HomeMy WebLinkAbout020-1333-30-000 ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT R`C
Owner �-
���!
Address
ST CAOIX ,�• a
City /State COUNTY
�'S�c'�a.•� , r yf ,- °,
ZONING OFFICE \
r � _
Legal Description:
Lot -4 Block Subdivision/CSM # e,,- J 4o.-4 1 d 5' Aia - ;�� �
'/, 6 '/, L i , Sec. WZ, TAN -R,,�4 W, Town of PIN # 0 i9c'- /.?33 3d
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer ST/PC /GSA' Setback from: House Well Gay 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: Cd.d Width , — Length Number of Trenches 2
Setback from: House Well P/L Vent to fresh air intake
ELEVATIONS
? 8'7
Description of benchmark - �/ Elevation eAPF
Description of alternate benchmark ! Elevation
q2
Building Sewer is G ST/HT Inlet r ST Outlet �YS� PC Inlet
PC Bottom Header/Manifold 97 � Top o Manhole Cover 1' 9• �'tf
Distribution Lines ( ) 9 7 ' ( ) 9 7- .� y ( )
Bottom of System ( ) %� -6
Final Grade ( ) c 1�1r 9 () ( )
Date of installation & Permit number .�4���✓� State plan number
Plumber's signature number ��9 �'d Date /---;;Y'
Inspector
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
P
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1
INDICATE NORTH ARROW
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division County: ST CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitaryhny"3
Personal information you provice may be used for secondary purposes [Privacy La s.15.04 (1)(m)].
P STOUTd er; R � IARD ❑ D U &ge E] Town of: - State Plan ID No.:
CST BMElev.: Insp. BMElev.: BM Description: Parcel Tatl��- 1333-30-000
CtIq °19 C6/ ST' S
TANK INFORMATION ELEVATION DATA A9800152
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
epti jy� r Sb Benchma ,� 22 /o�/ / �• �f�
Dosing
9a-
Aeration Bldg. Sewer o
3 Q4
Holding Inlet
TANK SETBACK INFORMATION d Outlet
TANKTO P/L WELL BLDG.
t Ventto ROAD Dt Inlet
eptic (Y a . NA Dt Bottom
Dosing NA Header /Man. L44 �7
We G• �
Aeration NA Dist. Pipe �
- - 7 r .,
Holding Bot. Systema -1'76 6 -
a. -?,
PUMP/ SIPHON INFORMATION Final Grade U. L L C 11 , n it
Manufacturer and
Model Number GPM
TDH Lift Frict' System TDH Ft
Fi
Forcemain Length Dia. Dist. To well
SOIL ABSORPTION SYSTEM
BDE N idth Length /� / No. Of�renches PIT No. Of Pits Inside Dia. Liquid gepth
,L I DIMENSION
SETBACK
SYSTEM TO P/L BLDG WELL LAKE /STREAM LE ING anu
INFORMATION Type of �( `� C O H BER
R U Mo el N er:
System:
DISTRIBUTION SYSTEM
Header / Ma [fold �� Distribution Pipe $)) � Spacing 1 x Hole Size x Hole Vent To Air Intake
Length Dia. Length Dia. "� Spacing rrt/t 2'l p
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over / � " / Depth Over xx D xx ee ed / Sodded xx Mulc e
Bed /Trench Center �l.p Bed /Trench Edges Topsoil El Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 27.29.19,S W ,NW \ 756 WILFRED RD- BADLANDS PRAIRIE LOT 13
_
{ � i�>1A - - 16 - U-p i L rk 1Ma Cove ✓'
2� �
5 �
Plan revision required? ( C] Yes �No
Use other side for additional information. k 5� / 3
SBD -6710 (R.3/97) Date Inspector's Sig ture N
Safety and Buildings Division
Vi scons i n SANITARY PERMIT APPLICATION 201 E. Washington Ave.
In accord with ILHR 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 81/2 x 11 inches in size. St. Croix
• 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 pro rams E] Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. 75 4 t 1-/ Frei i? G/ State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N
Property Owner Name Property Location
Richard Stout SW 1/4 NW 1/4, S 27 T 29 , N, R 19 Wor) W
Property Owner's Mailing Address Lot Number Block Number
1 Awatukee Trail 13
City, State Zip Code Phone Number Subdivision Name or CSM Number
Hudson, WI 54016 1 (715)549-6731 Badlands Prarie
PE F ILDIN : (check one) ❑ State Owned ltr Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms 6 ° town o f Hudson State Hwy 12
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo a 7 ' a 9. / 9. 175 0 - d - 193--?° _7 d
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 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 / , 42 ❑ Pit Privy
13 ❑ Seepage Pit (c S X 1 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. 17. Final Grade
900 Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) %,p -7/ Elevation
1125 1 1 3 0 .8 Na X9-6 Feet 100 . 5 0:eet
Capacity
VII. TANK in Ca allons Total # of Prefab. Site Fiber- Exper-
INFORMATION g Gallons Tanks M anufacturer's Name Concrete con steel glass Plastic App
New Existing structed
T nks Tanks
e tic Tan X 1650 1 Midwestern ® ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber I I I 1 ❑ 1 ❑ I ❑ I ❑ 1 ❑ ❑
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 Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
William Schumaker MP 227990 (715) 386 -3121
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 Date Issue Issuin ent Signature (No Stamps)
A roved Surcharge Fee)
�D A�
I� pp ❑Owner Given Initial 1?J e
Adverse Determination /Od
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -6399 (8.11/96) DISTRIBUTION: original to coun One copy To: Safeq a Buildngs Diraion. Owner. Pkwd .
