HomeMy WebLinkAbout040-1238-00-000 ST. CROIX COUNTY ZONING DEPARTMEN-T
AS BUILT SANITARY REPO ,
,.
Owner
Property Address / d VW e r e G X7'7` I '"
City /State
Legal Description:
Lot Z Block Subdivision/CSM # r a
1 /4 sn1 1 /a, Sec. 3 , T 2N -RAW, Town of PIN
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer ,h -, Arj es zki ,V Size, ST/PC /1 / -sy Setback from: House Well
PAL
Pump manufacturer Model �nZ/
Alarm location s
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of system: z &,// Width - ,-5 - Length S2_ Number of Trenches
Setback from: House � Well 5-5 P/L d Vent to fresh air intake
ELEVATIONS
Description of benchmark ,®e Elevatio
Description of alternate benchmark ��,� 7`r' a�� Tye_ Elevation 4'L)
Building Sewer 2r7, ST/HT Inlet % 41 ST Outlet PC Inlet
PC Bottom Z t j Header/Manifold T Top of ST/PC Manhole Cover D
Distribution Lines
Bottom of System () 9 c () ( )
Final Grade
Date of installation`b O4/ 9 Permit number 3 ��� �� State plan number
Plumber's signature 1A ) License number ems? ��'Y d _ Date
Inspector A6 ZZ —
Complete plot plan �
I
t )
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
I I (�BKg�
INDICATE NORTH ARROW
f
'Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count y:
' Safety and Buildings Division
INSPECTION REPORT ST. CROIX
G INFORMATION (ATTACH TO PERMIT) Sanitary Permit No -:
Personal information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)]. 344690
Permit Holder's Name: ❑ City [I Village g] Town of: State Plan ID No.:
GUNDERSON, Scott Troy
CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.:
16 �
10 2-" I r0h t,>A u,e L✓ 040-1238-00-000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic k C Benchmark 2 10,2.
osing (p
Al� W
Aeration Bldg. Sewer
Holding St/ Inlet 1 7 85.
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Air to
ir ntake ROAD Dt Inlet
ti (o f-,/a q6 N NA Dt Bottom a 0-4
Dosin 1, G b' T NA Header / Man. &`1 93.
Aeration NA Dist. Pipe �'$° B 99 93
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufactur Demand q, 1, t,
Model Number GPM
ts.�s TDH Lift Friction Systems TDH Ft
oss Head
r Forcemain I L 3 h �S Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED / Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIM N DIMENSION
LEACHING Manufacturer:
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM - -�
INFORMATION Type CHAMBER Model Number:
Syst m�e l il D Ail OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
•7
Length 77 Dia. Length 75' Dia. Spacing L' � -- f�?
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
xx Seeded/ Sodded xx Mulched
Depth Over Depth Over xx Depth Of
Bed /Trench Center Bed / Trench Edges Topsoil ❑ Yes El No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) 10IZe 11, '
TROY 3.28.19.1206,NE,SW 546 GilbertRoad - Countrywood Lot 69
apla.cs �r. -vM�" Via, %b �a v��-6b
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D> • I • ry hA - T 0 i j d i ^ y 4v it 4-" ce Ig 6w ( tod;' �a wo- J
Plan revision required? 64 Yes ❑ No G /, /
Use other side for additional information. �[
SBD 6710 (R.3/97) Date Inspector's Signature ert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
SANITARY PERMIT APPLICATI 2 01 W. Washington Avenue
1*6onsin P O Box 7302
Department of Commerce In accord with Comm 83.05, mss. Adm y
r Madison, WI 53707 -7302
• Attach complete plans to the count co only) for the s ystem, o not ss Cou r
P P ( Y P )
Y Y Y
than 11 11 inches i /�
t 8 2 x c es n size I'
k ` tya
• See reverse side for instructions for completing this a lication c,'.c to sar) Permit Numb
P 9 PP er
Q
Personal information you provide ma/be used for secon a t J 1
Y p ry purp0 S j eck i'f "revi§ion to previous application
[Privacy Law, s. 15.04 (1) (m)]. S
c� C X PI » ). . Number
1. APPLICATION INF R AT! N - PLEASE PRINT ALL INF TI
Property Owner Name Locatio ;,�
Spa G d�ys�.r! 1i T , N, R/ E (or
Property Owner's Mailing Address Lot Num Block Number
IL
er
City, State Zip Code Phone Number Subdivision Name or CSM Number
GWT ) 8 a S` v w I ® d
I. - TYPE IL I G: (check one) ❑ State Owned 't Nearest Road
V/ ❑ Village 1
Public 1 or 2 Family Dwelling - No. of bedrooms , _ Town OF IJ6e,r
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1239—co—cm
