HomeMy WebLinkAbout020-1333-00-000 ST. CROIX COUNTY ZONING DEPARTMENT/
AS BUILT SANITARY REPORT
y RE CEIVED
-
Owner
Address 12 ,5 sr cRolx
City /State couNrr.
ZONING OFFICE
Legal Description:
Lot 1l Block Subdivision/CSM # = -'
'/, ' '/. 41&J, Sec. -9 9 , T N -RAW, Town of _1YAe6 - a PIN # o ao /33� - o6
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer �. W" ,g yrku/ Size ST/PC / / 6 o �
S� _ 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: eo,u,,c1 Width S Length /J Number of Trenches 2
Setback from: House y0' Well 6 t Vent to fresh air intake
ELEVATIONS
Description of benchmark to •� -� v 5 �� S ®� C� 14 Elevation O
Description of alternate benchmark — L a o!�- fa- (� Elevation e' / -o
95r ,�S
Building Sewer ! e/S ST/HT Inlet 9A 41 . 1 ST Outlet- `17 f 5/ PC Inlet
PC Bottom Header/Manifold 4 S Top of ST/PC Manhole Cover Q f sZ
Distribution Lines () 96 ( ) f -5-, , r- ( )
Bottom of System ( ) /, `-/ �;' ( ) f -r-/ E G a ( )
Final Grade ( ) ° )7, b e) ( ) ( )
Date of installation - /F rPermit number tate plan number
Plumber's signature 0 1 1 1 . License number Z2Z 7 y; e Date. /
Inspector IF,4 Pmt
Complete 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
v
9 i CC-'�
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sa•� �.,'a�J ill ?C�� -
INDICATE NORTH ARROW
• Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division Count ST. CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary 5nift
Personal information you provice may be used for secondary purposes [Privacy Law s.15.04 (1)(m)). 3 // b
ST , �2`18AARD 1 ❑ fi i���a ge ❑ Town of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel T`�G�- 1333-00-000
— To ok Z � l
TANK INFORMATION ELEVATION DATA A9800149
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV.
e tic � � Bench �1 y. l 7 bo / of
Dosing
Aeration Bldg. Sewer 3 �7G E
Holding �- `� Inlet 5.71 C)5�, tA.
TANK SETBACK INFORMATION Outlet .L2 9795!
TANK TO P/ L WELL t AirI to ROAD Dt Inlet Airintake NA Dt Bottom
Dosing NA Header /Man. `G
Aeration NA Dist. Pipe tjv 1r_ 9s- "W .(,
Ner . rya q
Holding -. Bot. System so �5 9,
PUMP/ SIPHON INFORMATION Final Grade 7
Manufacturer Demand S WCA
Model Number GPM
TDH Lift L , ction System TDH Ft
m ead
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BE Width / 1 Length li ► No. Of Trenches PIT No. Of Pits Inside Dia. Liquid De h
DIMENSIONS ) s 4 DIMENSI
SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM
LEACH G Manufactur
INFORMATION Typeo ti� CH M T um er:
System o ` I '�
DISTRIBUTION SYSTEM
Header / Mani ;old Distribution Pipets) ' x Hole Size x Hole Spacing Vent To Air Intake
Length { 4 Dia - Length [ � Dia. _ Spacing A ? _r
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over ��VrDepth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Tr
COMMENTS (Include code discrepancies, persons present, etc.) (J?�
LOCATION: HUDSON 27.29.19,SW,NW 762 WILFRED RD— BADLAND PRAIRI� YOT 10
Z) !moo Wcl 0, t w�, pe-c✓ 4 - i - aa,
r/}z /'I
Plan revision required? ❑ Yes 06 No � t
Use other side for additional information. CY
SBD -6710 (R.3/97) Date Inspector's Signature
Vi scons i n Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 E. Washington Ave.
In accord with ILH R 83.05, Wis. Adm. Code P.O. Box 7969
Department of Commerce Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
3D_77 & 0
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)]. - 71 e A IN'O>{' Cd R 6/. State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION
Property Owner Name Property Location
1 1/4,S T 'NOR (or) W MW
Property Owner's Mailing Address Lot Number Block Number
1353 Awatukee Trail 10
City, State Zip Code Phone Number Subdivision Name or CSM Number
Hudson WI 54016 1 (71-0 -
II. TYPE BUILDING: (check one) ❑ State Owned ❑ it� Nearest Road
❑ VII age
Public 1 or 2 Family Dwelling - No. of bedrooms 6 Town OF
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number s
1 [] Apartment/ Condo o a9. I9. 750 ��a � .�,; -
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. ❑ 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 ® Seepage Trench 22 ❑ In- Ground Pressure f I 42 ❑ Pit Privy
13 ❑ Seepage Pit C aj S X 1 3 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
900 Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) t7X/ -&5 Elevation
1125 1130 .8 Na -9 5.54- Feet 99.04 Feet
VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION New Existing Gallons an Manufacturers Name Concrete strutted Steel glass Plastic App
Tanksl Tanks
is an X 165
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
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:
William Schumaker V MP227990 715 386-
Plumber's Address (Street, City, State, Zip Code):
1070 Scott Rd Hudson, Wisconsin 54016
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issue ISSui Signature (No Stamps)
® Approved []owner Given Initial Surcharge Fee)
S
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Adverse Determination I Ov dv /1 Ov i v v 1 r ce)
X. CM H OMI
_' l ,� PROVA REASONS FOR D
E� _ YJ bbr V1� 3 rAft*er 181 rsc,�%ej A ff' - M'- 3 Coo+ se parrA,4jbpj r &V1 I &44e- k
SBD -63W (FI t 1/96) DISTRIBUTION: Original to County, One copy To: Safety 8 Buildings Division, Owner, Plumber
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Wisconsin Department of Industry SOIL AND SITE EVALUATION
Libor and Human Relations Page L— of 3
: 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 Cr oix
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel #
62 -0 - /D7D 90
APPLICANT INFORMATION - Please pr'
t �tat� ` Reviewed by Date
Personal information you provide may be used for seco al p oses ( cy LAW., s`,t5. (1) (m)).
