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HomeMy WebLinkAbout020-1344-13-000 CROIX COUNTY ZONING DEPART I' ~ I�.#'t`F�1'T AS RUILI' SANITARY RBI'ORI' Owner ; Address City /S(ate i (, �n �3 Lcgal Description: Lot _1, Block AA Subdivision/CSM It c ti •- Scc] PIN W, Town of # fU —l�� L� —%�— SEPTIC TANK - DOSE CHAMBER - HOLDING TANK INFORMATION: Tank manufacturer _ (,U Q 0 1� c, Size ST/PC 106(y /9 Pump manufacturer Setback from: Iiousc — _J_ Well —� P/L 7 Zv Model - Alarm location (HOLDING TANKS ONLY) Setbacks: Service road —Lq1— Vent to fresh air intake /U /4 A Meter location /UA Water Line Alarm location 1U SOIL ABSORPTION SYSTEM: Type of system: Q Width � S.0 Length Number of Trenches Setback from: House Well P2 Vent to fresh esh air intake 5' p ELEVATIONS: Description of benchmark Description of alternate benchmark E le v ation P S ivt E •v+ }S°1A 0 4'-b Elevation /0(..? Building Sewer ST/HT Inlet ST Outlet- /Q /, / PC Inlet ---� PC Bottom "—'— Header/Manifold $ , Top of ST/PC Manhole Cover d , Distribution Lines Bottom of S Final Grade Date of iustallatio ermit number ? �� State lan nu P mbcr ti /q Plumber's signature 4 License number Inspector Date /Z /� � c o plot p1m plan L O NOTICE Please provide (lie 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 V X a � X ti 1� N INDICATE NORTH ARROW I v Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y: ;. afetyend Buildings Division Count INSPECTION REPORT Cv'o i T GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. - 77 ? i Permit Holder's Name: I ❑ City C] ilia a Town of: State Plan ID No.: �I i G Ad �6Y� /l CST BM Elev.: Insp. B Elev.: BM Description: / Parcel Tax No.: i 0o tom r k, i vL TANK INFORMATION ELEVATION DATA ,gooiZ Z TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. e Icy Bench ? ? Lq �7 - / U - D Dosing 4(}, 61 •33 •9 6 Aeration Bld .Sewer zAG Holding Inlet S TANK SETBACK INFORMATION Outlet TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet Air I ep i L (5 - 0 4 - -- �� f z� NA Dt Bottom Dosing NA Header/ Man. � $-g(� Aeration NA Dist. Pipe q* Holding Bot. System U7 C C- 7 PUMP/ SIPHON INFORMATION Final Grade (.V 161.,>1 Manufacturer I De and Model Nu GPM TDH Lift Friction System TDH Ft Forcemain ia. H Dist. To well SOIL ABSORPTION SYSTEM BENCH Width I Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN I N t2 DIMENSION SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type of CHA o e umber: System,►wI+) l?�� - OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length 1� Dia. h Lengt Dia. � Spacing � � �7lvt Z'7'Z SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over S r Depth Over xx Depth Of xx LSodded Seeded/ xx Mulched Bed /Trench Center Bed / Tre ges Topsoil El Yes No ❑ Yes COMMENTS: (Include code discrepancies, / persons present, etc.) 4'g� (� (rr, L _ L r f, � — )2/ . t — � -4 �inGG� l 16vk- .2-) zCJ. + 1k � (c� C 4•) wtv ►� f c�� a �s Plan revision required? ❑ Yes [�No / Use other side for additional informa � dip, q& SBD -6710 (R.3/97) Date Insp is Signature ert. No. V Visconsi n Safety and Buildings Division SANITARY PERMIT APPLICATION P E. Washington Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI W707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County r e? 0 r than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number 30 The information you provide may be used by other government agency programs ❑ 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 Property Own N me Property Loc lion p c G P/a, S T Z , N, R f*W) W Property Owner's Mailing Address L T � Lot Number Block Number City r ` Zip C /� Phone Number Q Subdivision Name or CSM Number le II. TYPE OF BUILDING: (check one) ❑ State Owned it� Nearest Road ❑ VII age - D Public r 2 Family Dwelling - No. of bedrooms Town OF p 61� III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) orb' 2 —/ 3 Q72) 1 ❑ Apartment/ Condo a v 7 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. XNew 2 ❑ Replacement 3, ❑ Replacement of 4_ ❑ Reconnection of 5 ❑ Repair of an _____System ________System_____________ Tank Only______________ Existing System _________ExistingSystem 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 1 1f�jSeepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: X00, 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 q S 6 g ©.7 Feet eet VII. TANK I in Capacity s Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App New Existing structed Tanks