/� olg. 1°1 1 206
1 []Apartment/ Condo D
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. gLNew 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
11 ❑ Seepage Bed 21 []Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12RISeepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit f f 43 C] Vault Privy
14 E] System-In-Fill S X 5-:f- � A �
VI. ABSORPT SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade
��d Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) '72, Elevation r,5
77s V,�e 0 / Feet Feet
VII TANK Capacit in all0 S Total # of Prefab. Site Fiber- Exper"
INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete st Con- Steel glass Plastic App
T nks Tanks
Septic Tank or Holding Tank /� jQOD ' �' R ❑ ❑ ❑ ❑ 11 Lift Pump Tank /Siphon Chamber Cl I El 1 01 11 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's Signa re: (No Stamp MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, Sta e, ip Code): Ala
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
NApproved [] Owner Given Initial I s d'D Surcharge Fee)
j `f-q 9
�S� 1 9 ,
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -6398 (R. 4199) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
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.
A. 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 licerised 'pumper Wherievef
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, 68 8-266 -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.
H. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
II. Building . If in e is public, check all appropriate boxes that apply.
use building type p pp . y
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 isto 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.
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Wisconsin Re%,r*nt of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3
d.abor„�+nr} litaman Relations
Divnsian of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
to
/
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, byi'
' � f St , . Cro��C
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEIA , r
dimensioned, north arrow, and location and distance to nearest road. pending 'r-
REVIEWS
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION
BY• DATE
PROPERTY OWNER: PROPERTY LOCAT
Richard Stout GOVT. LOT 1'14" 1/g,S,�,�8 19 (or) W NP
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # w -,M E OR CSM J-
1353 Awatukee Trl. 69 na t
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGEYErOW REST ROAD
Hudson, WI. 54016 015)549 -6731 Tower Rd.
New Construction Use [ xJ Residential /Number of bedrooms 3 [ ] Addition to existing building
j 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, ft2 750 trench, ft Maximum design loading rate • 5 bed, gpd/ft2 - - 6 trench, gpd/ft
Recommended infiltration surface elevation(s) 93.51 It (as referred to site plan benchmark)
Additional design / site considerations alt. site el . = 92.28'
Parent material pitted outwash plain Flood plain elevation, if applicable na ft
S = Suitable for system I CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem I g7 S❑ U 13 EI UI 1 C3S ❑ U CIS ❑ U RI S O U ❑ S ® U
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 Trench
{0{r G:•'
1
1 0 -13 10 r2 2 none 1 2fpl mfr Cfw if .5 .6
2 13 -29 10 r4/4 none sicl lfsbk mfr gw if .2 .3
Ground 3 29 -88 7.5yr4/6 none I fs osg mvfr na na .5 .6
elev.
97.2 ft.
Depth to
limiting
factor
:
R m rk
e a s
Boring #
:.ry :r 1 0 -13 10 r2/2 none 1 2msbk mfr gw if .51 .6
v_ 2 2 13 -32 10 r4/4 none sicl 2msbk mfr gw if .2 .3-
1}4: •n• •S.; }v$:,:`.
Ground 3 32 -88 7.5 r4 6 none lfs oscf mvfr na na .5 .6
elev.
97 .24`. ft.
Depth to
limiting
factor
+88
Remarks:
ST Name Print Phone:
Gary L. Steel 715 - 246 -6200
A ddress: 1554 200th AVe., New Richmond, WI 54017 MO2298
Signature: Date: CST Number:
j 4 -18 -96
PROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Page 2 '` of 3
PARCEL I.D. # pendinct ,
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouncl3y Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trer h
. g
1 0 -14 10 r2/2 none 1 2msbk mfr Qw if .5 .6
3
2 14 -30 10 r4 4 none sici mfr 9w 1 f .2 .3
Ground 3 30 -88 10 r4 na na .5 .6
elev.
