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HomeMy WebLinkAbout040-1235-00-000 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPgRT r Owner �aw+v1 G o Property Address 5 AI C,,t 6e ,1 R i City /State 4 1,, t s ow Legal Description: Lot 3 Q Block Subdivision/CSM # Cow-lk, w 01 W F ' /a s w t / a, Sec. , T2L-N -R 1 . 1 W, Town of 'r o x P�� 0— 1 2.3>: - 00 - U o f SEPTIC TANK - CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer _ k L„c ,'" fr rc..,J Size ST/PC I Zoo / Setback from: House _Q_ Well P/L * Pump manufacturer 1✓ r- Model ny i+-- Alarm location v i�- (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: lv = h L Width - Length 1, 9 . '7 6r Number of Trenches Setback from: House 1 Go Well > r ocj' PAL 13' Vent to fresh air intake >/ 0o' ELEVATIONS Description of benchmark 7 o 1P , T e Elevation d o, a c Description of alternate benchmark u i , ... Elevation In o, o a �uoT b��w5 101.1 Building Sewer t oq . 7 L ST/HT Inlet 10 4,-7 Z ST Outlet 1 o 4. 1 -1 PC Inlet w o PC Bottom ry Header/Manifold Top of STRC Manhole Cover 14) . 0 4 Distribution Lines ( +) T2, 5 4 9 7, 4 v (3) 1 Bottom of System () 9 6,)4 () q L S4 () 41, . a 4 Final Grade () 9 q, S () j S () 9?. g Date of installation 5 /?Uq Permit number 3 3 8e 1 State plan number Plumber's signature �� P Vc-L�, License number a a c 4 Date 3 a0/0- Inspector AdZZOC Complete plot plan ar NOTICE Please rovide the following g • A lan view sketch showing everything within 100 feet of the system. P g � S • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW 8' u v �o� X3 1 2 v V e ryv e T \ INDICATE NORTH ARROW Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM County: f 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)]. 338811 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: GELD, BONNIE S. TROY CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.: /w. ©jj pb� 0 J f c rs te r/ ;. 040- 1235 -00 -000 TANK INFORMATION F ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 00 Benchmark sy' Dosing Aeration Bldg. Sewer X19 Holding St Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet ,� j " . TANKTO P/L WELL BLDG. Air to i ntake ROAD Dt Inlet ir Septic 7 gyj ' l0 ' - NA Dt Bottom Dosing NA Header / Man. iy.:u ° 97.0 ' iu, yam• Qo..� . Aeration NA Dist. Pipe o 41 o, All Holding Bot. System is z� QGx PUMP/ SIPHON INFORMATION Final Grade 7 %9. Manufacturer Demand. Model Number P �.� ' CPM TDH Lift Frictr4n System __ Ft Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM i BED/TRENCH Width Lengt !! No. Of Trenches PIT No, Of Pits Inside Dia. Liquid Depth D IMENSIONS �� 3 l DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manu acturer: INFORMATION Type O =�- - CHAMBER Model Number: System: -F' , / j' /610' C 3 /t OR UNIT 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.) LOCATION: TROY 3.28.19,1176,NE,SW 549 GILBERT RD - COUNTRYWOOD LOT 39 ��.yy Ilirt9f tl r . 4 . ...,,.. a to 3 6° a3 r l. i � R Plan revision required? t ❑ Yes ❑ N( 0 Use other side for additional information_ SBD -6710 (R.3/97) Date Inspe or's Signature Cert No r r r ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 4 , E w� } f s 4 s } a 4 } _w g 4 t a 9 x m S wy } t } } >n g ..., .w.,. f € t e es i ewe € } � $ e s � 3 3 f a S x 4 } }4 4 4 � . _• .,...P ........_ 3 .. _ -. ,.. � _ ....._.. .,.,, ,.. P .. ..... w- ... -._ ..- a ._ �.., a. } } a „ F } A. E ... . r , a s i i i } b E } d Y � .. . .... .. w.,. . e.. � as. } sue. ems, k y s a i E k � (( e- 4 j S SANITARY PERMIT APPLICATION 2 Washi ngton Division Visconsi P.O. Box 7969 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County 1 than 81/2 x 11 inches in size. ST ( -. ice. • See reverse side for instructions for completing this application State Sanit Number The information y ou p rovide may be used b other g overnment ag ency programs Check if mil t�revious j lication Y P Y Y 9 9 YP 9 ❑ P p (Privacy Law, s. 15.04 (1) (m)1. