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HomeMy WebLinkAbout018-1015-40-000 ST. CROIX COUNTY ZONING DEPAI TI TENT AS BUILT SANITARY REPORT/. �i Owner �?' G1 / L' Address /✓T y - /o a 7`6 A /ice fia City /State M D 41 d OFFICE- Legal Description: Lot -- Block — Subdivision/CSM # Sec., T .29 N -RAW, Town of d PIN # - /0,(3"- ©- o �IrFM M a /S� SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer - lye, e )J'S Size ST/PC /W/ Setback from: House V� Well 19S / PAL, �� l Pump manufacturer Model Alarm location r---- (HOLDING TANKS ONLY) Setbacks: Service roa Vent to fr Witter-Line Meter location Al on SOIL ABSORPTION SYSTEM Type of system: M eAlili e, < Width S— Length CC' Number of Trenches ;7 - Setback from: House J01� Well A �2_ P/L Vent to fresh air intake ELEVATIONS Description of benchmark rO P e / $*te e. / Elevation r� Description of alternate benchmark _ 4g po% 1 , 0 ,a L?ydf pc d ) , ` - Elevation 9 S. ()J Building Sewer ST/HT Inlet ST Outlet- 4 7 6 PC Inlet PC Bottom '�— Header/Manifold To of ST/PC Manhole Cover . 7v? / Distribution Lines Bottom of System( C 7,oV, A Final Grade ( ) 6 ql $l () s L ( ) Date of installation �1 /3 /5r� Permit number State plan number ---- Plumber's signature A�*� License number v P Date /57 9f Inspector Complete plot plan ti 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 3 ARM I Ale, w i /000��� ba y sepria - t.4a K INDICATE NORTH ARROW Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM County: INSPECTION REPORT S'1'. CROIX G ENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: 315915 Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)j. GULTCH,rIsSCO I'T f1_�NII Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description Parcel Tax No.: bDe z oo TANK INFORMATION V ELEVATION DATA A9800304 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. eptic Bench G . le(P S (� O Dosing 34,2_ to.2 Aeratio9111 Bldg. Sewer [ 1 j1. D Holding 0 t .fit Inlet 41 - 41 2 , 17. /Z— TANK SETBACK INFORMATION /ok Outlet Q.55 9G. Gj TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake pti r NA Dt Bottom Dosing - --- _- a .__ A Header / Man. Z 3 Aerati NA Dist. Pipe 1f �2 9 / z Holding y Bot. System A l qif 2/ PUMP / SIPHON INFORMATION Final Grade Manufacturer De ma S mam Mu Model N GPM TD Lift Friction System - TDH Ft L oss H --��. Force Length Dist. To Well SOIL ABS TION SYSTEM DIM THEN W idth �. Length No. O Trenches PIT No. Of Pits Inside Dia. Liquid pth DIMENSION A SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM CHAM INFORMATION Type Gb t V111: Ct(! OR UN T R' Mod Num er. DISTRIBUTION SY TEM l/ Header / Manifold Distribution Pipe(s) e x Hole Size x Hole Spacing Vent To Air Intake r a � 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 E] Yes ❑ No ❑ Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCAT I]yA I ' O Jj N (r : /: HAMMOND 7.29.17,SW,SE 1564 100TH AVENUE 51 Plan revision re ulred. �] Yes ❑ No Q '� Use other side for additional information. t, Date Inspector's Sign ure rtt SBD -6710 (R.3/97) Vi SANITARY PERMIT APPLICATION 20 eE w shngtonAvesion sconsi to accord with ILHR 83.05 Wis. Adm. Code P.O. Box 7969 'Departmedt of Commerce Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County_ than 8 1/2 x 11 inches in size. S 7 O / • See reverse side for instructions for completing this application state sanitary Permit Number The information you provide may be used by other government agency programs ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Property Owner Name . 