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HomeMy WebLinkAbout038-1174-60-000 r 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 A INDICATE ORTH ARROW ST. CROIX COUNTY ZONING DEPARTMENT-, ' AS BUILT SANITARY REPORT Owner Property Addre - 9 City /State - ZZ, t . r ti Legal Description: Lot _16 Block Subdivision/CSM # 6,g t /a sip ' /a, Sec. y< , TAN -RAW, Town o jele PIN - SEPTIC TANK — DOSE CHAMBER — HOLDING TANK INFORMATION: i Tank manufacturer - Size ST/PC Setback from: House a15 Well Z 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: 1qA0 Width _ /,�2 Length 7s Number of Trenches Setback from: House Well s PAL -s Vent to fresh air intake ELEVATIONS Description of benchmark 3� s Elevation Description of alternate benchmark Elevation Ic—f, a4 Building Sewer 97, 7- ST/HT Inlet 9 ST Outlet 91 PC Inlet PC Bottom Header/Manifold 9-�?, 79 Top of ST/PC Manhole Cover % 7;�V Distribution Lines O 9_2 O ( ) Bottom of System Final Grade Date of installation /�` Pe it nu er State plan number i7 Plumber's signature License number ___2 ; ZL_]r Date – Inspector 2: zl�ll Complete plot plan � Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permi IX Personal information you provice may be used for secondary purposes [Privacy Law s.15.04 (1)(m)]. 3445 5 Pert/ Hpldet's 1N�:. El city s [] Villag Io : State Plan ID No.: CST I BM EBlrev(c;. liv Insp. BM Elev.: BM Description: – 1' Parcel Tax N &t 038- 1174 -60 -000 TANK INFORMATION 0 ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. Septic Benchmark too - a ' Dosing ' 411� 6 m r. 103, 08' Aeration Bldg. Sewer 4.8 Holding St/ Ht Inlet D 9 q(0 TANK SETBACK INFORMATION St /Ht Outlet q(01 CS TANK TO P! L WELL BLDG. Ventto Air Intake ROAD IMIGA Septic p r NA Dosing NA Header/ Man. I q2. :T Aeration NA Dist. Pipe C f¢ Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade ho, ( V. Y� Manufacturer Demandw 69 .c�� Model Number GPM TDH I Lift L oss Iction y H Ft ead For ain I Length Dia. H Dist. To well SOIL ABSORPTION SYSTEM Width Lengt r N f PIT No. Of Pits Inside Dia. �q epth EN I N a n DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Ma f urer: INFORMATION TypeO / CHAMBER del N ber: System: b5 OR UNIT DISTRIBUTION SYSTEM Header/ anifold h Distribution Pipe(s) u x Hole Size x Hole Spacing Vent To Air Intake Lengt (20— Dia. Length Dia. Spacing !n 5 ' 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 15.31.18.860,SE,SW 1135 212TH AVENUE I - J 4v � uetk l ` Z9 -41 Plan revision required? ❑ Yes M No Use other side for additional inforon. 03 oZ ©4 mati r J(� SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. I Safety and Buildings Division SANITARY PERMIT APPLICATION 201 W. Washington Avenue 1 4 sconsin P O Box 7302 Department of Commerce 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 Personal information you provide may be used for secondary purposes E] Checkif revision t��ous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N Propert Owner Na Property Location 7) 1/4 1/4, S T--?/ , N, R / E (or)8 Property Owner's Mailing Addre s Lot Number Block Number City, ate Zip Code Phone Number Subdivis on 5ame or SM Numbe aadw It. TYPE BU ILDING: (check one) ❑ State Owned V ❑ [3 i Nearest Road VII age , Public 1 or 2 Family Dwelling - No. of bedrooms Town OF 111 BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 115 31 . Is, S (p0 1 ❑ Apartment/ Condo Qs8 — 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. 