HomeMy WebLinkAbout038-1174-10-000 ST. CROIX COUNTY ZONING DEPART�g'
AS BUILT SANfrARY REPORT'
Owner
Property Address
City /State h Is
w 0,yti0
Legal Description:
Lot /0 Block Subdivision/CSM #
�, ul ' /a /4, Sec. �, TAN -R,�W, Town of
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer Size ST/PC %Q� ! Setback from: House ul Well , PAL f, �—
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: Szo Width 1� Length ��— Number of Trenches
Setback from: House `�/- Well s T PAL -?6 Vent to fresh air intake
ELEVATIONS
Description of benchmar Elevation
Description of alternate benchi 41 J,J Elevation /&T -,g
Building Sewer ST/HT Inlet , �o %D ST Outlet PC Inlet
PC Bottom Header/Manifold Oq 9-s/ Top of ST/PC Manhole Cover za2 /-j
Distribution Lines () 9z g () ( )
Bottom of System O 9e,, 19z O ( )
Final Grade O /e2z / O ( )
Date of installation 'S /l'P!`l` ermit number State plan number
Plumber's s' tur License number Date / !
Inspector
Complete plot plan �
r
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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
Why
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INDICATE NORTH ARROW
Wistronsin Department of Commerce Count
PRIVATE SEWAGE SYSTEM
Safety and Buildings Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: ST CR IX
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 338814
Permit Holder's Name: ❑ City ❑ Village ® Town of: State Plan ID No.:
M & G INC. STAR PRIARIE
CST BM Elev. - - Insp. BM Elev.: BM Description: Parcel Tax No.:
11 0o corn 038 - 1174 -00 -000
TANK INFORMATION ELEVATION DATA A9900078
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
ep s Q Benchmark zv Lo , A6C)
Dosing /a3
Aeration Bldg. Sewer Z 1pl 9
Holding S / Ht Inlet �p, Z V
TANK SETBACK INFORMATION / Ht Outlet l00 - 0
TANK TO P/ L WELL BLDG. A ir ir I to ntake ROAD Dt Inlet
A
Septi 30' / NA Dt Bottom
Dosing NA Header / Man. Z00q Z Z 19'
Aeration NA Dist. Pipe L 3 g�
Holding Bot. System C ( tr
PUMP/ SIPHON INFORMATION Final Grade
S. / a/- 4.
Manufacturer Demand : o s D
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BE E N R ENN H Width Lena / No.Of�Tr riches PIT No. Of Pits Inside Dia. Liquid Dept
�/ DIMENSION
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING anu acturer:
SETBACK CHAMBER
INFORMATION Svst v 30 '�' 7s D OR UNIT Mo umbe
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
J
Length _�__ Dia. Length .5:iL Dia. Spacing V I � 2 2A
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: STAR PRAIRIE 15. 31.18 , SW, SW 1123 212TH AVENUE
0 'EllPrHa7r �a7�o� Of S /�k
3` /0 `, vw a %5 , 3> ry a r - _ 2 .
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Plan revision required? ❑ Yes ❑ No
Use other side for additional information. F(
SBD -6710 (R.3/97) Date Inspector's Signa a ert. No.
W �
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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SANITARY PERMIT APPLICATION Safety and Washington Division
V isconsin 201 W. Washin ton Avenue
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 81/2 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
ae
Personal information you provide may be used for secondary purposes 3 �
❑ Check it revision to previo0s a plication
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION
PropertyQwn er Name Property Location
114 cj 1/4, S T , N, R (or
Property Owner's MailingAddr s Lot Number Block Number
I City tate Zip Code Phone Number Subdivision N me CSM
- lJ c ( )
ll . TYPE OF BUILDING: (check one) ❑ State Owned Nearest Road
Public 1 or 2 Family Dwelling L an F - No. of bedrooms /
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 1 5- 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. F, New 2. E] Replacement 3. E] Replacement of 4_ E] Reconnection of 5. E] 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
11 to Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure . / 42 ❑ Pit Privy
13 ❑ Seepage Pit �' XS� 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.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min_ /' ch) Elevation
Z -112 1
Feet Feet
VII TANK
Ca acct
in gallo s Total # of Prefab. Site Fiber- Plastic Exper
INFORMATION New Existin Gallons Tanks M anufacturer's Name Concrete strutted Steel glass App.
Tanks Tanks
1 - 45 - tic T — ❑ ❑ ❑ 1 ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ I ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for i stallation of the onsite sewage system shown on the attached plans.
Plumber' Name: (Print Plum is gna a ps) MP /MPRSW No.: Business Phone Number:
Plumber's Address (Street City, Stat ip Code):
c ' e A-
Zk" IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing ARnt Signature (No Stamps)
V Approved ❑ Surcharge Fee) Owner Given Initial /Q
Adverse Determination ! Yhlb 4 "
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
`W-0 %6 4c.
DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
SBD- 6398 (R.1 1/97)
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:
1. 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 thefollowing: 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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Viscorrsin Department of Commerce SOIL AND SITE E ATION
Division of Safety and Buildings Page of
Bureau of Integrated Services in accordance with s. J LRR 3l (_ ys ' m. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size fJarf Co ,,\
include, but not limited to: vertical and horizontal reference point (BM), rretlon an ECG Lv
percent slope, scale or dimensions, north arrow, and location and dista e� nearest road. rcel+l B•
APPLICANT INFORMATION - Please print all informat' 'T Reviv6 Date
4b. (1) (m t1�
Personal information you provide may be used for secondary purposes (Privacy Law, � �1, A
i 4
Property Owner Locatiory -'
t, 1� `' 4 1/4,S T� ,N,R (or�
_ zZa Property Owners Mailing Address Lot # jl �(7 _ Subd. ame MCS
City Ste Zip Code Phone Number Nearest Road
❑ City ❑ VII ® Town
New Construction Use: J W Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow' Recommended design loading rate _. � bed, gpd/fi �
trench. gp
Absorption area required bed, ft .:2a,�! trench, ft Maximum design loading rate bed, gpd/(t gpd/ft
Recommended infiltration surface elevation(s) qqD ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material 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 P S ❑ U 0 S ❑ U [P S❑ U 19 S El U ❑ S (9 U ❑ S �z U
II'I SOIL DESCRIPTION REPORT
Borin # Horizon Depth Dominant Color Mottles Structure GPD/ft
g Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Ct. Color G Sz. Sh. Bed , Trench
" on r. //
O _ 5 b
., d
Ground
v. >s
Depth to
limiting
factor
Remarks:
Boring #
JA AS 05
_.
- .s .
Ground
le
ft.
4 Depth to
limiting
factor
>,2Ljn. Re arks:
CST Nam (P ase Pri , Signa re Telephone No.
ZZ
Address Date CST Number
'0c' S '
SOIL DESCRIPTION REPORT
PROPERTY OWNER �� � - %� - Page of �3
PARCEL I.D.# gss // Z"/ =& -FJc�
Boring Horizon Depth Dominant Color Mottles Structure 2
9 Texture Consistence Boundary Roots
x '
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Ground
elev. ZZ21b� ' 4
Depth to
limiting
factor
> 2 in.
Ct p• y
Remarks:
Boring #
Ground
elev.
Depth to
limiting S y.1
factor
-�in. oto.'tY
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots PD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring #
1.9 13 - - 4e
p� O r rrS
Ground
elev.
/eft.
Depth to
limiting X01.2
factor v 6
?min. Remarks:
Boring #
F
Ground
elev.
ft. ,
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R. 07/96)
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, e Ad
UNTY
ji s C R o r x Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan not limited to vertical and horizontal reference point (B
4b. M), direction and % of sl P #
dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION REVIE Y DATE
PROPERTY OWNER: P TY LOCATION `'
;e /c h A RD 5 7 v 7 GO T $ � to /A 1/4,S, �1 3 � ,N,R �� E (o Wi�
PROPERTY OWNER':S MAILING ADDRESS DC NAME'S M If
35 4 w,4 7 A T.P. ,
CITY, STATE ZIP CODE PHONE NUMBER CITY °` REST ROAD
ftu so.J ��s, 5y of� s�fq I �5'cv Cc
Ipt<ew Construction Use I &4-fiesidential / Number of b6drooms 3 + 0 4 [ ] Addition to existing building
[ I Replacement ( ] Public or commercial describe
Code derived daily Bow y �� gpd Recommended design loading rate bed, gpdm 1 - trench, gpdjt
Absorption area required SS bed, ft ?5o trench, ft Maximum design loading rate 7 bed, gpol'h , F trench, gpdM
Recommended infiltration surface elevation(s) SEg Q . 3 ft (as referred to site plan benchmark)
Additional design / site cons rations
Parent material SCS I 1 r3yiP,E'A f R 07 Flood plain elevation, if applicable ft
S =Suitable for system C,- lMIONAL MOU�I D a U IN GR ❑ D PRESSURE E AT-G a U S YSTEM 'as ❑ U El SM
tt��
U = Unsuitable fors stem S [I U LK5 LW
SOIL DESCRIPTION REPORT '�//e : NT" ,PEco�+/��Nt7Ej�
Boring # Horizon Depth Dominant Color Mottles Texture Structure�y Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Toich
13 o /o ye 3/z /S 1�l
Z — 14 ACS , 8
Ground 3 D - yp /o xe sX S. O S �� .1 •
elev.
/D is ft.
