HomeMy WebLinkAbout020-1336-40-000 4 � 19 %a
ST. CROIX COUNTY ZONING DEPARTMED\.
AS BUILT SANITARY REPORT
Owner SA A-1 1Z L,E r .' 798
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Address - 79' 3 t o C /L 6'/j yr4) s - r caolx
City /State N v jJS o AA e ! '� / c°u pFF�cE
7CNING .,�
Legal Description: j
Lot HY Block --' Subdivision/CSM # �� D L e/�/Q S/ / t
'/. ' / + ,Sec. , T Zt'l - Town of vDSe H PIN # 6 Zo-
SEPTIC TANK DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer W�F(S Size ST/PC� / Setback from: House Well , 7 0 1 P/L c
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: L W { I Width 2 Length G t Number Setback from: Mouse �s Well ,2 1o` t P � t to fresh air intake o o re b nc) es Z
ELEVATIONS
Description of benchmark 2 ��C OP/ SaV�'�/ L bT LANE 7, 3 Z- Elevation /00, 00 ,
Description of alternate benchmark Toe mF 31-5XX Fo1✓N -0071,VM 1, 6fe Elevation 107, G$ '
, _ to 3,
Building Sewer (-- ST/HT Inlet 7ryf ` f0t'� T Outlet ? 10
PC Inlet
PC Bottom Header/Manifold 3 1 ��% (�` �op of ST/PC Manhole Cover 3 = O �� . O 9
" E 5 T E,4s 7'
Distribution Lines ( ) 1 , 3 f F "yS, p� O 3 4 s F p 2,9 7 ( )
/3.aSk 9
Bottom of System ( ) / j. 4 S — ?V o7 ( ) /5, = 3,q 7 ( )
Final Grade ( ) ! /, Sp � � . 3z () /(, 04 I Y, 3 �( )
Date of installation / /G /ft Permit number 20 2 Q / State plan number
Plumber's e si natur r
g License number S'OjSOO Date /7
Inspector lolc) C.(t�r✓ -kl✓�
complac plot plan a
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.
I
PLAN VIEW
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y:
Safety and Buildings Division Count
INSPECTION REPORT ST. CROIX
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)J. 320201
Permit Holder's Name: ❑ Cit [] Village Town of: State Plan ID No.:
MILLER, SAM H&SON
CST BM Elev. Parcel BM Elev.: BM Description: Parcel Tax No.:
I �U (J v ( Z" �L 020- 1336 -40 -000
TANK INFORMATION U ELEVATION DATA A9800390
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV-
e l/V i ea2� I °Ua Benchma' g , / /.� (( l.0 /va
Dosing j f , �. '� v /0 7.7
Aeratio Bldg. Sewer 16 -rj
Holding �A Inlet
TANK SETBACK INFORMATION 4f Outlet S g b/• L
TANK TO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic �� N/ (� NA Dt Bottom
Dosing NA Header/ Man. I'f. YI
Aeration Dist. Pipe s•iy S ��
2— 4 15 — . rs �
Holding Bot. System ��`� qy'L
D
PUMP/ SIPHON INFORMATION Final Grade 17. V 0 q3 L
Manufacturer De nd ✓H4leAr e G,93 /b'� _ c,
Model Nu er GPM
T ift Friction Syste TD Ft
oss
Forcemain Ia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width i Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS a i r DIMENSION
SETBACK
SYSTEM TO P/ L BLDG WELL LAKE/STREAM L6 CHING Manufacturer:
- -
INFORMATION Type �. CHAMBER Model Number.