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Wisconsin Department of Industry SOIL AND SITE EVALUATION
Labo,iand Human Relations Page 1 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 St. Croix
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
oa0 - la U- 9
APPLICANT INFORMATION - Please tI� ion Reviewed by Date
Personal information you provide may be used fors doses (PAva @�pLyw .15.04 (1) (m)).
Property Owner 1P. / Property Location
I Richard Stout ti� RLCLlbtc� `' \, Govt. Lot SW 1/4 NW 1 /4,s 27 T 29 ,N,R19 IK(or)W
Property Owner's Mailing Address j of # Block# Subd. Name or CSM#
1353 Awatukee Trai "�i ��'j? ' 1 13 : Badlands Prairie
City State Zip J Phoh' r "� ❑ City ❑ Village [ Town Nearest Road
Hudson WI 540 6`" ( Z4No�'ff - Hudson IState Hwy 12
® New Construction Use: ® ResidentialT� Brooms —F Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 9 0 0 gpd Recommended design loading rate . 7 bed, gpd/tt 8 _trench, gpd/ft
Absorption area required 12 8 6 bed, ft 1 12 trench, ft 2 Maximum design loading rate —7 bed, gpd/ft gpd /ft
Recommended infiltration surface elevation(s) 0_7
It (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 I Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system [g S ❑ U EIS ❑ U ® S ❑ U 1 [2 S ❑ U ❑ S ®U ❑ S [j] U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft
in. Munsell Cu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed ,Trench
1 1 0-14 7.5 r2.5 1 none L 2mabk mfr CS 2m .5 :.6
2 14-- 10yr3/4 none sil 2mabk mfi: cs if .5 -.6
Ground 3 36-E 9 10yr4/ none ms osg ml cs -- .7 .8
elev.
1 0 —ft.
Depth to -- - -- - —
limiting
factor -- —
8-_in.
Remarks:
Boring #
1 0 -1 7.5y 2.5/1 none L 2mabk mfr cs 2m .5 .6
2 15-40 10yr3/ none sil 2mabk mfi cs if .5 .6
2 3 40-E9 10yr4/E none ms osg ml cs -- .7 ;.8
Ground
elev. -
100 ft. _
Depth to -
limiting
factor
8 9 _in. Remarks:
CST Name (Please Print) Signature Telephone No.
w� "A& Se_ It "t.- kvx 4. AeN �� -_ 7 <S- 3 P G - 3/a t
Address Date CST Number
If I
/d 74 S �7T�Op� �a�s „� �✓ .T Ol �”
I
?ROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT
Page _I of _
4'ARCEL 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 1 0-11 7.5 r2.5 1 none L 2mabk mfr CS 2m .5 .6
2 14 -43 10yr3/4 none sil 2mabk mfi cs if .5 .6
ground 3 43 -91 10yr4/6 none ms osg ml cs -- .7 ' . 8
Blev.
100 ft.
-)epth to
imiting
actor
9 in.
Remarks:
3oring #
1 -12 7.5yr2.5/1 none L 2mabk mfr cs 2m .5 - .6
4 ` 2 12-32 10yr3/4 none sil 2mabk mfi cs if .5 ;.6
3 2 -91 10yr4 /6 none ms osg ml cs -- .7 .8
r3round
Aev.
100 ft.
Depth to
imiting
actor
91 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 0-14 7.5yr2.5 1 none L 2mabk mfr cs 2m .5 .6
5 2 14-36 10yr3/4 none sil 2mabk mfi cs if .5 .6
3 36-89 10yr4/6 none ms osg ml cs -- .7 .8
Ground
elev.
100 ft.
Depth to
limiting
factor
—' Remarks:
Boring #
Ground
alev.
tt.
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 /� i G In L4 ,Z 7 T4 o U f
Mailing Address j 3 S 3 K� e Trzc,; L
Property Address 7 l e e
(Verification required from Planning Department for new construction
)
City/State _ j4 U e1 s o �, . (� ; Parcel Identification Number
LEGAL DESCRIPTION
Property Location ! (0 %, Y4, See. --) - 7 . T a N -R l (7 W, Town of _ v c��S" o h
Subdivision _ A D L r9 h,03
Lot # � .
