HomeMy WebLinkAbout020-1345-40-000 ST. CROIX COUNTY ZONING DEPARTMEN
AS BUILT SANITARY REPORT ^�� �►
�.
RECEIVED4:
Owner..... , ,t 7„-,�! f IC.: o�t� �,r� `� °�'I � ����,•
Property Address ( �3 U 7 1998
City /State H u ( ,f3: t . ? s �,� � I �- �� ST CROX lr
L n \ COUNTY
\ ZONINGOFFICE �w
Legal Description: f;
Lot Block °`" Subdivision/CSM #
. u %4 = l %4, Sec. HOLDING TANK INFO T Z I N - R Town of I �� �=, �? Af PIN # ad = � 6
_.
tl.. �M .
SEPTIC TANK -- !JOSE CHAMBER -- TION:
Tank manufacturer t ,_ Size ST/PC M Setback from: House Well PAL
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
e
Type of system. l �`` ( Width Length �" ' r� Number of Trenc es .
Setback from: House ZS Well -? S P/L R 0 ' Vent to fresh air intake t L
ELEVATIONS
Description of benchmark , P +-% , / S L)C 0<,
r E levation
Description of alternate benchmark 70 f 0- B: (OL �-- Fe U MT 9'1'1 1 At .S /f Elevation
5 L _A/ IL 0j Il v , too
Building Sewer ST/HT Inlet 0, 57
ST Outlet � ( ' O PC Inlet --
PC Bottom -' Header/Manifold (' Top of ST/PC Manhole Cover � 3
Distribution Lines 5
Bottom of System ( ) ('�•� () 12,Y,'�. ( )
Final Grade
Date of installation /ISO/ ( Permit number - Q 6 State plan number
Plumber's signatur .� �'�� License number �3: Date
Inspector , �&�
Complete plot plan �+
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
ti�ee
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INDICATE N TH ARROW P AC k F /L p< V f
Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count k • CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitajy efrpitf:
Personal information you provice may be used for secondary purposes [Privacy L w, s.15.04 (1)(m)].
Permit Holder's Name: ❑ City q Village Town of: State Plan ID No.:
ILLER, SAM HUDSON
CST BM Elev.: Insp. BM Elev.: BM Descri do Parcel Tax No.:
N 4�
TANK INFORMATION U E EVATION DATA A9800538
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septi Benc rk (a- /s9 16Z)
Dosing A 14
Aeration Bldg. Sewer IU d I��a
Holding St I# Inlet (tea. q?•�
TANK SETBACK INFORMATION ( S / Outlet / /c�r �7• a ---
jAN4 P/ L WELL BLDG. Air Intake ROAD Dt Inlet
Septic p 3�J� NA Dt Bottom
osing Header /Man. /,�.a (y,/ �(p C / 7
A ation NA Dist. Pipe S' 0 10 , 77
Holding Bot. System 1 ; qs
PUMP/ SIPHON INFORMATION Final Grade •3 .77
Manufa Dem
M el Number GPM
TDH Lift L oss em TDH Ft
Forcemain Length Dia. Dist. To well - J
SOIL ABSO TION SYSTEM
BEDkTRE Width I Lengt No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DI tq. --.>- DIMENSION
SETBACK
SYSTEM TO P / L I BLDG WELL LAKE / STREAM ACHING Manufacturer:
INFORMATION Type , �.i CHAMBER r:
Syste O j 5 - OR UN
••
DISTRIBUTION SYSTEM h Zt �jl 8 S .-
Header /Manifold Distribution Pipes) y` 1 x Hole Size x Hole Spacing Vent To Air Intake
Length 1 Dia. n Length � Dia. JT Spacing �d (�
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 713 PACKER DRIVE - HOMESTEAD LOT 4
0/1 X14. eve— (
Plarirevision required? Yes [] No
Use other side for additi n information. I FF1 I I
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
Safety and Buildings Division
At PERMIT APPLICATION 201 W. Washington Avenue
n 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 1
than 8 1/2 x 11 inches in size. 5V
• See reverse side for instructions for completing this application State Sanitary Permit Nu ber
q� ICS
Personal information you provide may be used for secondary purposes ❑ Check it revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
ProE Owner Na operty Location
0flux4e �_ P t/4 O 1/4,5/1 T Z.. , N, R/'9 E (cjVZ
Property Owner's Mailing Address Lot N be Block Number
City, State Zip Code Phone Number Su division Name or CSM Number
a N o 39(a 17 a 7`
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑
Ei It � Nearest Road
Public 1 or 2 Famil Dwellin - No. of bedroo Town OF y voso _ It , D IUVE
Ill. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo
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. ,New 2 E] Replacement 3 E] Replacement of 4_ E] Reconnection of 5_ ❑ Repair of an
ystem ________ System _____________Tank Only______________ Existing System ________ Exi --- 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 Seepage Trench $1 DEW 1N�1i22 [] In-Ground Pressure 0 j 42 [] Pit Privy
