HomeMy WebLinkAbout020-1335-70-000 4
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NOTICE: Please provide the following: ?
!99
• A plan view sketch showing everything within 100 feet of the systems. - ocjtv�N o p
• Two horizontal reference points to center of septic tank manhole
cove r.
' r
• Show alternate benchmark, if applicable.
PLAN VIEW
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INDICATE NORTH ARR�W Uf t ;1 ' f.� ; C" fi / • �g•�jg
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ST. CROIX COUNTY ZONING DEPARTMENT ✓
AS BUILT SANITARY REPORT
Owner SA ►K & k i... l-I<fZ,
Address Z3o yc '-k I S t
City /State -1.� J> 5, o W t p- y c L
Legal Description:
Lot 17 Block -- Subdivision/CSM # RA >LA N 0
ALtt,)Sec. , T N -R 19
Town of 14 %-, L PIN # t 20 3
SEPTIC T
AM
SE CIiBER -- HOLDING TANK INFORMATION:
. TTI!.Q
Tank manufacturer E7 (s F ft.- Size ST/PC ( bol b�
Setback from: House Well 1 P/L 1 3
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: N IITrL A7 length o �yidth �... S� � ,
Number of Trenches �-
Setback from: House Z _ Well - P/L S 7 Vent to fresh air intake -2 o
ELEVATIONS:
a 3d"
Description of benchmark 10 Dr L ET e p / 1E) '�, , 2 S Elevation d 3 7 - 5'
Description of alternate benchmark Elevation
Building Sewer S go ST/HT Inlet ST Outlet J, 66 PC Inlet
PC Bottom — Header/Manifold (� ' y Top of ST/PC Manhole Cover Lam. (o Z...
Distribution Lines ( ) / 2 . () / Z
Bottom of System ( ) ``/ • 3S ( ) / -(. 3 S
Final Grade ( ) /O p f o ( ) &
Date of installation/ / / / /T e Permit number 31 lc o DO State plan number
Plumber's signatur '�� License number V?4.S-03rov Dat
Inspector
Complcic plol plan
Wiscor;sin Department of Commerce PRIVATE SEWAGE SYSTEM Coun
Safety and Buildings Division ' 9T . CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) SanitaYfg(5 :
Personal information you provice may be used for secondary purposes [Privacy w, s.15.04 (1)(m)].
Permit Holder's Name: LZf&Llyillage Town of: State Plan ID No.:
11 ILLER, SAM � ON
CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel 626Q-133
'
TANK INFORMATION ELEVATION DATA A9800387
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ,,,� d Ya °, Benchmark ,- J /e e �
Dosing - v._._. _. c(' fi
Aeration " Bldg. Sewer S 9, God
Holding St /Ht Inlet %
TANK SETBACK INFORMATION St /Ht Outlet
TANK TO P/ L WELL BLDG. A I to ntake ROAD Dt Inlet
Septic / 2.. Z- 4� �,r�-- NA Dt Bottom
Dosing NA Header n75 � Aeration �°`�� "" NA Dist. Pipe Holding,,,,.•° - "' °' y stem Bot. S U,
� �!
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand 6,, ~ .1, e7 /d'
Model Num 1' GPM
Friction"'~- -�a... -S��ystem
TDH Lift L H .... ._.. TDH- Ft
Forcemrain Length Did. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width J Le th _ , No. Of jrenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION i� • °' �� DIMENSION
anufacturer
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM HVl
INFORMATION Type O i + CHA
� BER Model Number:
System: r "��`�i�`' OR UNIT
DISTRIBUTION SYSTEM
Header Dia � Distribution n �� P � � � / x Hole Size a Spacing Vent To Air Intake
Length Len is Sparing i
SOIL COVER x Pressure Systems Only xx Mound Or rade Systems Only "-- --
Depth Over Depth Over 0 xx Depth O ff, 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 27.29.19,SW,NW 757 WILFRED RD - BADLANDS PR LOT 37
i ��iUL'3l;.A" ���'_-""" �k"� G+r rr � ".'- .�,/`- ' "u. � �('",. �i�(';�!r' '✓'� ;' f .(- 6c:..r', `'//,�- 7'` , L('a.� ,i/ < R.4'_ � ..✓� ��� ,l_''� .