1 Property Location I./ f�J 1/4 1/4, T 2 ,N,R/ W Property Owner's Mailing Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number e'w 7 a ® A f © (7< ) S II. TYPE OF BUILDING. (check one) ❑ State Owned ❑ Cit Nearest Road p Village If Public X 1 or 2 Family Dwelling - No_ of bedrooms A Town of M O D XX A ve III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 0/8 /D13 - - O -oeo 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. jV 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 W 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.) Pro osed (sq. ft.) (Gals/day/sq. ft.) (Min. /inch) Elevation 5 � 7-f O '���' A. 2Feet `f ® Feet Capacity VII. TANK in gallo Site Total # of Prefab. Fiber- Ex per- INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic A p p New Existing structed Tanks Tanks Septic Tank or Holding Tank X Irry I L l e os A rs , N ❑ ❑ ❑ 1 ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ 1 ❑ 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) Plumber's Signature: (No Stamps) MP)!NNIIMW No.: Business Phone Number: PI mber's A( dress (Street, City, State, Zip Code �Z2:? # jCvV J 6rL4 eN BOW IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanit ry Permit Fee (Includes Groundwater D ate Issue d issuinc Agent Signature (No Starnfs) Surcharge Fee) $ Approved ❑ Owner Given initial Adverse Determination Au X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R.11196) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber , I I I A 0�' �1 � . ���� Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in a5gordance s. ILHR 83.09, Wis. Adm. Code County Attach complete site plan on paper not less tha l2�xl1 'inches In size: Pl ;kh must include, but not limited to: vertical and horizo 1 of renc oliftM), direction end percent slope, scale or dimensions, north arr9l ; ejid locatri Vrs nce to nest road. Parcel I.D. # f 4 — ✓ �� APPLICANT INFORMATION - P/e f pri ail i►4� 6 Reviewed by Date ti Personal information you provide may be used for sk,cotidary purpos I PAQ�Law, s. 1&b4 (1 (m)). Property Owner (Nv1Nv0F:FIrE Prope , ocation L v , Govt. tt) 1/4 1/4,S T 2 ,N,R 1 VAM W Property Owner's Mailing Address �• i ;', ;i Lot # Block# Subd. Name or CSM# o City State Zip Code Phone Number Nearest Road ❑ City E] Village ® Town MIV isrlol ( 114 Al M d Al a / A v a:° CK New Construction Use: I( Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow Q gpd Recommended design loading rate bed, gpd/ft O trench, gpd/ft Absorption area required o O bed, ft ft 2 Maximum design loading rate _ bed, gpd/ft _ trench, gpd/ft Recommended infiltration surface elevation(s) 7� /if/. 2 9�, _ft (as referred to site plan benchmark) Additional design /site considerations - 4f tm/N e X P - - .S `X kr Parent material r—,4 ,1 C iA,4 / l L. / L ��ft S = Suitable for system Conventional Mound In- Ground Pres; Y - Holding Tank U = Unsuitable for system s U X S E] U ®S ❑ U U r U ❑ S U 0.1 SOIL DESCRIPTION REP( Boring # Horizon Depth Dominant Color Mottles Texture Roots GPD /ft2 in. } Munsell Qu. Sz. Cont. Color I Bed , Trench Ac rL YA Il l- O F — cd S v oorl Ground elev. Depth to limiting factor ?Min. Remarks: Boring # Ground elev. y . ft . Depth to limiting factor 714- Re marks: CST Name (Please Print) Signature Telephone No. Address Date CST Number PROPERTY OWNER U /7�� lyl e'll i1 SOIL DESCRIPTION REPORT Page of PARCEL I.D.