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION PropeAy Owner Name Property Location 4:t� 0 vV ri /4 S l C 1/4, 5 3 T 9 f j, N, R i, 4 (or) W Propert y Owner's Maili Address Lot Number Block Block Number Ila rt G r• 1 W City, State Zip Code Phone Number Subdivision Name or CSM Number 1, w J" h1, 5.10 9 (Z 0 W8 I s II. TYPEOF BUILDING: (check one) ❑ State Owned ❑ it� Nearest Road ie p age T 0 Public 1 or 2 Family Dwelling - No. of bedrooms To wn wn of III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 3. Zg I q ©Ao- 1 235 - o6- -o od 1 E] Apartment/ Condo 2 ❑ Assembly Hall 6 Q 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, M New 2 ❑ Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ______System ________Syrstem _____________ 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 Ty 41 ❑ Holding Tank 12 ($Seepage Trench n 22 ❑ In- Ground Pre�sure _� �S 42 E] Pit Privy 13 ❑ Seepage Pit (N 43 ❑ Vault Privy 14 ❑ System I I �� / r 3 X (oa• S VI. ABSORPT SYSTEM INFORMATION: X3 /. 8' •- j X/7..� 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.) (Galls /d /sq. ft.) (Min_hrich) Elevation 6 oo DDO ®?, l/. 9 —"' T6 0.4 Feet ? (l© Feet Ca acct W VII. TANK in allo s Total # of Prefab. Site Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete st noted Steel glass Plastic App Tanksl Tanks Septic TankQLiddiwj-Ta+k j 1010 )9,7 I Mi we / ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamberl ❑ I ❑ 1 ❑ 1 ❑ 1 ❑, 1 ❑ 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'sSignat re: (No Stamps) MP/ o.: Business Phone Number: c a r , dcl5t as oSS 71S'4a5 X175 Plumber's Address (Street, City, State, Z Code)_ Zd� s Fkl(s W, sjoaa IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date I ssued in Iss e t Signature (No Stamps) Surcharge Fee) � Approved ❑ Owner Given Initial Adverse Determination l on 1-1 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: 05 M 444 SOD -6398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Su" gs Division. owner, Plumber z 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. 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 hoiaing tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber into 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 8 1/2 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. i i La P� N , GONNA✓ GELD SCALE I -qo LOT 3q COUNTRY WOOP a A C pE5 8Y 00 FA44" V SRS a ?oSS4 to � °- 2t5,7s 7 /4LT 0 1, 1 �# R6I9 `b N 1 d Qa I 33 a 6m „ 4 Q �v I r Zoo GRL � 5 FVT i c- r, M gttM I I t ` PPYOvcp veN GSM-. ^"" E glO•d 34" 34,; 3 4 ,. NOTE: Sys7fm ToaE 2TUNCNES 11 NIGN CAPgcrr INFILTRa7ioN CAMBERS ANP 1 7RENCy 10 C9 ,4MBEkS FaRA TorAt o f JAM QERS 8 31. $ sq FT E,4CH = I04q Sq FT i II Wiscorisin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and•;duman Relations Dio ision of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, b f V. ' oiX not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or �,, , -- PAR CEL W #, .�. d dimensioned, north arrow, and location and distance to nearest road. , - `'. pend APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION <.� Yr A EVIEW15D BY DATE _ - ; PROPERTY OWNER: PROPERTY L Richard Stout GOVT. LOT N', 1/4 SW 1 /4,S 3 T" 28 ,R 19 for) W PROPERTY OWNER':S MAILING ADDRESS LOT # BLO K4 ` SUBD. NAMI OR CSM # i = j 1353 awatukee Trl. 39 n' ` t ` _ " CITY, STATE ZIP CODE PHONE NUMBER ❑CITY E]VILLAGZ fMtOWN ,A I ST ROAD Hudson, WI. 54016 (715) 549 -6731 Troy ~ Tower Rd. [ New Construction Use [ Residential / Number of bedrooms 3 [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate • 5 bed, gpd /ft • trench, gpd /ft Absorption area required 900 bed, ft 750 trench, ft Maximum design loading rate .5 bed, gpd /ft •6 trench, gpd/ft Recommended infiltration surface elevation(s) 96.05 ft (as referred to site plan benchmark) Additional design / site considerations alt. site = 95.85' system el. Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem ®S ❑ U ®S ❑ U ®S ❑ U KI S ❑ U [3S ❑ U EIS ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bound Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Treridi 1 1 -13 10 r2/2 none 1 2msbk mfr gw if .5 .6 2 3 -23 10 r4 4 none sicl lfsbk mfr gw if .2 .3 Ground 3 3 -40 7.5 r4/4 none sl 2csbk mfr gw na .5 .6 elev. 100. 4 0 -84 7.5 r4/6 none fs osq mfr na na.: .5 Depth to limiting factor +84" Remarks: Boring # 1 0 -10 10 r2/2 none 1 2msbk mfr 9W if .5: 2 10 -27 10yr4/4 none sicl lfsbk mfr gw if .2 .3 Ground 3 27 -45 10 r4/6 none sl 2csbk mvfr gw na .5.6 elev. 4 45 -82 7.5yr4/6 none s osg mvfr na na .7 .8 L 99.0 ft. Depth to limiting factor +82" Remarks: CST Name: — Please Print Gary L. Steel Phone: 715- 246 -6200 Address: 1 54 200th Ave. New Richmond, WI. 54017 m02298 Signature: �/ Date: CST Number: ,,� �f 4 -23 -96 PROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Page 2. . of 3 � PARCEL I.D. # pending Lot #39 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench �Q4= ti'f.+nvv ,., 3 1 0 -10 10 r2/2 none 1 mfr Mi 2 10 -25 10 r4/4 none sicl 1 around 3 25 -38 10 r4 6 none elev. i6t ft. 4 38 -48 10yr3/6 none scl 2csbk mfr cry na .4 .5 Depth to 5 48 -96 7.5 r4 6 none s limiting factor +96" �4 Remarks: Boring # 1 0 -13 10 r2/2 none 1 2msbk mfr :. 2 13 -21 10 r4 4 none s ' 1f .2 3 3 21 -29 10 r4/4 none sl 2csbk Mfr aw na Ground elev. 4 1 29-35 10yr3 /6 none scl lfsbk mfr Crw na .2 .3 44)G ft. Depth to 5 1 35-85 7.5 r4 6 limiting factor +85 ,�q.?� Remarks: Boring # �"' :•."': : : « :: Mfr 1f np �2 1 0 -12 10 r2 2 none 1 2 5 2 12 -27 10 r4/4 none sicl lfsbk mfr c1w if 3 27 -45 10 r3/4 none scl lcsbk mfr Ground elev. 4 5 -84 7.5 r4/6 none s OSCI mfr Depth to limiting factor 4 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(R.05/92) } I STEEL S SOIL SERVICE Gary L. Steel Richard Stout 1554 200th Ave. CSTM2298 NE4SW4 S3- T28N -R19W New Richmond, WI 54017 MPRSW 3254 town of Troy (715) 246 -6200 lot #39- Country Wood t N 1 " =40' BM.= top of steel pipe @ el. 100' y rx 1 t M N �S. Gary L. Steel 4 -23 -96 10-27 -1998 5:47PM FROM DELTA CONSTRUCTION 7153811166 P.1 o0 f- A� 4zaoo, G J6 1 /[ 1 , 7 j�,y Q�r•�a a ezi� e, gam. �6 y ST CROIX COUNTY SEPTIC "TANK MAINTENANCE AGREEMENT ANI.) OWNERSTIIP CERTIFICATION FORM Owner /Buyer Mailing Address I ( C r t -F � e S+ r ee- y o- r Fe,, '1 1* Property Address J r- �' 9 3 Ll b .rf Rod-4 I^o+ 3q Coy +'�`�S WOOL (Verification required from Planning Department for new construction) City /State H u J Sri n 1 i Parcel Identification Number 040 - l Z-3 S- O O O o n LEGAL DESCRIPTION Property Location PVC '/^, 5 '/1, Sec. 3 , T�N -R�W, Town of _77 � . Subdivision Pl a + Of Coun +,ry Wood F_,'rs -- A8C'3 V-1 , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # 5 I l 1 , Volume 1 3 S 7 _ , Page # Spec house ❑ yes Kno Lot lines identifiable A 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. 