A w
Plan revision required? ❑ Yes 0 Use other side for additional information. /O � Qy ,
SBD -6710 (R.3/97) Date Inspector's Sigfi.ture Cert. No.
i
SANITARY PERMIT APPLICATION Safety and Buildings t n Avenue
n
,, � sconsin . 201 W. Washington
`O P O Box 7302
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County /+
than 8112 x 11 inches in size. —56. Cra ix
• See reverse side for instructions for completing this application State Sanitary Permit Number
Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. 7 5 7 A // I ff �,l Rd
V V I' l�(�I � l.�•I - State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Propert Owner Name Property Location
S ff M M ((„t,.,F t/a 1/4, 5 ,� T J%' , N, R/ E (o W
Property Owner's Mailing Address Lot Number Bl Numbe
City, State Zip Code Phone Number Su division Name or CSM Number /Q A t! r
E OF BUILDING: (check one) ❑ State Owned it Nearest Road Vil *Public 1 or 2 Family Dwelling -No. of bedrooms -3 l To wn OF U L FA A FQ
III. BUILDI G USE (If building type is public, check all that apply) Parcel Tax Number(s) a? —f a /9./777
1 ❑ Apartment/ Condo
4V Z Ia -1 3 3 S` - � 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. E] Replacement 3. E] Replacementof 4 ❑ Reconnection of 5. E] Repair of an
-- _ - 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 JR Seepage Trench SibFWI 22 ❑ In- Ground P ressure 42 ❑ Pit Privy
13 E] Seepage Pit INF(� 10$T01L -3 S �o.ZS 43 ❑ Vault Privy
14 ❑ System-In-Fi I I
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absor P . Area 3. Absor . Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
P 9
s Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
.r 'Z_- p' ,�-^ �r S Feet �{ St Feet
Cap acit y
VII. TANK in Ca allo
g Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existin structed
Tanks Tanks , &+ Septic Tank o r Holding Tank 1 0 0 0 19 El 1:1 ❑ 1:1 E] Lift Pump Tank /Siphon Chamber ❑ 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 Name: (Print) Plumber's Signature: (No Stamps) MP /MPRSW No.: Business Phone Number:
4
A 5 - 0 3,f s 1 3'9 4a
Plumber's Address (Street, City, State, Zip Code):
d V to ,� S o
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater at Issue Issuing A ent Sig a No
Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination���
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 Industry SOIL AND SITE EVALUATION
`Labor and 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. #
0-�' 0 — X070 - 90
APPLICANT INFORMATION - Please print all information. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy-I Law, s. 15.04 (1) (m)).
Property Owner :s (� Pro erty Location
- `Y�1 Govt of 1/4 1/4,S T N,R or W
Richard Stout c , SW NW 27 29 1 9 f ( >
Property Owner's Mailing Address ; �� Lot #.. Block# Subd. Name or CSM#
1353 AWATUKEE TRAIL �. tWA 7 Badlands Prairie
City State Zip Code on umli'T G g ( Town
Hudson WI 154016 "t 5) 5 L t y ❑ Village Nearest Road
Hudson State Hwy 12
r] New Construction Use: Residential / N� r � e scribe: (�r6d od _ 4 Addition to existing building
Replacement El ement
P Public or commerci I ❑ as
Code derived daily flow 600 gpd Recommended design loading rate __7 bed, gpd /ft -B-- trench, gpd /ft
Absorption area required 8 58 bed, ft 2 750 trench, ft 2 Maximum design loading rate . 7 bed, gpd/ft . 8 trench, gpd /ft
Recommended infiltration surface elevation(s) 91.50 _ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material Glacier deposit _ Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill H_ Iding Tank
U = Unsuitable for system I ® S ❑ U U S ❑ U R] S❑ U W S ❑ U ❑ S ®U ❑ S O 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 0 -12 7.5 r2.5 1 none L 2mabk mfr cs 2m .5 '.6
2 12 -36 10 r3/4 none sil 2mabk mfi cs if .5 ;.6
Ground 3 36 -90 10 r4/6 none ms os ml cs -- .7 .8
elev.