0 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 1110 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 [] Vault Privy 14 E] System -In -Fill IZ� X 3 f = VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. S stem lev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min .h ch) �/. 7� Elevation 15 1 9 Feet Sweet Capacit VII. TANK in Ca gallo s Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tank Sgp tic Tank — ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for i stallation of the onsite sewage system shown on the attached plans. Plumbe s Nam : (Print) Plumber's S n ur : (NrmocY P /MPRSW No.: Business Phone Number: It P um er's Address (Stre ,City, Staje, Zip Cop): IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sa itary Permit Fee (includes Groundwater ate Issued Issuing gen i na re (No Stamps) Approved []Owner Given Initial � , Surcharge Fee) /� y Adverse Determination / X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11I97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber l�Cd�P4Src"t7 �d6.t' �YOUSc 07� b7r ` r — - - -- �a� �s 9' Wisconsin Department of Commerce SOIL AND SITE EVALUATION f Division of Safety and Buildings Page of Bureau of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. parcel . . # All + D APPLICANT INFORMATION - Please print all information. Revie ed y Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ?? Property Owner Property Location U ! � , - r" Govt. Lot 114 1 /4,S - T / ,N,R E (or)j ee- "�J'q Property Owner' Mailing Address Lot # Block I Subd. Na m or Zs 6 City ta Zip Code Phone Number ❑ Ci g ty [--] ills a © Town Nearest Road S' }� 2 New Construction Use: Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow t)tl gpd Recommended design loading rate _ bed, gpd/ft -,-,t!�-- gpd /ft Absorption area required 558 bed, ft , S2 trench, ft Maximum design loading rate �� bed, gpd /ft _ trench, gpd/ft Recommended infiltration surface elevations) ft (as referred to site plan benchmark) Additional design /site considerations s - Parent material s 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 Z S ❑ U JZ S ❑ U Xs ❑ U I ©S ❑ U I EIS ® U EIS O U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trench IX :. Ground S elev. �ft• , Depth to limiting �` Z factor Remarks: Boring # h am.: Ground elev. Depth to limiting factor Remarks: CST Name (PI sa Pri Signature Telephone No. Address Date CST Number 3,10 ��_ SOIL DESCRIPTION REPORT PROPERTY OWNER Page of 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 Ground elev. ft , Depth to limiting factor in. ' Remarks: Boring # Ground elev. ft. Depth to limiting factor 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 # ; 13 Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R.9/98) -Z�,)L'- �� � l�,��� �J s� ��- sal Yl sic /S- 7 4-4 /`•tom s e.� �D �� yS _ a5 s� J ��/ 0 A Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page of 3 labor end Human Relations Division o(Safety ll Buildings in accord with ILHR 83.0 fWis to �� I1NTY s- Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. de�yt I D # not limited to vertical and horizontal reference point (BM), direction and % %w z_ t._ dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION PLEASE PRINT ALL INFORMATIO RE� BY DATE PROPERTY OWNER: ERTY I,OCAT�ON` �;; �� c ti A 9D S TOUT 4, SG�J �� T 9� ,N,R /� E (oo PROPERTY OWNER':S