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 Conunerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained uwst be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date S GNATURE OF APPLICANT 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office. J _ �C1 sfdNATuRE OF APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Inchide 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 VOL 11, 57PAGE���� STATE BAR OF WISCONSIN FORM 2 — 1982 CJ .L WARRANTY DEED DOCUMENT NO. '' .- .,...._.r...:,.:., _� .... ST. CR'QIX CO., WI RICHARD O. STOUT R+tprd Irrr Perard - - SEP 15 1998 conveys and warrants to BONNIE SUE GELD I }f r 9f pRad THIS SPACE RESERVED FOR RECORDING DATA —. �..._ .._ NAME AND RETURN ADD MSS the following described real estate in St . _ Croix J County, State of Wisconsin: 1 1 6 Lot 39, Plat of Country Wood First Addition, Town of Troy, St. Croix County, Wisconsin. 040- 1235 -00 -000 PARCEL IDENTIFICATION NUMBER TRANSFER °° U I FEE is not This is property. (is) (is not) Exception to warranties: easements restrictions, rights -of -way and covenants of record, if any. Dated this / day of Septe A.D., 19�$_. n Ric l lard O. S tout _ (SEAL) (SEAL) i (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) y State of Wisconsin, ss. St. Croix -- County authenticated this day of 19 Personally came before me this day of Sep tember , i9 9$_, the above named — Richard O Stout TITLE: MEMBER STATE BAR OF WISCONSIN I i (If not, _ _ Rrt? tf � Poulin � authorized by §706.06, Wis. Stats.) Notary Public to me kiao' to be the person who executed the foregoing State Of Wisct)11Stn instrument id acknowledge ie sa e. !I I THIS INSTRUMENT WAS DRAFTED BY Janet P. Stout -13 5 3 AW-a tttkee -T . - -- i, Hudson, Wi. 54016 Notary hc, County, Wis (Signatures may be authenticated or acknowledged. Both are not My commission is pirn .ne t. If nol, state expiration d necessary.) Names of persons signing in any capacity should by typed of printed below their signantres. STATF BAR OF WISCONSIN Wisconsin Legal WARRANTY DEED form Nu. 2 — 1982 'WISCONSIN. NOTE LOTS 38, 39 8 40 REOUIRE A 21' WA&ETER CULVERT WHEN CONTRUCTING MVES i 2 2 38 1a Z N� 2.71 AC. 118,002 SO. FT. / N6 3 39 A 2.19 AC. N61 95, 519 SO. FT. J. �fc 40 ti 2,66 AC. „ S87 0 38'55 N� 115,884 S0. FT. `fl 125.00 2. 34 AC. 101,716 SO. FT. C OL 0 s� 418. � 1 �5 _Q L h .0 N o \\ 10 0 .yti 42 \ 2.10 AC. \ \ 91,478 SO. FT. \ \A Z 1 � A3 ' O 4 r 0s,, lt 0 0 ' 2 \ N N 43 \ w� s9e 2.01 AC. I ^_ 87,760 S0. FT. v LINE ._... 58 2 19 72e 7 s 71 -- -- _ } z 1 N A 9 m �Gti i m 91 4 SO r w . J J .. u A co �4 m O s i bQ %s3s s z Ati • • ob . 3 6a 00 05 , I `• Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y Safety and Buildings Division Co unty - CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary3P2rivh: Pers nal information you provice may be used for secondary purposes [Privacy IT, s.15.04 (1)(m)]. parm oldRrO�la�ger, [} Village [] Town of: State Plan ID No.: CST BM Ele i�ltVl� Insp. BM Elev.: BM Description: Parcel T 0 1 0 - :- 123 r D 0 - 000 TANK IN OR TION ELEVATION DATA A98005 TYPE NUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ai 'take ROAD Dt Inlet Septic NA Dt Bottom Dosing I NA Header/ Man. Aeration NA Dist. Pipe Holding Bot. Syst PUMP/ SIPHON INFORMATION Final ade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. H ead Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS N DIMENSION SETBACK SYSTEM TO P / L LDG WELL LAKE / STREAM IIIILEACHING Manufacturer: INFORMATION Type Of HAMBER Model Numb System: ftUNIT DISTRIBUTION SYSTEM Header! Manifold Dlstrib n Pipes) x Hole Size Hole Spacing Vent To Air Intake Length Dia. ngth Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems On Depth Over Depth Over xx Depth Of xx Seeded/ Sodded x Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No Yes ❑ No COMMENTS: (I ude code discrepancies, persons