HomeMy WebLinkAbout040-1236-20-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
Safety and Buildings Division
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.1 (1)(m)). 353208
Permit Holder's Name: ❑ City ❑ Village [2 Town of: State Plan ID No.:
Yuen st James I Town of Troy
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
/o o to O `� 040- 1236 -20 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic _ eA&el Q n OCD Benchmark Z 00
Dosing Alt. BM S
Bldg. Sewer P 0 Y 9y
Holding St Ht Inlet Z_
TANK SETBACK INFORMATION st
TANKTO P/L WELL BLDG. Air to
I ntake ROAD
Air
Septic - Aj4 31 / NA Dt Bottom `� Z
Dosing O 41A f 2 r NA Header / Man. �r S
Lrl
Aer Dist. Pipe
2 Z
c Ti sG y 36
Holding Bot. System Z
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer 6 u Demand St cover 7
Model Number GPM
TDH Lift5:,p Friction System TDH Ft
Forcemain Length foo Dia. Zr Dist. To Well
SOIL ABSORPTION SYSTEM
BED / RE Width Len th No. Of Trenches PIT No. Of Pits Inside Dia. Depth
DIMENSIONS Z DIM
SYSTEM TO P / L BLDG WELL LAKE/STREAM FLEA C anu acturer:
SETBACK AM BI?
INFORMATION Type Of CHAM Mo umber:
System: C4ylu / f /Ov �/4 OR UN IT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length —4ZL Dia. r. Length Dia. _� Spacing 2r Z Z
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.) Inspection #1: 1( / 17/ 9'Inspection #2:
Location: 530 Gilbert Road, Hudson, WI (SE1 /4, SW1 /4, Section 3 T28N -R19W) - 3.28.19.1188
1.) Alt BM Description= w p� u f Tou.�Ai2 >i 'a
2.) Bldg sewer length= 3 Y'
- amount of cover = Z0 — 4iS
3.)1.e r� '� 41 s e � aroma G✓�S
G�Se� ^—O!e � �'GalS�oy�
Plan revision s [] No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert No
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
Safety and Buildings Division
•
NVisconsin SANITARY PERMIT PLICATION 2201 B Washin Avenue
Department of Commerce In accord with Comm 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 81/2 x 11 inches in size. .S/ v l
• See reverse side for instructions for completing this application State Sanitary Permit Number
3673 aieg
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 J.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Property Owner Name Property Lociation
�r_ or
'1/45 1/4, 5 Ta , N, RI9 E
Property Owner's Mailind Address Lot Number Block Number
s �
City, State Zip Code Phone Number Subdivision Name or CSM Number
dsvr� 6r ( > 4:, w o
I. TYPE OF BUILDING: (check one) ❑ State Owned ❑ It� Nearest Road
�/ ❑ ViI age
El Public 1 or 2 Family Dwelling - No. of bedrooms own OF
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) � � -)A .
(�
1 E] Apartment/ Condo 0 T � — l2X _Z0
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. j. New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of S. ❑ 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 ❑ Seepage Pit I I 43 ❑ Vault Privy
14 ❑ System -In -Fill �� S ),0-5
VI. ABSORPTI 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 (s q. ft.) Proposed (s . ft.) (Gals/da /sq. ft.) (Min. /inch) Elevation
Feet 97 9 Feet
Cap acit y
VII. TANK in Ca allo
g Total # of r Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App
New Existing structed
Tanks Tanks
Septic Tank or Holding Tank f I I P .,Cl El ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber r ❑ 1 ❑ 1 ❑ 1 ❑ i n ❑
VIII. 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: ( o S amps) PRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zi Co e):
l &_L/ gx
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate I ssued Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee) rD Adverse Determination 4' oaa6— 1f' 1 ,
X. C NDITIO F APPROVAL / REASONS FOR DISAPPROVAL:
SBD -6398 (R. 4199) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
. 1
2.