Depth to
limiting
factor
> i
i
Remarks:
Boring #
... / o -!l to Y 3! C_ Z 7�
3
2- l/- yG 7, 5 y)e y �c� �J s CW 7 i
Ground
elev.
/ 6 a/,j ft.
Depth to
limiting
factor „
Remarks:
T Name: - Please Print R d Q C R T 2A L Q R I'C I-, T- Phone. 7 38( o _ 818 JC
Address: o -
Signature Ulbricht & Associa Date: CST Number:
Private Sewage Consultants
$55 O'Neil Rd.
Hudson, Wis. 54016
ORIGINAL
PROPER!YOWNEA RI?AMP 54007 SOIL DESCRIPTION REPORT p Z 3
age _ of
PARCEL I.D P / y Er_
I
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Barry Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed I et CS
Z g -3o '7,s Y A / s �1L
Ground 3 30 yo is M
elev.
I
Depth to
limiting `
factor
Remarks:
Boring #
E) l 1 0- - r es
Ground
elev.
I �
Depth to i
limiting
factor
Remarks:
Boring # ,
1 o -/o /a 3/� - / / ,Q c
—
-30 /o y S. 0 S SL. C
Ground
I el =
ft.
i
I I
Depth to i
limiting t
factor , r ^
Remarks:
Boring # }
I .... 1
1
Ground
elev.
(t.
Depth to
limiting
factor
Remarks:
0011 O•f7n10 /\C Mn\
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer �l �-
Mailing Address 135 PAW NT u, R, HL,P St+rJ
Property Address I / ,5L3 a I
(Verification required from Planning Department for new construction)
City /State Parcel Identification Number C IP 11 - 00 b
LEGAL DESCRIPTION
Property Location ' / <, ' /a, Sec. 1 , T -R _,Zff_ W, Town of
Subdi
Certified Survey Map # , Volume , Page #
Warranty Bred # 511 O � �/ . ,Volume ID!!�_ Page # P
Spec house ,19, yes ❑ no Lot lines identifiable•p!� ❑ no
SYSTEM .MAINTENANCE
peruse and maintenanceof your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every ,t, - ^^ :r ^^^Aed J y 2 t irrncr•rl n,?mnvr what vnn nttt into the SV00 -
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, 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 fuII 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 Zoning Office within 30
days of the three year expiration date.
S14TATURE qF APPLICANT DATH
OWNF,R CERTIFICATION
I (we) certify that all statements on this form arc true to the best of my (our) knowledge. I (we) ant (are) the owner(s) of
the p described above, by virtue of a warranty deed recorded in Register of Deeds Office.
I I - � � dt - )() / /99
SIG TURF 61 APPLICANT DATE
* * ** ** Any infon- nation 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
IDOL 1 409FN(T91. /o
STATE BAR OF WISCONSIN FORM 2 — 1982 599051
WARRANTY DEED KATHLEEN H. WALSH
REGISTER OF DEEDS
DOCUMENT NO. ST CROIX CO., WI
RECEIVED FOR RECORD
RICHARD O. STOUT 03 -08 -1999 10:15 AM
WARRANTY DEED
EXEMPT #
CERT COPY FEE:
conveys and warrants to M & Q, INC. COPY FEE:
TRANSFER FEE: 111.00
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, , D tG l`+ s }Ott -
State of Wisconsin:
13 A W a 4 u ke.e_ l r.
Lot 10, Plat of Apple River Bend, Town of Hu, cis oh Lul: g6
Star Prairie, St. Croix County, Wisconsin.
038- 1174 -00 -000
PARCEL IDENTIFICATION NUMBER
This is not homestead property.
(is) (is not)
Exception to warranties: easements restrictions, rights -of -way and covenants
of record.
Dated this 5th day of March A.D., 19 99
Richard 0. St out (SEAL) (SEAL)
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Wisconsin,
ss.
St. Croix
County
authenticated this day of 19 Personally came before me this 5th day of
Mai7ch 19 99 , the above named
Richard O. Stout
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by §706.06, Wis. Stats.) to me known to be the person Cdy ecuted the foregoing
instrument and acknowledge th a f �/V o ��' < ✓,q
THIS INSTRUMENT WAS DRAFTED BY f @ @f C �
Janet P. Stout N
1353 Awatake Tr
SEC /s 4�
Hudson, Wi . 54016 Notary Public, ty, Wis.
(Signatures may be authenticated or acknowledged. Both are not My commission is permanent. 10 not, state expiration date:
necessary) Az&u ,.Z1r
" 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 — 1982 Milwaukee. Wis.
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1.57 AC. EXC. ESMT. G o_
68.415 SO. FT. 3 1.6S AC.
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1.46 I.C. ExC. ESMT.
63,397 SO. FT
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