c yst l,'(1 2 Z� �G( OR UNIT
DISTRIBUTION SYSTEM 9 k G W A_ Gf
Header / M anifold � Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length ) 7 • ` ! Dia - Length 5 4 • � Dia. 3 `/ Spacing l0 s �Y6N 7 ZC�
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over 7Bed./ th Over xx Depth Of xx Seeded / Sodded xx Mulched
Bed / Trench Center Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS (Include code discrepancies, persons present, etc.) /" y
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LOCATION: HUDSON 27.29.19,NW,NW 793 WILFRED RD— BADLANDS PRAIRIE LOT 44
Plan revision required. ❑ Yes eNo
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspec is Signature C ertt
1
ADDITIONAL COMMENTS AND SKETCH '
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building Water Systems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County �d�
than 8 112 x 11 inches in size. it
• See reverse side for instructions for completing this application State Sanitary Permit Number
3 a 0e?0/
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)J. `79 3 1w J`f Ibr . (A d State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
/4
) 1/4, S 4 T Z , N, R/ W 7
E(
Property Owner's Mailing Address Lot Number Bl Nu
City, State Zip Code Phone Number Subdivision Name or CWN /
to /� 1 0?Z, )' Z769 Q TK7tlIe � ��r�
II'. TYPE OF BUILDING: (check one) ❑ State Owned ❑ ' l t lage Nearest Road
Vi
Public 1 or 2 Family Dwelling - No. of bedrooms 3r own OF ke' L
111. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) A7 ?. 7 p�
1 F Apartment/ Condo o 2 r 3 3(' - Q
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. ❑ Replacement of 4_ [] Reconnection of 5_ E] 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 XSeepage Trench S /DEWt yLf 4-- 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 Seepage Pit Iff IN FILI f - XT0A 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
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation ,
5 3 S 7 4 73 .9 Feet IQId.0 Feet
capacit VII. TANK in allo Total # of Prefab. Site Fiber- Exper
INFORMATION g Gallons Tanks Manufacturer's Name Concrete CO ^" Steel glass Plastic App
New ___ strutted
Tanksl Tanks
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ 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 Stamp) MP /MPRSW No Business Phone Number:
OC
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sa ary Permit Fee (Includes Groundwater a I ign
Surcharge
pp roved F] harge Fee)
Owner Given Initial C% A dverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SHD -6398 (R. 05/94) DISTRIBUTION: Original to county, One copy To: Safety & Buildings Divi ion, Owner, Plumber
INSTRUCTIONS ;
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608 - 266 -3815.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
IL Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use- If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 'through 7.
VII. Tank information- Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, ocation of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells water mains /water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and ':he location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss, pump performance curve, pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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Wis Department of Industry SOIL AND SITE EVALUATION 1 3
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or arid 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. #
___... oaC) .- lazL/ -Ir)
APPLICANT INFORMATION - Please print all infognat Reviewed by Date
Personal information you provide maybe used for secondary p)§pos (Privacy Lav✓, s 15.04 (1) (m)).
Property Owner Property Location
Richard Stout qt! ,� Govt. Lot NW 1/4 NW 1/4,S 27 T 29 ,N 9 1K (or) W
Property Owner's Mailing Address "'.) r '' Lot # i Block# Subd. Name or CSM#
1353 Awatukee r- 1�` y � `G � 44 Badlands Prairie
City State zip Cc4 .' Phone er [:1 city El Village [j Town Nearest Road
Hudson WI 5401.x' (.,7�) 549 ,6'' �1 Hudson Badlands
[13 New Construction Use: ® Residential / Number of bedrooms 1-4 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 600 gpd Recommended design loading rate 7 _ bed, gpd /ft gpd /ft
Absorption area required 858 bed, ft 750 trench, ft 2 Maximum design loading rate • 7 bed, gpd /ft - 8 trench, gpd /ft
Recommended infiltration surface elevation(s) 93.9 ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material Glacial d 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 as ❑ U E� S❑ U 9s ❑ U I 9 s ❑ U ❑ S Pu ❑ S )J U
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD /ft
9 Texture Consistence Boundary Roots
in. Munsell ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 0 -1 10yr3/4 none is 1mbk mvfr cs 1f .7 :.8
1
2 10-SO 10yr4/E none ms osg ml cs - .7'.8
Ground ,
elev.
99
Depth to
limiting
factor
9 0 in.
Remarks:
Boring #
1 0-12 10yr3/4 none is 1mbk mvfr CS if .7 ..8
2 12-92 10yr4/6 none Ms Osg M1 CS - .7 ,.8
2
Ground
elev.
96.3 �Dt.
Depth to
limiting
factor
in. Remarks:
CST Name (Please Print) Signature Telephone No.
41 r V e, h u,.a 1 -e 7! 5 -391 _ _ J, —_ _
Address Date CST Number
ziezo 3 M h � a27 ff
t Richard Stout SOIL DESCRIPTION REPORT
`'PROPEN'TY OWNER Page 2 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 -38 10yr3/4 none 1S Imbk nvfr 3S If ,7 ,,g
38 -90 10yr4/6 none s DSg ill s - .7 8
Ground
elev. ,
9 6.9 n
Depth to
limiting ;
factor
9 0 in.
Remarks:
Boring #
1 -39
4 2 9 -8 10yr4/6 none ms osg ml cs -- .7 ;.8
Ground
elev.
96 ft.
Depth to
limiting
factor
8 9 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 -40 10yr3/4 none is lmbk mvfr cs if .7 .8
2 40-9D 10yr4/6 none ms osg ml cs -- .7 .8
5
Ground
1 0 �iev.1 ft.
