HomeMy WebLinkAbout030-1018-70-100 ST. CROIX COUNTY ZONING DEI'ARTMENT
AS BUILT SANI'T'ARY REPORT
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Owner
Address
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City /State
"^r !N GOP FIGE
Legal Description: 1,
Lot Block Subdivision/CSM
Sec. ,, TN -RAW, Town of PIN -70 one
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer yJ ,`I u/ee/e," ST/PC Gad D/ Setback from: House Z� Well L ?4� 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: D A) Width Length S7 Number of Trenches .:9—
Setback from: House .3S W P/I, Vent to fresh air intake
ELEVATIONS
Description of benchmark Elevation
Description of alternate benchmark Elevation
Building Sewer 1 ST/HT Inlet /03. d7 % ST Outlet /d.?. 01 PC Inlet
PC Bottom Header/Manifold Top of SUPC Manhole Cover
r
Distribution Lines ( ) _��l.
Bottom of System
Final Grade
Date of installation Permit number 3 /s State plan number
Plumber's signature ��.� License number Date
Inspector Get el',
Complete plot plan a
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Y'
Safety and Buildings Division Count BT . CROIX
INSPECTION REPORT
• GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar5 P
Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)]. 1 u t5
BALLANTINE�, ROBERT �Vi� Town of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: l Parcel Vlb:L:1018-70-000
( Go (Do S
TANK INFORMATION ELEVATION DATA A9800288
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic l BencV (p� /07 ILO
Dosing a, Z �V7'IVS
Aerati Bldg. Sewer /D`l'7
Holding St -kf Inlet ,q. ( 03 . c) - /
TANK SETBACK INFORMATION _WK St W Outlet
TANK TO P/ L WELL BLDG. Air Intake ROAD Dt Inlet
Septic " 1 NA Dt Bottom a
Dosing Header / Man. 15
q0
S f •p
Aerat on Dist. Pipe 1 7 9
Holding Bot. System g• 5Z 9 S /3
r. q•o
PUMP/ SIPHON INFORMATION Final Grade 6 -b J0 S
Manufacturer Dema d ' (� (PO JQ
Model Number GPM
TDH Lift Friction System TDH Ft
oss Forcemain Len Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED / N Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIME CEO DIMEN I N
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEAC /^
SETBACK CH BER
INFORMATION Type Of 7 I �i � � OR U Model Number: -
Syste oeel — 1
DISTRIBUTION SYSTEM 1 I
Header /Manifold Distribution Pipe(s) Hole Size x Hole Spacing Vent To Air Intake
Length � Dia- � Length � � Dia. c�J Spacing / A5 T/ 7a
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 E] Yes E] No ❑ Ye ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) 3-2, �o
LOCATION: ST. JOSEPH 5.29.19.79A,NW,NW 1188 42ND STREET
Plan revision required? []Yes ❑ No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's SiYinature ert No.
Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 W. Washington Avenue
`h sconsin In r Wi . A m. e P O Box 7302
Department of Commerce acco d with ILHR 83.05, s d Cod Madison, WI 53707 -7302
• 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. 5 r C..-"V `)e—
• See reverse side for instructions for completing this application State sanitary Permit Number
s� -8
Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
Ifold vT AO % 4 1 e t/ 4 / 4 1 1/4, S " T jrd , N, R E (or
Property Owner's Mailing Address Lot Number Block Number
I lea .'2 411" 1
City, State Zip Code Phone Number Subdivision Name or CSM Numbe
�� d .✓ ° s e tr ( > 12-13
11. TYPE OF BUILDING: (check one) ❑ State Owned it Nearest Road
Village
Public 1 or 2 Family Dwelling - No. of bedrooms 3 Town OF 7 ®
111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
o3d- fd i�r- �d —lid I 1.791- 1a
1 [] Apartment / Condo 5- M.