VO
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. fhe 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
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 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 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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Wisro sin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor`"and Human Relations
r Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
L
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must inclu¢, bud k roix
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale,,or dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION—
PLEASE PRINT ALL INFORMATION y DATE
PROPERTY OWNER: PROPERTY OCATION
Richard Stout GOVT. LOT ' 1/4 SW 1 14;S 3 T 28 ,N,R 19 for) W
PROPERTY OWNER':S MAILING ADDRESS LOT # I BLO # • SUED. 'NA `OR 1 L'
51 na
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE 0 ,-* NEAREST ROAD
Hudson, K. 54016 (719 549 -6731 Troy Tower Rd.
[ :j New Construction Use [x] Residential / Number of bedrooms 3 [ J Addition to existing building
I ] Replacement [ ] Public or commercial describe
Code derived daily flow 450 g pd Recommended design loading rate • 7 bed, gpd /ft • trench, gpd /ft
Absorption area required 643 bed, ft 563 trench, ft Maxi design loading rate • 7 bed, gpd /ft .8 trench, gpd /ft
Recommended infiltration surface elevation(s) It (as referred to site plan benchmark)
Additional design / site considerations na. ber 43.93
Parent material pitted outwash plain Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem 1 ® S ❑ U ®S ❑ U ®S ❑ U 13S ❑ U -E] S ❑ U ❑ S IJ
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tmnch
1 0 -12 10 r2 1 2 Mfr r_
2 12 -26 10 r4 4 n if .4 .5
Ground 3 26 -80 10 r4 4 none
elev.
96.7 ft.
Depth to a
limiting
fact
80
Remarks:
Boring #
1 0 -11 10 r2/2 none 1 2msb
1 2 11 -25 10 r4 4 none
Ground 3 25 -31 10 r4 4 non
elev. 4 31 -82 7.5 r4/6 none s oscr ml na n
98 ft.
Depth to 7
limiting �� 33 Z .
factor
+82"
Remarks:
CST Name. Please Print Phone:
Gary L. Steel
A ddress:
4 200tb Avel, New Richmond WI. 54017 m02298
Signature: Date: CST Number:
4 -23 -96
PROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D. # pending '3
Lot# 51
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 0 -12 10 r2 2 none 1 2msbk mf r
2 12 -28 10 r4
2msbk mvfr
Ground 3 28 -80 7.5 r4 6 none s 0sa m
elev.
9 7.43 ft.
Depth to
p 3
limiting
facto
Remarks:
Boring #
1 -20 10 r2 2 none 1 2msbk mfr f .5
4 2 10-33-/ 10 r4 4 n
4 ' t +
Ground 3 3 -80 7.5 r4 6 n
elev.
96 ft.
Depth to 35-
limiting
factor
+80"
Remarks:
Boring #
1 -12 10 r2/2 none 1 2msbk mfr cs if .5 .6
` 5
2 2 -24 10 r4 4 none
Ground 3 4 -34 10 r4 6 none
elev. 4 4 -84 7.5 r4/6 none s OSCF ml na na .7 .8
97 ft.
Depth to
limiting
factor
+84"
Remarks:
Boring #
v
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
r
STEEL'S SOIL SERVICE
Gary L. Steel Richard Stout 1554 200th Ave.