Tanks Septic Tankoc�awk S ❑ ❑ ❑ ❑ 1 ❑ Lift Pump Tank /Siphon Chamber ❑ I ❑ I ❑ 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 Na e: (Print) n Plumber's nature: (NOS m MP /MRRS1f?No.: Business Phone Number: ; 2 GY ` KP Plumber's Address (St t, C ate, Zip Co ool 5 i; 0 IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater at ssue Issuing e t Signa (No Stamps) Ip Approved ❑ Owner Given Initial I Q % Surcharge Fee) Z 7 Sl Adverse Determination l / '7(Jr -,ra-L X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBt }6398 (R.11/96) DISTRIBUTION: Original to county, One copy To: Safety B Buildings Division, Owner, Plumber III I- o 4- /3 44 LL ti -41 LID 6e 6 14 - L - A - & DA - 1 - Z( - :;: , C- - r(C- TE L CU g r C. 10 771 Wisgonsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor wind Human Relations Dion of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 1 es in size. Plan must include, but St. Croix not limited to vertical and horizontal reference poi nGe to neares difgti n % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and dis t dR 020- 1020 -90 APPLICANT INFORMATION- PLEASE T ALLI?4N 't10..� REVIEWED BY DATE PROPERTY OWNER: -P OPERTY LOCATION i - `G - VT. LOT 1/4 1/4,S T ,N,R Kernon Bast RU ,� _:,� ATE NW 14 29 19 :k ( or) W PROPERTY OWNER':S MAILING ADDRESS ST CRv/}�{~T - L T # BLOCK # SUBD. NAME OR CSM # 948 LaBarge Rd. C0 3 na Grass Ran a First Addn. CITY, STATE ZIP COD . CITY []VILLAGE [MOWN NEAREST ROAD Hudson, WI. 54016 15.386- 7 `. Hudson McCutchen Rd. [�q New Construction Use [x] Residential / Num 4 [ ] Addition to existing building ( ] Replacement [ ] Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate • 7 bed, gpd /ft • trench, gpd /ft 2 2 858 2 750 2 .7 .8 tren ch, / Absorption area r wired bed ft trench ft Maximum design loading rate bed, /ft tre c , d ft requi 9 9 9Pd 9P Recommended infiltration surface elevation(s) 98 - ft (as referred to site plan benchmark) Additional design / site considerations trenches spaced to code 3.50' below surface grade Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable for s stem 2 S ❑ U ® S ❑ U I ® S ❑ U 13S O U ❑ S CC ❑ S 97 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft Trench .......... Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench __....1....' 1 0 -10 10yr 3/3 none 1 2msbk mfr gw 2f .5 .6 2 10 -31 10 r 4/4 none sil lcsbk mfr 9W if .4 .5 Ground 3 31 -84 7.5yr 4/6 none ms osg ml na na .7 .8 elev. 1 02.4 ft. Depth to limiting factor +84" Remarks: Boring # 1 0 -6 10yr 4/3 none sl 2m r mvfr 2f .5 .6 2 6 -12 10yr 4/4 none sl 2mgr mvfr gw if .5 .6 Ground 3 12 - 80 7.5 r 4/6 none cos osg ml na na .7 .8 102ele1 ft. Depth to limiting fact 40 Remarks: CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200 Address: 1554 200th.-Ave., New Ric mond WI 54017 Signature: y� Date: f� _� CST Number: m02298 PROPERTY OWNER Kernon Bast SOIL DESCRIPTION REPORT Page 2 of _3 PARCEL I.D. # 020 - 1020 -90 . Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft Boring # Horizon in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trench V `.........3. 1 0 -9 10yr 3/3 none 1 lcsbk mfr 9w 2f .4 .5 2 9 -22 10 r 4/4 none sic lcsbk mfr 9w if .2 .3 Ground 3 22 -80 7.5yr 4/6 none ms osg ml na na .7 .8 elev. 1 00.2 ft. Depth to limiting factor +80" Remarks: Boring # 1__ 0 -13 10 r 3/2 none 1 lcsbk mfr gw 2f .4 .5 2 13 -43 10 r 5/4 none sil lcsbk mfr gw if .4 : : .5 Ground 3 43 -80 7.5yr 4/6 none ms OSCF I ml na na .7 .8 elev. 9 7.5 h, Depth to limiting factor + 801, Remarks: Boring # 1 0 -8 10 r 4/3 none sl 2mgr mvfr gw 2f .5 .6 5 2 8 -17 10 r 4/4 none sl 2mgr mvfr gw if .5 .6 Ground 3 17 -29 7.5yr 4/4 none ms osg ml gw na .7 .8 elev. 4 29 -39 7.5yr 4/6 none fs osg mvfr 9w na .5 .6 9 6.8 ft. Depth to 5 39 -80 7.5yr 4/4 none cos osg ml na na .7 .8 limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(8.05/92) STEEL'S SOIL SERVICE Gary L. Steel Kernon Bast 1554 200th Ave. CSTM2298 NE4NW4 S14 T29N - R19W New Richmond, WI 54017 MPRSW 3254 town of Hudson (715) 246 -6200 lot #13- Grass Range First Addn. N 1 =40' BM.= nail in Elm tree @ el. 100' Alt. Bm.= nail in Elm tree C el. 101.10' 36' 510 VL th �top Gary L. Steel 9 -26 -97 II_ 04/17/1998 07 :05 7152623679 TONER PAGE 04 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP ) CERTIFICATION FORM Owner/Buyer L Mailing Address 3 o f S cr S �= L > v ., Al ( Property Address 1 01 , - t l� A SS `} ,v `�, 1 Y+ L eL � (Verification required from pl ann i ng D partment for new construction) u ti' ( j City /State S ?