HomeMy WebLinkAbout038-1084-95-004 cltoix co .�
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,( 'rY `;�bNt�r �)E PAR'I'MENT
AS t3ti,' SANIAARY Itl"p IZ'I'
Owner
Address 1, tJE ,
Cit /State zovz - 13 C0-T ,
Y
. Zvi/ R rCN Molup Vt/ ,
Legal Description:
Lot Block Subdivision/CSM It . I E d p
'/, NE '/, S , Sec. Z O , T N -RtW, Town of` PIN # 638` 168y- 95 - 00Y
SEP'T'IC TANK — DOSE CHAMBER — HOLDING 'TANK INFORMATION:
Tank manufacturer 45E yt/ Size ST/PC / / Setback from: House Well P/L 3S
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: Width _L z _ Len L
Setback from: House ---L— Number of Trenches
_ Well P/L 30 Vent to fresh air intake SS
ELEVATIONS:
Description of benchmark
Description of alternate benchmark ToP lac ru � � l Elevation
o
� , � Elevation 16 S y3
Building Sewer %CC , S!S ST/HT Inlet ST Outlet `I7• S PC Inlet
PC Bottom Header/Manifold g3. b / Top of ST/PC Manhole Cover 160.7-3
Distribution Lines
Bottom of System(
Final Grade ( ) C/
Date of installation 161 'Permit number 32OZ6 U
State plan number
_ _ {'
Plumber's signatu _. License number - --�Z `/Z Date / /ZO/ q46
Inspector -,,, r ty
Complctc plot plan K
Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM 'u * . CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanit�r�P��t,LVo.:
Personal information you provice maybe used for secondary purposes [Privacy aw, s.15.04 (1)(m)j. lJ
Permit Holder's Name: ❑ Cit ❑ Villa Town of: State Plan ID No.:
ETTERKIND, RICH ST AF PIL
CST BM Elev.:
too Insp. BM Elev.: BM Description C s �J Parce�T ,8uq�084 -95 -00
1 Ad LA4, c.
TANK INFORMATION ELEVATION DATA A9800448
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV.
S Ic �Yia I0cqz� BencF9 rk �,$$ 1 0 04 ' l0
Dosing A��: -7' '. /C-91 :�
Aera Bldg. Sewer ,�„ �, ��,5 S
Ho ing C Inlet
7 as 97
TANK SETBACK INFORMATION t Outlet 7. 3 97,
T NK TO P/ L WELL BLDG. Air I to ntake ROAD Dt Inlet
ir
Septic �� ►V f� NA Dt Bottom
Dosing NA Header / Man. �' p
Aeratio Dist. Pipe
Holding Bot. System
PUMP / SIPHON INFORMATION Final Grade
Manufacturer and
54
Model N ber GPM
TDH Li Frictio System TDH Ft
Forcemain Length Dia. Fi Dist. To well
SOIL ABSORPTION SYSTEM
BENCH Width Length 5_q j No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIM EN I N Z' DIMEN I N
SETBACK
SYSTEM TO P/ L BLDG WELL LAKE/STREAM L HING Manu ac u
INFORMATION Type O C MBER
S ste 3Q �3r Nl OR UNIT odel Number:
Y �,
DISTRIBUTION SYSTEM
Header/Manifold / Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air take
Length f Dia. Length 6 V Dia. �� � Spacing SGN Z7 Z
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 / Trent h Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRAIRIE 20.31.18,NE,SE 2042B COUNTY ROAD C
C��If l�p� bldg v��,f 1m--
By
3 S y -,k. w.a i "fftj 4,r d DIPI .I,,,,ES 88 (sue.
Plan revision required? 16 Yes ❑ No
Use other side for additional information. I n 1 9,7 1
SBD -6710 (R.3/97) Date Inspector's Signature ert.
Safety and Buildings Division
Visconsin SANITARY PERMIT APPLICATION 2 1 Box Washington Avenue
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code 3
Madison, 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County c
than 8112 x 11 inches in.size. `74 • 6I-c l Y,
• See reverse side for instructions for completing this application State Sanitary Permit Number
Personal information you provide may be used for secondary purposes ���
[Privacy Law, S. 15.04 (1) (m)]. ❑Check if revision to previous application
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Prope owrier Na Propert Location
CH V�rrafz X1 /4 1/4, S ZO T 31 . N, R 18 E (or) 40
Propert wner's Mailing Addres r um er Block Number ------
City, State - ,t j ZipCode C � hone umber ame umber "
w T J
11. TYPE F BUILDING: (check one) ❑ State Owned ° O Nearest Road
Public 1 or 2 Family Dwelling - No_ of bedrooms 3 Town OF STAR E
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/Condo I g • 438 - /0 P 00y
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. MNew 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an
------ System ________System Tank Only______________ Existing System _ Existing System
B) E] 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 Oseepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13
El Pit /2 X 5� 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 /sq. ft.) (Min. /inch) Elevation
8 Feet Feet
VII. TANK Capacity
in gallons Total # Of , Prefab. Site Fiber- Ex per.
INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic A p p
structed
Tank Tanks
epticTank g an D O /coo �� ❑ 1:1 ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ 1 ❑ ❑ I ❑ 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' ign S ature (No amps) M /M
P PRSW No.: Business Phone Number:
J,Gr x Y, I 2z3z Liz 7/s - z9 - 31Y
Plumber's Address (Street, City, State, Zip Code):
x Z76 sEIR 51
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D atelssued — Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial f�o°°� Surcharge Fee) q 2 e,8
Adverse Determination � ! 6�� JdA _ _
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
�?iC 1�E 12�CiND A!� �y sF- 20 7 31 N. R 18
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MPI°S 2Z3Z NZ ® $&nrP"AZj4 BASE of
FEna foS WIT )�50 A/B&W
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Laiborann d Human amanRelations In dustry ,
La SOIL AND SITE EVALUATION REPORT Page _of
Labor and 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 O
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.
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
�- -� lie ' yYt GOVT. LOT 1' 1/4 JF 1/4,S 3 N,R �f7 E r
PROPERTY OWNERS MAILING ADDR ' S.. n LOT # BLOCK # SUBD. NAME OR CSM #
CITY, STATE ZIP CODE PHONE NUMBER CITY VILLAGE OWN NEAR T RO
New Construction UseX Residential / Number of bedrooms [ J Addition to existing building
Replacement [ J Public or commercial describe s'
Code derived daily flow ' gpd Recommended design loading rate _ , bed, gpd /ft C) trench, gpd/ft
Absorption area required bed, ft trenpb, ft Maximum design loading rate _bed, gpd /ft - trench, gpd/ft
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design / site considerations G
Parent material Flood plain elevation, if applicable ft -7 S = Suitable for system VENTIONAL 0 D - OUND PRESSURE T BADE SYSTEM ILL HOLDING
NK
U= Unsuitable fors stem 2 S El U S U S❑ U S O U El U ❑ S U
SOIL DESCRIPTION REPORT
Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Botxtdary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
Bed Trer
Ground
AT Z - V I t
Depth to
limiting
fact
Remarks:
Boring #
7v Ground �1
rI
a
Depth to
limiting
factor
' Remarks: S
CST Name:— Please Print Phone: /
a ✓�-- - L G
Address:
�C7 l
Signature: Date: CST Nu ber:
Soil Test Plot Plan
Project Name Stephen Germain Byr Bird Jr.
Address 1947 93rd St.
Somerset Wi 5
TM #3479
Lot 4 Subdivision --- --- Date 8/ 21/95
NE 1 /4 SE 1/4S20 T 31 N/13 W
Township Star Prairie
Boring ()Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft of Fence Post Red Ribbon
System Elevation 94.8/9 * H R p Same as Benchmark
742' Property Line
00'
B -5 30' B -2 50 '
n
0
c
8% 30' Pro 3
o Slope Bedroom
a House
n 60' -3 60'
Rep A Pri A
30'
B -4 1
1
.M.
45'
170' 742' Property One
t19/08,'98 TLT); 14:02 FAI 715 2 94 4498 CEDLI OS LiTitiBBR CO.
-- S 10001
09 - 88 - 97 11:11 CROSS COUNTY ID- 7152943138 p,. 1
- -- _
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuytx R/ C/ - /XRD A
Malting Address _4 z s-
Property Address ZO E1 fj (,+
i(Venrcation required (rant P arcing Deparamnt for new construction) _
City /State Parcel Identification Number 438- /0 8 y- 5 -- 00 'V
LEGAL DESCRIPTION
Property Location _'/., 5*6 t /, Sec. Z.O _ T j/ _N- /$' W, Town of s'7,oq2 jPirdi
Subdivision Lot # 1_ .
Certified Survey Map # Va // !�►9 GE 3073, Volume /I . Page # -76
Warranty Deed # 5 � 3 / Z . Volume / l 7 7 . Page # 5x- G
Spec house 0 yes ❑ no Lot lines identifiable D yes ❑ no
SYSTEM MAINTENANCE f
Improper use and maintcnanceof your septic system could readt in its premature failure to handle wastes. Proper maim t ice
consists of pumping out 6c septic tank every three years or sooner, if needad by a hoe -wed pnwgw. What you put irnto the s, n6 ,m
can affect the function of the septic tank as a treatment stage in the vrasta disposal system.
The property owner agrm to submit to St. Croix Zoning Dcpartmont a ceiafrcatioa form sighed by the owner ant (. i' a
master pluyabmt, journeytaaa plumber, restrictedplumbet or a licensed p=qm verifying that (1) the on -site wastewaterdisposal s.'" i m
is in proper operating condition and/or (2) after inspection and pumping (if accessary), the septic tank is I= than 113 full of sb f" e_
Uwe, du uadehsigsod have read the above requirements and agree to maintain the private selvage disposal system with the star fl As
set forth, hraein, as set by the Department of Comtmorvc and the Depaswww of Natural Res=C4M, Stott of Wiseoasi L Certify h} ion
stating that your septic system has bran maiataiaacd must be completed sad returned to the fit. Crain Couary Zoning OJT= wit T.l 30
W ; -K/wl year expiration date.
