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HomeMy WebLinkAbout020-1283-50-000 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT r % Owner Address City /State , - -^ Legal Description: o �� tit9 ' Lot /15 � Block — Subdivision/CSM # -# llOc Zi '^ i 1 'kl %. &�/, Sec. Z(2_, T2�LN -R /W, Town of l{ i PIN # D .- SEPTIC TANK - DOSE CHAMBER - HOLDING TANK INFORMATION: Tank manufacturer � s ' PI _��_ Size ST / Setback from: House � Well I, Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh a Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM:, Type of system: e eim Li Wid 5 � Length 1 Number of Trenches. 2 Setback from: House 'eD • Well P/L — Vent to fresh air intake Yf ELEVATIONS Description of benchmark K evation Description of alternate benc Elevation Building Sewer • D L STS Inlet A ST Outlet r PC Inlet PC Bottom = Header/Manifold P7. S Top of ST/PC Manhole Cover 9P s �7 Distribution Lines () !F,7, !F,7, y 7 () Bottom of System O p`, S' 7 Final Grade /P0z Date of installation Permit n ber State plan number Plumber's signature License number �-�: /� d''d Dater gL I ZZ Inspector complcte plot plan or 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 /1 Y No w�G �.�T. ,Lflr��v% f�u���d S• T INDIC4TE NORTH ARROW 1'Y1 p r JUisconsin Department of Commerce 3afe ty and'BuildingsDivision PRIVATE SEWAGE SYSTEM Count yST. CRO INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitaryfel"61: Personal information you provice maybe used for secondary purposes [Privacy Laky, s.15.04 (1) (m)j. CAREY, BR�E & MARY Ej b Q ❑ Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: I L Parcel T " 1283 -50 -000 ` J 0 / Y D 2— V C OY"P4 TANK INFORMATION ELEVATION DATA A9800150 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic � j � lx_ Bench k ,` ©5 I p� 1 vv Dosing -77 b ,5 -00.'7¢ Aeration Bldg. Sewer Holding Inlet (,.Z4 X6.1 TANK SETBACK INFORMATION St 4 Outlet (o¢ j (0 . 44 0 9 6 . o TANK TO P/ L WELL BLDG. A�irhintake ROAD Dt Inlet NA Dt Bottom Dosing NA Header / Man. y 93 4 6 Aer tion NA Dist. Pip 1 '1(1 0T 4 , 19 7-2, Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade fc �' �I9 1 7 Manufacturer mand C� Co L eA toU t ` 9 Mod umber GPM TDH ift Friction S ste TDH Ft Forcemain Lengt Dia. I Dist. To Well SOIL ABSORPTION SYSTEM BED idth Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth IMEN I N n® DIMEN I N SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACH cturer: SETBACK INFORMATION TypeO r ,II CHAMB o e Num Syste . a L `T NI A,, OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) (, � x Hole Size x Hole Spacing Vent To AirIn�ake Length Dia. Length Dia. T Spacing 7"yV` i~.} Z7 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 20.29.19,NW,NW 445 VIRTUE ROAD 1' A . I- t 1 3 , o+6vv\ 01, 'S 14 �b ovG bpi Ic��` Sca,,� I ��zI Plan revision required? ❑ Yes �K No / Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature VN. SANITARY PERMIT APPLICATION 20 e E W Igton A si N *sconsin In accord with tLHR 83.05, Wis. Adm. Code P.O. Box 7969 Department of Commerce Madison, WI W707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8112 x 11 inches in size. • See reverse side for instructions for completing this application State sanitary Permit Number 30 - 776 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 Pro y O Name Property Location �) �,r n r Wt 14 GrJ 1/4, S T , N, R E (or Property O ner's i Addre Lot Number Block Number S City&Ste Zip Code Phone Number Subdivisio Name or SM umber 1 . TYPE OF BUILDING: (check one) ❑ State Owned it� age Nearest Road Public 1 or 2 Family Dwelling ❑ VII - No. of bedrooms To OF k �q 107V AX III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) a lo p • I, � • I '5w g 1 E] Apartment/ Condo O.Z,9 — — ro 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. 