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HomeMy WebLinkAbout006-1023-10-000 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner — ,i�5 d Address --� City/State Sr c k 8 49s► � O NV a�� Legal Description: ,h ro Fib / Lot Block Subdivision/CSM #� '/, A L° '/. jam, Sec., T lt&,W, Town of Q PIN # SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION Tank manufacturer 17uCXc v Size6S VPC 10601 Setback from: House "7'0 Well ^ P /L 13 0 Pump manufacturer Model V Alarm location -� (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: A d Width _ Ar Length SD Number of Trenches -- Setback from: House . V Well — P/L .�tO Vent to fresh air intake ELEVATIONS Description of benchmark e1 - Elevation /oo ` Description of alternate benchmark Elevation i Building Sewer ST/HT Inlet 92.68 ST Outlet `/ .21-s z PC Inlet PC Bottom Header/Manifold 92 3 Top of ST/PC Manhole Cover `� y Distribution Lines () l/. g.' () ( ) Bottom of System ( ) `O. S5y ( ) ( ) Final Grade /0 ( ) ( ) Date of installation t /7 Permit number -?1 S^'5> V State plan number Plumber's signa ure License number Z �y7� Date Inspector (Complete plo- w 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� s► � 1 t INDICATE NORTH ARROW ��- T �. A tv j,,,ti -► 6,�, ,� �Ta�� �� �� 1� �,� � � %� /�c /°fie `�$-� / �. cts r /ate I S t 97 �L r ' r �7S sa 3 V1- V i 3 � 0 - y • Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitaryl1 W9.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: SETTER, ELDEN CYLON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel TAW-4023-10-000 �Qo �(7I� k) t tKL 6 TANK INFORMATION EVATION DATA A9800365 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic H U kt�. 14 Bench rk 3.0q Dosing Aeration Bldg. Sewer Holding 9 Inlet ®3, c� 1 A 2, f. 92..!06 TANK SETBACK INFORMATION St/ t Outlet to S TANK TO P/ L WELL BLDG. Air I to ntake ROAD Dt Inlet Air Septic O r �l k �✓� NA Dt Bottom Dosing NA Header /Man. 41.01 a17 - -C) Aeration NA Dist. Pipe I I . q 5• Holding Bot. System i Z 4 PUMP/ SIPHON INFORMATION Final Grade to, Manufacturer mand 174.Maw,L1 Model ber GPM TDH Li Friction Syste TDH Ft oss Forcemai n Len H Dist. To wen SOIL ABSORPTION SYSTEM BED/TRENCH Width f Length No. 22 Of Trenches PIT No. Of Pits Inside Dia. Liquid epth DIMENSION r V �d DIMENSION SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHI ac`tu`rer. SETBACK �,, CHAM R INFORMATION Type ZI r N IA N IA OR UNI Model Numb syst frrIpbw -him, 11 DISTRIBUTION SYSTEM Header/Manifold Distribution Pi e(s) x Hole Size x Hole Spacing Vent To Air Intake Length 1 Dia rA Length V 1_1L Dia. Spacing 2,- SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over tv�, Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center 16 h Bed / Trench Edges Topsoil ❑ Yes ❑ No E] Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: CYLON 11.31.16.150,NE,NE 2276 250TH STREET V Flo vSe h e , + G'I'N $f✓vG- i ✓! 5ff »'l G i ,t f j - a V ug 1 00 '* ?s Is ' • V 1—A [J ICU L- ry fJ 13th I �+ t m $ aoF�lun ii4�r. Strlot,.� Plan revision required? Yes ❑ No I Use other side for additional information. / �' 9 `� - 7 SBD -6710 (R.3/97) Date Inspector's Signature Co. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: e t i m e e a k E i E } 3 s 3 S 3 � e e z e t e i a e u ,gym e F . .� M. i 3 { s an 5 3 t , i a 3 3 } s t 3 ' e e f s { s x a r n e 9 a r x r F e a { Safety and Buildings Division 2 01 E. Washington Ave. SANITARY PERMIT APPLICATION N *L c o ns in P.O. Box 7969 In accord with iLHR 83.05, Wis. Adm. Code � Department of Commerce Madison, WI 53707 -7969 • 1 Count Attach complete plans (to the county copy only) for the system, on paper not l ess y , than 81/2 x 11 inches in size. ST Q 0. 