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HomeMy WebLinkAbout022-1024-50-000 1 ST. CROIX COUNTY ZONING DEPARTME ` =' AS BUILT SANITARY REPORT 4L n (� Owner Address _ �_ i�a$ t sr caaIx City/State 2 � '.=� Y � cau+v 1AlNca Legal Description: Lot Block Subdivision/CSM # '/4 ' /,-, Sec. �, TN -R Ze_W, Town of PIN # ,�,�LS/ — s SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer s Size ST/PC 1,�Wl Setback from: House 1-Y Well _:sL3. P/L _ Pump manufacture_ r, 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: "a Width i , Length :2 r Number of Trenches Setback from: House •_ Z Well gs_ P/L 2-,) Vent to fresh air intake ELEVATIONS Description of benchmark & _d, ,z _ s ;�, s Elevation Description of alternate benchmark Elevation Building Sewer & 4 ST/HT Inlet ST Outlet- PC Inlet PC Bottom Header/Manifold l;J, ;/s Top of ST/PC Manhole Cover ,9'.=2/, Distribution Lines O O ( ) Bottom of System Final Grade ( ) 9K_1 Date of installation 2 i /& P rmit nu r �� A �TYfA State plan number c Plumber's si natur t e g License number �- ����ILS Date Inspector complete plot plan it 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 �i G Ouse INDICATE NORTH ARROW f Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary315810: Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1) (m)]. )tjy$*0�0 Na7AMES n of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel TM_:1024- 50-000 t) 00 I rod YK B Jl� C, Id r h TANK INFORMATION EL VATION DATA A9800198 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic f S rr Do Benchmark I (01(4. 1 Op Dosing Aeration Bldg. Sewer 4-5-r j/6 .6 � Holding St Inlet .5 •33 S g TANK SETBACK INFORMATION Ms �.��^ S a Outlet S•S� s: 6a TANK TO P/ L WELL BLDG. Air Intake ROAD Dt Inlet eptic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Q'•77 �a• 3 Holding Bot. System C?. 73 PUMP/ SIPHON INFORMATION Final Grade ('.0S" S •, /� Manufact eemancl 5{ , y►�IaNl�o�t 3. '7 7, 1 4. MooeNumber GPM T Lift Friction stem TDH Ft ead Forcemain Length Dia. Dist.Towell SOIL ABSORPTION SYSTEM E / TRENCH width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth ION � q DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHIN Manufacturer: CHAMBE System INFORMATION TypeO ZZ • ��is � S � �— OR UNIT o el Num er: DISTRIBUTION SYSTEM Header /Manifold �� Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length _V Dia. p g S� S acin r *\- IAt/` 4 C— t+ }'72 SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over ry Depth Over xx Depth Of xx Seeded / Sodded xx Mulched Bed/ Trench Center �� Z Bed /Trench Edges so( p Yes p No COMMENTS (Include code discrepancies, persons present, etc.) LOCATION: KINNICKINNIC 9.28.18.133B,NE,NW 484 VALLEY VIEW ROAD t •� L-Ae7 5 G w�� 1 �� Z ' co,rk"" 6 t av sc Pla rev s`on r quire? ❑ Yes fZ No 2 Use other side for additional information. 0'G SBD -6710 (8.3197) Date Vk I pedor's Sifattire Cert. No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ° I I I I V scon SANITARY PERMITAPPLICATION 2 01 e E.WashingtonAve 'sion In " P.O. Box 7969 In accord with ILHR 83.05, Wis. Adm. Code 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. • See reverse side for instructions for completing this application State anitary Permit Number 3is��o The information you provide may be used by other government agency programs E] Check it revision to previous application (Privacy Law, s. 15.04 (1) (m)]. S'amc State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Prope Owner Name Prop Loc tiiio S T N, R (or) W a.5 Prope Owner M ling A dress Lot Number Block Num er City, a e ip Code Phone Number Subdivision Name or CSM Number ( ) II. TYPE OF BUILDING: (check one) ❑ State Owned Cit Near t ad ❑ Village Public CR 1 or 2 Family Dwelling - No. of bedrooms Sj Town OF ;11 III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 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 jZ 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 ® Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure t i 42 ❑ Pit Privy 13 ❑ Seepage Pit 1 a' X S 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 VII. TANK in Capacit Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturer Name Concrete Co Steel glass Plastic App New Existing structed Tanks Tanks eptic Tank ❑ ❑ El 1:1 1:1 Lift Pump Tank /Siphon Chamber ❑ 13 ❑ _ 01 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for inst lation of t si a sewage system shown on the attached plans. Plumber' Na : (P ' nt) Plumb s Si t o mp MP /MPRSW No.: Business Phone Number: Plumber' Ar dress (Street ity, S zip Cod IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater YjApproved ❑ Surcharge Fee) Owner Given Initial J GD o,� �� Adverse Determination < D X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: S8D -6398 (R.11/96) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber r 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 -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. II. 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. 1�4y 4 - zz/Ge,O �,�,o .S - G7Xs� �> J �® S4 ez J 7,r u �l L�,�G,� ,[7,Pjueald i I Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services �' ` / with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not I /2x11 1 iri Ian must County include, but not limited to: vertical and rl refer M), and percent slope, scale or dimensions, aaybv, and I isi9L earest road. Parcel I.D. # APPLICANT INFORMATION - prinit�# nf�itio Re r Dar. Personal information you provide may be used bronda ry P ������ s Laws. "1 (1) (m)). ' Property Owner J ICE y ' Property Location l / ` "_ _.