96 ft.
Depth to Q '
limiting
factor
+88"
Remarks:
Boring #
1 0 -15 10 r2 2 none 2msbk mfr C1w if .5i .
T airy
4 2 15 -30 10yr4 /4 none sici lfsbk mfr f
iy r:': { :?Si{
Ground 3 30 -84 10 r4 6 none 1 f s osa mvfr na na .5 i .6
elev.
9 4.9 ft.
Depth to
limiting
factor
84
Remarks:
Boring #
"p.- :;<: >aq.-": 1 0 -14 1 2
;,y.,�. ,,.:,:
2 14 - 10 r4 /4 none sicl 2rnsbk mfr if
3 33 -80 10 r4/4 none lfs I os
Ground
elev.
95 ft.
- 3
Depth to
limiting
factory
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(R,05t92)
• AP
STEEL'S SOIL SERVICE
Gary L. Steel 1554 200th Ave.
CSTM2298 1 Richard stout New Richmond WI 54017
MPRSW to 3254 o Tro y N -2 715 246 -6200
town of Troy
lot #69- Country Wood
N
1 =40'
BI.= top of !" steel pipe C el. 100'
3 6
a ��1
�t
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J
C�
Ga L. Steel
4 -18 -96
SYSTEM ELEVATION AND SIZING CALCULATIONS
Below Grade Aggregate Soil Absorption Systems
Permit Number 9/14/99 Date
X X. Gravity Distribution
only 1 Pressure Distribution
3 ft Suitable Soil ,
6 in Aggregate Depth 2
4 in Nominal Pipe Diameter
450 gpd Estimated Daily Peak Flow
0.60 gpd /ft Wastewater Infiltration Rate
750.0 ft Minimum SAS Size
92.28 Ift Proposed SAS Elevation
Soil Surface Acceptable Finished Grade EL 3 (ft)
Boring Grade Limitation SAS Elevation (ft) System Minimum Maximum
Number Elevation (ft) Depth (in) Lowest THighest Elevation? 94.78 96.61
1 97.20 88 92.87 95.70 No Cut required
2 97.24 88 92.91 95.74 No Cut required
3 96.50 88 92.17 95.00 Yes
4 94.90 84 90.90 93.40 Yes
5 95.03 80 91.36 93.53 Yes
1. Depth of suitable soil required below the infiltrative surface for treatment.
2. Depth of aggregate below distribution pipe.
3. Based on chosen system elevation, and aggregate depth. The addition of
fill for cover or the reduction of finished grade may be required to meet
minimum or maximum code standards.
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
SBD- 10553 -E (R.05/98)
09/07/99 TUE 11:08 FAX 715 262 5823 The Gunderson's 0 001
S®p -07 --99 10:16A R-
ST CROIX COUNW
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION mm
OwntrfBuyer _ e�j, ^ 0 � ► T C/L�[ ��i�C .� �..
Mailing Address
�y F 1 , e V -- - A'd 0 -4;
Property Ad-drew . .rz....,�►M W � S L 4 / 1 IV Ti
(Wri£caftm from P mg Dcpadment fw new construction) r?
City(State & �,�v: ' — Parcel Identification Number C' `{� - l � �'�' " de' –00 G
L AL DIEt.SMUMON .
Property Location •3 . T 2T N-R,j W, Town of
Subdivision r Lot # .
Certified Survey Map # _ _.- Volurne , Page # ~` _
Warrant Deed # -(moo + I l " V lum, 1 �f 3 . Pa #
Spec house D ye:� no Lot lilies identifiablc xYes 0 Do
QX= &J&TNTAWANCE
Improper vse and maiaat aceo[yatr septa wysoem emad await m its pRematuee raibmc m bandie Wastes. Proper anaint
exists of Pwm piteg attt Tits sepue t o& eveay Ibiza ymn or socom it needed by a hmased punqxr_ What you par face The sysecos
can affect du harden of dw sepdt bah as a tteamtas =V is die waft disposal system.
