HomeMy WebLinkAbout020-1345-30-000 (3) ST. CROIX COUNTY ZONING DEPARTMENT /,
AS BUILT SANITARY REPORT'?: +4(, ". �. ;•
Owner S� rtf 6N E/Z C° Nov
`
Property Address 7 poloC,& i z m 1 V� (, croc;
City /State 1Y c.) D.S®>•! t_ .)1 S J�Q /6 ZONINGOFF71 j,
Legal Description:
Lot Block Subdivision/CSM # 1 o7f
5 w /4e. W ' /4, Sec. /f , T z9 N-Rl'?ffl Town of f t,1 D e PK PIN # n o — 13 4 5 — 3 D
SEPTIC T N DOSE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer Wf� ! j+ - �Z Size ST/PC � '/ Setback from: House Well P/L
Pump manufacturer Model
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: L AZ Width 3 Length SG � � � Number of Trenches Z._...
Setback fiom: House Well P/L Vent to fresh air intake
ELEVATIONS
Description of benchmark L °T 1'1t'E S>= ��/ZNr Elevation
Description of alternate benchmark c f' C� Z2 1,00" F O u K U 1 10 N Elevation
Building Sewer ' 1,70 ST/HT Inlet q- ST Outlet I:r S L PC Inlet
PC Bottom _ Header/Manifold 10 ,a6 Top of ST/PC Manhole Cover S p
Distribution Lines
Bottom of System O "� ! , O � ` , ( )
Final Grade 7, 90 ( )
Date of installation Permit number �� S(° State plan number
` t
Plumber's 'gnature V�lh�t Wl���•t � License number kf Date c /�
V 0 6
Inspector Nzk bm I Complete plot plan �
s
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
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, 'Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
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Safety and Buildings Division
INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar5 �er 916 -:
Personal information you provice may be used for secondary purposes [Privacy L s.15.04 (1)(m)]. bb
l LLillage Town of: State Plan ID No.:
M1LJ�;K, SAM e 17 B �N
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
�1 .f wl
TANK INFORMATION ELEVATION DATA A9800547
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Vt/l� j 006 Ben h ,� l0.s 1lv. 5
Dosing AI-1 - f� 3.� JU6 •�o{ - �
A Ion Bldg. Sewer D j0/,
ding Q /'I* Inlet 9 f D /,"
TANK SETBACK INFORMATION (9>10-0utlet
TANK TO P / L WELL BLDG. Air I ntake ROAD Dt Inlet
ir
eptic ►..( � Z, / NA Dt Bottom
Dosing Header /Man.
eration NA Dist. Pipe lO�l ypD - �
Bot. System ? g $', 16
PUMP / SIPHON INFORMATION Final Grade 7• �p3.3
Manufacturer
Model N er GPM
TDH Lift Friction System TDH Ft
H
Force Len th . Dist. To well
SOIL ABSOR SYSTEM
BED CTRENCH Width Length o. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
IM ,� D
SYSTEM TO P/ L BLDG WELL LAKE / STREAM LE G Manufacturer:
SETBACK C
OR AMBER
INFORMATION Type f 1V Mod Nu r:
5s
y U
DISTRIBUTION SYSTEM
Header / M l old r Distribution Pike s} r x Hole Size x Hol
Dia. Length Ski e Spac g Vent To Air Intake
Length 5 Dia. n Spacing 4
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: HUDSON 11.29.19,SW,SW 717 PACKER DRIVE — HOMESTEAD LOT 3
//
li 11. 11-0/g
Plan revision required. [:]Yes O No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature Ce No.
' Safety and Buildings Division
Vi sconsin SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue
I n accord with ILHR 83.05, Wis. Adm. Code P O Box 7302
Department of Commerce Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County Goa �X
than 8112 x 11 inches in size. N .