-- Govt Lot 1/4 1/4,S T ,N,R (or' Property Owner's Ma' ing Address Lot # Subd. Name or CSM# 11 Sta Zip Code Phone Number ❑ ❑ Village earest ( ) ge (� Town N ❑ New Construction Use: ❑ Residential / Number of bedrooms C Z> Addition to existing budding 0 Replacement ❑ Public or commercial - Describe: Code derived daily flow '36Q gpd Recommended design loading rate _ bed, gpd* _ Tench gpolft Absorption area required _ bed, ft trench, ft2 Maximum design loading rate , , 7 — bed, gpd* gpolR Recommended infiltration surface elevation(s) & 93 it (as referred to site plan benchmark) Additional design/site considerations , Parent material 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 0 s❑ U 10 s❑ u WS El u ED ❑ u ❑ S z1 u ❑ S O U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 13 / in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench / - rF J �2 Ground ` s �� elev. 9ft - Depth to limiting factor Remarks: Boring # r r S S.' i Z. Ground — s - �� p� , lla,� Depth to limiting factor R marks: C7Z Peas rin Signatu Telephone No. Address Date CST Number SOIL DESCRIPTION REPORT y PROPERTY OWNER Page r� of PARCEL I.D.# Boris # Horizon Depth Dominant Color Mottles Structure 2 Boring in. Munsell Qu. Sz. Co t. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trench ILI J� zz 4Ld -4z Ground / � e / 18 � V. 7�f — ft. Depth to limiting factor Remarks: Boring # E Ground elev. ft. Depth to limiting factor 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 # ; Ground elev. ft. Depth to limiting factor in. Remarks: Boring # 131 Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) ©" 9s y� i '7 0r")f /7pGSK 3B ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer ✓I f 5 y �a �� 6 UL&Auc - Mailin g Address g �� a 1 L4 L„1 Property Address (Verification required from Planning Department for new construction) City/State /State ha�t5 l� ��� Z3 Parcel Identification Number - /OGg ty LEGAL DESCRIPTION Property Location IJ E '/a, N \r ' /a, Sec. T W, Town of Subdivision , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # 5779U7 , Volume , /3aa , Page # _17G Spec house ❑ yes 4 no Lot lines identifiable Oyes ❑ no SYSTEM MAINTENANCE Improper use wid 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. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a masterplumber, 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. I/we, 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 d s of the thr a year expiration date. j L� S_ 1 NATURE OF 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 t e property de cribd above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT DATE i * * * ** ent. tt! *!R it being revoked b the Zon Departm Any information that is mis- represented may result in the sanitary perm g y g P ** 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 w t • ' 578827 8Q27 STATE BAR OF WISCONSIN FORM 1 — 1982 WARRANTY DEED DOCUMENT N / D ' E o. VOL . 4( ;E �6 13 2 1 REOiPfEVQS - 6 - FILE This Deed made between Edmund Benedict and 3 T• CRQ(X CQ„ Wi Edythe Benedict , husband and wife, y Virginia A. n '.< rr r f!��t,.� Schwan, Power of Attorney MAYO 8 1998 Grantor, and James B. Neubauer, a single person 9.30 A m 1. �i Ro latltr of 09045 Grantee, Witnesseth That the said Grantor, for a valuable consideratio one J 61lar and other good and valuable consideration conveys to Grantee the following described real estate in St. Croix THIS SPACE RESERVED FOR RECORDING DATA County, State of Wisconsin: .,Ak.c Ain RcT, ARM AnnRFRR Part of NE4 of NW- Sec. 9- T28N -R18W described as 4�00' follows: Commencing at the Southeast corner thereof DAVID J. ESTREEN thence North 89 West, 580.5 feet, the point of . LOCUST L S beginning; thence North 89 West, 340 feet; thence HU X04 304 L W) ST. North 00 04' East, 295 feet- thence South 89 East, 250.6 feet; thence South 17 East, 308.9 feet to the point of beginning 022 - 1024 -50 PARCEL IDENTIFICATION NUMBER Edmund Benedict is also known as Edmund E. Benedict and Edythe Benedict is also known as Edythe L. Benedict. Attached hereto is copy of the Power of Attorney under which this deed was executed. i sANSTER This is homestead property. FEE (is) Together with all and singular the hereditaments and appurtenances thereunto belonging; And _grantors warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions, reservations, and covenants, if any, of record, and highway rights of way and will warrant and defend the same. Dated this 27th day of April , (SEAL) u,-) (SEAL) * _ * Edmund Benedict by Virginia A. Sc (SEAL) I AIL (SEAL) * * Edyt e Benedict by Virginia A. S chwan POA AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. Pi e4(-Ce' Count. authenticated this day of 19 Personally came before me this1- day of April _19 9 the above naifr' * Virginia A Schwan as PEA fob TITLE: MEMBER STATE BAR OF WISCONSIN Fcirm inrl RPnPrI i r t anti Frlvi -hA' `BP�it.'d1C t 5 , r (If not h-'hand and wife authorized by §706.06, Wis. Stats.) tome known to be the ersons w 'Eke used the fore ` P �1? � g9 L `ng instrument and acknowledge the same. ; 1 - THIS INSTRUMENT WAS DRAFTED BY °' I f Edward F. Vlack, Davison & Vlack M , * t ar River Falls, WI 54022 Notary ublic, I' 42 ry County, Wis. (Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration date: necessar — ry �I • Names of persons signing in any capacity should by typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc. Form No. 1 — 1982 Milwaukee. Wis. N 1/4 CC SEC. 9 -- T I I 133A I / - NW 1/4 I 174.0 LOT 1 I cv 133C N cc AAAA I 250.60 I 0 0 to CD N 1336 — 361-25 340.00' r� I i 136 A .SL 1 4 — Nw 7 i 9 29/590 0 0 0 rn 136 0 I