HomeMy WebLinkAbout038-1185-30-000 ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SAM[TARY REPORT
Owner
Property Address d . 2 J>
City /State 1 YQ e 7
Legal Description:
Lot 3_ Block Subdivision/CSM #
5 ' /,. t /4, Sec. /Z T / N -R /8 — W, Town of PIN # �� �`' `'�1'3 ' -T
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer Size -'/PCB / Setback from: House 8 Well US 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: g ey Width A? — Length 3 C Number of Trenches
Setback from: House -41* 7 WelL P/L Vent to fresh air intake .5
ELEVATIONS
,03.1
Description of benchmark I 1/C Elevation fop
Description of alternate benchmark Elevation
Building Sewer c X, S&/HT Inlet c � ST Outlet 9l ` P O 2. PC Inlet
PC Bottom Header/Manifold Top of ST/PC Manhole Cover
Distribution Lines
Bottom of System
Final Grade O 9 71 - 7 -
O ( )
Date of installation Ln/ 41`ermit number ,73k7os` State plan number
Plumber s ignature ' i nature License number ZZ /S/y f Date
Inspector
� Complete plot plan p'
y
f
I
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
�t
r 3�
211 4
INDICATE NORTH ARROW
Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count
INSPECTION REPORT ST. CRO X
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar BIgrgt&g.:
Personal information you provice may be used for secondary purposes [Privacy Lam, s.15.04 (1)(m)].
PerlpLtHolder'S1Vagq @: El Citg7gkIlaPv�T�vp�of: State Plan ID No.:
CST BM Elev -:- �1riV Insp. BM Elev.: BM Description: Parcel T ®x.:1185-30 - 000
/SU, O� o Q , 00 A9900126 l
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS - ELEV-
Septic ,r� Q' „r Benchmarks 3,1 /93- r'
Dosing
Aeration Bldg. Sewer
Holding St / tZ Inlet ` 9L • 3 '
TANK SETBACK INFORMATION St/ lit Outlet
TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet
irl
Septic mad T ��' s�s , NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe 5ly� S,�
Holding Bot. System �.a -11- '
PUMP / SIPHON INFORMATION Final Grade 7 S • �, JS�
Manufacturer Demand
Model Number GPM
DH Lift Friction Syetem TDH Ft
Forcemain Length Dia. FFii Dist. To Well
SOIL ABSORPTION SYSTEM _
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIME N ION ' 3G ' / DIMENSION
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER Model Number:
INFORMATION Sys /�°wt ssl y lb , y/ � 'SUS OR UNIT
System:
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length 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.)
LOCATI STAR PRAI / RIE 13.31.18.934,SW,SE 1390 211TH AVENUE
r
/
Plan revision required? ❑ Yes M�
Use other side for additional information. 6 / 7 .v 6
SBD -6710 (R.3/97) Date Inspe or's Signature Cert. No.
Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 W. Washington Avenue
Visconsin In 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 system, on paper not less county
than 8 1/2 x 11 inches in size. ST.
• See reverse side for instructions for completing this application State Sanitary Permit Number
Personal information you provide may be used for secondary purposes E] check if revision to NO. plication
[Privacy Law, s. 15.04 (1) (m)). State Plan I.D. Number
1. APPLI ATI N INFORMATION - PLEASE PRINT ALL INF RMATION
Property Owner Nam Property Location pr n
s t 4 SW 1/4 S`� 1/4, S /3 T 3 / , Nr V 0 E (or) 10
Pro pert O er's ailing Address J�ubdivot Number Block Number
G �
City, State Zip Code Phone Number is, Nam o er
�(RJ 01 H Ql ) 21 / e-'r X A TS
II. TYPE OF BUILDING: (check one) ❑ State Owned / o Cit TN Road
[] Village 1 ( } y A 00 ,.
Public 1 or 2 Family Dwelling - No. of bedrooms � Town OF Qiv
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 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
11ig[Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit /gX3G 43 ❑ Vault Privy
14 ❑ System -In -Fill
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_) ProJ�osed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
qSO (o y,3 b W — 95�� Feet 97 5(.3 Feet TANK Capacity
VII. INFORMATION in ga llons Total # of Manufacturer's Name Prefab. Con- steel Fiber- plastic Exper.
New Existing Gallons Tanks concrete strutted glass App.
Tanks Tanks F 49 eptic Tan or ® ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ I ❑ 1 ❑ 1 ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plum er's Signature: (N amps) MP o.: Business Phone Number:
ZZ AV7 G 3 7
Plumber's Address (Street
ty, State, Zip ode):
3 /Yo 5 14me, w.,as`voo
IX. COUNTY/ DEPARTMENT US ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater a r9 i�� te Issued Issuing Agent Signature (No Stamps)
[v] El Owner Given Initial t9i:� Surcharge Fee)
1 �
Adverse Determination m tlon
I
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (8.11197) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
eve IQ�n e/ 7 �¢•► �.