• See reverse side for instructions for completing this application State sanitary Permit Number
Personal information you provide may be used for seconds u oses Check if r to p►evLus applic ion
Y p Y P rP ❑
[Privacy Law, s. 15.04 (1) (m)]. 1 - aCX� State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALLINF RMATION r
Property Owner Name Property Location
L 4.jrl%L J I UA /4 5 t.J 1 /4, S f T Z - # , N, R E (od
Property Owner's Mailing Address Lot Number Block Number
Cit , State Zip Code Phone Number Subdivision Name or CSM Num er
Z
64- o 6 12 l ) z.? �o rt1 e.
T YPE OF BUILDING: (check one) ❑ State Owned O ;tr Nearest Road
❑ VII age nn�
Public 1 or 2 Family Dwelling - No. of bedrooms .3 own OF JV $Of-/
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
Q II s
1 F1 Apartment/ Condo II ' 3 `4C� r �� Q
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 MNevv 2. C] Replacement 3. E] Replacement of 4_ [] Reconnection of 5, [] Repair of an
Sy_stem System Tank Only_________
Exi tin System Exlstin System
s
� _ _ _________ � _____
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
12KSeepage Trench SIDE t,+t�e 0040, 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 F_1 Seepage Pit 1Sd t MP1 L r+eAtfO, - X 3k ��-� 43 ❑Vault Privy
14 ❑ System -In -Fill 1.
V1. 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 sed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) �� Elevation
7 Z_ Feet 10A?QS' Feet
VII TANK Capacity g allon s Total # Of Prefab. Site
g Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer s Name concrete Con- Steel glass Plastic App
New Existin structed
Tanks T nk
eptic Ta Ing an QQ(".:� Ii 1 ❑ 0 ❑ 11 11
Lift Pump Tank /Siphon Chamber ❑
Vlll. 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 Si nat : (No ps) MP /MPRSW No.: Business Phone Number:
K E _` �L - I�i0 "01 7 3 X - Plumber's Address (Street, City, State, Zip Cod
1 0 7 .0 k Q 6 So S 4
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IX. COUNTY / DEPARTMENT USE ONLY
C] Disapproved Sanitary Permit Fee (includes Groundwater f e I ssued Issuin Ag t Signature (No Stamps)
Surcharge Feel
1$ pp
A roved Initial
❑Owner Given //��
Adverse Determination 0 V Ila
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X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
j SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
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Wisoonsin`Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3
Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
Envimnmental By Design
Attach complete site plan on paper not less than W1 x 11 inches in size. Plan must County
include, but not limited to: vertical and ho ' k ence point (BM), direction and St. Croix
percent slope, scale or dimemsions i tt� akrolarr o , 'on and distance to nearest road. p {,D.#
APPLICANT INFORMA P /ea a part 41 formation.
Personal information you provide used urpo (P y taw, s. 15.04 (1) (m)). Reviewed By Date
\'��
Property Owner ;;,......_. Property Location
MILLER, SAM Govt. Lot SW 1/4 SW 19 S 11 T 29 N,R 19 W
Property Owner's Mailing A " ' Lot # Block # Subd. Name or CSM#
TROUTBROOK "�, c`Y �ht�tx `' ' 3 - Htxnestead
City ` �;tatezo FftneNum r 0 City E] Village ®Town Nearest Road
Hudson 7 - 3$ Hudson I McCutchen
Z New Construction Use: tiel Number of bedrooms 3 []Addition to existing building
Replacement Public or commercial describe
Code Derived daily flow 450 gpd Recommended design loading rate 7 bed, gpd/ft .8 trench, gpd/ft
Absorption area required 643 bed, fF 562 trench, ftz Maximum design loading rate •7 bed, gpd/ft .8 tr ench, gpd/fF
Recommended infiltration surface elevations) 103 ft (as referred to site plan benchmar
Additional design / site consideration area for primary is borings 2, 3, & 4
Parent material Wind blown loess over Qlacial outwash sands 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 ® S ❑ U ® S ❑ U ® S ❑ U ( ❑ S ®U ❑ S ®U ❑ S ® U
SOIL DESCRIPTION REPORT
Borin 9# os
Horizon Depth Dominant Color Mottles Texture Structure Consistence Bound GPD/1P
in. Munseil Qu. Sz. Cont. Color Gr. Sz. Sh. Ro Trench
l 1 0 -16 10yr3 /1 - A 2msbk mfr cw 2f .5 .6
2 16 - 37 1Oyr4 /4 - sil 2msbk mfr cw if .5 .6
Ground 3 1 37-1041 7.5yr5/6 - s Osg mI - - 7 8
elev
102.40 ft
Depth to
limiting
factor
>104
Remarks:
2 1 0 -7 10yr3/2 - sl lmsbk mvfr cw 2f .5 .6
2 7 -18 7.5yr5/8 - s Osg ml cw if .7 .8
Ground 3 18 -60 1Oyr4/6 - cs Osg ml cw - 7 8
elev
105,95 ft 4 60 -106 7.5yr6/4 - s Osg ml - - .7 .8
Depth to
limiting
factor
>106
Remarks:
CST Nam (Please Print) Signature: _ ��_ Telephone No.