0/ *, • See reverse side for instructions for completing this application State Sanitary Permit Number E� ES y ou p rovide may be used b other g overnment agency programs I The information y p y y g g y p g C heck if revision to previous application (Privacy Law, s. 15.04 (1) (m)I. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N Prope Owner Name Property Location is va, 5 �t T , N, R E (or)8 Prop rty Owner's Mailing Address Lot Number Block Number C ty, State Zip Code Phone Number Subdivision Name or CSM Number s ! I ( ,n.2 • `g ) . TYPE IL IN : (check one) ❑ State Owned El 'ty Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms Town OF 2 S�O T T 111. BUILDING USE (if building type is public, check all that apply) Parcel Tax Num r(s) 1 ❑ Apartment/ Condo © - /0 O 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 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 f§- Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit ��X s'� 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 YZE o 6 9 , �/ 0 Feet 99•'.S Feet Capacit VII. TANK in Ca allon Total # of r Prefab. Site Fiber- Exper. INFORMATION g allo ns Tanks Manufacturers Name Concrete Con Steel glass Plastic App New Existin strutted Tanks Tanks Septic Tank O -- hoc* 4 5 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ I ❑ LEI I ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) PI er's Signatur o Stamps) MP /MPRSW No.: Business Phone Number: 2Z9 9 7 7/4' .2 6 -CC 4 7 Plumber's Address (Street City, State, Zi Code): 3? Z 0 .1; S7 S fto IX. COUNTY/ DEPARTMENT US ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued is fu Ag t Si ature (No Stamps) ,,,, �� � /, Approved []Owner Given Initial ov Surcharge J Fee) Adverse Determination 100 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: i S8D-6M (8.11196) DISTR ION: Or+9ic%at to County. One copy To: Safety S 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 Administrative "ode will be Wisconsin � 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 i to be installed. Il. 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. Installi lumber is to fill in name, license number with ap refix (e. MP, etc.), P Y 9 P . P 9 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 8 112 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; k) 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.. Tai vA aw 7l� $ Togo /00 Y �PpM z t o s° L 9 l � J V75 t �sf �. bo o Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of 3 Bureau of Integrated Services in accordance wit,. . JE O.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches ' sizO' Plan nit I County include, but not limited to: vertical and horizontal reference point V)� irect , ' , 1f` S percent slope, scale or dimensions, north arrow, and location an { -d `ance to'nearest road. Parcel LD. # S.. , oo ro /vas - /o APPLICANT INFORMATION - Please print all inf 4fh.wtion I C;R01X Reviewed by Date Personal information you provide may be used for secondary purposes (Pri* , ' s. 15A$(f T` Property ,L Owner ,0 t Property Location f 13 P7 s t / er off' 1J4 �'i /4,S Ji T 3 ` ,N,R 7(� E (or(o Property Owner's Mailing Address -hot ' ._....'