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Al" At "A'St'LO 1►JCH =S SUT i.t0 "Ott - r"AW 42 1uLHES pflOW FIPJOkL GRADE
MAXrWA 0EPr4 O F EXCAVATION FR0m ORia1N„ b9Aolt \, 'IVL ec / ! Z 1"CHEs
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. Wisonnzin Department of Commerce SOIL AND SITE EVALUATION Page 1 of —
Division Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
Crille Trucking & Excavating, Inc.
Attach complete site plan on paper not less than 8% x t 1 inches in size. Plan must County
include, but not limited to: vertical and hrizonta n BM), direction and _ St. Croix
percent slope, scale or dimensions, ;n nd t� 09n tance to nearest road. Parcel I.D.#
f
APPLICANT INFORMATION se rir*U in on. — - -- - --
Personal information you provide may be u 1 sewn Rya nvac 15.04 (1) (m)). R ev i ewe d By Date
Property Owner + Property Location
Casey, Dan IQ07 - Govt. Lot SW t/4 SE im,S 13 T 31 N,R 18
Property Owner's Mailing Address u''+ ST CROIX i Lot # I Block # Subd. Name or CSM#
323 S awmill Lane COUNTY _ 3 Priarie Flats
-- ---
City State r e e \ (� City F1 Village Town Nearest Road
New Richmond WI 15- b Star Prairie Hwy 65
New Construction Use: Resi er of bedrooms 3 []Addition to existing building
Replacement n Public or commercial describe
Code Derived daily flow 450 gpd Recommended design loading rate 7 bed, gpdA .8 trench, gpdfft
Absorption area required 643 bed, ft 562 trench ft Maximum design loading rate .7 bed, gpdfftz .8 tr ench, gpolfF
Recommended infiltration surface elevations) y r ft (as referred to site plan benchmark)
Additional design 1 site considerations
Parent material -wash 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 N S❑ U ❑ S❑ U ❑ S U ❑ S❑ U ❑ S❑ U ❑ S N U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD/ft
Boring# Horizon Bed Trench
in Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. C onsistence Boundary Roots - --
1 1 0 -15 7.5YR2. -- - - - - -- SIL 1FA MVFR AW 1VF .2 .3
2 15 -32 7SYR416 --- - - - - -- CL IFABK MVFR AS 1VF 2 .3
- - -
Ground 3 32 -99 7. 5YR5/3 ---- - - - - -- S O -GR ML - - -- - -- .7 .8
3 '
Depth to y —
limiting
factor _-
99 in.
Remarks:
2 1 0 -12 7.5Y R2.5/1 — -_ -_— S11L 1FAB MVFR AW 1VF .2 .3
2 12 -33 7.5YR4/6 --- -- - - -- CL 1FAB MVFR AS 1VF .2 .3
Ground 3 33 -96 7.5YR5/3 ---- - - - - -- S O -GR ML - - -- - -- 7 .8
ele - --
Depth to
limiting
factor
96 in.
Remarks: - -- - - -- - - - -- -- - -
CST Name (Please Print) ature: Telephone No.
DENNIS GILLE �/ - - - -- --- - - /�'= ?4 r _G 6 7
Address CST Number Ref #
377— N O S T j4mep, [� t oo 96/97 3 Yo 106
PROPERTY OWNER: Casey Dan SOIL DESCRIPTION REPORT Page 2 of
- PARCEL I.D. #_ Gille Truckiniz Truck" & Excavatin, Inc.
Depth Dominant Color Mottles Structure GPDt
Horizon in Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. � onsistence Boundary Roots ---
Tr
Bed ench
3 1 J13-36 7.5YR2.5/1 -- - - - - -- SIL IFA MVF AW IVF .2 3
2 7.5YR4/6 --- - - - - -- CL 1FABK MVFR AS 1VF .2 .3
Ground 3 7.5YR5/3 - - - - - - -- S O -GR ML - - -- - -- .7 .8
elev - - - — - - - - - - -
Depth to
limiting - —
factor lie
96 in- , - - -- - - -- — - -- - - - - - -- - -- - - - --
Remarks:
4 1 0_11 7.5YR2.5/1 -------- SIL I — 1FA MVFR AW 1VF .2 .3
2 11 -26 7.5YR4/6 --- - - - - -- CL 1FABK MVFR AS 1VF .2 .3
Ground —
3 26 -96 7.5YR5/3 ------ --- S O -GR ML - - -- - -- 7 .8
elev
Xtr
Depth to
limiting --
factor —
{
Remarks: — _ -- - - -_ _ —_ —_ —_
5 1 0 -12 7.5YR2.5fI -- - - - - -- SIL 1FABK MVF AW 1VF .2 3
2 12 -31 7.5YR4/6 --- - - - - -- CL 1FABK MVFR AS 1VF .2 .3
elev 3 31 -98 _ 7_5YR5/3 -- - -- S O -GR - I - - ML _ -- --- - -- .7 .8
Ground —+
Depth to
limiting -- -
factor
Ab
98 in.