13 ] Seepage Pit /NCILT/1,d roll 2.X 3 X ZS 43 ❑ Vault Privy
14 ❑ System-In-Fi I I
V ABSORP 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
4 / . 5 - 0 $(p - M s 7 2_-.- . 97, S$ Feet 0) r _S - Feet
Capacity
VII. TANK in Ca g allons Total # of Prefab. Site Fiber- Exper.
INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete st on- Steel glass Plastic App
Tanks Tanks
SeptiCT 000 ! F15 -- ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ 1 ❑ ❑ 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) Plumber's Signature: (No Stamps) MP /MPRSW No.: Business Phone Number:
Do(L -�
Plumber's Address (Street, City, State, Zip Code :
10 H O RTZ4C_ 2 ao( 14 lJ 0,5 0 JV L,4j S O
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate slue Issuin A nt Signature (No Stamps)
E(A roved Surcharge Fee) � .1
pp ❑Owner Given Initial + ([� 00/
Adverse Determination h uD II
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber ,
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Wisconsin 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
Environmental By Design
Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and S t. Cro
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D.#
APPLICANT INFORMATION - _ �t formation.
Personal information you provide may be } r�a�condary pu ' (pl y t aw, s. 15.04 (1) (m)). R ��yy iewed By Date 11 K• I Nd� 2 1Wv$
Property Owner ' P' rt Property Location
MILLER, SAM 7> R .C;t. 'Ld
Govt, Lot SW 1/4 SW 1/4 S 11 T 29 N,R 19 W
Property Owner's Mailing Ad dr i r^ r- r ; Lot # Block # S Name or CSM#
" Ki4a t f
TROUTBROOK RD 4 Homestead ._ j �',�.�
City to Zip eNumb City Village ®Town Nearest Road
Hudson r ' 69 Hudson McCutchen
Z New Construction Use: of bedrooms 3 ❑Addition to existing building
Replacement fSli6 j rq6 N iA W ecial describe
Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/ is .8 trench, gpd/fP
Absorption area required 643 bed, fl 562 trench, ft Maximum design loading rate .7 bed, gpolfts .8 tr ench, gpd/ft
Recommended infiltration surface elevation(s) IW.W' q 7. St ft (as referred to site plan benchmar
Additional design / site consideration system to be in area of borings 1, 3, & 4
Parent material Loess over glacial outwash Flood plain elevation, if applicable na ft
S= Suitable for system Conventional Mound In -Ground Pressure AT Grade System in Fill Holding Tank
U= Unsuitable for system ®S ❑ U ® S El U ® S ❑ U ®S ❑ U ❑ S ®U El S ® U
SOIL DESCRIPTION REPORT
Boring# Horizon
Depth Dominant Color Mottles Structure GPD/fts
in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Roots Bed ; Trench
l 1 0 -8 10yr3 /2 - sl lmsbk mvfr cW 2f h.q ,&,f
2 8 -30 10yr5/6 - sil 2msbk mfr cW if .5 ! 1 6
Ground 3 30 -98 7.5yr6/4 - s Osg ml - - . .8
elev
102.32 It
Depth to
limiting
factor
>98 ; `•
Remarks:
2 1 0 -28 10yr3 /1 - sil 2msbk mfr cW 2f .5 .6
2 28 -49 10yr5 /6 - sil 2msbk mfr cW if .5 .6
Ground 3 49 -96 7.5yr5/6 - cs Osg ml - - 7 ; 8
elev
99.33 ft
Depth to
limiting
factor
>96
Remarks:
CST Name (Please Print) Signature Telephone No.