present, etc.) LOCATION: TR 3.28.19,NE,SW 549 GILBERT ROAD — COUNTRYWOOD LOT 39 Plan revision required? ❑ Yes [:]No Use other side for additional information. I I F_ SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH ; SANITARY PERMIT NUMBER: I Safety and Buildings Division Vi sconsin SANITARY PERMIT APPLICATION 201 W. Washington Avenue P O Box 7302 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 Sanitary Pe mit Nurn 3 Z I/ 4P LH 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 INFORMATION Prope y Owner Name Property Location i4 1/4,5 T , N, R E (or)69 Property Owner's ailing dAress Lot Number Block Number i ri Cot , State Zip Code Phone Number Subdivision Name r CSM Number er ®� ( ) I. TYPE OF B I DING: (check one) ❑ State Owned ❑ it Nearest Road ❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms _ own OF III. BUILDING USE (If building type is public, check all that apply) o Parcel Tax Numbers) 1 ❑ Apartment/ Condo .2 _Bd 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 Q 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 Q Replacement 3. E] Replacementof 4. Q 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 E] Mound 30 E] Specify Type 41 [3 Holding Tank 12 E Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 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. /inch) Elevation Capacity Feet Feet VII. TANK in gallo s Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App New Existin strutted Tank Tanks Septic Tank or Holding Tank 0 -�-� wY e 14- ❑ E] ❑ 1:1 1:1 Lift Pump Tank /Siphon Chamber w `— / ❑ ❑ El 13 ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of t e nsite sewage system shown on the attached plans. PI ber's Name: (Print) �. Plumber'sSign oSta p #f'1MPRSWNo.: Business Phone Number: s id -6.S +:r (Stre(t, y, State, Z' Code): X92 IX. COUNTY / PARTMEN USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps) Wpp roved E] Owner Given Initial Surcharge Fee) l�b t� Adverse Determination / X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 R.11/97 DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber l 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 toinstallation 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 nd Buitdln s'Division 6 08 L26 6 -3151. y � . • . 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. 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 �pecificatioi�*r3ot smaller thap 8 Y2 x 11 inches-must be subm a�ounty. 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. ' rAGF GIF PUP kP CHAM5ER CROSS SEC AA1G SPECIFICA'ri0kiS / VE IJT CAP L(C.I. VEKJT PIPE WEATHERPROOF APPROVED LOCKING DOOR, JUNCTION BOX MAMHOLE COVER s WWDOW OR FRESH 12 "MIU. AIR INTAKE GRADE I I Y" M IN. I8 "/11u. CONDUIT �-- _ 18 "MIN. - - --- _ _ - -- WLET PROVIDE _T AIRTIGHT SEAL i I * l A I II 1 I I I ALARM B I I I I c *APPROVED I I oN JOINTS WITH I ELEV. FT. APPROVED PIPE - -� 3' ONTO PUMP ` OFF D SOLID SOIL CONCRETE BLOCK RISER EXIT PERMITTED ONLY IF TANK MANUFACTURER HAS SUCH APPROVAL SEPTIC E SPECIFI DOSE TANKS MANUFACTURER: C (JLIMBER OF DOSES: 3 PER DAy TANK SIZE: f2pd GALLONS DOSE VOLUME ALARM MANUFACTURER: S. i f i) INCLUDING BACKFLOW: �'� =L-- _ GALLONS MODEL ►DUMBER: CAPACITIES: A= 23 OR � — GALLOWS SWITCH TYPE: 1 4/7 vL✓l B= �'-_ IMCHES OR _7L GALLOM5 PUMP MANUFACTURER: 40,kLd C= IUCHES OR GALLOIIS I MODEL NUMBER: — 22�20 cf // D =_ FICHES OR L— GALLOAIS I SWITCH TYPE: ly,,owt,,. NOTE: PUMP AND ALARM ARE TO BE I MINIMUM DISCHARGE RATE 10 GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERE MCC BETWEEN PUMP OFF AMID DISTRIBUTION PIPE.. FEET + MINIMUM NETWORK SUPPLY PRESSURE , , , , , , , , �-`J— FEET + 1.0_ FEET OF FORCE MAIN X � F Yorr.FRICTIOU FACTOR_ FEET TOTAL DSMAMiC HEAD = FEET INTERNAL DIMEMSIONG OF TANK: LENGTH ;WIDTH �� ;LIQUID DEPTH 1 �� 5 1GNE D: LICEOSE IJUMBER: 1, • ' ' • / M OD EL • ' • , Su GOULDS .. mp . Pec fi' ttflns � ' /aHP j METERS FEET -Up to 40. ,'GPM' '° MODEL: 3871 Discharge size 1'/ NPT 9 30 Solids: Vs maximum 6 Motor - 25 Single phase: 115V W 6 20 Materials of Construction = Brass/thermoplastic 5 15 Features and Benefits 4 EPOS 0 *Top suction eliminates a 3 '° impeller clogging. 