_ Pa=l Identification Ntnnber " " duo /oav y� LEG ;SCRIPITON Property Location A) �- % <� N W ' /a, Sec. _ / _ T q N -R W, Town of Subdivision z 4 S /a n S �i d `~� Lot # Certified Survey Map # Volume Page # Warrtutty Deed # Volume Page # Spec house O yes Kno Lot Imes idetitfiable Pf yes 0 no MTEN MA►�NTENAI�t consists weandmaiateoaeceofyovrseP s y st emcouldmsoitisitspruirature I fammtoboodlewastes. mai�t0eoaaee CM affect tundi of svdc tack ovary ftm years or s000m if umded by a lioensed p� What you put; into the � septic tw*05 a tatmaa stage is !ha waste dispose] , ne mast plrrmbP �ym ic adAw jtriaob� �8 mutt! tt aoa fam skmed by the .Own r and by a is in PMW operating condition and /or � p or a 1tcPsedpuasperve�'iQ8 tit (I) the ors -site �rasttwaterdispoaal system (Z) mspccaon aad pumping, (if aeoessary), the septic is less than 113 full ofdudge. uVw". the uad"signod have read the above regrrireatents and 49M to maintain die privato sewage disposal system with *a standards f ork herein. as sat by the >Jepartmeot of Oommaroo and the D of Natnrxl stating dat your reptie system bas been Resources State of Wisconsin, Ccrtifcation days �d ditc maiadriaed aunt be completed and retrurrad to the St t�oitr County Zoni Office within 30 1 �. Y� expiration date. Zoning s1 �61 F:li� � 4 i°1 Y, / j CANT DATE OWNEK CERTIp'ICATION the I (we) cet* that aU stateuWnts on this form are t mo to the best of my (our) iaaowledge. I (we) am (are) the owners) of pro perty dcscrrbed above, b e f a warranty deed recorded Register of Deeds Once p St NATtAM F APPL 1 ;V, 9 DATE �. • « «« Any information that is tail -m Trescntod may tesalt iu the sanitary permit being revoked by the Zoning Deparelwerrt. `• Include with th's application: a stamped warranty decd from the R pgister of Deeds office a copy of the certified survey map if reference is made in the warranty decd ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer � H Mailing Address 3 0 Property Address - Z D T l 3 6?2/4SS L A) o 5�— (Verification required from Planning Department for new construction) City/State �- 8' S ° ``� W Parcel Identification Number LEGAL DESCRIPTION Property Location Ill �- %., N W y., Sec. 1 l, T 2 9 N 1 9 W, Town of Subdivision rL ie 4rS �i r1 S �� �i `� Lot # Certified Survey Map # Volume . Page # Warranty Deed # Volume . Page # Spec house ❑ yes �f no Lot lines identifiable yes Q no SYSTEM MAitMNANCE improper use and mainteaanceof your septic system could result is its pramatumfarTure to handle wastes. Rmq=maiatcnanoe consists of pumping oat the septic tank every throe years or sooner; if needed by a licensed pamper. What you put into the system can affcd &C 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 p journey=nPlumber, restrictedplumber or a liceasedpumperverifying that (1) the on -site wastewaterdisposal system rs m PrWer operating condition and/or (2) after inspection and pnmrping.(if necessary), the septictankis less than 1/3 full of sludge. Uwe, 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, stating that your tic State of Wisconsin.. Certification septic system has been maintained must be completed and returned to the St. Croix County Zoning office a within 30 days of the three year expiration date. 0 1/ 1,2y 9 SIGRATU1W 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 abovF, b e f a warranty deed recorded in Register of Deeds Office. SIGNATURE F APPLICANT DATE « « « « «« Any information that is mis- represented may result m 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 f ) � ya�� QAGE�4 I V + " . .5 77906 STATE BAK - F SI[�TFIIRIGT 1 — 1982 I WARRANTY DEED DOCUMENT NO. REGI5T�R'S 0r'FICC k nnnal da ,T_ R= PPr —Ba -st and KPrnnn ,T_ Bast ST. CRC?!,, e APR 2 4 1998 conveys and warrants to . Randy L'. Hiekel -and Liza L: Hiekel 4 ' I S P. husba and w ife ceX4xti °I+: L�;SSa _ —_ Regis or D99 ds THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in faint Cro County, /00dY "V, e� State of Wisconsin: iU Lot #13 Plat of Grass Range, First Addition Zeoe l �ya2Z Town of Hudson 020 - 1020 -90 PARCEL IDENTIFICATION NUMBER This i -s _ homestead property. (is) Exception to warranties: Easements, restrictions and rights -of -way of record, if any. 1- R '_ � ' i '•i I LL ` a .. :P (., - �f� 1 �� , •, ... .. it #i �wr C' / I f 'ate IIII ar.. �'1AP 27 X17 1 : 3 E 1 26'369499 PAGE . 002