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. 1Z New 2 ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5, ❑ Repair of an
- _____System _ - ____ - _System _____________Tank Only______________ fxistingSystem _____ -_- 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 L►]c Seepage Trench 22 ❑ In- Ground Pressure 42 Q Pit Privy
13 E] Seepage Pit "" X 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
SSG Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
" Y Feet IM,. Y Feet
Capacity
VII. TANK in Ca allo Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing structed
Ta , � n ks Tanks
epticTan ✓� / Q" `7?,` sYt sip✓ ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ I ❑ I ❑ 1 ❑ 1 ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se ge system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature (No Stamps) MPRSW No.: Business Phone Number:
W; w a� QS B I l A a
Plumber's Address (Street, City, State, Zip Code):
4% a c t o ,r/ ^ �l
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued ISS Ag
$� ent Signature (No Stamps)
Rpp ❑Owner Given Initial coo ' I I
A roved Surcharge Fee) I'�
� / 7 ( y / (
Adverse Determination f t00
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 be partment of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but St. Croix
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. 030 - 1018 -70
APPLICANT INFORMATION— PLEASE PRINT,A- Lfi'INF`O'RMATITON R IEWEDBY 71 DAT
PROPERTY OWNER: PROPERTY LOCATION
Claire Dilts !GOVT. LOT NW 1/4 NW 1/4,S 5 T -3 N,R 19 E{(or) W
PROPERTY OWNERS MAILING ADDRESS u _ T # BLOCK # SUBD. NAME OR CSM #
1218 Trout Brook Rd. 6 na Csm
CITY, STATE ZIP C O 1 I - O ,�7 , � CITY ❑VILLAGE MOWN NEAREST ROAD
Hudson, WI. 54016 ( 71 4096 St. Joseph I 42nd. S t .
k ] New Construction Use [ ] Residents - '1' Q ` fr gs ! .'� ' 4 [ ] Addition to existing building
j ] Replacement [ ] Public or co arc SO
Code derived daily flow 600 gpd ended design loading rate .7 bed, gpd /ft .8 trench, gpd /ft
Absorption area required 8 5 8 bed, ft 7 5 0 trench, ft Maximum design loading rate .7 bed, gpd /ft .8 trench, gpd /ft
Recommended infiltration surface elevation(s) 98.50 ft (as referred to site plan benchmark)
Additional design / site considerations a 1 t ..area = 96.90
Parent material outwash Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem :E] S ❑ U EI ❑ U :K1 S ❑ U 4a ❑ U C3 S ❑ U ❑ S a u
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
..................
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trerich
1 1 0 -11 10 r 4/3 none sil 2msbk mfr 2m .5 .6
2 11 - 10 r 4/4 none sicl lcsbk mfr C1W lm .2 .3
Ground 3 24 -84 7.5 r 4/6 none ms oscf mvfr na na .7 .8
elev.
19 .5 ft.
Depth to
limiting
factor
+84
Remarks:
Boring #
1 0 -10 10 r 4/3 none sil 2msbk mfr qw 2f .5 .6
2 10 -29 10 r 4/4 none sil lcsbk mfr 9W if .4 ':.5
3 29 -84 7.5yr 4/6 none ms osg mvfr na na .7 1.8
Ground
elev.
10 2 . 5 ft.
Depth to
limiting
factor
+84
Remarks:
CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200
Address: 1554 200th. New Rich on WI 540
Signature: /7,,�_ Date: 10-23-97 CST Number: m02298
STEEL'S SOIL SERVICE
Gary L. Steel Clai D i l t s 1554 200th Ave.
CSTM2298 NW4Nw4 S5- T30N -R19W New Richmond, WI 54017
MPRSW 3254 town of St. Joseph '(715) 246 -6200
lot #Q -csm
N
1 =40'
BM.= nail in Pine tree C el. 100
Alt. Bm.= nail in Pine tree Cel. 102.60
soil evaluation was done to satisfy a zoning requirement and may or
may not be suitable for your use.
04 g� Ile
Z-
A.
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Gary L. Steel
10 -23 -97
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
' r OWNERSHIP CERTIFICATION FORM
Owner/Buyer 0 6tl-+ V /c�61 rq X/t_ t�AnI ll
Nj9
Mailing Address // 0 (Q A0 wTC xool .)C d * a NU D,5 6 j W / 5 a,
Property Address 1 n I rJ 56 N o 6 l:, nk
(Verifrcatioa rcquircd from Planning Dcpartmcat for new construction)
Cityxtate Parrel Identification Number ' �' ! c7 $ - 7U
d
LEGAL DESCRIPTION
Property Location y, Sec. J . T-LI N -R -W, Town of 5 logg -r � .