CSTM2298 SE4SW4 S3 =T28N -R19W New Richmond, WI 54017
MPRSW 3254 town of Troy (715) 246 -6200
lot #51- Country Wood
1 " =40'
BM. = top of 1 steel pipe @ el. 100'
� / /D
"
1
uT ( 1 �+
5 :3 a �a� / r y L. Steel
4 -23 -96
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address s -3 7 T 5 7 — fyc'
Property Address 3
(Verification required from Planning department for new construction) l .ono
City /State &� OC6tJ / t//' Parcel Identification Number
LEGAL DESCRIPTION
Property Location S %,,4 '� V4, Sec. T_ 2 ZN -R_L!4_ W, Town of ,7 Gam_
Subdivision G-t'� U2 �'— f f �-e) 6 o . Lot # S
Certified Survey Map # Volume . ,Page #
Warranty Deed # , Volume Page #
Spec house ❑ yes 9-no Lot lines identifiable ® 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
masterplumber, journeyman plumber, restrictedplumber 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 Nataral Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and retivaed to the St. Croix County Zoning Office within 30
jAnM f the three year xpiration date. i 9 1 7 1 1 ,
OF A1 LI
( DATE
OWNER CERTIFICATIO
I (we) certify that all statements on this form are true to the ofmal , Pwledge./ I (we) am (are) the owner(s) of
the property des re , by virtue of a warranty deed recorded' ` '44't!T of Deeds Office
M O NATURE OF APPLIC 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
Jf
STATE BAR OF WISCONSIN FORM 2 — 1982 109010
WARRANTY DEED KATHLEEN H. WALSH D�
A REGISTER OF DEEDS f�
DOCUMENT NO, Ypj 1458PAGE 424 ST. CkOIX CO., WI
RECEIM FOR RECORD
Gregory V. Johnson and Jill M. Johnson, husband and 09 - 23 -1999 11:20 AM
wife WARRANTY DEED
EXEMPT I
CERT COPY FEE:
conveys and warrants to James F. Yuengst and Michele L. CORY FEE:
TRANSFER FEE: 112.50
Yuengst husband and wife as marital property with RECORDING FEE: 10.00
rights of survivorship RAGES: 1
THIS SPACE RESERVED FOR RECORDING DATA
NAME AND RETURN ADDRESS
the following described real estate in St. Croix County,
State of Wisconsin:
L
040- 1236 -20
Lot 51, Country Wood First Addition to the Town of PARCEL IDENTIFICATION NUMBER
Troy, St. Croix County, Wisconsin.
I
is not
This homestead property.
(10 (is not)
Exception to warranties: subject to easements and covenants of record.
Dated this 23rd day of S ep t ember / A.D., 19 -- 99 --
A (SEAL) ° ' (SEAL)
(SEAL) • (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Wisconsin,
ss.
St. Croix �y
authenticated this day of 19 Personally came before me this 2 jr day of
�c .,.,r e.. h— , 19 the above named
r �r 11 T h ,t 1131 Mr Tnhn
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by §706.06, Wis. Slats.) �-,tte known to be the person t ho executed the egoing
umeni an ac no ted the same.
THIS INSTRUMENT WAS DRAFTED BY T A ter
. William J naopir}s � t •,' w �. � J. '`9 LlUs{ VI'
St. Cro x Count Wis.
SAII corn A qtr t , F{ A W'r ek(I* Nofary Public, y
(Signatures may he authenticated or acknowledged. Both �fe o&. •• My commission is permanent. (If not, state expiration date:
necessary)
19 )
• Names of persons signing in any capacity should be typed or printed below their signs —m
STATE BAR OF WISCONSIN Y' L.QN a&* Co.. Inc.
WARRANTY DEED Form No 2 — 1982 Mm a. . W.,
i
M 0 100. t$ zy w. .. % I /QC> I
- 0 1,84 AC. EXC. ESMT
80,207 SOFT. y I 1
525.61' I N
S85 °433 „ W 104.00'
:: as
2' I / CD
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AO N N
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0 o W / / I UD
cn N 9es N I / 41 n
C 2.37 AC. I
- 103,073 SO.IFT
pp 1.87 AC. EXC. ESMT/ /
a, o, C„ O 81, 453 SO. FT.
C)., C> C5.. s
n S7
N N a UJ I 07'44
51
'I N TV
v
2.59 AC.
3 112,947 SO. FT.
N
1.82 AC. EXC. ESMT.
79,414 SO. FT.
>e
N N is N
W
l N —1 N
V H f N LL.
> O O O
O O O /
Z / IA Ss9°
W
J // . 50
76;_ : 4
ooe- ��
o ° o o°. N 2.09 AC./ y / / 1 lc
a 10,==
,4 rr -w .r / / / o \ �j
8 90,870/SO. FT �0
in _ 49
a9
ad %a O 1,03 AC. EXCASM� ! /
44,897 Sg FT / 6 /
2.09 AC.
91 ,053 SO. FT.
1.98 AC. EXC. TEMP. CUL
/ / 86,136 S0. FT.
N / � � 615.30'
3 0 09'24 "E / 214.66' .21 mmmmm�
�I N89 °0924 "E 976.17'
+V So' RADIUS TEMPORARY
22.17' CUL- DE -SAC TO BE a
'
REMOVED UPON ROAD I J N F) _/? I I ` L a
Q
EXTENSION
�
100, SHEET 2 OF 4 SHE
200 300 400
I