0 New 2 ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an System System _____________Tank Only______________ Existing System ________ Existing -- -- - yytem 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 CZSeepage 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. evation Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (M in ./ inch) t El M �.S Feet oo.o Feet VII Capacit . TANK in g allons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App New Existin structed Tanks Tanks ept n ' - 6e*-e1<v ❑ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber — — _ ❑ 1 ❑ 101 ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume res onsibility for installation he onsite sewage system shown on the attached plans. Plu ber's N (Print) Plumber's Signature: (N amps) MP/MPRSW No.: Business Phone Number: P erZ 's Address (Str et, C y, State, Code): or lu S�{O -I J IX. COUNTY /IDEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate I ssued Issui Agent Signature (No Stamps) Surcharge Fee) ®Approved [ Given Initial 0 p© /Z t� r /s)Gjg CSl�. Adverse Determination // I I L X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD6M (R. 11/9B) DISTRIBUTION: Original to county. One copy To: Safety 6 Buildings Division, Owner, P wnber -st y/ O f \ 49 E -y !r toy* l! ZOT n rot ✓�� r rte° �_ 3 h SLR fPR�IE /L� / /OO.P 6 -z s _ Suru�yor'S rOC(. f Sb ' Fi7,«✓st��� 'rrrurrr srf-ra.: �S �9'Cr�atr,pJTLD "��i Ci9C C h�z'�i . Q z —pry H)� "j { i 7� ' I R M N ,1 va it ~_Fi �� o � LL 0 J � i Wisconsin Department of Industry SOIL AND SITE EVALUATION Labor and Human Relations Page of Division of Safety and Buildings in accordance with S. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Plea RS's' -ih Pion. R wed by Hate_ Personal information you provide may be used fo e�Cgri}i6r pure ses (Pn s. 15.04 (1) (m)). I S S Property Owner Property Location Govt. Lot NW 1 / 4 NW 29 1 /4,SNN T N,R 19 E (or) kX William Harwell k - Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# s. 767 Aldro Road 1 1 5 Willow Ridge East II City State Zip ode.., Phf�- fpl7rYtber ❑ City El Village ® Town Nearest Road Hudson I 5 0 V6 j`. iotlitsgF# I' ` 0 Hudson Co. Road A v k] New Construction Use: Residential r of bedrooms 3 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 450 gpd Recommended design loading rate _ . 4 bed, gpd /ft gpd /ft Absorption area required a n n bed, ft 7 5 0 trench, ft Maximum design loading rate _ 5 bed, gpd /ft gpd /ft Recommended infiltration surface elevation(s) 9-6 ft (as referred to site plan benchmark) Additional design /site considerations See Page 3 Parent material G1a.Pia- 1 n,_1+ W 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 1 0 S ❑ U ❑ S R] U ❑ S [X_1 U I ❑ S [X U ❑ s KI U ❑ S E� U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 1 1 0-84 10 r2/1 none sil 2fsbk mfr -- 2m .5 .6 2 84 -120 10 r2 2 none sl lfsbk mfr -- -- Ground elev. 99 .9 0 ft. Depth to limiting factor 12I) - - -in. Remarks: Boring # 1 0 -86 10 r2 1 none sil 2fsbk mfr -- _ S -6 2 Ground _ elev. 99 ft. - -- Depth to limiting factor Remarks: CST Name (Please Print) Signature Telephone No. Address Date CST Number PROPERTYOWNER William Harwell SOIL DESCRIPTION REPORT . Page ')._ of _3_ PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Structure 2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench 3 1 0 -9 10 r2 /1 none sil 2fsbk mfr -- 2m .5 .6 , Ground elev. ; 10 a —Eft. Depth to limiting ; factor 9 in. Remarks: Boring # 1 0 -8 1 4 ; Ground elev. 99 1 90 ft. Depth to limiting factor 8 6 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 # 1 0 -91 1 0 r2/ 1 none sil 2f sbk mfr 2m • 5' .6 5 Ground elev. 10 Depth to limiting F: L factor 91 - - in ' Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBDW -8330 (R. 08/95) �3'/rlf / oZsta� P F��y !