SIGNATURE OF A PLICAn DATE J
owivER CE�tTIFICATiON c
t (we) certify that all smwmcuts an this form are true to the best of ray (our) knowledge. I (we) am (are) the owns t ' o!
the petty tibed abo e, by virtue of a ry d ;e d in Register of Deeds Office.
SIGNATURE OF APPLICANT DATE
i
- --- -- Any information that is mis- repres=tcdmay rmlt in the sanimry permit being revoked by the Zoning Deparanent_ tiP I r`.
— Include with this application: a swamped Warranty deed ft m the Register of Deeds office
a copy of the ccrtiCed survey MP if tt faeaoe is made in the wastunry deed
09/10/98 THU 10:00 FAX 7159484165 Dan Foust Q001
Sap -10 -98 08:07A Global -MN 16127488200 P-01
'JOB 1177 -.46
54341 WARRANTY DEED
Document Number
lWurn Address MAY 8
Ck 11:30
Parcel I.D. Number
Stephen J. Germain and Melanie Gernisin, husband and Wife, convoys and vrdffwkts to Richard
vetterkind, a single person, and Kimberly J. Parneli, a single person, the following
described real estate situated in St. Croix County, Wisconsin
Part of SF114 ofNEI/4 and pan of NFI/4 of SE114 of Section 20-31-18 described as follows: Lot 4 of
Certified Survey Map filed March 20, 1996, in Vol, "I I", page 3073.
TC)GETHER WITI I AND SUBJECT TO a joint driveway, as the same is depicted and shown on Lot 4 of
Certified Survey Map filed in Vol. "11", page 3073, and as located on Lot 3, of Certified Survey Map
recorded in Vol. "5", page 1413.
This is not homestead property. M196FER
!A
FEE
Exception to warranties: Easements, restrictions and rights-of-way of record, if any.
Dated this day of May, 1996,
(SEAL) —(SEAL)
Stephen'). Germ lin Melanie Germain
AUTHENTTCATION
Signature(s) Stephen J. Germain and Melanie Germain,
husband and wife, authenticated this Jf t day of
May, 1996.
- I I . I
")r"� -) , i I#
Kristina Ogland
TITLE: MFMBER S'I'ATF BAR OF WISCONSIN
THIS INSTRUMEN1 WAS DRAFTED BY:
Attorney Kristin Ogland
fludson, WI 54016
99-19-97 09:03 RECEIVED FROM:7159484165 P-01
� D
FILED 2
6 MAR 2 0 1996 No
541 KATHLEEN H. WALSH 3
Register of Deeds
SL Croix Co., WI
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Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page -L- of
Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County ,
include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
O3 - 0 4 - I -oo
APPLICANT INFORMATION - Please print all information. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy law, s. 15.04 (1) (m)).
Property Owner Property Location
e-4 K i n Govt. Lot M F_ 1/4 5 1/4,S a d T 3 ' N,R I E (o
M
Property Owner's ailing Address Lot # Block# Subd. Name or CSM#
qbq To mbti - )ar,`e, _ 1A pt, b y V. I I Ft. zon
City State Zip Code Phone Number
❑ City El Village ®Town Nearest Road
S o nn ef t-+ I Lo s Y D ;.S ( 715 )a`17 1 t r ra' R
® New Construction Use: Residential / Number of bedrooms 3 Addition to existing building
❑ Replacement Public or commercial - Describe:
Code derived daily flow q50 gpd Recommended design loading rate S bed, gpd/tt trench, gpd/ft
Absorption area required goo bed, ft SO— trench, ft 2 S M I Maximum design loading rate • 5 bed, gpd /11 _ trench, gpd /ft
Recommended infiltration surface elevation(s) y15_} l ( 9 ;t• ab� (,o ,7 + g ( 9L), y 8) It (as referred to site plan benchma k)
.evchlF VS-f ,n f'.I'rr, +e S For +/,Si$ W0.1Q S+; 11 �ntao+►+w+e�� .5 +.1-
Additional design /site considerations hems SAN A i s So Roc Ic .i
Parent material Ql 0.G l A' 6 V t S C, �j h _ Flood plain elevation, if applicable tt
I T = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
= Unsuitable for system Os ❑ U h4 S ❑ U [ g S ❑ U 1A S ❑ U ❑ S [9 U ❑ S X U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Fr e w 01 F .5
1 9 - ) v � R a h - -- °- -- S �- d M b k rat Fr 4 0 Ir 5
Ground D •3b - 7, 5 1 R` 13 FS 1 F5bk Mfr C w Ivr . S
_l ft. 36-9 0.5 M L. — , - 7
Depth to
limiting
factor
5-in.
Th
Remarks: r r
Boring #
I 0 -13 1D `1 �� L am 5b k mFr C w Q
1 3 - ` f R -"' S L M b v— m I F r
Ground $-$0 7 , 5 `� p O M l.. 17 ,
elev.
q 3.'13 ft.
Depth to
limiting
factor 11
--j Remarks: 'rh ^ a V" \ a 0 h V G k v I
CST Name (Please Print) tignature Telephone No.
(> r) °I-a r 5 _ ; yY 3 5 S8
Address Date CST Number
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