`B1'ock# Subd. Name or CSM# Ci State Zip Code Phone Number city ❑ ' lage ® Town Nearest Road ❑ Ci fn-et �L so Sf New Construction Use: Residential/ Number of bedrooms 3 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 1So and Recommended design loading rate bed, gpd /fF— (v — trench, gpd /ft Absorption area required O7_ bed, ft2 2j -(_) trench, ft Maximum design loading rate 7 bed, gpd /ft gpd /ft Recommended infiltration surface elevation(s) 1 w, 0 / ft (as referred to site plan benchmark) Additional design /site considerations Parent material OL 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 R4 S ❑ U �.S ❑ U ® S ❑ U I ❑ s 0 U I EIS ® U EIS �M U SOIL DESCRIPTION REPORT Boris # Horizon Depth Dominant Color Mottles Structure GPD /ft 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench l / o 2 Si C t �,� 5W <z 3 elev � ft. Al (o °Sb �" �v l7 Depth to limiting f c or ?�in. ' Remarks: ' O Boring # 1 0-4 s Ji I/Aw c?w ac 17- 2 Sys' / C 4 ZWK m v<rW c14 z�aRjy/s In c Ground elev. c� left. Depth to limiting T f c or in. Remarks: CST Name (Please Print) ignature Telephone No. . - & br _ aGd' 0 _ Address Date CST Number SOIL DESCRIPTION REPORT , PROPERTY OWNER �. 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 If 41-Y Ground 3 q ).3 V6 s L c eS elev. �f 9� t 5.96 s Depth to limiting factor 7 in. ' Remarks: Boring # .......................... • I8" '/ -� CAL vFiP arm r^ Z • 3 a S 17 � l y Ground Sf 9 elev. Depth to limiting �fa�c r 7 ]f 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 # , �« % .� � jyF' A116 (2 4 - / !/)o ' S� -.2c) 3 �/` C G PC/ as Ground Depth to limiting r Remarks: Boring # Ground elev. i Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) ��oT ��cn / Si me, NE Nr s hl 73 N/f A w in TL IT 7S' I b Z' 7S F 1 0 -1 3� I e yg, is/ b got a ST CROIX COUNT' SEPTIC TANK MAINTENANCE A 3REEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer r e- n2 ' Mailing Address _ � Property Address (Verification required from Planning Department for new cons City /State Parcel Identification Nul ; tber 00 (o - /o z 3 - i o LEGAL DESCRIPTION Property Location A)f_ '/., AIG Y., Sec. , T 3 { N- R-_-__6. W, Town of Subdivision , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # 3 � 9 � , Volume Page # Spec house ❑ yes ❑ no Lot lines identii iableK] yes ❑ no SYS r M MAINTENANCE Improper use and maintenance of your septic system could result in its pri mature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed bS a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste dispo A system. The property owner agrees to submit to St. Croix Zoning Department i certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verl f'ying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if neces nary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain thi private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of N. ,itural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and return -d to the St. Croix County Zoning Office within 30 day three year ex n date. SIGNATURE 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 property d ribed ve, 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 permil 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 refereno ; is made in the warranty deed A A STATE BAR OF WISCONSIN FORM 2 — 1982 WARRANTY DEED DOCUMENT NO. VOL 1343 PACT 1.15 'Harold J. Levendoski and _�tdl§Tff S �Av— Delores E. 1'evendoski, husband and wife T. CROIX CO., WI conveys and warrants to Elden W. Setter, A single � JUL 2 7 1998 person 9:30 A 221t:ir ate... ik J. THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in St. Croix County, State of Wisconsin: DAVID J. ESTREEN NE 1/4 of NE 1/4, Section 11-31-16, 304 LOCUST ST. St. Croix County, Wisconsin. HUDSON, WI 54016 0 0 fi__ inza __1_0__ PARCEL IDENTIFICATION NUMBER TRANSFER $111n W, This is not -- homestead property. (is) (is not) Exception to warranties: Municipal and zoning ordinances of record and recorded easements, restrictions and reservations. Dated this ci - r n day of July —, A.D., 19 98 (SEAL) t o f (SEAL) r. � 1 � -(SEAL) (SEAL) • Dc-lorpq F_ T.Ivpndoski AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, Polk County authenticated this day of 19 Personally came before me this h day of July ._ 1948—, the above named Harold J. Levendoski and DP I o r P TITLE: MEMBER STATE BAR OF WISCONSIN husband (If not, authorized by §706,06, Wis. Stats.) to rrw kno o ho ecuted the foregoing trist.umcri owled THIS INSTRUMENT WAS DRAFTED BY Bert Clear Lake, WI 54005 N, County, Wis (Signature may be authenticated or acknowledged. Both are not %IV miss ima u IS state expiration date. necessary.) Narrici of pc­ns,igning in any capicit) should be :sped or premed below ;heir 5,6nAmes. STAFE BAR OF N% IS( 01>1`% Vosorisin Leo Dian "ARRAN IY DEFID For., No. 2 1982 Ic !� ,A i C h p q t w ?w l(V O A A s . CLOSING STATEMENT "ransferor: Harold J. Levendoski SS# 398-38-7931 Delores E. Levendoski SS# 396-42-3823 545 County Line Avenue Clear Lake, W1 54005 Trar;';f eree: Elden W. Setter SS# 394-54-2450 812 Elmer Avenue Amery, WI 54001 Property: NE 1/4-NE 1/4, Section 11-31-16, St. Croix County, Wisconsin. C" J'U1-Y , tom . 1998 ------------------------------ ------------------- "ale Price: $40,000.c A d tn e.t tEF No proration of 1998 real estate taxes 'transferse shall, pay when due in 1999 J!'r DUE' TRANSFEROR $40,nr,0.00* V -value of real estate acquired from transferee on date hereof under a like K.ind excliange pursuant to Sec. 1031 of the internal. Revenue Code $20,000 - 0 Cash paid by transferee DUE TRANSFEROIR $40,000.00* Th-e real estate transfer f ee, title insurance, rat -torne>y/closilig fees and eXpenses are shared equally by transferor -arid transferee and are paid from funds outside of closing. ACCEPTED AND ACKNOWLEDGED as true and correct this of July, '1998. a y TRANSFEROR TRANSFEREE --- j Harold J, ei Elden W. Sei Delores E. Lev nd� G lDe �a �� �� ➢7-i 2 PA �f. �h, e �� L,. cl 38'4 22'7 � 13'9 8T1 1710 367 5'11 "1 TB7 uvv N T�� O O ti ZD 1 b) b n r KITCHEN rl LIVING — 13'1 a, 13'9 x i 4'8 ED co f' tL T W N HALL ENTRY Fb t, 3'2 x 12'8 3'8 x 8'11 �* MASTER BDRM 1 2'6 x 1 r1 ASTER BAT 9'5 x 8'2 CL SET ---�`— 5'5 x 4'2 0 i ,! CLOSET 5D � T e'e„� LIVI 14G AREA 1 SQ f — 1 5 8'1 4'4 3'3 63 "1 79'7 3'11 "1 ,001 4'67 881 T 8'9 8'67 i�- - - -' -- W4 - -_ -- �� 1 I 4 � �i f I i�'� t ,t ii i J t �'! i i i 1 i ;` f• ;� i �_ __... _ _ ._ l s '�, � t i; :4 .; ;. ` �_ � i '.' !, l t ;.._. i� _.. __..,� ,., .. _ _ .. .. ..._..._ _ .. k j � � ` ' i i �....._......... ... .. I .! I I Lo et A*.fter� w � g ale `n e.-I � _ 3 ' 4 _ -- 2 2 - 7 - 7 9 5 2 8 1 3'11 310 - T7 � U i j CI t' - 1sa� BATH UTILITY is 77x 77x47 -- FAMILY i P 177 x 1411 HALL �--`+— ra Ilk ry N I I , �; `LAUNDR -L- E:: r CLOSET j}' CLW'3ET T4 N U _— BEDROOM _ FICE O I t�v 109 x 1311 133 x 910 —' �` - - - - -- I STORAGE - - -� 11'4x&6 W7 H e5 8'2 65 4'9 147 102 _ 5'01 807 10ES64q ft 1 ,.. � , • __ . _w —_..__ _ r .. _. _ .__ _ .. — � _.� _.._ �--- ..._.._ __ __ _._ ... _ ._, � 1 �, € � f� �! ,; is � � �� ' t �) Y 3 � i _ < 1 i j is j r° _ _._. r . � 1 { � � 'j ; i •, � ... .. Z .... ._... _.. 44 i � ' i t i t i ! a 3 � ' 5 � �' �� I �w,.. �........ �......_ ..... � �,� ... ... .......... -.�. .... _ _ �........... .«�..�...�r. �.. _ .. ............... _.... .. ._.. ..... ._.......__ ..�_.. .... l i 1 �� 4 �..... _....__. - __ + f ' --. .. __._..._._ _._..__._s