2 5 EPO4 • Corrosion resistant , construction. 0 0 0 10 20 30 40 50 U.S O!T7 • Float actuated switch. ° z 4 s e ;o ;2 A, CAPACITY METERS FEET MODEL DVP03 Pump Specifications Features and Benefits 0 6 20 `h° and V2 HP • EPO4 impeller- semi -open design = 5 Up to 60 GPM with pump out vanes to protect 15 Maximum head to 32' mechanical seal. Z 4 Discharge size 1 1 /2 ' NPT • EP05 impeller - enclosed design 0 3 ,o Solids: 3 /4" maximum for improved performance. 5 2 5 Motor • Rugged glass - filled thermoplastic ' All motors feature ball casing and base design provides o ° bearing construction superior strength and corrosion . 0 5 10 15 20 25 30 3s 40 U.S.GPM resistance. Single phase: 115V 0 2 4 CAPACITY 6 8 loot. Materials of Construction • Cast iron motor housing for Cast iron efficient heat transfer, strength, Thermoplastic and durability. Stainless steel • Corrosion resistant threaded stainless steel shaft. • Available for automatic and manual operation. • GSA listed models available. All Models are designed for continuous operation and feature stainless steel hardware. r Wisconsin Department of Commerce SOIL AND SITE EVALUATION 'Divisiori pf safety and Buildings Page—/ of Bureau of Integrated Services in accordance with s. ILHR 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 I.D. # APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Pro y Owner Property Location '� Govt. Lot -- 1/4 1/4,S T� ,N,R E (C45? roperty Owner's Mailing ess Lot # Block# Subd. Name or-G6Po4# City State Zip Code Phone Number ❑ City ❑Village T wn Nearest Road New Construction Use: Residential / Number of bedrooms Addition to existing building El Replacement ❑ Public or commercial - Describe: Code derived daily flow A� gpd Recommended design loading rate bed, gpd /ft trench, gpd /ft Absorption area required bed, ft trench, ft Maximum design loading rate bed, gpd /ft trench, gpd /ft Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design /site considerations �c L� Parent material _�����' /ice 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 El U � S ❑ U ❑ S U El U ❑ S U ❑ S P U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench L - o z . Ground _ _ 5— elev. Af , G4 r-7 --ft. Depth to limiting factor > f min. Remarks: T �,� 2� 1�t'/ /� � Z/1/ Boring # 2 D- /o sxz ihS - /o – L C_ 51 z — s Ground w elev. /4�. ft• Depth to limiting fa for 7f in. Remarks: ig y CST Name (Please Print) Signature Telephone No. D9 ;?f - s?v Addres Date CST Number ?D 2 C___z' ©23 o i2 l d'D PROPERTY OWNER 4 44� 1 lf SOIL DESCRIPTION REPORT or � y `� Page PARCEL I.D.# y V �1jJ — 6/ Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3 eqyx Z Ground elev. r Depth to limiting factor in. Remarks: z p — S 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 # Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) I � t l 4U4 Ir r t oy y i T T 3i? fi �-� iL �,� _ o IL 5-4- .1�lSt'�A��E' � ALL to SC•¢ L F . Icrt/ = pY y' > nxr/i , �- = Y Jc S� CZ i • y y,s j o/P, y cF l7 .mac Dk ro � � ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM 6 �. _ , �' Owner/Buyer -¢- — Mailing Address FV Property Address c le y — (Verification required from Plann ng Department for new construction) City /State Parcel Identification Number _,yY LEGAL DESCRIPTION Property Location 'A, Sa/ '/4, Sec. 3 , T -4' N-R - ZEW, Town of Subdivision Lot # _ Certifled Survey 11'Inp # , Volume , Page # Warranty Deed # ✓` ( 93 , Volume bf z , Page # _ t '��.