MAILING ADDRESS L it ' BL•6t;1( If SUBp� OR CSM If 1553 1 4 w,4 7T0 ,e�:= T iP, �e r CITY, STATE ZIP CODE PHONE NUMBER []CITY A EMIAG��-groww— EST s4or( (7/5)s�fq _ PRh� �. ,yrvy. CC (p4ew Construction Use (&-JItesidential / Number of b6drooms 3 tO q () Addition to existing building I ) Replacement ( ) Public or commercial describe Code derived daily flow y °oy gpd Recommended design loading rate bed, gpd/ft ' $ trench, gpd1ft Absorption area required ?5k bed, ft - trench, 11 Maximum design loading rate ' T bed, gpd/ft ' g trench, gpd/ft Recommended infiltration surface elevation(s) _SE_ � .3 ft (as referred to site plan benchmark) Additional design / site cons rations Parent material ��CS I i (3 0 R k k A PDT Flood plain elevation, if applicable ft S = Suitable for system C MOUND IN -G_ R"DD P A SYSTEM IN FILL MLDMG TANK U = Unsuitable for stem Gas O U 9 O U Iffy LS ❑ U 9.8-0 U 1 ❑ S SOIL DESCRIPTION REPORT '�I2 = Nob ����`►rFN�E� Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bound3y Roots GPD /ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed iench .., / o •2a to yR 3 /tf S C f7 •7 Ground 3 " fO 7.5 y y�� S . o ST C — • 7 g elev. Depth to limiting factor Remarks: Boring # ... / 0-1-S to yR 3/ �S iP d CS 3 4 -r 7 , 5 - VR Mee s. D s � — — 7 Ground elev. Depth to limiting 6 1 0 > 3 0 Remarks: ST Name: — Please Print R O Q t R T V L Q R i'C L\ T Phone. 71S Address: / C - 1 - CST 1• ��'.Z Signature: r c ht & XssoclateS Date: CST Number: Private sewage Consultants l 655 O'Neil Rd. Hudson, Wis. 54016 ORIGINAL PROPERTYOWNER R't�D S�r��T SOIL DESCRIPTION REPORT Pa 3 age _ of PARCELI.D.tt E /f1 Er — SL•vf� Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bwxuy Roots GPD /ft In. Munsell tau. Sz. Cont Color Gr. Sz. Sh. - tench 3 .: (9-/ I a re 3i 5 �+ d c s /f 8 116- 1 7 7.5 YR 3/ .o 14 Ground 3 z7- fO 7. YR Y/6 elev. y� •- ft. Depth to _ limiting factor U,S t Remarks: Boring # /e YR 3 /f s 1 40 Yid d,� C5 7 f3 Ground 1 .1 - 7•S YR Y /6. elev. X3. ft. Depth to limiting factor it z� r �� 3 Remarks: Boring # i a 0 - ►o YV2 31t( � Yom, ��' of e c5 �f 7 1 . 8 2 -!� 7.5 YR 3l r ' ves / �l,r �. _ . ? 18 Ground - Ao 7$ S. Q elev. Depth to limifi - ` factor Remarks Boring # t ................. .................. Ground ` elev. it. I Depth to limiting factor Remarks: f i l , y � 1p co � w C 7- Go r- VI m � o N • bm G � rn Qj m Q r Q GN o � < ` w s� o �'� w ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERS141P CERTIFICATION FORM OwnerBuyer In d � c`tl d AaPnS; Mailing Address I?S9 AwATIAket. TP. D60 rj -,tc L Property Address / 5 ' a I .1L �tlr New RJC � A N ICp J (Verification required from Planning Department for new construction City /State N 'Loj R­- 'ATV.ot­tp Parcel Identification Number 0,39 - J /2 ( - - 000 LEGAL DESCRIP'T'ION Property Location '�,E '/,, SUJ ' / <, Sec. T 31 N -R Town of SAAR /R /E Subdivision n nnL- k,v -e k &W,1D Lot # 42 Certified Survey Map # , Volume , Page # Warran ty Deed # Volume HM-, , Page # , Spec house Ayes ❑ no Lot lines identifiable,W 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 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. ;' 0 l3ol9 SI NAT OF APPLICANT DATE: OWNER CERTIFICATION I (we) certify that all statements on (lit. form are true to the best of my (our) knowledge. I (we) ant (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. /Jo / 'if SIG14ATURE APPLICANT DATE •. «.s. 