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HomeMy WebLinkAbout020-1342-10-050 \ o \ \ { 9� 0 ® a % m . / k § . � I % § « m E $ b to c § �§ f& a� E ƒ : k &§fE Ecf% E \§ s ©22 »o zS0co § e@ §#z7 \ k o r 0- \ƒ\\ \k � I . « R E z 0 = 2 j Z - N / z \ } ) z 2 ) $ z ® \ 2 / J / f § '2 I e @ % } / $ : fA 3 Q \ } CO k " _ � _ . � . . ) �© 2 k \ CL 9 ) �) 0 0 CL \ \ i t j k EL b 1 \ 0 2 a a t � Co 2 3 § \ k 00 CO 0 I D§§ 7 /k§ _ E ! §) \ k z / (a 2 0 § in k cl E < § @ / 8 �) @ S J . / / \0 _j (\ §. . 6 § 2 �7 0 - G R 2/ a q o z/ I §/ . i « \ Z ) \ k a § Z 3 a 2 �o v 1 RECEIVED �s71-0 �q9�) 10- 307730 JUL 112014 ST. ROIX COUNTY !TY o .OMM D p r �J S Page Property Owner Parcel ID# 3 ® 9 ® Boring# c1:1� oring 125i pit Ground surface elev.�_ft. Depth to limiting factor C. in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu.Sz. Pont.Color Gr.Sz.Sh. ff#1 f#2 - i q 4 F7 Boring# ❑ Boring Soil Soil® Pit Ground surface elev. Q ft. Depth to limiting factor_, in. lication Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ff#1 ff#2 6 ,� - [� Boring � ❑ Boring# Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. Lf.1 02 "Effluent#1=BOD s>30:5 220 mg/L and TSS>30_<150 mg/L Effluent#2=BOD 5<30 mg/L and TSS <30 mg/L The Dept.of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format,contact the department at 608-266-3151 or TTY through Relay. SBD-8330(Rl I/11) i ,bZ'EZZ M„zS,ES-FON :7-77- - —'X , ,os t ► 1 f O x v � 00 N 5 C1 � s O � \S \ F1sQ .10' 4 3g 10 \\ RA p� aRc-sz$,°p r �. y _ SANITARY / PERMIT STS,/ x COUNTY '`) DILHR TRANSFER UNIFORM PERMIT # (PLB 67 --) 30 - 7 7 3CD E PERMIT RENEWAL DATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D. NUMBER: ._-- -- g 2 - 98 N- 2s -qa -- PROPERTY LOCATION: CITY: ,U %a LJ '/a S3�,Ta N,R / E (or)� VILLAGE: TOWN OF: d� l LOT NUMBER: BLOCK NUMBER: SUBDIVISION NAME: NEAREST ROAD, LAKE OR LANDMARK: y =r S L (i fTCt '64 `C G PREVIOUS ANITARY PERM HOLD (IF CHANGED): SANITARY PERMIT TRANSFERRED TO: 1 NAME: N NAME: PHONE NUMBER: ADDRESS: PHON , k' E NUMBER: ADDRESS: I, the undersigned, hereby assume responsibility for installation of the private sewa system that has previously been approved for this property. PLUMBER'S SIGNATU E• PREVIO SP M (IF CHA ED): PLUMBER'S ADDRESS: / PR VIOU LUM S DRESS: 75� MPRSW NUMBER: PHONE NUMBER: MP /M R W NUMBER PHONE NUMBER: .S,? 990 (his ►��U 3lal (l �) - SIGN447JRF OF ISSUING AGENT: DLAPROVED: DISTRIBUTION: Original - County �Q Copy - Bureau of Plumbing � Copy - Owner DILHR -SBD -6399 (R, /82) Copy - Plumber '1 W s► pnsir Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division CountyST . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanity "677t ".: Personal information you provice may be used for secondary pur oses Privacy LV, s.15.04 (1)(m)). Permit Holder's Name: U Town of: State Plan ID No.: WEST LAKE BUILDERS CST BM Elev.: Insp. BM Elev.: BM Descript Parcel Tax No.: GZo- I�42--(o -056 TANK INFORMATION ELEVATION DATA A9800135 ; o;L ZT, L% TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark S i b Dosing Aeration Bldg. Sewer [ Holding St/ Ht Inlet ' TANK SETBACK INFORMATION St / Ht Outlet 41C r TANK TO P/ L WELL BLDG. Air I to ntake ROAD Dt Inlet ir Septic NA Dt Bottom Dosing NA Header/ Man. Aeration NA Dist. Pipe �Z Holding Bot. System V-70 PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand`s Model Number GPM TDH Lift Friction System TDH Ft oss Fi Forcemain Length Dia. Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width � Length n No. Of Tre nches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSI .o DIMEN I N SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type O model Number: System: ' °? ! -C OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over [ Bed h 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.) LOCATION: HUDSON 32.29.19,NW,NW 674 COTTAGE LN — WINDSOR HGTS LOT 5 Plan revision required? ❑ Yes [RNo Use other side for additional information. I FF1 I I SBD -6710 (R.3/97) Date Inspector's Signature Cert. No ViSANITARY PERMIT APPLICATION 201eE W B n il gtonAve sion scons 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 8 1/2 x 11.inches in size. ::�]Z" , l x • See reverse side for instructions for completing this application State sanitary Perm itNurnber 3o-r 7 3a 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 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Prop rty Ovv er Nam Property Location _ L 1/4 1/4, S T , N, R or Pro pe