• Spec house d yes W no Lot lines identifiable K yes O no SYSTEM MAI 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. She 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. 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. & 2� _ t 1) l �i 9y SIGNATURE OF APPLICANT DATE OWNER CERTIFICA'T'ION 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office. ,• SIGNATURE OF APPLICANT 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 VOL T )1 PAC[ 99 SFkIE BAR OF %%A';(0 i\ Ft 2 - 14:42 I L NVARR :`.ti 1 - Y 1)1:E1) DOCUMEM NO _ `REGi3`7TS 0 F��� - RICHARD O. STOUT ST. CrPr,�iX CO.. W! SE P 15 1998 r co and „arrant _ BO - 'E SUE G F LO t!ie 11 dr;, nheL'... ai e t. ... St. C CO X eG << � Mate „ t �ti a onst,i / r — Lot 39, Plat of Country Wood First Addition, C {�� Town of Troy, St. Croix County, Wisconsin. 040 - 1235 -00 -000 TRANSFER � Q FEE is not I h:> E ` ":p " "a •" " "' easements, res + ictions, rights -. -f -way and covenants of record, if any. I / ,: 1 1 _September 98 Richard O Stout 1A; - -- - - - - - Ali CHliN I (CATION k( KNON\ LE.DGMENT �:4 n..:;: State of "X I'Consrn, - _ St. Croix September lv 9$ Richar 3 O._ Stout u 13rWia POOH t' Notary PUMIL SC+tC iff �`'j�CttD�lil Janet r Stout 1353- Awatukee Tr. ' Hudson Wi 54016 � l V� 1{: R.1� I1 1�I I U 1 111 81H ,% N it ,,A.I♦ ., _ „ 1 r,•i \.., _ I ^gin: WARRANTY DEED ti a1'1: BAR OF Wl. .,, FOWlit REGISTER'S OFFICE ST. CROIX CTY., VA pEi,8l�12T L. SINGERtIOUSE 1:11 bERNIE H. SMEMIGUSE, ked for PAMI husband and wife, and each in their own individual i U N 3 1996 right and capacity at -�v � rw 12:15 P.M t•onvr+; nr.d v:;,rrant� to - K.K * ✓ ,1 �i k RI(FVM Q. 5 a resident of the Town of St. Joseph, RegMK of a..d. St. Croix County, Wisconsin for $1.00 and other gcod and valuable consideratia += %Tr. Richard 0. Stout 1353 Awatukee Trail • ue 1+ >tl•'• "ink lescribcd rta +. estate in . St. Croi c ,_.... ,ty• Huds+m i4? +�1C16 Mate of Wisconsin Tax Pa[cel No: .._ - -. -- ... -. Lots 16, 17, 19, 22, 25, 27 and Outcot 1, fl nth, Wisconsin. Woud, =n the Town of Troy, - AND ALSO Lots 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 4 43, 15, 46, 17, 4P, 49, 50, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 6- 66, 6 69. 69, 70 and 71, Plat of Country Wood First Addition, in the Town of Troy, St. Croix C _ Wisconsin. AND ALSO Any other lots, outlots and other lands. described in that Land co dated June 2, 1995, recorded June `, 1995, in Vol. 1124, Page 496-, Doc. %, 529 in the office of the Register of Deeds for St. Croix County, Wis'onsin, EXCFdPT those lots, outlots and other lands previously conveyed by deeds from 7rEintors to grantee AND F-v-r- M public roads and any other portions dedicated to `_ne Town of Prey by said plats of Country Wood and Country Wood First Addition. Together with and subject to easements, covenants, _eservati - )ns and restrictions shown on said Plats or otherwise of record, if any. This deed is given in full and final perforT.:ance and satisfaction of that Land Contract recoraed in ':ol. 1124, Paae 496, Th!s is not homestead ),rotterty. Doc. No. 1 �2 0 ' R. Triancfer f ,-10 Urendi'�. (is) (ic not) }:x,epti to warranties: day of 96 F E I v MATCH y QftWAWD z ON f7 ` J : n \ O .4 z N c o \ m to m .a g w tr" A, .TS• x � z ' ao m x o OD Cc m ' O z ma �1 \ ma N N• Ni � to n to N F � ( N ` g2 \ N (J 0 ' \ N till. m 'n N � � • m �