Property Owner / r . (� \ perty Location
Richard Stout i_Z ` �' fi�o . Lot SW 1 /4NW 1 / 4, s27 T29 N,R 1 g )C (or) W
Property Owner's Mailing Address - �2 91 lit Block# Subd. Name or CSM#
1353 Awatukee Trail - 1` '-
' �r cROlx [ Badlands Prairie
City State Zip Code hone N g ® Town
FFIO� City El Village Nearest Road
Hudson WI 540 1 6
1�� -6 , Hudson IState Hyw 12
[New Construction Use: [Residential / Numb
edrooms _ Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 9 0 0 gpd Recommended design loading rate 7 bed, gpd/ft gpd /ft
Absorption area required 12 8 6 bed, ft 2 1 12 5 trench, ft 2 Maximum design loading rate • 7 bed, gpd/ft2 • 8 trench, gpd /ft
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material Glacial deposit 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 IN S ❑ U K] S❑ U ®S ❑ U EIS n U ❑ S E U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft2
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed , Trench
1 ` 1 -16 7 . 5 r2 . 5 1 none L 2mabk mfr cs 2m .5 � . 6
2 16-44 10yr3/4 none sil 2mabk mfi cw if .5 -.6
Ground 3 44-96 1 0yr4 /6 none ms osg ml cw -- .7 ' . 8
elev.
99_ ft.
Depth to
limiting
factur -- - - -- -. --
9 6 in.
Remarks:
Boring #
1 0 -20 7.5yr2.5/1 non L 2 mabk mfr cs 2m . . 6
2 220-46 1 0yr3/4 none sil 2mabk mfi cw if .5 .6
3 46 -96 10yr4/6 none ms Osg ml cw -- .7 _8
Ground
elev. - - - - -- - - - -- //�
Depth to - —
limiting
factor
9 6 in. Remarks:
CST Name (Please Print) Signature /
r , j•. S'�f;usn e1A L,J �J •.. '� - - - - - -- (
Address -- Date CST Number
f a 7� .5'c. • tr s-a� a e 'Y -7 9 90
PROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D.#
3oring # Horizon Depth Dominant Color Mottles Structure 2
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed .Trench
3 0 -16 7.5y none L 2mabk mfr cs 2m .5 .6
2
, 16- 44 none sil 2mabk mfi cw if .5 .6
around 3 44 -84 1 0yr4 /6 none s osg ml cw -- .7 , . 8
Aev.
10 Q-i3t.
jcl k�
)epth to
imiting
actor
84 in.
i i i
Remarks:
3oring #
1 -18 7.5yr2.5/i none L 2mabk mfr CS 2M .5 .6
4 2 18-41 10yr3/4 none sil 2mabk mfi Cw if .5 .6
3 - 44-H 10yr4 /6 none ms osq ml Cw - .7 .8
around
:lev.
10 0 0 5 fi, ;
Depth to
Imiting
actor
R? 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 -
5 2 PO-45 10yr3/4 none sil 2mabk mfi Cw if .5 .6
3 k 6-92 10yr4/6 none ms osg M1 cw -- .7 .8
around
elev.
100 ft.
Depth to
limiting
factor
92 Remarks:
3oring #
around
elev.
ft. '
Depth to
imiting
factor
in.
Remarks:
SBDW -8330 (R. 08/95)
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer r� ► c A At 0 34
Mailing Address 13 5 3 a u K e - r l z q;
Property Address
(Verification required from Planning Department for new construction)
City/State 14 U ` 0 ` 7 �J � Parcel Identification Number
LEGAL DESCRIPTION
Pro Locati S
petty lv /., /., Sec. Z 9 N -R Z_LW, Town of
Subdivision _ ,4,-) �A h n s ; ,2 i �. Lot # _
Certified Survey M # Volume . Page #
Warranty Deed # 5 3 5 y Volume l a U . Page # Y y �_
Spec house ❑ yes ❑ no Lot lines identifiable yes ❑ no
SYSTEM --M UMNANCE
o consists lmproperwea ndmabdenaaeeofymsepticsy�couldr =kinitspt�ema = far�umtohandlewastes .Propermarnteaanee
pump Out the Vic ter* eVcrY three years or sooner, if needod by a Licensed What
can affect the fnmction of the - P you put into the system
septic tank as a h+atment stage in the waste .