Ow er's M Address Lot Number Block Numb City, Styt Zip Code Phone Number Subdivision Na a or CSM Numb ( ) II. TYPE OF BUILDING: (check one) ❑ State Owned Cit Nearest Road Village Public JE 1 or 2 Family Dwelling - No. of bedrooms _ Town OF III. BUILDING USE (if building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 0 1$4 21-1 — 6 50 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 E0 New 2 ❑ Replacement 3, ❑ Replacement of 4. ❑ Reconnection of S. [:] 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 42 C] Pit Privy 13 ❑ Seepage Pit / 8' k G'7 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. /i ch) Elevation Feet 9<7 Feet Capacit VII. TANK i Ca allon n Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App Tanks New Exist Tanks n structed tic Tank mark ❑ 11 1:1 1:1 11 Lift Pump Tank /Siphon Chamber ❑ I ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the ndersigned, assume responsibility for in allation ofthp onsite sewage system shown on the attached plans. Plum r' Na t Plum is na am s) MP /MPRSW No.: Business Phone Number: 2A)A _ — P umber' Ac dress (Street, City, State ip Code). , IX. COUNTY / DEPARTMENT USE ONL ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued lissuing Agent Signature (No Stamps) NApproved ❑Owner Given Initial a� Surcharge Fee) j q1gqjq8 j Adverse Determination 1 To Its X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R.11/ge) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber ����� ,�. /�,�s N� /y- �w /y- � �� �� - Tom,✓ � q� e- 9d' 71 by r� l e� kd r fli a � r i � I l�.lYhn ,���J��✓.�� I d�P�si r 'Nscorisiii Departrnent of Commerce Division of Safety and Buildings SO SITE EVALUATION Page of Bureau of Integrated Services in trse R 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 1 -x 11 i Plan must Count include, but riot limited to: vertical and � ' ,� . �eferrce and " percent slope, scale or dimensions, north arrow andtlocaat distance to nearest? Parcel I.D. # U � 1"97 APPLICANT INFORMATION - Please all ini Reviewed try Date Personal inform m information you provide ay be used for 1514 Property er J, , _ �( Location ill., Govt Lot 1/4 1 /4,S T ,N,R (or&_-- Property owns s Mailing Address Lot # I Subd.7 or CSM# LO Z �. City State Zip Code Phone Number ❑ city d [ age Town NearA R New Construction Use: Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate — bed, gpo4ft gpd/ft Absorption area required _ bed, ft ft Maximum design loading rate — bad, gpcL* try, gPd Recommended infiltration surface elevation(s) 22a It (as referred to site plan benchmark) Additional design/site considerations Parent material AN 2 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 RS ❑ u ® S❑ u IDs ❑ u [ m U ❑ s Z u SOIL DESCRIPTION REPORT Bo Horizon Depth Dominant Color Mottles Structure GPD/ft g Texture Consistence Boundary Roots 13 in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed , Trench Ground _ elev. " Depth to limiting factor > 9S- II I Remarks: Boring # 13 Ground elev. Depth to limiting ' factor 2-y1Zin. Rema CST Name (PI a nt) Sig na re Telephone No. Address ate CST Number PROPERTY OWNER SOIL DESCRIPTION REPORT Page of 3 PARCEL I.D.# f S � Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground _ elev. Depth to limiting factor z =in. Remarks: Boring # 13 /1 Ground elev. Depth to limiting factor 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 # l 17 W S Ground ele ft. Depth to limiting factor 7_�ain. Remarks: Boring # [3 Ground elev. ft. , Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) �D, L�o�' 7 ©3 f7uosoy.� SIN G'.9- i i i 51 I r - - ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNER.S'HIP CERTIFICATION FORM, Owner/Buyer A Mailing Address Property Address _ - -�- (Verification required from Planning Department for new construction) -,, -- City /Stare �. i Parcel Identification Number LEGAL _DE SCRI P TION Town of Property Locatiott ,4 y,, . Subdivision - r.,,d Z ____M ,Lot # Certified Survey Map # __ Volume , Page # W;irranty Deed # ., �5 S 1 � _. Volume 1 ZZ I , Page # Spec house ;& yes 0 no Lot lines identifiable 21 yes ❑ no SYS NIA TN'x] N ANCF Improper use and maintenance of your septic system could result in its premature failure to handle wastes- Proper Tn.2tititf.nance f consists of pumping out the septic tank ev ery tivee 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. 