HomeMy WebLinkAbout038-1183-20-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
Safety and Buildings Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No -: IX
Personal information you provice may be used for secondary purposes [Privacy Law s.15.04 (1)(m)]. 344545
PermitJ.ij ft'�Nan El City ❑ Villa e Town of: State Plan ID No.:
t riiJ�; 1NV , STAR YD IRIE
CST BM Elev.: Insp. BM Elev.: BM Descriptio Parcel Tax No.:
U o a S Ic s l G�rh �� 038- 1183 -20 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic �� �Zp d Benchmark 3 �f 1U3.P" /00
Do' ,�i /03./
Aeration Bldg. Sewer ,2,
Holding �f Ht Inlet ,� d
TANK SETBACK INFORMATION 0/ Ht Outlet Z f 7 I
TANK TO P/ L WELL BLDG. Vent to ROAD
Air Intake
Septic ;A - toe) ' S / Z J r NA
NA Header / Man.
Aeration Dist. Pi e z L �` 96• G C
Holding Bot. System T-1
V q S,
PUMP/ SIPHON INFORMATION Final Grade y
Ma cturer Demand
Model Number M
TDH Lift L riction Syes TDH Ft
Forcemain Length Dia. FFii Dist. To well
SOIL ABSORPTION SYSTEM
BED / RE H Width Len th No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DI 1 N r U Z DIM
SYSTEM TO P/ L BLDG WELL LAKE/STREAM L G cturer:
SETBACK
INFORMATION Type O C R
er:
System: TOO r�00� OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length � Dia. �� Length Ems= Dia. r � Spacing ` Z 2 Z Z q J
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.) to ill
LOCATION: STAR PRAIRIE 21.31.18.919,SW,NW 2089 COOK DRIVE
Z O /
co (1e✓ Z > I Co je r
Plan revision required? ❑ Yes �] No
Use other side for additional informs ion. I T k2 Z k,�'l I L�L�,
SBD -6710 (8.3/97) Dat Inspector's Anature Cert. No
Safety and Buildings Division
Vi scons i n SANITARY PERMIT APPLICATION 2 01 W. Washington 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 8 112 x 11 inches in size. '5'7
• See reverse side for instructions for completing this application State Sanitary Permit Number
3yyYs
Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION
Propert Owner Name Property Location
/f .r1 „l t va 1 /a, S a T3 , N, R/' E (or) >
Property Owner's Mailing Address Lot Number Block Number
G ;?
Cit , State Zip Code Phone Number Subdivision Name or CSM Number
C i`C t Ol (
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ !ty Nearest Road
❑ Villa
Public 1 or 2 Famil Dwellin - No. of bedrooms Town of '1e Coo
1111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo U s < �� ���•� 1
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 E_New 2 [] Replacement 3. ❑ Replacement of 4. ❑ 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ffseepage Pit a Z f 43 C] Vault Privy
[] 14 System -In -Fill 7 1fZ*tCk
VI. ABSORPTION SYSTE ORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
y�O Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
r
Feet Feet
Capacit
VII TANK in gallo S Total # Of Prefab. Site Fiber- plastic Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con - Steel grass App.
New Existin structed
Tanks Tanks
eptic Ta r Holding Tank Q 1 �� CS ,�/ ❑ 11 El E] El
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ I ❑ ❑
VI11. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: ( t ps) P PRSW No.: Business Phone Number:
l ht cyt sl� � /s-
Plumber's Address (Street, City, Sta Zi Code):
,.mac � a 140 .,- 3 G
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sa itary Permit Fee (Includes Groundwater ate Issued Issuing Ag ° ° °''' ture (No Stamps)
Approved El Owner fee) Owner Given Initial '/ �( 1y /
Adverse Determination S . i
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, plumber
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Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page of
, Bureau of Integrated Services i 6c¢o)'6rid4lWA i s ILHR 83.09, Wis. Adm. Code
I f Coun
Attach complete site plan on paper not less th 81/2 x 11 ,uh.ei e. �st ry
include, but not limited to: vertical and hodzo tal reference' directi
percent slope, scale or dimensions, north arr w, and location and distance to n are t road. Parcel I.D. #
6r
1 - ! , •1` µr
19 97 ,
APPLICANT INFORMATION - Please;Orint all � 4 tion. ;` , Reviewed by Date
Personal information you provide may be used for secondary pur g� �y, s. �y5:W ) (m)).
Prope Owner _ -Property Location
~ >` j Govt. Lot ) 1/4 1/4,S T� N,R E (or&
Property Owner's ailing Address Lot # I Block# Subd. ame r CSM#
Ci Sta V' Zip Code Phone Number ❑ City ❑ ge Town Neare Road
I t l I �=,L 71 New Construction Use: Residential / Number of bedrooms 1 � Addition to existing building
Replacement H Public or commercial - Describe:
Code derived daily flow gpd Recommended design loading rate �� bed, gpdfft - -2—trench, gpd/fl
Absorption area required 1 'e3 bed, ft ft Maximum design loading rate _ bed, gpd/f1 gpd/ft
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material 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 0 S El ®S ❑ u ®S ❑ U I Z S ❑ U I ❑ S ® U ❑ S ® U
SOIL DESCRIPTION REPORT
Boris # Horizon Depth Dominant Color Mottles Structure GPD/ft
Boring Texture Consistence Boundary Roots
n.• >. ..::> in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
1
Ground
elev. �ez Az
Depth to .
limiting ,
factor
Vin.
Remarks:
Boring #
Ground
Depth to
limiting
factor
> Rem s:
CST Name (PI ase rint) '� Signature Telephone No.