# QAp- /044"- ye °/ Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench 51- ;2 /M' s6 M V G LV a -4 d Ground elev. Depth to limiting , factor 7#—in. Remarks: Boring # v,2 - /6 S 4 ;2 M .f MV, A S M i* 6 Ground elev. Depth to limiting factor Ikin. 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 # 6 G a M 6 /MF ,� S 12 mews M4 Ground elev - Depth to limiting factor 73--in. Remarks: Boring # Ground elev. ft. ' Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) - -- _ - -1- . I : { a -- - -- - - -- - - - - -- -- i - - - -- - - -- -- —I IF y -- - i- - - -- ;- - - - - - - -- - - - -- i I 7 I. ' a ' a i I I I _ : - - - -- 1— I L4 - ' ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/NMpbr �• �� �--��> Mailing Address Property Address (Verificatioa required from Plaaaiag Deparument for new constuctioa) City/State { 5L.PI�P arcel Identification Number LEGAL DESCRIPTION Property Location ,5 4J %, %, Sec. T2 -R ZW, Town of by M Ala 111e Subdivision Lot # Certffied Survey Map # Volume _ Page # Warranty Deed # Volume Page # Spec house - 0 yes IN no Lot lines idea fiable C3 yes ❑. no SYSTEM-AIAIlVIENANCE IU M M m uscmdan k kna =ofyoursq)dcq st =coddr=itiiLits PC= handieerastes. Proper consists of pumping out tine septic tank every there yeast or sow if needed by tHeensedptunpm what yott Put. iato tba so= can function. of tine septic teak - as. a tzeaftment stage is the Vastedisposal_s7d= T110 PwPcr(Y" owner agrees to submit-to-SL Cwk Zodwg Department a =dfrcation fQmj6 signod by the owner and by z ]o Y P restdctedplmmbcroritffcc=dpmmpervedfykgtbat (I) theon-dt6�dispvsatsystem rs m Pmpa operating condition aa&or after' and �) of P�P�g "C nty), reptixc�taak�is less than lt3 - fall of shrdge. Ywc. &e andessiguedhave _read, fire above rogaireawnts and agree to maiata;. rho private sewage disposal system with tine standards set fo"k horeia,'as set by the Dqurtmeot of Commerce and tine Departs-, of'Naturd Resomccs; State of Wisconsin.. 0=0cx#ioa zftting that Yom scFt'c has been maintained mast be eomplctod and rctumed to fire St, Qoix.Couaty Zoning Office within 30 days. of the three year expiration. date. / /off 9 E !r SIGNATURE OF APPLICANT DATE OWNER, CERTIFICATION I (we) certify that all statements on this foam are trw to tine best of my (our) I mowledge. I (we) am (are) the owners) of the Property described above, by virtue of a warranty deed reoorded in Register of Deeds Office. SIGNATURE OF APPLICANT DATE «s « « «« Any information that is mis may result in the unitary permit being revoked by the Zoning Department. « «« ««« «« Include with this applicatloa: a cu uapod warranty deed fiom the Register of Dodds office a COPY of the cectiCod survey map if reference is made in the warranty dood aocurncrvT No. WARRANTY DEED STATE BAR OF WISCONSIN FORM 2-1982 !! U e,"/--1 582188 �� 1 �i _ � ',T1C X45 I \d i� REGI5T�i��`S OFFICE Carl A. Nielsen & Lisa E. Nielsen his wife ST. CROIX C o.. wl indi .vidually...a -nd ... each ... in. their own.. right.. 08611 fur 44dard __ JUL 0 2 1998 convoys and warrants to Scott T...Culich _ &. Lori J. Gulichi 8 :45 \ A M husband and.wife as marital property. _ .......... ............................... Re star of Deeds ........ ......................... . .... ... ... .... ... -... .- ....... .. .... .. ... .... -. ... ... .. RI -TUI1N l0 Ow Law Firm, S.C. St reet -I I ... ..... ................... .... ... .... . ...... .. f . .... _ ...... ...- - -.... 