ACRES 0 1 131,284 SO. FT. m ; 3.01 ACRES 3.011 ACRES m rn v Vi Lp m \ m \` S O S 331.20' AI, gao ------ N89'26'46 "W 204.58' •:1s4.c 2115.60' - - - - -_ - - - - R =N89'38'55 "E � AlL / al,, WETLAND SOUTH L, 5 331.35' (TO EAST 1/4 CORNER) -- - - - - -- - THE NE R= N " E 25 YR H.W.L. ,x - 918.37