�a o lv� e ll v ib G Go Opp �,d57'a /lev S/iou ct�{ U5 ihucll 7"eSrad are— ct-S �oass:6 /e 4L_c.aa3 e- 4 c) 7' S',;ZG D,il G� � �`eG� at c a- yn e d 7 ar c� a- 5 x /00 T r e wC A e .9 dv Z a k 1 e ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner /Bayer o'e I- Mailing Address �1 Property Address 1 VS - U Lr (Verification required from Planning epartment for new construction) City/State Le4T C Parcel Identification Number 12;w — /a k9 LEGAL DESCRIPTION Property Location At,) %., &( t / %., Sec. -Zo . T, N- Rf�_W, Town of /Ad" r 4 Subdivision 41, � /I Aflge 4 /✓ Lot # / / S Certified Survey Map # Volume . Page # Warranty Deed # Volume /3.z o . Page # 06�' Spec house ❑ yes J O no Lot lines identifiable 0 yes ❑ no SYSTEM MAINTENANCE Improper use and numAcnanocof 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 weded by a licensed pumper. What you put into the system can affect the fimcdoa 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 ownerr and by a master plumberjoumeynimplumber. restrictedplumberor a licensedpumperverifying 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 fidll 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. SIGNATURE �OF PPL I 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 above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLI ATE « « « « «« 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 '578510 STATE BAR OF WISCONSIN FORM 2 — 1982 WARRANTY DEED DOCUMENT NO -. ICE $ T, CROIX Co., WI William C. Harwell a single person i Qa 0i fur Rgoard MAY Q 41998 1:45 `` PM conveys and warrants to Q�,�,, Brett L. Carey and Mary A. Carey, husband and wife as R. Ister of Dead* survivorship marital proopea THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in St. Croix County, G"i(A-E. U>4fk�e_( or_>$k�Y_ — State of Wisconsin: Igo l C C )uLt C I t' a,} 020- 1283 -50 PARCEL IDENTIFICATION NUMBER Lot 115, Willow Ridge East III in the Town of Hudson, St. Croix County, Wisconsin. $ � A�NSFER This is not homestead property. xsk (is not) Exception to warranties: Easements, restrictions and rights -of -way of record. Dated this day of April A.D., 19 98 SEAL L �t/ (SEAL) * William C. Harwell (SEAL) (SEAL) i AUTHENTICATION ACKNOWLEDGMENT Signature(s) \ vJ' ((I G��r G' ,( � State of Wisconsin, ss. County authenticated this 3 day ci 19 Personally came before me this day of Ll� April 1928_, the above named 061 LA- 0 Will iam U. Harwell, a single person TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Stats.) to me known to be the person who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Attorney Kristina Ogland Hudson, WI 5 Count Wis Notar Public, y, Y (Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration date necessary) 19 .) ' Names of persons signing in any capacity should be typed or printed below their signatures. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. WARRANTY DEED Milwaukee. Wis. Form No. 2 — t982 I Burnet Realty welcomes You 1-0 WILLOW RIDGE FAST Presented By: _� Ery Swansor3. .,r- ;�. ��� ���R � .00•aaT .00 .:c'soa .ao•�oz .oa•3Lt I m 103 103 a! 106 I r.JQe AG 1317 .C, ai 1134 K aj 1191 AG ml 'Y w C� nj roI of of tr�n: • - f*1 � J rol rn 206. e2 • pp55 <_ OVIERLWX 1 2 Y 1. Z33 AG 0 107 no 093 AG m m ddd �1 Q 1157 AG 123 n /9 of m Q _. 1.3.43 AC T s'90g Lo•:zz p CIS (O n 00 t21 c J .Sc 1.ISS AG ° tlt n 0 t_083 AG N 00' SST - s►r 0 p R 1.360 AC- 0 120 Ere tv . a � 2 _ 01 n' 12 r-441111 z cr .+ a 119 f.QS9 AG o ei m 1.332 AG ' O� �1 c 109 rJ tt r y `1 •Os. 1;290 AC 118 0 e 113 p 1.51 pO`� �1 1.287 AG ° p 9 i 9 n 114 1 • p 1.078 ..G j9 %. 1 its • � J � �, 1.O29 Acr - j 1q.8j • e� 1• t Pl• 11 a .�.�.�. ` I.190 A C OO `A 117 r SCLO 1.272 Ac C4 1 • N .A WILLOW RIDGE EAST T% Ery Sw -, Q oz� 7 7 7- 7 J, 4 3 Gff ice = 4 88 -582 -�;