1430 Second eet -- • ... ........................ jHudson, Wisconsin 54016 the following described real estate in St,_ ................... County, State of Wisconsin: j Tax Parcel No: _018- 1015 -40 -100 i The West quarter (Wl /4) of the South Half of the Southeast Quarter (S 1/2 of SE 1/4) of Section 7, Township 29 North, Range 17 West. Ij �i P i! l� S -St TRANSFER FEE I, I This .. 1S ... nO.. ........... homestead property. (is) (is not) Exception to warranties: Toqether with and s ubject to anv other easements, covenants, reservations or restrictions of record, if any, but this shall not be deemed to extend any such other recorded encumbrances beyond the term 1 11115 established b law therefor. �j le t.. ... ......... day tr July ... I9 t _.... (SEAL) _. _. (SEAI,I I .Carl A. Nielsen ........ _ i .. y ............... •--- ............ _ . .................... (SEAL) ............. (SEAL) I -Lisa E. Nielsen _ ...... ................... _.. j I AUTHENTICATION ACKNOWLEDGMENT j� Signature (s) of... Carl.. a�.. -.�IJ C- - �C.Tl..gnd-...... STATE OF WISCONSIN Lisa E. Nielsen, his wife ss. JJ ... -.... � - ...... ..... ...... ....... .County. � authenti d thi ay Jlll ........ 1s.. Personally came before me this ........... ....day of - • r (' . t. -. ............ me d . 19... -.... the :.thuvc named - - - -- - -.... ... - - -Huq _..0 wine -. Attorney ...... ................ NA 'i TITLE: ME9 . .. ... - - - - - -- • - -•- iBER STATE BAR OF WISCONSIN - ---• / ----- •--- -.... -••-----•------------------------------ (If not. -- -- -- ........... _.._........__........- i .... nuthorized by i 706.06, Wis. State.) to me 1:tlw•n to he tile pctarn _.. whn cxecutcd the fol"I.Milig instrument ;Ind acknowledge the same, THIS INSTRUMENT WAS DRAFTED BY li i� Grin/l�w Firm, S.C. ( ... ..... ..............I..... - - - - -- . 430 Seccilad_,St. , Hudson, WI 54016 - . .... ........................... .......................... Notary Pu c . ... bli _ ......... ...........- County, Wis. (Signatures may he authenticated or acknowledged. both 6­11-ssion is permanent. (If not, state expiration are not necessary.) date: .. -.. - - - - -- 19- ........) • Name-4 of persons milrninq in any capacity should be t.ype'l or print. I bolo- their WARRANTY DEED STA•I BAR OF WIgCON o!, Wlsr nrt5ul (ndal Blank Co Inr y �II IIIIIIIIIIIII U' II��IIIIIIII IIIIIIIIIIlIISA��9�9A�� ;, �' �- 11 ,iI�I IIIIIIIIIIII ■■ mmum -1 If�� 1111111 IIIIIIIIII !' = 111111111 ((111111(1(1 (�III`II�(( I�IIIIII Illllllllfllfillllllll uunnuuuw _ 11111111111.11 1 I � � � II:� �.IIIIIII IIIIIIIIIIIIIII IIII IIIIIIIIIIIIIIIIIII � i III�IIIIII�II�I Il LIIIIII II I'MMl IA� �II 111111111111116 it IIIIIIII III ",II�,��IIr�O�� i Callaway R35ri _. « 0 -A Ng � f•,Gi .e•At g 11 - I d 1 1 a w= I L__1 --------------- 1 1 II II 1 1 11 y. 1 I O II El O ,( O� yp� E a a b O a A • I D I � - cn z -. � o �y H. li 1I Wp m = O Oo_ l(1 a ii f� - x x O 0 Y II r� III I .r Callaway R35 2 a J a „0-,9ro - - - - - -- Z ! f I ro,St u9-,OZ � � O LL ° I } o � to 11 big 0 % J � I' I :::::::: -c I I <g , ', ►�� I I ------------ 4 M I � i YY `. I I ............ V,N39 000M .. ............ I WW t=o o o r I u o-,II 1 9-,II ^-• j e YS -�- a N X c< e 4• I EE wade IMs I.- u I d a3) n aa e _ ENE 110•,IL yyrr I Callaway R35 a i o_ W R CO Z .goo b �w,. �,. �oora7l ,1•d Q � Q' Q 4 • a s \ q IN k � r b 19 all ill JA lot s: AA w'L.L� 6Y. ■���wZ � 00 000a oo.Ro 000ao- • • • 0000C 9. .. H x � loci w r Hj 11 r. 0 0 ,