97. ft.
Depth to
limiting
factor
9-()—in.
Remarks:
Boring #
1 0 -32 7.5 r2.5 1, none L 2mabk mfr cs 2
2 2 32 -60 10yr3/4 none sil 2mabk mfi cs if .5 ,.6
3 60 -110 10 r4/6 none ms osq ml cs .7
Ground
elev. - - - -- - - - - -- -- - --
95.7 ft.
Depth to
limiting
factor
1 10 in. Remarks:
CST Name (Please Print) Signature Telephone No-
Address Date CST Number
l� o r
w" 3 -7 If 17
?ROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT AA
Page
?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 0-20 7.5yr2.5 1 none L 2mabk mfr cs 2m .51.6
2 20-48 10yr3/4 none sil 2mabk mfi: cs if .5
around _
3 48-92 10yr4/ none ms osg ml cs 8
flev.
9 5 ._ -Q_ft.
depth to
imiting
actor
92 in.
Remarks:
3oring #
1 0 -6 7.5 r2.5 1 none L 2mabk mfr cs 2m .5'.6
4 2 6 -36 10yr4/4 none sl 1mbk mvfr cs if .4;.5
3 36 -90 10yr4/6 none ms osg ml cs -- .7..8
around
aiev.
97. 10 ft.
, ]epth to
imiting
actor
Remarks:
Horizon Depth Dominant Color Mottles Structure GPD /ft
Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Boring # 1 0-1C 7 .5 r2 .5 1 none L 2mabk mfr cs 2m .5 : 6
5 ,, 2 10-40 10yr4/4 none sl 2mbk mvfr cs 1f .4 :5
3 40-S6 10yr4/ none ms osg ml cs -- .7 .8
Ground
elev.
95 JQft.
Depth to
limiting
m g
factor
9 _ 6 _— in. Remarks:
Boring #
around
Aev.
':depth to
limiting
factor
in.
— Remarks:
SBDW -8330 (R. 08/95)
C4 11019
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer c AA M ( Lt, E.. I -
Mailing Address R o y X/ S/
Property Address 7SI LA.) I L
(Verification required from Planning Department for new construction)
City/State Parcel Identification Number Z 3 '.� S— 70
LEGAL DESCRIPTION
Property Location %4, N U )'/4, Sec. , T_4LtN -R / W, Town of PQI)L Z O Al
Subdivision - L-" :a L A Alb S Z'/`C (4c , Lot # �
i
Certified Survey Map # C D 11 Ca , Volume Page #
Warranty Deed # f $ 3 , Volume Page # /7
Spec house <yes ❑ no Lot lines identifiable tv 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.
I
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 wastewater disposal 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.
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, 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 ee year expra on date.
ce
6SIQ0 kTLXt 6F 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 abpvc, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNATURE F 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 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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VOL II- )
STATE BAR OF WISCONSIN FORM 2 – 1982
WARRANTY DEED
DOCUMENT NO _
REGISTER'S OFFICE
-- R-LCHARD-- a-- sTOFIT ST. r CRQ X CO. WI ,
JUN 2 5 1998'
conveys and warrants to - 3: P M
T"'S SPACE RESFRVED FOR RECOAOWG nATA
A• RE A OO RETURN ADDRESS
the following descnbed real estate in tOlX L,
County, Sh1� n7 LL �
State of Wisconsin:
Lots 37, 38 and 42, Plat of Badlands Pe) /.+ f
Prairie, Town of Hudson, St. Croix County, HU oSo". 1d,
Wisconsin. ...
PAFC.EL OENTIFICATION NUMBER
T
b�
TRANSFER
FEE
s 2 61 eo ,
This is not homestead property
lLS) is not)
Exception to warran easements, restrictions, rights -cf -way and covenants
of record, if any.