Subdivision Lot It -
Cerfified Smvey Map # _ .S6 q / 9 0 Volume . Page # 3 3 /
Wamamty Deed ## S .7 a `/ 3 Volmne, 13,3 �' Page S Y
. / . #
Spec house 0 yes G no Lot lines identifiable [ yes ❑. no
SYSTEA :W_ A'INl'W NCE
Im ps +o p eras emda�y , �uPooaldItmitsp tobandlewastes.ProF�erabcaanae.
W=E ft of mapiag cat &-. septic tank Cvtxy &= y= or seem if needed by a Rccasod paarpcn ' What yum pat.into Me system
cam afffoct6c fmcfim of dw teptic taatcas_a ttauct stace is t$e traste aSposal cystcm,
Ile pr owe agrees to sabmirto SL Crain Zoning Dcgut=nt it .catiscatioa form, signed by the ow= and bq a
P ] pt rGStactodpl or: FieCasedpuaipcxtraifying�at( Ijd ,coaaitowad=ztcrdisposalsyde&
is m propcx opczatng Condition aadlor (2) after imspoctlm tad paarpn (if n c =Uy), tie septic tank.is I= den 1/3 fig of sludge.
Y* ihc UMdea 4MCd. , hm -road tie above requirements and a&= to naiad-;- the private sewage disposal system wi& do standsids
Set ford4 herein. V5 get by & Dgctactof Comm =e Qre Dq=rW=d ofN' d=d
Resourocs; State of Wisconsin.. Cxtificafioa
fiat
Yom septic system has'bom maintainedamst be eompldcd and rctumod to the SL Qcoix County Zoning Office within 30
f the thrx yrar ex date,
GNATURE OF APPLICANT DATE
OWNER - CERTMTCATLON
Y (we) cmay d at all statemcats on ties form am true to the best of my (our) Imowledge. I (we) am (are) the owacr(s) of
abov b virtue of a warranty deed r000cdcd is Register of Deeds Officc.
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Aesml—
MWA TM. OF APPLICANT DATE
Any information that is rats « « « « ««
pCrscatedmay rca& in the sanitary permit being revoked by the Zoning DepsttameaL
Indude with this application: a cumPod warranty deed from the Register of Deeds office
It Copy of the Certifed survey map if reference is made in the warranty deed
AIL 1`�`� ��GE 547
STATE BAR OF WISCONSIN FORM 2 — 1982
a3 V J WARRANTY DEED
DOCUMENT NO.
Claire H Dilts and Jeanette H. Dilts, Trustees ]Oe. of the Claire H. and Jeanette H. Dilts Revocable Trust dated Februar 20 1997 57, cone
and warrants to Robert J . Ballant and Virginia L. J U L 0 8 1 Ballantine a /k /a Virginia Bal lantine , husband and wife 11 : as survivorship marital property
Re is }pr of
THIS SPACE RESERVED FOR RECORDING DATA
NAME AND RETURN ADDRESS
the following described real estate in St. Croix County,.
State of Wisconsin:
`f 0) to
030 - 1018 -70
PARCEL IDENTIFICATION NUMBER
r
That part of NWkNWk Sec. 5- T29N -R19W described as follows: Lot 6 of
Certified Survey Map recorded in Vol. 12 of Certified Survey Maps,
page 3391 as Doc. No. 569190.
This deed is given in complete satisfaction of that certain Land Contract
between the parties hereto dated December 3, 1997 and recorded December 9,
1997 in Vol. 1281, page 414 as Doc. No. 569611.
This is not homestead property.
(is) (is not)
Exception to warranties: Existing highways, easements and rights of way of record.
T �
Dated this day of July A.D., 19 98
Claire H. Dilts and Jeanette H. Dilts
Re able Trust dated Fzb . 20 1997
(SEAL) (SEAL)
H_ Dilts, Trustee
(SEAL) (SEAL)
Jeanette H. Dim, Trustee
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Wisconsin,
ss.
�T• ICY O , coun - j
X
15
;69190
INSTRUMENT DRAFTED BY MICHAEL ERICKSON JOB NO. 97 -75
BEARINGS ARE REFERENCED TO TH
UNPLATTED LANDS WEST LINE O F THE NW1 /4 O F SECTION
- - - - -- 5, ASSUMED TO BEAR S00
TROUT BROOK NORTH
CENTERLINE WEST LINE OF THE NW1 /4
— 500 o n
.212,00' wb' � V1`
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