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HomeMy WebLinkAbout020-1109-55-100 ST. CROIX COUNTY ZONING DEPARTMENT.,, AS BUILT SANITARY REPORT Owner A Address `'s *�© " i City /State ! "` r 99 r;�U pox 8 Legal Description: a � E / Lot --Z _ Block Subdivision/CSM # � ai c `r '�• Sec..3�, T,2.2-RAW, Town of PI SEPTIC TANK - DOSE CHAMBER - HOLDING TANK INFORMATION: Tank manufacturer Size ST/P / 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: Widt�a �_ Le � Number of Trenches Setback from: House Well P/L W_ Vent to fresh air intake ELEVATIONS Description of benchmark f Elevation ,La Description of alternate benchmark _ Elevation 7.) Building Sewer ST/HT Inlet ST Outlet a fz PC Inlet PC Bottom Header/Manifold 27-22 Top of ST/PC Manhole Cover Distribution Lines Bottom of System Final Grade Date of installation ermit number State plan number Plumber's signature �/� License number, Date Inspector G Complmc plot plan 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 s" 3 1= yd scr K INDICATE NORTH ARROW I . `Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count �Safetq and Buildings Division 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)]. 320208 Permit Holder's Name: ❑ Cit ❑ Village Town of: State Plan ID No.: SANDQUIST, DAVID HUDSON CST BM Elev. Insp. BM Elev - BM Description: Parcel Tax No.: 1 Uv I I ) 0 1 r or, S 020- 1109 -55 -100 TANK INFORMATION ELEVATION DATA A9800396 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. eptic � l Bench r el 7� � p� ! Od Dosing 4P, eM li dOd• Aer n Bldg. Sewer C17 7 Holdin S Inlet �7 S" 7 TANK SETBACK INFORMATION 9 Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Airintake e tic Z� W�� � 0_ NA Dt Bottom Dosing NA Header /Man. ° I7.4Z Aeratio NA Dist. Pipe _ S 77/5 Holding Bot. System �U,� - 2 PUMP/ SIPHON INFORMATION Final Grade Jv 917 Manufacturer De nd �} AK (� 7. 1� Model umber Y PM TDH Li Friction System TDH Ft L oss e Forcemain I Leng la. I Dist. To Well SOIL ABSORPTION SYSTEM TRENCH Width / Length � / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth EN I N IZ - DIMENSION S SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHIN Manufacturer. A» SETBACK CHAMBER INFORMATION Type Model Number: Syst m 3�� N'ti _- OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) r f f x Hole Size x Hole Spacing Vent To Air Intake Length SL_ Dia- "� Length �� Dia. Sparing 5 A S i 27 2-1 SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of 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 36.29.19,NW,SW 808 CTY RD N 0 TVP k N E - A , 6 M - • 1�/ u'1 �� • S �r G c+�h �0 1�r+ lei ih Wit ` 14 e 4y �rti Plan revision requl e ❑Yes N0 A � Use other side for additional informs ' n. SBD -6710 (R.3/97) Date Inspector's Anat Cert. No. r�- ADDITIONAL COMMENTS AND SKETCH ' SANITARY PERMIT NUMBER: I e I , , I r _ , 6 r F p r � + 3 F F � P + E t ` 7 8 E 1 { m Y wg E �m. E , . . d 3 i , , s + 3 f i , S Safety and Buildings Division SANITARY PERMIT APPLICATION 201 1 E. Washington Ave. Visconsin of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI W707 -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. • See reverse side for instructions for completing this application State Sanitary Permit Number 3 zoz,o e 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 I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION �^ Property Owner Name Property Location 1/4 I j va, S T , N, R /(Or)S> Prope O er's Mailing Addres Lot Number Block Number City, St a Zip Code Phone Number Subdivision Name r CSM Numbe II. Y E OF BUILDING: (check one) ❑ State Owned 1� ❑ Cit Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms 7 9 T of Ill. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo — /0 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 eepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12] Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 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. nch) Elevation Feet Feet Capacity VII. TANK in Ca allons Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con steel glaze Plastic App Tanks New Tanks Existin strutted Septic Tan olding Tank ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber I ❑ I ❑ I ❑ 1 ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for ins II tion of he onsite sewage system shown on the attached plans. Plume Nam : (Print) Plumb 's S at t MP /MPRSW No.: Business Phone Number: Ph I mherl Address (Street, y, tate, Zip Code): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate ssue Issuin g nt Signature (No Stamps) Approved El Owner Given initial I 6 I Surcharge Fee) 16 / Adverse Determination 6 I X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R 11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Number INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe 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 -3151. 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, location 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 the 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. i I ,Q,�v,'p �5�.,J,o�u,st ,y�J /y stil��-�k� 3G - Ta9i�✓- �9u1 � ,2, ,ao5Ra cJ e t a� moo' 33 Wisconsin Qepartment of Commerce SOIL AND SITE EVALUATION W) lion of Safety and Buildings Page of Bureau of Integrated Services - iT�'a6porda(lce with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not I st ttltn 8 1/2 x, 1 inches in slz`k Plan must County include, but not limited to: vertical an agPontal r� pmja to nt (BM), ditection and percent slope, scale or dimensions, r`1h arrow, afrd- tooat) 3n�nd distance"jo nearest road. Parcel I.D. # f Z p - ] 1 C9 -55 OC� ✓ APPLICANT INFORMATION m_ Pease prjbi( t fiiJ nat on:` R ' wed by Date Personal information you provide may be u d�fipksecondarypyrgQSp� (Privacy t aw, � 15.04 (1) (m)). � Property Owner Property Location Govt. Lot ` j 1/4 U ) 114,S T2 N,R g Property Owner's Mailing Address `� ... `� ! �- Lot # Block Subd. Name or CSM# gm ' City State Zip Code Phone Number ❑ Ci ❑ Village [S Town Nearest Road 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 —7 bed, gpd /fF gpd /ft Absorption area required �2 S bed, ft 7!r6 trench, ft Maximum design loading rate 7 bed, gpd /ft2 _S trench, gpd/ft Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design /site considerations Parent material La�/ _ j /o � :�I 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 (X] S❑ U S ❑ U [K S ❑ U R] S❑ U El S � U ❑ S 0 U SOIL DESCRIPTION REPORT Boris # Horizon Depth Dominant Color Mottles Structure GPD /ft 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench f Ground elev. ' Depth to limiting factor Remarks: Boring # Ground - elev. ft. Depth to limiting factor ?m in. Remarks: CST Name lease M , Signature Telephone No. "- - / - - Addre s Date CST Number L SOIL DESCRIPTION REPORT PROPERTY OWNER 1 Oh) -'h •L sl sr — Page of--f, PARCEL I.D.# Boring Horizon Depth Dominant Color Mottles Structure 2 g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench i 8 Ground 3 �� elev. Depth to limiting factor Remarks: Boring # ' .S r Ground _ elev. I&Lft- Depth to limiting factor ? Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /f12 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ; 8 j „S , Ground — elev. �� -ft• 1 Depth to limiting factor in. Remarks: Boring # i Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) �/ GTt� / /(/6J� S(�1�- ✓cc --�� �a9� 7C� /91r+� GtGZS'E.3.tJ //v � cS��� � �r11S�✓�J � = �Scrr.E do g �S q�,U/t1`•E /mt�lzS L.'srrr �a5�G3 � bd ✓'vv, . 9 � a y , y I 33 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address Property Address 4®9 i'7�/ _J I (Verification required from Planning Department for new construction) City /State; L&zcn 1 Parcel Identification Number LEGAL DESCRIPTION Property Location �� V., �� ' /�, Sec. �, T -% C4 N -R�W, Town of OA 1 �O� Subdivision , Lot # Certified Survey Map # �'"1 3 ,Volume _ Page # Warranty Deed # 5 , Volume ,% '���� Page # �4 / Spec house 0 yes 51 no Lot lines identifiable tO yes O no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could restnit 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. 