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Home My WebLink About032-2112-20-000 ' Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM County: INSPECTIO ST. CROIX GENERAL INFORMATION (ATT CH TO PI MIT) SanitaryPermitNo.: Personal information you provice may be used for secondary urposes [Privacy aw, s.15.04 (1)(m)]. 320213 Permit Holder's Name: ❑ Cit Villa e Town of: State Plan ID No.: MEAD, TOM SO1�I�SET CST BM Elev.% Insp. BM Elev.: BM Descript on: Parcel T x �h = 2112 -20 -000 o ! TANK INFORMATION ELEVATION DATA A9800401 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ' a .C.a G�y Benchmark SS c:5 Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet 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 Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand1"� Model Number GPM TDH Lift Lriction System TDH Ft Forcemain Length Dia. FI Dist. To We SOIL ABSORPTION SYSTEM BED / TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIM EN I N SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type O CHAMBER Model Number: System: 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 TBed epth Over xx Depth Of xx Seeded / Sodded xx Mulched B !d Center /Trench Edges Topsoil El Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATIO SOMERSET 11.3 / 0.19 // ,NW,SW / 1638 7 / 0TH ST — PINE MEADOWS LOT 2 / 1 r Plan revision required? lb ❑ No Use other side for additional information. "r SBD -6710 (R.3/97) Date Inspector's Signature Cert. No Safety and Buildings Division Visconsin SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue In accord with ILHR 83.05, Wis. Adm. Code P O Box 7 Department of Commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8112 x 11 inches in size. S r • See reverse side for instructions for completing this application State Sanitary Permit Number Personal information you provide may be used for secondary purposes E] Check if revision to previo / Z pplication u [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location aM.5W1 /4,S T3O ,N,R E(or)W Property Owner's Mailing Address / Lot Number Block Number QDI GC City, State Zip Code TPhone Number Subdivision Name or CSM Number. Q ) I ZJ e- e� II. TYPE F BUILDING: (check one) E] State Owned C ity Nearest Road Public 1 or 2 Family Dwelling No. of bedrooms _ o Town of Llr�t 7 s 7` — III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo a Clio — 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 S ❑ 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. kNew 2 E] Replacement 3 E] Replacementof 4_ ❑ Reconnection of 5 E] Repair of an ______System -------- System Tank Existing S Existin S stem ---------------------- y---------=--- - - - - -- 9 y--- stem ---------------9-y---- 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 RSeepage Trench 22 ❑ In- Ground Pressure / 42 [] Pit Privy 13 E] Seepage Pit o S'r S7 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 yS .. D Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation Feet f 9 Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex p er INFORMATION New Existing Gallons Tanks M anufacturer's Name Concrete Con- Steel glass Plastic A p p T nks Tanks strutted Septic Tank T,nk, A A/ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber I I ❑ ❑ 1 ❑ 1 ❑ I ❑ ❑ 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: Stamps P PRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/ DEPARTMENT USE ONLY ,-t,s ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuin nt gnature (No Stamps) I�f I A roved Surcharge Fee) ,�-� pp ❑Owner Given Initial y Adverse Determination `v D <� o6 (T X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber "ve 1 1 P qo v- It o' "Ilk f 74� iscol�I�n Department of Commerce IL AND SITE EVALUATION Divisicn of Safety and Buildings Page of Bureau of Integrated Services ,//:ill S. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not I `titan 81� in size. must County 'Zqi► include, but not limited to: vertical and W re (BM), ` : and percent slope, scale or dimensions, no and location and distant est road. Parc . J U !, r' 1997 j d APPLICANT INFORMATION - e prin$�" " ""'ti Reviewed by Date Personal information you provide may be used 3FOGWE 5.04 (1) (m)). ProperW Owner Property Location a y E Z► Govt. Lot ) 1/4 1 /4,S T ,N,R (ore Property Owners Mailing Address Lot # I BI Subd. ame or CSM# C Sta Zip Code (Phone Nub ❑ City ❑ Village 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 bed, gpd* _,E_ trench, gpd/ft Absorption area required _ bed, ft ft Maximum design loading rate — bed, gpd/ft trench, gpd1ft Recommended infiltration surface elevations) ft (as referred to site plan benchmark) Additional design/site considers ' s Parent material Flood plain elevation, if applicable ft S = Suitable for system Conventional T a Mound In -Ground Pressure AT -Grade System in Fill Holding Tank U= Unsuitable for system ® S E] U s❑ U 0 s ❑ u 1 0S ❑ u ❑ s ® u ❑ S M U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trench Ground v Depth to limiting factor Remarks: Boring # ef Ground _ _ elev Depth to limiting factor 2!zzin. Remar : CST Name (P rint) Signature Telephone No. _ Address Date CST Number t SOIL DESCRIPTION REPORT PROPERTY OWNER/7114 )' /�/9.J.�";� } Page of °. ,1 PARCEL I.D.# 1 Boring# Horizon Depth Dominant Color Mottles Structure D/ft 2 g G Texture Consistence Boundary Roots Q ss ",,-- in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. Bed ,Trench / 0.-g )e- � ivA / / (2 . 7 , k F:L."r... Iii Ground A ,0/ > elev. 5 JS y5" 5/G �� 75X°'5 A /7.-- _ r.... / e/J /r� , 7 ; .' ft ?XG 7s '�h i 7 5 yP742 ,5- o — — AY '1)/,' Depth to ' limiting fa or in. Remarks: Boring# e-/4 4" 4 �,� /s /�e1,. ,n / n_,J �' 7, , �' F , e-JQ is r/i/ Ai . /.z..�— u) /,� 7 g s" ,5 lg-s,7 05—A /VJ � ,s/ r,S //,-,5,-- ,.... / :5 2- , 7 : 4 Ground Ay- elev. "I 67,94 7:c--e / i...�,n .'5--: 17/4 s/ /, /a,4 — — ,I/1° , A/y- /r�1.O ft. 7` Depth to limiting ' factor - - 8 7 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 'e4 4 Boring# / l / q1. ./ / -/,, /, l /, .- l e.z,) !J.:, , 7, , g . / J7 7545,,% ,.zey.,^ / - 4/ , 2 . Ground elev. /an 7 ft. ; Depth to - ; limiting factor . in. Remarks: Boring# - lel i_ Ground elev. ft. . Depth to limiting factor in. Remarks: SBD-8330(R.07/96) II :illiscolIC Department of Commerce • L AND SITE EVALUATION Division of Safety and Buildings - q r Page / of 2 Bureau of Integrated Services in : ••• t L171030, 4 1 s. ILHR 83.09,Wis.Adm. Code Attach complete site plan on paper not I `tha i 81 in size.: must County _ / include,but not limited to: vertical and •.i i• r p M�- •I 1 (BM), -.• and <'),(6___.--<<6,x percent slope,scale or dimensions, • + :• • ,and location and• .'. f• :-rest road. JUN 3 U 1997 r i.K .,c ''`` APPLICANT INFORMATION- prinf� ti• , Reviewe�?7- 17�-se Date Personal information you provide may be used ?_^. .:temearacg 5.04(1)(m)). Prope Owner Property Location J � ' 0 Govt Lot I 1/4,5-0) 1/4,S T ,N,R 0(oreiV �/��°� 7�'��R.� by � _�F� Property Owner's Mailing Address Lot# Blom Subd. ame or CSM# / ?74/,/ yam- , /I/ 1Z ,PeL is State Z Code Phone Number tR Nearest Road p ❑ City ❑ Village � Town / , I (Jul' IS�,/9/7 I( ) .�,�,..e.V 7 I ��7.72`. ❑New Construction Use: XI Residential/Number of bedrooms 7 Addition to existing building 9 ❑ R ep la c Replacement 0 or commercial- Describe: Code derived daily flow gpd Recommended design loading rate , 7 bed,gpd/ft2 ,g trench,gpd/ft2 Absorption area required 8) bed,ft2 750 trench,ft2 Maximum design loading rate , 7 bed,gpd/ft2 -g trench,gpd/ft2 Recommended infiltration surface elevation(s) Q 7 ft(as referred to site plan benchmark) Additional design/site considera • s / w <1 • Parent material s 9,,. .. /< -. // _,r r:., . ..,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 ®S ❑ U I S ❑ U ❑S ❑ U ®s ❑ u ❑s ® u ❑s 0 u SOIL DESCRIPTION REPORT 1 Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu.Sz.Cont Color Gr.Sz.Sh. Bed .Trench 0`g /ek// /v/ A 7 : ,8 Ground _3 cam- 7s-e5--- /ii ii- /S AV /n,�.