The propcM owm aveoa to submit to St Or*& Zotttag Uepattaneat a oenification font% Biped by the owruer and by a
mastcrphambmioumcymmp . to actedphmtberofs liceuscd pu:npa venfymg that (1) the ou -six wrastewaeerdivmW system
a in proper opwatg eoa:dbios me dfor (2) after iobpecuoa sad paompog (if accessary), die septic tank is kss dum I13 fall of sk*c.
Uwe, den tmdersigntd bave: read Titre above requacu a s and agree to maiauin the pavote sewage: disposal system with the standanU
$et foftk berein. as Set by the Depsttnm of Conmeace sad tie Depu metat of Natural Rcsootees. State of Wisconsin. Cetti*atic a
sating that yaw septic symm has ban maiaumed num be completed and tecumed to the St Croix Ca mty Zoning Oran= wit an 30
days of &a three evirad m date..
X Cl
SI ATURE F PLIC11] DATE
QM NU CFATMCATION
i (wee) eertity that aA swommes on tbk form are tine to am best of my (our) luwwk Agc. I (we) am (ate) the owners) of
NA delta above. by viox of a wr4migy dead recorded i RegWcr of Dccds Office.
C1
E OF LI DATE
.s..a• Any im Ogmation drat is nas-Mnoensedamy teaulc is d w staimry permit be* revoked by the Zoning Depattawatt. ••••••
•• fact ade witk this r ppticadow a staMped wananty dead float the Register of Deeds office
a copy of dr- certified mavcy map if wethr epee is auada to the warranty dead
Y 5
' STATE BAR OF WISCONSIN FORM 1 -1992 � EaQ9'1 218
WARRANTY DEED KA ;tiM 8N
STXa q a
`
DOCUMENT No. _
,V 4L FN EM
This Deed, =& & between xTr oann n mm 0? 10 - i!!9 fs3b NI
WIAW IM
Graruor, I COff CM F9r
and SCOTT R. GUNDERSON and LORI A. �I Co a 11.70
GUNDERSON. husband and wife, AE=D6 FtEt ILN
- Grantee, I Ogg '
Witnesseth, That the said Cc a tor, for a +aluablc mrt�.ie+adaL
f
cottveys to Grantee the following described real estate In St, CtOi x TNT SPACE PkSEPVED FOR RECORDING G:TA !
C UM state of wiaconsin: NAA* AND RETURN ADDRESS
Lot 69, Plat of Country Wood First Addition,
Town of Troy, St. Croix County, Wisconsin.
I
040- 1238 -00 -000
PARCEL 0ENTIFICATION NUMBER
+ I
I�
I
II
This is not homestead property. `
(is) (is nos)
Together with all and singular the heredhiments and appurtenances thereunto belonging; ?
And Richard O_ Stout
warrants that th:.. title is good, indefeasible in fee simple and free and clear of encumbrances except
easements, restrictions, rights -of -way and covenants of record,
�
and will warrant and defend the same.
Dated this 15th day c; __ . July .19 i
(SEAL.) (SEAL) I)
(SEAL) (SEAL) I�
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) ,. State of Wisconsin,
rs.
St. CSo1x minty
I I authenticated this __._ day of ' 19 Personally came before me t::s I Sth day cl
j T iny_ _, 1939-, the above named
-- — — Richard O_ Stout
TITLE: MEMBER STATE MAR OF WISCONSIN N OfARY y
I (If nee, C%-rA- tFV
authorized irk 3706.06, Wis. Stats.) W t ,. `� red the fotesping
instru d ac t ,.
THIS INSI RUMENT WAS DRAFTED BY —� i
Janet P. Stout l
a tax ee Tr. – -- – I
i —. Notary blic, C.I�N County, Wis. i
11 tSlgnatures may be authenticated or acknowledged. Br': ire not l+ly mmissionrinanent. (if not, state expiratt; i
II necessary.)
E • Names d pawns signing in ary ^oxen. <h „vld by typed r n mt.: t3ov ;hdr stgnuures.
I STATE SAS .')F Wt5CONSIN WO -onM y n t.' Rlw* C4-4v.
WARRANTY DEED
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