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HomeMy WebLinkAbout042-1084-60-000 ST. CROIX COUNTY ZONING DEPARTMENT • AS BUILT SANITARY REPORT Owner & tk.,• Property Address 9 ? y - 7& , 'h A P City /State /? Lt , � s LA, 16 Z 3 Legal De scription: Lot Block -- Subdivision/CSM # 5 k ) 1 /4 3t 1 /a, Sec. 3 , T Zg N -R (& W, Town of PIN # oyZ- i08 490 SEPTIC TANK — DOSE CHAMBER — HOLDING TANK INFORMATION: Tank manufacturer 4)" s C, SizC Setback from: House Well P/L r2 -- Pump manufacturer 41A Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road / I)A Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: I 1�zyu -k Width ��� Length - 7 Number of Trenches z- Setback from: House Well P/L ,:�)a'r Vent to fresh air intake ELEVATIONS Description of benchmark id n Z � ��� f { d� e- Elevation io Description of alternate benchmar i t e, ri., r Elevation `T 7• c'3 Building Sewer ST/HT Inlet boo ST Outlet PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover Sd Distribution Lines �a () ( ) Bottom of System (ri) 1) cr Final Grade () �7 (-o 5 () ( ) Date of installation Permit number State plan number i Plumber's signature - License number Date 9 / // f Inspector Complete plot plan Or I 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 N ^ n1 K lD f 1 IV INDICATE NORTH ARROW Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: ST CR IX Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 338868 PerTWiQW, N IAN ❑City "EN Town of: State Plan ID No.: CST BM Elev.:. , Insp. BM Elev.: Description: W y Parcel Tax No.: 0'+f� • a r BM o,.,, y - C 042 1084 -60 -000 TANK INFORMATION ELEVATION DATA 32 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ( Z c 9p Benchmark /'' `' � ; O Dosing , A4 �l � 91 S3 Aeration Bldg. Sew ) �l �J 'f, V6 , � ILI Holding St /Ht Inlet (o if yV x•(09 s O� TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Air i to ntake ROAD Dt ir Septic l Jay r NA Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION al Grade, Manufac r emand htiu^A / 3" 2-. SO Model Number GPM TDH Lift L 1 On TDH Ft F main I Length Dia. Dist. To Well SOIL PTION SYSTEM 12 r,Q",L, 9w TRENCH Width I L gth 1 N . Of eriches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN I S DIMENSION SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Map c er: / I SETBACK CHAMBER INFORMATION TypeO Model Number: System: > 1 0 OR UNIT DISTRIBUTION SYSTEM Header / anifold 6r Distribution Pipe(s) x Hole Size x Hole Spa ng Vent To Air Intake Length Dia. 'Length Dia. pawn `cr.0 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: WARREN 30 9.1 .474,SW,SE 974 70TH AVENUE n WF Z �, a Z• 1 ,;e� � � . D ,�Q�Q� Scu.er� ls! "+ .a.e -�, cam / Z ) ai Plan revision required? ❑ Yes C4 No _ y S IZ I 1 14 1 Use other side for additional information. 1 Q x SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. Safety and Buildings Division *sconsin S ANITARY PERMIT APPLICATION 201 Box Washington Avenue Departmebt 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. ,1 rc • See reverse side for instructions for completing this application State Sanitary P ermit Num Personal information you provide may be used for secondary purposes E] Check it revis to a lication (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property O ner Name Property Location va - 1 /4, S T a9 , N, R /8 k(or)Q Property Owner's Mailing Ad ress a Lot Number,, Block Number City, St a ��GG � Code Phone Number Subdivisio Name or CSM Number II. TYPE F BUILDING: (check one) ❑ State Owned !t Nearest Road Ei Public 1 or 2 Family Dwelling - No. of bedrooms n Tow a n OF �Cc.i �� � f¢ III BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) n 0. L4-7 1 ❑ Apartment / Condo 6S/7- - /0F5" - 4 j t7 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. A New 2 ❑ Replacement 3 ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an ------ System ________ System _____________ Tank -------------- 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 � epage Bed 21 Mound 30 Specify Type 41 ❑ Holding Tank 12 Se E] ❑ epage Trench 22 ❑ In- Ground Pressure ' x . 42 ❑ Pit Privy 13 El Seepage Pit _ O �! 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 (s ft.) (Gals/day /sq. ft.) (Min-/inch) r r fy, - 76 Elevation 750 - 2/03 I Ig 72 92, f Feet j Feet VII. TANK Capacity g all o ns Total # of r Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App New Existing structed Tanks Tanks I p ank or k i zw / 2-oo K ❑ ❑ ❑ ❑ ❑ TMT - um - p - Tank /Siphon Chamber I ❑ 1 ❑ 1 ❑ 1 ❑ I ❑ I ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plum er's Signature No Stamps) MP /MPRS�V J,11 o.: Business Phone Number: f r i�'�— Plum is Address (Street, City, o Stat Zip Cde): 7* .