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 06/30/89 WED 19:32 FAX 715 986 4687 REGISTER OF DEEDS 0 002 ,rGl_ 1438PA 328 �a STATE IJAR OF WISCONS[N FORM I -1982 E3059v$ WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS DOCUME N o. ST. CROIX CO., NI 4 RECEIVED FOR RECORD This Deed, made between_,. RICHARD 0. STOUT 06 -30 -1999 11:50 AM WARRANTY DEED Grantor, C COPY FEE: and —_ M & . _ , INC- _, _ _ COPY FEES TRANSFER FEE: 119.70 ;i -- — - RECORDING FEE% 10.00 PAGES: 1 .Grantee, }i W9tnesseth, That the said Grantor, for a valuable oorrsideratim i Conveys to Grantee the. following described real estate in St. cr O1X THIS SPACE RFSF.R' ✓CD FOR RECORDING DATA I County, State of Wisconsin: , NAME AND FETUP.0 ADDRESS Lot 16, Plat of Apple River Bend, 'down of my(}qI04' t r, G.e�rr Air, Staff' Prairie, st. Croix County, Wisconsin. V �k ke -� r s "'y a ill0 I i 038- 1174 -60 -000 PARCEL IDCNTIFICATIaN NUMBER I �i I� ,I Ii r, I ! 'I I 'i 4 iy i This., is not homesuad property. (is) (is not) Together with all and singular the hcTediterrvenrs and appurtenances thereunto beloa &g; And--,,, Ri chard. O. St -- — warrants that the title is hood, iadefeas ble in fee simple and free and clear of encumbrances cxCept easements, restrictions, rights -of -way and Uovenants of record, and will warrant and defend the same. ii Dated this 30>tih day of _ (SEAL) ?, Richard O. S tout s (SEAL) (SEAL) (SEAL,) I I• AUTHENTICATION ACKNOWLEDGMENT State of Wisconsin, 1 --. --- St. Cro County. I' w authenticated this — day of __- 19 Personally came before me this 30th day of i Jun 19 9 — 9 , the above named _..... Richard _ O. StO w, j TITLE: MEMBER tiTATE BAR OF WISCJNSIN — (if not, Cry r authorized by §70606, Wis. SLats,) to me lmown to be the 1xnson___..._who executed the foregoing instrument and acknowledge the same, i i :NSTRUMENT WAS DRAFTED BY 01-'�g00 Janet P. Stout 6�6 Hud Wi ._5401 6 Notary Public, - Counry,Wis. (Signarures may hc authenticated cr acknowledged. B: ):h ax not My eomnl;sicn is permanent if no state expiration date: necessary) Ncnics of persm iiping in •ny a pvIty should by typed (ir prinlyd helow I'.reu sl�nanucs. Wlscone,n t. Wel Blenk Co., Inc STArt: 1lAR OF WISCONSIN Wwaukee. Ws. vaARILANTY DEED Form No. 1- 1982 Ll7 06 1999 6 7152473622 FEMEAX, TEAM 1 REALT't PAGE 01 AP-P R IVER REND 'tiL't eWC L)lal t0[egoarQ >,a a iepl' OC a aeao7•.cta., e.M.p[etl LY al ._ b aa eOSt. DaCa t� i as a LOT 21 r •tit ac h 9'•I4'iE - x. a(:OY(iFFM )) 06. � ,'; •a. #.t ,al r. �" i7�3j) C1pYFYi ) t -q R. t1ag. binq [arc d+sa7 rlaeF Qsditt� a� e.:[tn9 To _ F j VOTE d Elra std of xc¢ P[aistu. Yavt7 prat! RY that to aicecaawc ,� s,M,u• C Fs „[....,. Iati n °n to RF'R we +rapa.,d Slat �, + r .y ` .w raOur" �! 9 , . � aL Gam+ Laed t.Jvd i. to& Fta[ ty , '.ice �y�. �,#",a LOT 24 l ing QJ • 'P N . + K'� Me rR1 +Yi+ m., . w iplFl F, ++t.a u kaen L..O I — f9 —t A Q., [ ;. +. YtnaF Le N+R4, 6 n e1c.V. Mwi pnYpsy at YtNOiM aR pnd Nacut W R. enl, t,:�ar FFYt q K + fie sw ` 1 a KgriW MY wN - t Nn, Y s. e Sort nrM: n na'a2 IuiN V !! rti.i cY11aa Fs+ 1+M af++at W " FN[JUYW tM. FWYIY N) "l-F R Htgt IiN. jy a ,ldasSaa A tat)w nk) d t)F[rua 'tamp, a'll' waaee.[ " ✓ 1 .es N a tK.q N1YY k /Nw tk 4skk,a YNip 0. ilk a sst cM 1 ft 1 \ o RtY +n tcc tM ,x ai kYlk hNN 101 }MIN M . v, > LOT 14 'i +�.f4 19. rr, `.•• 4 � ry s.tY ra #so J Ey Vol y A F Sr atC w IfFi I x a �• � y.. ' Y OF ., 40