The property- owner agrees to submit to St: Croix Zoning Dew a cettificafioa fors. signed by the owner. and by a
P ] resnictedplumberora tiaensedpusmperverifymg that (1) ft on-site wastewaterdisposal system
is m proper operating condition and/or (2) after inspection and purnping.(if necessary), the septic.tanlcis less $man 1/3 full of sludge.
Uwe. the Undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, bercin,'as set by the Department of Comore= and the Department of Natural
stating that Yom septic system Stage of Wisconsin.. Certification
of the three �� has bees maintained mist be completed and returned to the St. Croix County Zoning Office within 30
days Year expiration date.
RX �1" 0 % Z9
SIGNATURE OF APPLICANT D A / /
ATE
OWNER CERTMCATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner of
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
i k � , a�j ;- 4-/ 7S
SIGNATURE OF APPLICANT
DATE
« « « « «« Any information that is mis- representod may result in the sanitary permit bong revoked by the Zoning Department. « « « « ««
«« Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
i
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STATE BAR OF WISCONS114 FORM 1 -1982
WARRANTY DEED
DOCUMENT a
NO. M --�_ -
I�II. -.- -_ -- REGISTER a GFFICC
ST. CROIX CO., WI
This Deed, made between The Na.L Corpo r tion F0111WRIM0
a Wisconsin corRoration, organized Aril 1 1996 and j
fil With th Wisconsin b etretary ot State on DE 2 0 199fi
pr , , Grantor, 3:30 P. M and Richard 0. Stout
LdAk
Register of DYncs -
Grantee,
Whnesseth, That the said Grantor, For a valuable cmAdmd -
conveys to Grantee the Following described real estate in St Croix THIS S RE FOR RECORDING DA TA
County, Swe of Wisconsin: NAME AND RETURN ADDRESS
Richard 0. Stout
1351 Aaatukee Trail
n.,, '.? 4U I O
t:o t1 to tt ola�,m>s :ta grantee Gary reversionary rigl l:. tf 3s- and i oars t< to 1Se
in Vo;l. sot, lag* 212, Doe No. 35&521, aszd ii VD 598, i�lg$` "
t; g-
' � w '1:1"�YC6tC3d''�1TC13C1'tyf
(ia3 'pia �ntifi)
' � yd # T art J at tier tlxtr'shtewd1uy4exrts and:appurtenances- thertunto belonging;;
See E *hi.''b'it B tva to
,
asYd l.?�Ya+t tttt tddefe6d..the same.
duy a , .DRS'�embar
Tb*
(B8A1:) tom.)
OT VA*C014TN
w3» to the known to tilts; pdwm who meted the foreob
instrument and aio g oft ,fine.
TMIS"it!11 F1i3!I�I WAS -0.14 �FTLD t1'
R: ?�CIR 1Ci$� Grnd�L 6 V�+letain OR
s t or selmi edod -16th am not idy
t+dpTay srce► aarp(�elrakSistr arene
vot T2*f4 FAA 43
EXHIBIT A
Legal Description
The NGL Corporation to Richard O. Stout
The South Half of the Northwest Quarter, the Northwest Quarter of the Northwest Quarter,
and the West Half of the Southwest Quarter of the Northeast Quarter of Section 27,
Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin.
Bxcxpt that portion of the Northwest quarter of the Northwest quarter of said Section
27 described as follows: Beginning at the Northwest corner of said Section 27; thence
along the North line of said SOCIion 27, South 88 degrees 23 minutes 58 seconds East
160 feint; thence, diagonally, South 29 degrees 07 minutes 38 seconds West 338.27
feet to a point on the West line of said Section 27; thence along said West line, North
0 degrees 54 minutes 02 seconds Past 300 feet to the Northwest comer of said
00 j" to: ft 0& Of St. OMk County for hi&way
WOMWO ift the Ofte Of 1 of Deads fbr St. Ooik Cowy, ids, In
ut 257, pale II -sand V-0lume 302, pop 2
-' d& At +- tt to the Wisconsin T �
e of ..° of Deeds, in Volume 472, page $5, doeu -305105;
40 dw =Wq Own road along the North line of tht west Quarter of *e,
NOdhvm QUWW Hof Sin 27.
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Exhibit B
Liens and Encumbrances
The NOL Corporation to Richard O. Stout
(t) Municipal and um ng ordinances and agreements entered under them, (ii) recorded
easements for distribution of utility and municipal services, ('iii) mcorded building and use
restrictions and covenants, and (iv) general taxes levied in the year of closing.
ems
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