� �J / �� o-X7 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuin gent Signature (No Stamps) O / Ap proved []Owner Given Initial —1 Surcharge Fee) Adverse Determination �/� La X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: original to County. One copy To: Safety & Buildings Division, Owner, plumber JOB r,/+f 1 r/i I+t Lh TIMM EXCAVATING Route 1 Box 192 SHEET NO. OF 'Z • WILSON, WISCONSIN 54027 CALCULATEDBY DATE (715) 772 -3214 (715) 386.5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE a'S a. .. ..............................> .... .... ..... ..... ..... ..... .... .... .... .... ..... ..... ..... ..... ...................... ..... ..... ..... .... .... .... .... ..... ..... .... i � o .. .............: . .. .... ... 3 ...... ... ..... ... ... .... ...... ........... ..................... ........... ................ ........................ ��� ..... . ...... ...........; i .... ..... ..... .... .. - . ........... ........... .......... ....................... .......... ........... .......... ........... ........... ......... . ..... ........... ...................... .... f .. t ..... .......... . ... .; ; . .... .... ....... ..... .. ...... .......... .......... ........... . ... .. ... ..... .. ..... ........ .. .. .... ... ... .. .... ................. .......... .................................. .� .......... ........... ........... ........... ................... .... ........... V Y.... l7 t P(a.usR ...... r•dd .... .......... ..,... f . .. ............. ........ ... ! . . .... ..... ,. ........... . . .. ........... , , ... ........ .,., .... .... - p ,.......... ....... ,... ,... X ........ _... ............... ............... ........... ... _ PRODUCT 205-1® Inc.. Groton, Mess, 01471 , To Order PHONE TOLL FREE 1- 800 - 225-6380 JOB TI M M EXCAVATING SHEET NO. OF Route 1 Box 192 WILSON, WISCONSIN 54027 CALCULATED BY DATE (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCAL ......... .......... ........... . .... .... ..... .... .... .... .... .... ..... ... ........... ........... .... .......... .......... ........... ........... ...... ...... ...... ....... ....... ...... ...... ...... ...... .. ........... ........... ........... ........... ... .......... ...................... ........... ........... ........... ........... .......... .......... .......... ....... ... ............. .......... .......... ........... ...................... . ...... .... .......... .................. . ......... r .......... ........... ............ .......... ........... .......... ................. ............. ... . .......... .......... ........... ........... .......... .......... ........... .......... ........... ........... .......... . ........... ...... ... ..... ........... ........... .......... .......... ........... ........... ...... ........... .. . ... ........ ....... ..... .. .. ................... ...... ........... ... .... .......... .......... ........... . ....... .......... ........ ........ ............ ........ ............... ............ ............................ .......... ..... ........... ........... ........... ........... .......... ........... ........... ........... ........... ........... .......... ............ ........... ........... ........... ........... .......... .......... ........... .... .. ........ ...........:...........:...... .....:...........s...........:. ......... ........... ............ ........... .............. ........... ........... ........... ........... .......... ........... .......... .......... .................. ........... ........... .......... ....................... ........... ............ ; 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PRODUCT 205-1 � lft, Groton, Man. 01471 To Ner PHONE TOLL FREE I-800 -225-M Wsconsin`Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page / of 3 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. If APPLICANT INFORMATION - Please print all information. Rev d bV Date Personal information you provide may be used for secondary pure r c 15.04 (1) (m)). ` 7 z m Property Owner ,L ::- / n roperty Location ,, t. Lot S� 1/4 ��1/4,S 3b T N,R �� E (or)© Property wner's Mailing Address l i_� ,`_f�� s Lot BIocK# Subd. Name or CSM# City State Zip Code `'Phone Ni leer77 1999 Qpl ty ❑Village F* Town Nearest Road Q Q r re rn New construction Use: Residenti ` �Kir6'rbw of bedrogrn Addition to existing building El Replacement Public or com r jD s>cr�d: Code derived daily flow gpd Recommended design loading rate 01 7 bed, gpd /ft z —Z-8—_ trench, gpd /ft Absorption area required _ bed, ft SO trench, ft Maximum design loading rate + 7 bed, d /ft g g gp 4Y trench, gpd /ft Recommended infiltration surface elevation(s) g� f* ?"_- 12 I'll 9 `/, 70 ft (as referred to site plan benchmark) Additional design /site considerations Lt7Wer-- fert" 42 , 90 Adt• �C�U• r�m�rL � Gac �( QG� � Parent material G �a . Q �; + 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 [3 S❑ U IN S ❑ U WS Flu XS ❑ U ❑ S ®U ❑ S 91 U SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /ft g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Ground 3 d r y _[ -- t- _S YYl C S , 7 elev. eft. i i (� "— py) m . Depth to limiting , factor /zn _ in. 4b" ey' (r 10 5" Remarks: Boring # - 10 101 3 4 -41K, 110 ti/ 4 / +r Ground U /' y �" L^ hn 'Wt I C s 7 elev. 7 , oft. 5 a � , tr✓ — � . 8 Depth to d3 ti limiting factor LZ-( Remarks: CST Name (Please Print) Signat Telephone No. Address Date CST Number �f y PROPERTY OWNER �� � f' +� SOIL DESCRIPTION REPORT 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 Z - 1 -Zb l D S , hk N1X- r . �v Ground 2& elev. . J Depth to limiting factor �in. 31.Z IE,7.2 Remarks: Boring # v o -L d rZ Mqb Ground p elev Depth to limiting factor 7 d in. Remarks: FHorizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # 0 -ZO l a Z l — L- a {� � C S S s 10 m e fug 3 s- -7Y i v r /y Ground r C'3 • 7 ' elev. Depth to limiting factor 3`D n. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) Vo z e- 0. 3 06 OF 30 v N SY5 e6 lJ Lf jy5<rwL c[c✓ UPeer- 4(- V Y,aG j + 01 O e O. UO n 7' 41or+�-, t " 3 QG teS iQybo / � L I s y sa 'C � o � Z � rn I r h C i ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer &&*� -rtf / �u Mailing Address _ la:5' Property Address (Verification required from Planning Department for new construction) City/State e,-5 GtJz Parcel Identification Number LEGAL DESCRIPTION Property Location S AJ '/4, T C '/4, Sec. , T Of' N-R /& W, Town of Gya rl�� Subdivision 41 9 , Lot # IVA . Certified Survey Map # Volume , Page # Warranty Deed # lirUV 7v , Volume / Y/ , Page # bKd Spec house ❑ yes X no Lot lines identifiable ;0 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. 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 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. Si MATURE 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. 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 ' V0I 141. )MEW 6►ooss WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD Document Number: 04-05 -1999 8:00 AM WANTY DEED Return Address: EXEMPT # CERT COPY FEE: COPY FEE: TRANSFER FEE: 204.00 I 4 RECORDING FEE: 10.00 i 5Y01' (0 PAGES: 1 P"C Number (PIN): 042 - 1084 -69 This Deed, made between Frederick G. Lenertz Land and Cattle Company, L.L.C., a Wisconsin limited liability company, Grantor, and Brian K. Smith and Carol I. Smith, husband and wife, as survivorship marital property, Grantee, Witnesseth, That the said Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin: SW '/4 of SE %4 of Section 30, Township 29 North, Range 18 West, St. Croix County, Wisconsin, except Certified Survey Map in Volume 8, page 2191, Document No. 456664. This is not homestead property. Together with all and singular the hereditaments and appurtenances thereunto belonging: And Grantor warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements and restrictions of record and will warrant and defend the same. Dated this 1 S ' day of April, 1999. FREDERICK G. LENERTZ LAND AND CATTLE COMPANY, L.L.C. Steven B. Goff, Power of Attor e Frederick G. Lenertz ' ACKNOWLEDGMENT STATE OF WISCONSIN ) ) SS. ST. CROIX COUNTY 1 Personally came before me this 1 s' day of April, 1999, the above named Steven B. Goff to me known to be the persons who executed the foregoing instrument and acknowledge the same. Pamela A. Skorude, Notary Public 'j ; St. Croix County, Wisconsin My Commission expires: March 17, '2co.,��Q THIS INSTRUMENT DRAFTED BY: Steven B. Goff Bye, Goff & Rohde, Ltd. PO Box 167 River Falls, WI 54022 SBG\LENERTZ\CLAPP \D 1 WD Smith