Certified Survey M ap # Volume
. Page #
Warranty Deed # Volume l a / U . Page # Z
Spec house 0 yes (] no Lot liners identifiable)O" yes ❑ no
SYS17�'M- 147A1N XENANCE
consists Of h % wO p er useud wlkftanceofyousepticqst=couldresaltinitsI atmiPf ffmctohandlewastes.Prol=mand anee
Pumping out &e mac Unk evcrY throe Yeats or sooner, if needed by a licensed pamper. What you put into the system
can affect the frmcam of go septic tank as a beatment stage in the waste disposal system.
The PWPCdY Owner agrees to mbmk to St. cmix Zoaiag Department a cer ification form. signed by the owner and by a
wasterpb=bcrjomzp=phmLbcrmstdctedphmdwora Iiaensedpumperverifymg that (1) the on -site wastewaterdisposal system
is m proper operating condition and/or (2) after won and pampmg. f if necessaq), the septictank-is less $ran w full of sludge.
Ywc. dic undeakned have read the above rcqW=caft and agree to maintain the private sewage disposal system with the standards
set fork hemin. set by the Department of Commerce and the Department of Natural
Resources, State of Wisconsin.. Certification
stating tW your septic system has been maintained must be completed and r umed to the St. Croix.Couaty Zoning Office within 30
days of the three year expiration date.
SIGNATURE OF APPLICANT
DATE
OWNER - CERTIFICATION
I (we) ccr* 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 a b virtue of a warranty deed recorded in Register of Deeds Office.
@.1A" uZ . UV jA -- Z
SIGNATURE OF APPLICANT
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 dad from the Register of Dads oflice
a copy of the certified smcy map if reference is made in the warranty deed
STATE BAR OF WISCONSIN` FORM 1 -1982
WARRANTY DEED
MOMENT
PSGISTER0 OF iCE
ST. CROIX C O.,
WI
This Deed, made betwaen The 140L C000tat on !00111 PAM11
a Wisconsin cor orat on Organized Aril 1 1996 and
e: wi t h a Wisconsin Setretary of State on D E C 2 0 1996
Apr11 3. , Grantor,
Richard 0 Stout ;t 3:30 P. M
and
Register of Dutics
Grantee,
Wiitnesseth, That the said Grantor, IDr a w1mble mrlsidrtad�
convey to Grantee the following described teal estate in St Croix —_ T HIS SPACE RESERVED FOR RECORDING DATA
County, State of Wisconsin: NAME AND RETURN ADDRESS
Richard 0. Stout
1351 n w
atukee Tr it
P try
x �, ►,'. .
i1r -Jaims .tozantaa an+ r?evera:ioary rim, tics- and tartsx -fin- Ohre
. s
0"t. isa' Vor .* . :pap 212, Disc.: .No.. 35 #521, - And iit Vx� -1. 50, .pap �1�t
..; 4 1 , � �.:• a�ad- propeaty,
tiid ttanot) _
attar l+tr,tlst <It#radtt eM and:appunenances- themmo belongings:
$are! Ekhib u B he eto
sp d 1 { ?l+twCrtt #IV#&Aeftrid the some.
may. :dtY ot I�saxsamise r ,19 _.;x_ .
., ,. G*d)
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of vt¢MCONi N
x to the lttown toy rise peat whQaaddt#ted G�teatttl
irtitrutneitt and atlede aerne.
Tf�HI I�lEal f WASH DRAFTLD BY
'Re M. itacige. Orlet1 & Rvlstain
zoo
No
Y, 'ttAy etxtttyi(ca*d or adrtittuvledgtd. Be►tIa art not MY
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''!" �116Yn�Y5�1► f �+ y;{ a�6tt�WaamTet` t+ y dt� - - '�27eaNk'CheVr'�f�i!gtaNf. '':: - -
vet Tai "4 FAcf4 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.
Except 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 Section 27, South 88 degrees 23 minutes 58 seconds East
160 feet; thence, diagonaUY, South 29 degrees 07 minutes 38 seconds West 338.27
feet to a point on the West line of said Section 27; thencee along said West line, North
0 degrees 54 minutes 02 seconds East 300 feet to the Northwest corner of said
-. . - fteeltest�asd - "
t...
-< to: dw rw of St. C Mk County for highway puVion as eatttbli
MOOMdW Id dte Ofte Of dO logister of "Deeds for St. C'"t* Cou lty, NNW, in
VvhM 7 III And Vie 302, page 24
6 9 . fl& At WRY V=t tD the Wisconsin- Tdephom Compay ,
t* ONO Of said of Deeds, in Volume 472, page 185, do meet 30610;
Ica the exilft town mad along the North line of tl Northwest Quartet of the
Nortrwestr Quarter of Secdon 27.
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Exhibit B
Liens and Encumbrances
The NOL Corporation to Richard O. Stout
(i) Municipal and zoning ordinances and agreements entered under them, (ii) recorded
easements for distribution of utility and municipal services, ('iii) cncorded building and use
restrictions and covenants, and (iv) general taxes levied in the year of closing.
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