- s'- 3 S"
Address Date CST Number
PROPERTY OWNER SOIL DESCRIPTION REPORT ?
Ja ra Page zV_ 9f
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Structure
in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed , Trench
o-
Ground s dfr
I —
Depth to
limiting ? �
fa or
Remarks:
Boring #
I e
JL
E3
Ground 7, , -
elev.
,�iLft. f
Depth to 6
limiting
factor
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots G PD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring #
I va
XU
Ground
Av
elev. y
O-e—
Depth to
limiting ;
factor
min. Remarks:
Boring #
cm s ,
a
Ground
elev.
ft.
Depth to
limiting
factor
'n ' Remarks:
SBD -8330 (R. 07/96)
Air S,*
caw /7! . . . . . _
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer John N. Heintz / P. C. Collova Builders, Inc.
Mailing Address 905 County Road H, New Richmond, WI 54017
Property Address 2089 Cook Drive, Somerset, WI 54025
(Verification required from Planning Department for new construction)
City/State Star Prairie, W1 Parcel Identification Number 6 3
LEGAL DESCRIPTION
Property Location S W y., NW %., Sec. 21 . T 31 N -R 1 W, Town of Star Prairie
Subdivision circle C Lot # 2
Certified Survey Map # . Volume . Page #
Warranty Deed # 5 5 0 5 21 Volume 1202 . Page # 234
Spec house 13 yes ❑ no Lot lines identifiable ® yes O 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.
6- X 4, l 3 /
NATURE OF APPLI
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 pro rty described above b virtue of a warranty ty deed recorded to Register of Deeds Office.
x G 103 / `
r
NATURE OF APPLI 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
Jz
State Bar of Wisconsin Form 2 — 1982
j0 s r z WARRANTY DEED
DOCUMENT NO. 2Pj ST. T. CROIX GC., W1
VOL 120 ?PacE._ r 4 '
James Barnett, a married man -OCT 7 1996. !:
- - " - - - - - -- --- - - - - -- -- -- - - -- d
at 10:00 A. M
J
N John Heintz and Patricia J.
conveys and warrants to . -- -.- .._ - --- -- - - -- -. .-_ —._. _ .._ ..—
Heintz, husband and wife as s marital _
property _..
_-_..._._ __.--- -- -- ---- -.-- °-�-- _. ---- -- _..._ THIS SPACE nESERVED Fon RECORDING DATA
NAME AND RETURN ADDRESS
- -- - - - -- -- - - - - - - - -- REINSTRA & VAN DYK, S.C.
�� - - -- -- - - -- i 201 South Knowles Avenue ,
the following described real estate in St. Croix New Richmond, Wisconsin 54017
C'ouniv, State of Wisconsin: - -- -~ '- - - - - -_ _- '
038-1088-30:
(Parcel Identification Number) 038 - 1089 -
and 038 - 1089 - 30 - 110
SEE ATTACHED SHEET
7RAN§FER
This.- -- s_- not -. - -_ - • -____ _._.. homestead property.
(is) (is not)
I
Exception to warranties: Subject to all easements, restrictions and covenants of record.
1;
2nd October 96
Dated this . __... _. - -- •- - - -._. day of - ------ -_.._. -- - -- - -.._ _._.....__, 19 ,
(SEAL) _ ._._... — (SE-Al.) i
James Barnett +
(SEAL) i
i
AUTIIENTICATION ACKNOWLEDGMENT
Signaturets) James Barnett STATE: OF WISCONSIN
ss.
aulhcx jjlwm� 1 Ihix 2nd dad of October 19 96 Personally cants beforc Site this day: of
' 19 the abo�c navied
Hendrik W. Van Dyk
11 I LF: ktl- .nlllF.I( - s - 1 "k l l: Il,\li 017 WISCONSIN
tlr ntn.
aulhorircd by §706.116. Wis. Slats.) to me known to he the person who executed the
foregoing instrument :Ind acknowledge the same.
11115 INS I IMMEN I WAS NIIAF I Et) By '
REINSTRA & VAN DYK, S.C.
201 South Knowles Avenue +
New Richmond, Wisconsin 54017 Notary Public 0%lln1y. Wi %.
(Signalurc, may he authenticated or acknowledged. Bolls are not My con)nlission is pernlancnl. (II nut, state expiration tl tic:
n�•li.�a
.19 .1
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fi'L1'I'E IIAR UP WISCONSIN Wtscunsin t.rgal Slank Cn . lm
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ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
p p p p p N 9 n 11 ST. CROIX COUNTY GOVERNMENT CENTER
" " ■ +, 1101 Carmichael Road
Hudson, WI 54016 -7710
_ (715) 386 -4680
February 23, 2000
P.C. Collova Builders
Attn: Pat Collova
705 County Trunk E
Hudson, WI 54016
RE: Septic Inspection for John Heintz located at 2089 Cook Drive,
Circle "C ", Lot 2, Town of Star Prairie, St. Croix County, Wisconsin
Dear Mr. Collova:
A septic inspection of the above referenced property was conducted on January 26,
2000. This property is located in the SW' /4 of the NW' /4 of Section 21, T31 N -R1 8W,
Circle "C ", Lot 2, Town of Star Prairie, St. Croix County, Wisconsin. At the time of the
inspection, this septic system was found to be code compliant for a three (3) bedroom
home.
If you have any questions regarding this, please contact our office at (715) 386 -4680.
Sincerel
J n Sonnentag
Zoning Technician
/sm