Depth to
limiting
factor
9 0- - Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
SBDW -8330 (R. 08/95)
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ST CROIX COUNT;,
SEPTIC TANK MAINTENANCE A6 EEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer S/4
Mailing Address 34D X -V ( S
Property Address 9 l.rJ 1 L L f - 9 j p 2 C> A O
(Verification required from Planning Department for new coils tr'd(' ;on)
City /State cJtb SAN Parcel Identification Number C7 Z0
LEGAL DESCRIPTION
Property Location / %,, f�k� V. Sec., TN -RW, T own c : v A s 0 N
subdivision L A ND S Lc) 14
Certified Survey Map # :56 O / e'o Volume , Pag<
Warranty Deed # _520 (04 -S E Volume _ , Page tr _ 2
Spec house Kyes ❑ no Lot lines identifiable Yyes ❑ no
SYSTEM MARITENAN E
Impr4per use and maintenance of your septic system could result in its pre :ailure to handle w- ;us. proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by - .:tensed pumper. V t you put into the system
can affect the 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 10aa, signed by the ow::';
master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wa stewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is le.- 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disp.: - ystem with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, Statr " "isconsin. Cert; ; 7 nn
stating that your septic system has been maintained must be completed and returned to the St. Croix County 7..o. ng Off!.: !
days of the three year expiration date.
Z ��aA�
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g YE
ATURE APPLICANT DATE
CERTIFICATION
,';l'_(we) certify that all statements on this form are true to the best of my knowledge. I am (are) the owner(s) of
the rap�'ty 4eaeribed above, by virtue of a warranty deed recorded in Register of lic;cc: Office.
-
ATURE APPLICANT
r.
* * * * ** Any information that is miS- represented may result in the sanitary permit being revoked b,, 7 ^ning Department, * * * * **
Include with this application: a stamped warranty deed from the Register of ?; -eds office
a copy of the certified survey map if reference i : ade in the warran 1 d e, - �d
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6438 STATE BAR OF WISCONSIN FORM 2 – 1942
I WAt',TRANTY DEED
va
�I RE IOUlc
! i chard n Stout � t ��� ,
!' 5 T sP � ter he e W 1
R
it OCT 0 3 1997
(! conveys and warrants to s am F - M i 1 1 e1 2:00 PM
Reg ister of Deeds
THIS SPACE RESERVED FOR RECORDING DATA
i
NAME AND RETURN ADDRESS
the following described real estate in Si— r-roi x County, (, .
(; State of Wisconsin:
Lots 16 and 44, Plat of Badlands Prairie,
Town of Hudson, St. Croix County, • �'� $C>C�O
Wisconsin.
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�i PARCEL IDENTIFICATION NUMBER
$ T f ER
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This is not homestead property.
(is) (is not)
Exception to warranties: easements restrictions, rights-of-way and
covenants of record. !�
!I
lst Octobe 97 !
Dated this day of A.D., 19
ll
it
(SEAL) (SEAL)
Richard O. Stout * 1
l
I� (SEAL) (SEAL)
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AUTHENTICATION ACKNOWLEDGMENT
;i
Signature(s) State of Wisconsin,
i f ss.
St. Croix
! County.
authenticated this day of , 19 Personally came before me this 1St day of
October 19 97 the above named
Richard O. Stout ;I
* �f
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, i
authorized by §706.06, Wis. Stats.) to me known to be the person who executed the foregoing
instru n d acknowledge the same.
I
THIS INSTRUMENT WAS DRAFTED BY
Janet P. Stout j
A ;!
Hudson , W i _ 54016 Notary Publ c, S+(, r is L County, Wis. I
(Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (if not, state expiration date: i
necessary)
• Names of persons signing in any capacity should by typed or printed below their signatures. �!
STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. �!
WARRANTY DEED Form No. 2 — 1982 Milwaukee, Wis.
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
e an ST. CROIX COUNTY GOVERNMENT CENTER
_ "i■" 1101 Carmichael Road
Hudson, WI 54016 -7710
(715) 386 - 4680
January 4, 1999
First Federal
Attn: Tammie
Hudson, WI 54016
RE: Septic Inspection for Sam Miller located at 793 Wilfred Road, Lot 44 of
Badlands Prairie, Town of Hudson, St. Croix County, Wisconsin
Dear Tammie:
A septic inspection of the above referenced property was conducted on October 7, 1998.
This property is located in the NW of the NW of Section 27, T29N -R19W, Lot 44 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,
R �i Eslin er
Assistant Zoning Administrator
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