Thomas C. Nelson 715- 246 -2454
Address Environmental By Design Date CST Number Ref #
1432 120th Street, New Richmond, WI 54017 8/17/98 227387 76
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PwPERTY�6 MII IE1z, s AM SOIL DESCRIPTION REPORT ���e Page 2 of 3
PARCEL I.D.# Environmental Bv Desi
Depth Dominant Color Mottles Structure GPD ft?
Horizon Texture � 0 - nsistence Boundary Roots
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
3 1 0 -8 10yr3/1 - sil 2msbk mfr cw 2f .5 .6
2 8 -17 10yr5/6 - sil 2msbk mfr cw if .5 .6
Ground
elev 3 17 -46 7.5yr6/4 - s Osg ml ew - .7 .8
105.13 ft 4 46 -120 T5yr6/4 - s Osg rw - - _7 _8
Depth to
limiting
factor
Remarks:
4 1 0 -9 10yr3 /1 - sil 2msbk mfr cw 2f .5 .6
2 9 -21 10yr5/6 - sil 2msbk mfr cw if .5 .6
Ground
elev 3 21 -27 10yr5/6 f2d5yr5 /8 sil 2msbk mfi cw - -- --
105,73 ft 4 27 -39 7.5yr6/4 - s Osg m1 cw - 7 8
Depth to 5 39 -42 7.5yr6/4 - gs Osg ml cw - .7 .8
limiting
factor 6 42 -104 7.5yr6/4 - s Osg ml - - .7 .8
21 -27
r t r r r i i i
Remarks:
5 1 0 -12 10yr3/2 - A 2msbk mfr cw 2f .5 .6
2 12 -24 10yr3/4 - sil 2msbk mfr cw if .5 .6
Ground
elev 3 2438 10yr4/6 - sil 2msbk mfr cw if .5 .6
104.38 ft 4 38 -49 10yr5/6 clf5yr5i8 A 2msbk mfi cw - -- --
Depth to 5 49 -116 7.5yr6/4 - s Osg ml - - 7 i 8
limiting
factor
38-4.9
Remarks:
Ground
elev
Depth to
limiting
factor
Remarks:
E BY D
1432 120"' STREET, NEW RICHMOND, WISCONSIN
715 - 246 -2454
PROJECT NAME HOMEMAD 3. PAGE 3
DESCRIPTION sw % SW 1 /, SECTION 11 T 29 N, R 19 W
TOWNSHIP Hudson COUNTY St. Croix
�vw v, c' CA
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SCALE 1 _ �� Tom Nelson
BM i. S C L o t i,oR -n e (L �.\ \ U o csTMO 2605
BM Z.
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer JM L.P;4C
Mailing Address '20 K �*` �.
Property Address 7 f�C k �- -7) k j Ve
(Verification required from Planning Department for new construction)
City /State DDS 0�4 Parcel Identification Number
LEGAL DESCRIPTION
Property Location ' /a � ' / a, Sec. -R , Town of
Subdivision (-� O s T E /� Lot #.
Certified Survey Map # 3 , Volume Page # 3�
Warranty Deed # ssg foo `s , Volume I �" 3 lw , Page #
Spec house yes ❑ no Lot lines identifiableXyes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenanceof 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 licensedpumper 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.