Dated this 25 th day of June t9 98 .
Richard 0. Stout (SEAL) (SEAL)
(SEAL) (SEAL)
'7
AUTHENTICATION ACKNOWLEDGMENT t t:
,f
Signature(s) State of Wisconsin,
St_ Croix ss
--
nt
�Z ,
authenticated this — day of 19-- pvscnulb imt before me this _ day of
..r!une 19 , the above named
R ichard o-u +j
Ti FLE: MEMBER STATE BAR OF WISCONSIN
(If not,
x
authorized by §706.06, Wis. Stars.) ZO to me known -.w be i person who executed the foregoing +
y instrument and srk t +cie ge the same. 's
THIS INSTRUMENT WAS DRAFTED BY K
Janet P. Stout
- - 3-3 - 5 3 Awatukee - Tr:
_– hudson , _ –KL`_ (i._— Notary Public. County, Wis.
(Signatures may be authenticated or acknowledge PE My commiss.. s permanent (If not, state expiration date
• Nim , of t,—n, 6:n 1iy -pu.n) sb , i.:d hl tqad, p—i,d belo.. ;hr;,
STATE tl %R OF WISCONSIN :vsca',. i.ayv BCV •• 'o nr. �
DEED form No. 2 - 1482 MAVar r.�e Y.'a
9 E 543.76' - \
z ►' 1
1-05.96' 88.10
U fi 16.00' -- ----
1
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M.W.L. - 911.0
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Ip
o
n
_ " 'or m N •�
..> 39
^� t
i� t r S 88'26' E
3.64 ACRES
c
158,617 SQ. FT. ,4
N
7
e i
5 89'59'06 E 6933 >3 �
489.1 ?' 205.,,• 0
_ 81_3' 8.. W 41 -� a
.1
3 95.4
�'!, 7 •l I ' � V � j „ •� to
ib-
W h
~ O h
F, " 36 n
i 3.73JACRES
f , 2.69 ACRES u � 82 3 SQ. FT.
11
• sue`,,,, \` .374 ,. T�. C6 �
t 7 �Q. F =
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B UM= ELEVA FOR BLS
:.
MATCH �
1016 ry.
S84'13'28"W E SH 3
S 'L: 88.82
8"7..55 =0803 11 E yy� Al '
l 37. SOr ,•p1 I : O yr"'� -R
65.
n • ' 2pj 8p t".
0 SJ'• Tg1i26�• \4 `
t g
,30 -rli �. 8.93'
,•' 30. i
_1 N
Y 15 J o
CRES 1 4 D S "E O
64.13 z
637, SQ. FT. THL o s ,
Z W THL '7 93 82 F
3.00 ACRES
130,681 S0. FT.
h
.100 ACRES
^ 133.672 S0. FT.
r/h
343.51' 50A0' 318.33'
E __....�, 3267.18'
~` I
UNPLATTED LANDS
I SCALE IN
C. S. Af,
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
4 e n x o u e i► ■ ST. CROIX COUNTY GOVERNMENT CENTER
_ NJ 1101 Carmichael Road
Hudson, WI 54016 -7710
(715) 386 -4680
December 11, 1998
First Federal
Attn: Tammy
Hudson, WI 54016
RE: Septic Inspection for Sam Miller located at 757 Wilfred Road, Lot 37 of Badlands
Prairie, Town of Hudson, St. Croix County, Wisconsin
Dear Tammy:
A septic inspection of the above referenced property was conducted on October 20, 1998.
This property is located in the SW' /4 of the NW' /4 of Section 27, T29N -R19W, Lot 37 of
Badlands Prairie, Town of Hudson, St. Croix County, Wisconsin. At the time of the
inspection, this septic system was found to be code compliant for a three (3) bedroom
home.
If you have any questions regarding this, please contact our office at (715) 386 -4680.
Sincerely,
James K. Thompson
Zoning Specialist
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