Remarks:
Ground-- - - -- - - - - -- --- - - - - -- -- ---- - - - - -- -- -- - --
elev
Depth to
limiting —— -- — —
factor
Remarks:
i
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343
ST CROIX COUNTY
SFpTIC ':'ANK MAINTENANCE AGREEMENT
AND
GWP ERSHIP CERTIFICATION FORM
O _ ��-�/C _ �✓ fi�,,�
Mailing Address �tl .�! / � VW 7
Propenly Address
(Varificatrorx required frou i Planning Dbparment for new constntetion)„_� J
City /State -AL Parcel Identification Maribor �.Q� 8' Z j 19S "��
L E GAL, I)ESCRIPTIO
Property Location SW ► /�,�_ % Ss c. /3 . T /_ ,fit -}/ W, Town ofT —
Subdivision �if -Qv�.l �� Jot #
Certified Survey Map # Volume Page # _
Warrant Deed # i I
Warranty � �.�-- �`'...C�.� . Volume `��� Page # __ ^ ` y..�___._•
Spec douse ❑ yes 0 no Lot lines identifiable 9 yes ❑ no
SYSTEM MAMFNANCE
Improper use and maintenanceof your sel pc aystetn could result in its p rematu re failure to bandie wastes. Proper ma.inteu =ce
consists of pumping out the septic tank every tbrt a years or sooner, if tttedod by a licensed pumper. What you put into the system
can affect the f mcdon of the septic tank as a tmi ime ut stage in the waste disposal system
The property owner agrees to subuutt to St, Cx*ix Zoning DeppLtnent a cartlflcation form, signed by th e owner and by a
masterplumbbr, Journeymanp1mber, resttietedpl uraberor a licettatdpumper verifying that (1) the ou -site wastewater dispo s al system
is in proper operadug cond.itinn and/or (2) after in: �ection siod pumping (if Necessary), the selstic tannic is less than 1/3 full of sludge.
I/we, the undersigned have read the above requirti tusnts and aveo to maintaia the private sewage disposal system with the standards
set forth, herein, as set by the Departmett of CoT. sere and the Department of Natural ResowteR, Ststo of Wisoornsla. Ctwt,AdAtion
stating that your septic system has been maintainer I must be completed and mturnad to the St. Uotx County Zoning Office within 30
days of a 6ree year expiration 6te.
SIGNATM OF APPLICANT DATE
O WNER CERTIFT1 ATION
I (ate) certify that all statomonts on this ; ► cm are true to th e best of my (our) knowledge. I (we) am (are) the owner(s) of
tine property described above, by uc of a warm ity decd recorde:l in Rtg;ster of Deeds Office.
CGNATURE OF APPLICA2Q'T DATE
•., F " "'' Ajay information that is mis- represented rr ay result in the sanitary permit being revoked by the Zoning Department. • "� ••
Include with this application: a stamped warn tnty deed from the Register of Deeds office.
a copy of the a rtified sw inap if reference is ttade in the wgrranty deed
VOL 1�jp PAU?
STATE BAR OF WISCONSIN FORM 1 — 1982 60446
WARRANTY DEED KATHLEEN H. WALSH
REGISTER OF DEEDS
DOCUMENT NO. ST. CROIX CO-9 WI
RECEIVED FOR RECORD
This Deed made between Daniel J. Casey and 04 -01 -1999 10:00 AN
Betty D . Casey , WARRANTY DEED
husband and wife EXERT N
, Grantor, CERT COPY FEE:
and Steven D Rank and Ann M Rank, COPY FEE:
TRANSFER FEE: 56.70
husband and wi fp as survivor -sbiT RECORDING FEE: 10.00
marital property PAGES: t
Grantee,
Witnesseth That the said Grantor, for a valuable consideratio
conveys to Grantee the following described real estate in St. C r O i x THIS SPACE RESERVED FOR RECORDING DATA
County, State Of Wisconsin: NAME AND RETURN ADDRESS
�v H
Lot Three of Prairie Flats Addition in 5' j 9 S. K NoI✓�£s
the Town of Star Prairie, St. Croix
County Wisconsin. /�/ �-- R t w H I N�
�
038- Iris- 30 - 0 00
PARCEL IDENTIFICATION NUMBER
This is not homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And Daniel J Casey and Betty n raspy
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except recorded easements ,
rights or way and covenants.
and will warrant and defend the same.
Dated this 25th day of March 1 19 _2 — .
(SEAL) 6 (SEAL)
CZZ
Danie J. Case Bet D. Casey
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Wisconsin,
ss. -
St. Croix County:
authenticated this day of 19 Personally came before me this 2 5th day of
March 19 9 9 , the above named
Daniel J. Casey and Betty D. Case
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by §706.06, Wis. Stats.) to me known to be the person, S; who executed he [oregoing
instrumen and knowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
John D. Walsh
John D. Walsh
Notary Public, S t. C r o i x County, Wis.
(Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration date:
necessary.) November 25, 2001 , 19 .)
JOHN D. WALSH
• Names of persons signing in any capacity should by typed or printed below their signatures. Wisconsin Notary Public ��
STATE BAR OF WISCONSIN MY Commission Expires V1?, on? LegarAlank Co., Inc.
WARRANTY DEED Form No. 1 - 1982 Milwaukee. Wis.
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