�9" - & 1 l l f l�d
ATURE F 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 pgoperty described above, by virtue of a warranty deed recorded in Register of Deeds Office.
��" AA/'1 i / r ///
(wA kT - oV APPkic
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
i
� HL 1?:36
STATE BAR OF WISCONSIN FORM I - 1'`92
SJS6S� WARRANTY DEED
DOCUMENT NO. _ — -
1EGISTER'S OrF1 -F
This Deed made between Susan R . Anders a s i n q 1 e ST CROIX CTY., kvi
person WO far Pi°--t
APR3 0 ?i?'
- - -- I
and Sam E. '.Miller, a single person Grantor- 3:25 P. MI �
♦' -�.t." it � .l.r I
Grantee,
Witnesseth That the aid Grantor, for a \-aluahlr axwderanc o f o ne _
dollar and other valuable consideration
conveys to Grantee the following described real estate in S t . Croix THIS SPACE RESERVED Fr1A RECORC -%G CATA
County State of Wisconbin: %AwE AND RETURN ADDF - S5
Sam E. Miller
Sam Hiller Construction
Trout Brook Road
Hutson WI 54016
0 - 2 - 90 -110
za.r►CEL BDENTWiCAriDN NUMBER
Part of the ATE 1/4 of SW 1/4 of Section ' 3,
Township 33 North, Range 20 Ilest, St. Croix
County, Wisconsin described as follows:
Lot 2 of Certified Survey l:ap filed August 8, 1985 in Vol. "6 ", Page 1559,
Doc. No. 404156.
- IT NQFER
t~
This is not homestead property
tls) its not)
Together with all and singular the hereduaments and appurtenances thereunto
And Susan R. Anderson
warrants that the title is good, indefeasible in fee simple and free and clear of encuntbra. -c. c•.cept
easements, covenants and restrictions of recoz�!, if any,
and will warrant and defend the same.
Dated this day of
1SEAL) (SEAL)
• Susan R. A d erson
(SEAL) — tSEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of N•isconsin,
S CIOIX
— Cir)unty
authenticated this __ day of 19— Pemw,&, v -Ame before me this'
Susan R Anderson -
TITLE MEMBER STATE BAR OF WISCONSIN _ 0'
(If not,
authonzed by 47106.06. W'is Stats) to me knr -ar. � :tr the person exec utrpli °(yttguu-ti
itist rulTr^ fr 1w. C the Dame "'
THIS INSTRUMENT :JAS DRAFTED tie
Robert F. "all — �Sl -- -- - - - -
- - - -- -- - - --
Hudson WI 54016 - -- St. C roix
- - - — Count)•, WIs
iSicnatures ma\ be arithenncated or ackno"Ied�ed N are not hh" ;r^ : _x.ur. permanent llf not. >iair .xpirauon date
rte celia r \" 1
srAlr. BAR Of \ \ISLO \ >I\ •• .. -= ya 'f , h,`,w � �'
% \aRR.A\IV [)Fit) form No 1 - 1982
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
�— ST. CROIX COUNTY GOVERNMENT CENTER
$ n n u 1101 Carmichael Road
NNNN�
Hudson, WI 54016 -7710
(715) 386 -4680
March 10, 1999
First Federal
Attn: Tammy
201 South 2 nd Street
Hudson, WI 54016
RE: Septic Inspection for Sam Miller located at 717 Packer Drive, Lot 3 of Homestead,
Town of Hudson, St. Croix County, Wisconsin
Dear Tammy:
A septic inspection of the above referenced property was conducted on November 17, 1998. This
property is located in the SW' /4 of the SW' /4 of Section 11, T29N -R19W, Lot 3 of Homestead,
Town of Hudson, St. Croix County, Wisconsin. At the time of the inspection, this septic system
was found to be code compliant for a three (3) bedroom home.
If you have any questions regarding this, please contact our office at (715) 386 -4680.
Sincerely,
eodEs er ���
g
Assistant Zoning Administrator
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