� ,-Y•. / 41 , 7: , g ft -- 9/ 7.5-:t°- / A� /s ��3_ / — 4/ / 7: ,e Depth to limiting factor min. ' Remarks: Boring# / l 6-/ jG'. �/ /1 G� /'�,-' ! n�J , ; . 0 l�JS 111 Xe°Yh /i /1 , /m r / �,�� /.z, 7: ,8 3 : -7 �cc- , ,% /s �h ..r ,,,, / (2u) ))/7 _ 2 : - f Ground 7 Y'-90 /d if�74 .f/ s-./ �5'�`b,( x,14- ,s — ..5 : G jlift. ,,S' 2}-g2 /8 th ,t/ / / - ,,., / _ — ,5--; , Depth to limiting factor 792 in. Remar : CST Name (P rint) Signature Telephone No.,,,,// Address Date CST Number So"/ 2"2914 i � ', X W I 5--- -,26, Z.,---,2_5--97 i.9/1/ �s -97 yam �tf��S y- I i ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer Mailing Address .$ 1 Z, 4 Property Address (0 3 $ '7O Ck; st , w 4 w `mod (Verification requited from Planning Department for new construction) City/State Parcel Identification Number 0 3A -'; -41 a ~ - LO o (0c LEGAL DESCRIPTION Property Location Nw_ 1 /,, 514 5 y,, Sec. 1 / . T -JO_ N -R I W, Town of Subdivision ^ - - I S Lot # a Certified Survey Map # Volume , Page # Warranty Deed # 7 el , :z Volume L ml , Page # 3-S V Spec house ❑ yes P"no Lot lines identifiable eyes ❑ no SYSTEM MAINTENANCE Improper use and 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 master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal 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 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 days three year expiration date. SIGNATURE OF APPLI /Zl /9 C 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 i the rty described above, by v' a of a warranty deed recorded in Register of Deeds Office. NAT URE OF APPL CANT DATE * * * * ** 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 from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed VOL O�i 1 1 STATE BAR OF WISCONSIN FORM 2 – 1982 WARRANTY DEED DOCUMENT NO. RST Mark A. Fagerland and Ct>ris A Fagerland husband ST. Q. I wo and wi fe Rw'd ►or IbaoN JAN 0 6 1998 conveys and warrants to Thomas Mead and T ° tra Me =d his -nd 9:30 a. M and wife, ' ►••Y.-tk 0j.1' Re d fl�adll THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in St. CIO1X County, State of Wisconsin: KRISTINA OGLAND P" Estreen & Ogland r•O. Box 359 Itudson, W1 5 4016 PARCEL IDENTIFICATION NUMBER Lot' 2, P of Pine Meadows in the Town of Somerset, St. Croix County, Wisconsin. $ TRANSFER zo FEE This is not homestead property. IkL (is not) Exception to warranties: easements restrictions and rights -of -way of record, if any. Dated this 3 day of December lglq 97 7 9 f (SEAL) /!/�v °it�ILa...✓J /Z'J /(sEAL) A. F erl (SEAL) (�– tL) Chris A. Fa er AUTHENTICATION ACKNOWLEDGMENT Signature(s) Mark A. Fagerland State of Wisconsin - -- - - -- -- - - -- — Chris A aryl ss. authenticated this 3 - 0 0 - - day of Decembe 97 County. Y , 19_ Personally came before me this day of 19_, the above named . Kristin Oglat TITLE: MEMBER STATE BAR OF WISCONSIN e (If not, authorized by §706.06, Wis. Stats.) to me known to be the person _ who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Attorney Kristin Ogland Hudson, WI 54016 Notary Public, County , Wis. (Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration date: necessary.) 19_J I Names of persons signing In sny apaity should by typed or printed below their signnuro. - - WARRANTY DEED STATE BAR OF WISCONSIN Whin Lead Blast Co. k , Form No. 3 – 1983 gawe/ua Wis UTILITY EASEMENTS N O POLE OR SURVEY STAKE, OR OBSTRUCT VISION ALONG ANY H DISTURB ANY LINE L OR STREET LINE. DISTURB ANY THE DISTURBANCE OF A SURVEY STAKE BY ANYONE IS A VIOLATION OF SECTION 236. OF WISCONSIN S TATUTES. AND PRIVATE PUBLIC HAVING HERE ST FORTH ARE FOR THE USE HT TO SERVE THE AREA. OF BEARINGS WEST LINE 0 A PUBLIC BODIES 0 11, ASSUMED TTED LANDS m� o� Z 0 '21'54 "W 1300.43' m 299.07' 111.58' 225.00' 0 CA W O N (4 h v N L 4 / ° o mN m (D. -.- � mew O rfl Z n> o m �I O L OD " ' rn vi Q z 0 CA .....� . / 0 + I tn C _ °o w I O N01'11'35 "E 352.42' )TH STREET I I W , W O� m °Z