Thomas C. Nelson 715- 246 -2454
Address Environmental By Design Date CST Number Ref #
1432 120th Street, New Richmond, Wl 54017 8/17/98 227387 75
PROPERTY OWNER: MILLER SAM SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D.# Environmental By Desi
Horizon Depth Dominant Color Mottles Texture Structure onsistence Boundary Roots GPDlfts
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed : Trench
3 1 0 -10 10yr4/3 - sil 2msbk mfr Cw 2f .5 i .6
2 10 -15 10yr4 /4 - is Ifsbk mvfr Cw if 1 4 .6
Ground
elev 3 15 -29 10yr7/4 - s Osg ml Cw - .7 .8
101.82 ft 4 29 -36 7.5yr5/4 - gCS Osg ml - - 7 8
Depth to 5 3648 7.5yr7/4 - s Osg ml - - 7 i 8
limiting
factor 6 48 -96 7.5yr5/6 - s Osg ml - - 7 ' 8
>96
Remarks:
4 1 0 -10 10yr4/3 - sil 2msbk mfr Cw 2f .5 .6
2 10 -22 10yr4 /4 -- is 1 fgr mvfr Cw 1 f - ! 6 .6
Ground
elev 3 22 -29 7.5yr4/4 - s Osg ml Cw - 7 8
102.58 ft 4 29 -43 7.5yr6/8 - s Osg rnl Cw - 7 8
Depth to 5 43 -96 7.5yr5/6 - s Osg ml - - 7 8
limiting
fact
>96 �f
Lc
Remarks:
5 1 0 -7 1Oyr5 /3 - sil 2msbk mfr Cw 2f .5 ! .6
- 2 7 -26 7.5yr6/8 - s Osg ml Cw if .7 i .8
Ground
elev 3 26 -96 7.5yr6/6 - s Ogg ml - - 7 8
99.97 ft
Depth to
limiting
factor
>9
Remarks:
Ground
elev
Depth to
limiting
factor
Remarks:
E BY DE51GN
1432 120 STREET, NEW RICHMOND, WISCONSIN
715- 246 -2454
PROJECT NAME HOMESTEAD 10 4 PAGE 3
DESCRIPTION SW % SW %, SECTION 11 T 29 N. R 19 W
- . TOWNSHIP Hudson COUNTY St. Croix
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SCALE 1" Tom Nelson
BM 1. • Top o� l o r, Wz_ csrMOzsos
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer Z ;J#f4tk( III t L 4r5ec
Mailing Address 84nX /S /
Property Address - 7 1 5 rlc L
v n �
(Verification required from Planning Department for new construction) -
City /State Ha DS O Parcel Identification Number
LEGAL DESCRIPTION
Property Location o U,/ '/4, '/4, Sec. �, T ZI` N -R � � ; Town of 7 DSC1ST
Subdivisio /( S TES n , Lot #_.
Certified Survey Map # S 4 7 I — ,Volume , Page # 3
Warranty Deed # S S d 40 `f , Volume 3 , Page # Q 7t 't–
Spec house yes ❑ no Lot lines identifiably 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.
f
`'SIG ATURE OF APPLICANT DATE
QWNER 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 proptty dew. ' ed 0 ve by virtue of a warranty deed recorded in Register of Deeds Office.
(
1
A OF XPPLICANT 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
p oU
VOL 1236 PACE
p STATE BAR OF WISCONSIN FORM I - 1
558654 WARRANTY DEED
DOCUMENT NO _ — --- - -
IEuIMR5 OrFI .E
This Deed made between Susa a . Anders a sin g le STCRQh '• %Vi
person
APR 3 0 l:j {'
Granwr. 3: 2 5 P. M
and __Sam E. 'Miller, a single person,
•1ojt..r Ditiwy
Grantee.
Witnesseth That the aid Grantor, for a,- Auable wrisiderati of o ne
dollar and other valuable consideration
conveys to Grantee the following described real estate in S t . Croix TI+.S SPACE AESERvED Fr,A RECJRG GATA
County, State of Wisconbin: &.&AM AND RETURN ADDr S5
Sam E. biller
Sam Hiller Construction
Trout Brook Road
Hutson WI 54016
032- 2071 -90 -110
zOACEL IDENTIFICATION NUMBER
Part of the CIE 1/4 of SW 1/4 of Section 1 3,
Tovnship 3t3 North, Range 20 llest, St. Croix
County, Wisconsin described as follows:
Lot 2 of Certified Survey N.ap filed August 8, 1985 in Vol. "6 ", Page 1559,
Doc. No. 404156.
-MA tj'�HER
This is not homestead property. FEE
(Is) its not)
Together with all and singular the hereditaments and appurtenances thereunto be.Ir-i:.1.4.
And Susan R. Anderson
warrants that the title is good. indefeasible in fee simple And free and clear of encun:bra: co � +cepi
easements, covenants and restrictions of recoz:. if any,
and will warrant a nd defend the same.
Dated this CJt/ day of _ ly
(SEAL) — -- (SEAL)
• Susan Jc. A derson
1SEAL) —_ tSE•lL)
•
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of 'Wisconsin,
S:. -
Gelinty
authenticated this _— day of 19_ Persar Zv - rte before me thu' ���' / _• y a
tip ` �la�.:njaxicr name
Susan LZT Anderson
TITLE MEMBER STATE BAR OF WISCONSIN _ W
Wit° sr-- - - " - - --
authon :ed by 1706.06. Wis Stats) - ^ .
to me Itthwr_ u :r the person �\'vl�i eurvte�Ahe-tvrtguuti
riowe
ld•e iael '•.,,. .. '
^
Instrume V /
THIS INSTRUMENT .YAS GRAFTED nr . j
Robert F. 'rail -- - -
Hudson WI 54016 -- -- ------- - - - - --
St. Croix
-- -- — - -- -- -- - - - -- Nota�' P a - - - - -- — - — County, WIS
Sienaiures ma) he anthruicated or acknoNicdhcd 3fah are not Aiy >:cr. s permanent Jf nnr, ,tare r\pu.1 date
necesi rr \" )
TAT V. BAR Of \ \ISCONSI♦ 3aorC nc
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