71e property owner agrees to submit to St. Croix Zoning I )epartment a certification form, signed by the owner and by a master pluniber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewat: rdisposal 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 u•idersigned 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 three year expiration date. SIGN U i,E APPLICANT DATE A OWNEI CERTIFICATION I ; ve) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of the propel, described above, by virtue of a warranty deed recorded in Register of Deeds Office. 'j, =�� `, / �( Ql� SI ATURE APPLICANT DATE * * * * ** Any informatinn that K m19 rrprrCrntril may rrault in the eanitary permit being revoker] by the Zoning Department. ** Inr111414• 1' 411 MIN 1111111iriItiml i .Liinl" I i� ;llI,111h drrd ftiun till' 1'•l'l-i•Irt of Dr( „fli"r a copy of the certified sur neap if reference is made in the warranty deed 585978 VOL 3.352PAO -61• Document Number WARRANTY DEED This Deed, made between, Neil L Wilcoxson and Mary Jo Wilcoxson husband and wife, Grantor, and David J Sand q uist and Laurie A Sand q uist ST. CROIX CO.. WI R�c'd . °wr R�ngrd husband and wife, as survivorship marital property, Grantee. AUG 7 �9�� Witnesseth, That the said Grantor, for a valuable consideration of one dollar and other valuable consideration conveys to Grantee the below described real estate in 9 130 St. Croix County, State of Wisconsin. 7� This is homestead property. R tMr q�r, Together with all and singular hereditaments and appurtenances thereunto belonging; And Grantor warrants that the title is good, indefeasible in fee simple and free and clear of + encumbrances except Recording Area easements, covenants, and restrictions of record, Name and Return Address and will warrant and defend the same. ATTN: Mortg Dept (Parcel Identification Number) Flrst National Bank of R IV ®F Fah 020 - 1109 -55 Iba PO Box 466 Falls W! 64 Part of the NW 1/4 of the SW 1/4 of Section 36 -29 -19 described as follows: Lot 1 of Certified Survey Map filed may 27, 1998 in Vol. "12 ", page 3456, #579813. T RPSFER FEE Date his day of si , 199 f� A�� 1 ? ei1 WHS&son ` Mary J lcoxson AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN COUNTY Personally came before me this day of the authenticated this day of above named Neil L. Wilcoxson and Mary Jo Wilcoxson to me known to be the person(s) who executed the foregoing instrum nd ack owledg the same. signature 2 type or print name type or print name C 2" 6� A, TITLE: MEMBER STATE BAR OF WISCONSIN Notary Public County, (If not, My commission is pQrmpnent. (If" not, state expiration date: authorized by §706.06, Wis. Stats.) a 7 THIS INSTRUMENT WAS DRAFTED BY `Names of persons sigr�:in any Capacity should be typed or Reber~ F. Wall printed below their sign tu'es P L' 8 L \ C C. (Signatures may be authenticated or acknowledged. Both are not �'� •, necessary.) �' „ GG r 1 �� � � I � � �__ __- �-- -_ __ s PILED 2 Al Q y 2 7 1998 10 5'79813 ' >TH LEEN If m 3 erol Demos Croix Co., WI CERTIFIED SURVEY MAP L �r LOCATED IN PART OF THE NW 1 OF THE SW 1 I OF SECTION 36, T29N. R 19W, TOWN OF IIiJDSORT, ST. CROIX COUNTY, WISCONSIN. PREPARED FOR: 0I u+JSo T DAVID SANDQUIST,LcL"f ► e. '`�• 0 z 818 C.T.H. "N" /� D1111rus �. l w 0 Li H WI 54016 7 + 'L ('n y o o L s - w � 0 V) 0 OWNER �l opjl V--• O O NEIL & MARY WILCOXSON `'' .�' v 0 N G Nw UNPLATTED LANDS �, q /cog w W m W1/ CORNER N89 . 50'35 "W 218.16'° w SECTION 36 a w mI w co 40' ZJ V) a ZD I W N t D Q1 min o� LOT 1 bi N 2.689 ACRES INC. R/W h Q I pj 117,148 SQ. FT. rn J 00 Z 2.502 ACRES EXC. R/W O 108,986 SQ. FT. W I C — — — 00 P y r - w (o °D N o O I� i - 00 O cn r U) o; i Q N � rush 0 11 3 S PARCEL IN V) O w p 0 468/51 F- CV nVY aM , 40W 0 � W � S82'29'53 "E 246.42' M S82 ' 2 9'53 "E 4 cos U) 120.28' S82- 29'c, „ v 248.23' 00 r7 Lo to ONP LATTED L ANDS LEGEND SW CORNER SECTION 36 ALUMINUM COUNTY SECTION CORNER MONUMENT FOUND O 1” X 24" IRON PIPE SET WEIGHING 1.68 LBS. 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