'Pane property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a rrta.ster, pltimber, jout plunibe.r, 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 113 full of shidge.. I1we, the undersigned have read the above requirements and agree to maintain the private sewage disposal systern with the standards set foith, herci.n, as set by the Department of Conunerce and the Department of Natural Resources, State of W isconsin, Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office ixithin 30 da ie for year exp'rat' n date. P t T DATE SIGNATURE OF A. PLI AN O _ CERT IFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (arc) the mvner(s) of t city d scri>i d above, by t irtue of ranty decd recorded in Register of Deeds Office. SIGNATURE OF APPLICAN DATE O ***+ 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 front the Register of Deeds office a copy of the certified survey map if reference is made in the wanfanty deed - -- ;-------------------------------------------------------------------------------------- - - - - -- - I STATE BAR WARR O 2 — 1982 555130 ^ DOCUMENT NO OL i' '� P AU06 REGISTr4 ,=FIDE sr. .r � Mary K. Kral, a single person, CROIX ro, %W ;u FES 3 1 r ,. conveys and warrants to W est i Lake Build I nc. , at 10: A. M '- a Wi_nconRin enrn =` Aaplatar d Dom :,:; T HIS SPACE R ESERVE P FOR RECORDING DA NAME AND RETURN AOOIE88 the Wikn+ing described teal estate m _ St. Cro x Count); ; # , State of Wisconsin: i) 020- 1093 -10; 020 - 1093 -60; tCA NUMBER I . (See Attached Exhibit "A ") (l t, t I� I } 3r i This is homestead property i T Bxceptiontovmrrattie& Easements, restrictions and rights -of -way of record, if any. !� X'' I 1 Dated this day d January A.D., 19 97 i k Ic .� Mary K. Kral (SEAU (SEAL) iI ' AUTHENTICATION ACKNOWLEDGMENT Signatures) State of Wisconsin, ' sa. t St. Croix C ou I authenticated this day of , 19 Personally came before me this O day d January 19-17—. the above named _ as K K ral, a single rson, �! II TITLE: MEMBER STATE BAR OF WISCONSIN I l (if n ot, _ authorized by §706.06, Wis. Stets.) _ to me known to be be person who executed the foreamv I inst Wiedg, the same- i ` -� THIS INSTRUMENT WAS DRAFTED "3Y Vw ltttnrnPy Kriatina flSlartd ! $ Hitricnn 41T 54n16 Notary c, County Wig j - (Signatures may be authenticated or acknowledged. Both are r-x My o is rmanent. (if not, state expirati date: l I j necessary) - Names of persons signing i-. any capacity should by typed, r printed below their signatures. R WARrt tNTY DEED STATE BAA OF WISCONSIN Wic°'�' � m t Form No. 2 - 1982 voL 1221 PRIW5 EXHIBIT "A" SE1 /4 of NW1 /4 EXCEPT the South 66 feet of West 660 faet thereof and EXCEPT the East 3 -1/2 rods of South 20 rode thereof and EXCEPT that part lying Ely of O'Neil Road; The North 66 feet of East 678 feet of NE1 /4 of SW1 /4; Part of SW1 /4 of NE1 /4 described as follows: Outlot "1" of Certified Survey Map filed October 15, 1980, in Vol. 0 4 0 , page 1001, Doc. No. 367079. All in Section 32, Township 29 North, Range 19 West, St. Croix County, Wisconsin. Part of NE1 /4 of SW1 /4 and part of SE1 /4 of NW1 /4 of Section 32, Township 29 North, Range 19 West, St. Croix County, Wisconsin, described as follows: Commencing at the N1 /4 corner of said Section 32; thence S0 (bearings referenced to the N -S1 /4 Section line of said Section 32, assumed S0 0 12 . 40 "E) 2696.16 feet along said 1/4 Section line to the point of beginning; thence continuing S0 0 12 1 40 "E 35.40 feet along said 1/4 Section line; thence N89 0 57'50 "W 678.01 feet; thence N0 6 16 1 48 0 E 132.48 feet; thence S89 0 37'30 "W 647.66 feet; thence N0 0 05 1 05 0 W 19.24 feet;. thence N89 0 09 1 26 "E 660.06 feet; thence S0 0 05'05 "E 66.01 feet; thence S89 0 09 1 26 "W 12.09 feet; thence S0 0 11'40 "E 66.00 feet; thence N89 0 09 1 26 "E 678.04 feet to the point of beginning. TOGETHER WITH AND SUBJECT TO A non - exclusive easement for ingress and egress as described in Quit Claim Deed dated January 12, 1987, recorded January 15, 1987, in Vol. "716 ", Page 200, Doc. 4 No. 421395. a i i �I LJ ;0 Ln Ul wv fi I m cCV O C N w tm b b p9 %kk `. �- '• � o co - €Z LION c J 4 M a Y ° • �� �; oc 6 ' I N y y �o :Z7 D� Z 1 b o � N m o ;� y\ a i eb b x �, r' G C-) Uj O O IQ 1� on rn o��.r� O ��•� y m D 00 7 al r �N3n by .^ /4 '``` • art },� _" GO��,.,� C�'� ( m 0 .b a te \ e� =� o a. El LO r 1 �Q w p II Ii _----- - - - - -- 7 74" ^' cn � � vi o LO u ` 62 , (D cn m o OD D - N LA r ' j Sao In rn ,I) (A C A )-, A 1 m U , LA� j C)nl iJ C] D pn X m x M p A \ �n 'n I UI I i'�) �l I Ib LO