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HomeMy WebLinkAbout042-1060-20-000 (2)Wisconsin Department of Commerce Safety and Building Division PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)], Permit Holder's Name: City Village Township Mark Jensen TOWN OF WARREN CST BM Elev: Insp. BM Elev: BM Description: W.00 ��� siq Top c( S doe, iu�. TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic j�ces� IDDD Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic I �y Dosing Aer do H Iding PUMP/SIPHON INFORMATION Manufacturer 1 Demand GPMx Model I tuber 1 7 1 TDH Lift Fricti n Loss Syste ead TDH t 1 Forcemain ngt JL� Dia. ]Dist. to Well SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. Croix Sanitary Permit No: 651272 State Plan ID No: Parcel Tax No: 042-1060-20-000 Section/Town/Range/Map No: 21.29.18.336B STATION BS HI FS ELEV. Benchmark 0.65 �00. (�5 l �U OD Alt. BM p�q , -k C-0\1,-r q Bldg. Sewer St/Ht Inlet 7 $5 q2. b St/Ht Outlet q2 -sI Dt Inlet �cx�� -nn� 92.0 Dt Bottom Header/Man. Dist. Pipe Bot. System Final Grade St Cover BED/TRENCH DIMENSION. Width Le h No. Of Trenches PIT DIMENSI No. Of Pits ide Dia. did Depth SET CK INFO MATION SY TEM TO P/L BLDC3 WELL LAKEiSTREAM LEACHIN CHAMB OR UNIT Manuf cturer: T Of S st yp y Model Number: DISTRIBUTION SYSTEM Head r/Manifold Distri x Hole Size x Hole Spacing V Air Intake e(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Svstems Only xx Mound Or At -Grade Svstems Only Depth Over Depth Over xx DepLLI1 of xx o7[:] xx Mulched Bed/T �ench er ed/Tre h End s Topsoil Yes No '❑ Yes ❑ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 812 HWY 65 1.) Alt BM Description = 2.) Bldg sewer length - amount of cover = Plan revision Required? ❑Yes ❑ No IV 02 lv2-3 � Use other side for additional information. � � ❑ l SBD-6710 (R.3/97) Date Insepctor's Sig ture Cert. No. Safety and Buildings Division County f ` ,�/� ' B I AUG 2 8 2023 f= 201 W. Washington Ave, P.O. Box 7162 anitan ermr N D S -P j (W be fIltd. M' Co. 'toy ) P C&L-IMY Madison, W 53707—7162 — � ,,,,�; s; �,, ,pVelonme.nt- Nnn Sa,n�•ta�� Permit Application 7 Statt- T rapnqazuor, Numb;7 In accordance with SPS 383 -2 1 (2), VVis. Adm. Code, submmiori of this form to the appropriate governm=unit Project AclartsS (if ch thaw mading address} is required prior to obmin* a sanrtanr permh Note: Armlication forms for state-owned POV,7S are submitte4 to the Depwi nerz< of Safety and Professional SCrvles. Personal information you provide may be used for secondary iDurpuses in accordance with the Pbvacy La:%,, s. 15 -K I )(m), .31am. L fir-ation Information - Please Print AM Information -AP Property Owner's Name Parcel ld6o Property GNvner'sVtaihi- Ada-s, 1mpT' Locanor L4-> Gvvt Lot ct" S= zip Code Phone Number -715-- 7xil 7? q y Cie one) F IL TvDe of RuMing (check A that appi-s-1) L2 7 S i -I'D d, I is i c�r- N me F�10r'Family Dwelling - Number of Bedrooms Ir Block 0 ❑ Public/Commercial - Dies Hbt Use❑ c1tY of Village of CSM Number❑ ❑ State Owned.- Des=-b-- Tj -,, t 7J Town of IIL Type of Permit: (Check; only one bol on fine -A, Compiete Line B if applicabie) A A- 7 New System © Repia=merr S-%,=iL foo �T-= =/Hol ding Tani`. Replaccin-cm Only El C)th-- Modifi=or to Existing System (explam) 1R. ❑ Permit Renewal ❑ Per=. Revision 7— Change of Plumber Permit Transfer to Nem, List Previous Permit Number and Date Issued =CP Before , iration owner IN'. Ty of POWrS S'vstem/Compon nt/Device: (Check all that apply) ype ❑ Non -Pressurized ID -Ground El Pressurized ln--Cirround ❑ ha -Grade ❑ Mound > 24 in of suitable soil El Mound < 24 M' of suitable SOE Holding Tank ED C)th-_- Dispersal Componerit (explain) El Pretre=e= Device (explain) V. DispersRI/Treatment Area Information: D--si= Flow (pd) Desigr, SoE Apphca:lior RaLe(pdsf) Disp czsa Area Required (sf) Dispersal Axm Proposed (sf) SystSystemEin-ation YTP I VL Tank Info Capacity' in Total Of 1v1anufi=W= Gallons Gallons units C 6. M c� New Tank • Existing Tanks 0 A Jo F Cc ^eP4 cr Rojdmc T Dosing Onanity=- 'VIL Responsibility Statement- L the undersir-med, assume responsibilim for imrtall2tioin of the POVkTS shown on the attached pians. R i " Business Phone Number Plumber's Name Trent) Plumber's iumbcr's Simauu-, M]OyTR�Numb=" AF 0 0-7 b 9 C- 4. LA-V Plumb�s Address (Street, City. State, Z11) Code) U NM Coun epartment Use OnA, ;K Approvec ❑ DiSaDDrov--c' PcrmitFP4- Date Issued iss"liliz Aaem. Si 0"ame7 G7v--r Rzason fcr- D--ma' DL Conditions of ApprovaMmsons for Disapproval At=ct U. complete plans for me system "C su Dmir ti, use 1—ounr% onn OE P2PVF UHL ff=Q, LU2M C- JL,- X 11 UALUIM LE SLZC ?'F SBD-6398 (R. 11111) ,I r dic 0 r 3144(e4lojr PZ, 0 r IC�4 4AI ,I r dic 0 r 3144(e4lojr PZ, 0 r IC�4 4AI 0 ST. CRO r�Tv SANITARY SYSTEM F'l°': OWNERSHIP/ADDRESS FORM Office use o��y cror.dzaoa, Community Development Department will utilize this information to provide the property owner with information regarding operation and maintenance of your new or replacement sanitary system! This information will be provided as part of our ongoing efforts to protect public health, your well, groundwater, surface water, property values, and county resources. Once approved, this completed form and educational information will be sent to you by email. OWNER/BUYER INFORMATION Owner/Buyer Mailing Address City/State/Zip Phone Number (required) Email Address (required) . Parcel Identification Number (found on the property tax bill) NEW SYSTEM: LEGAL DESCRIPTION Property Location 1/4 , 1/4 , Sec. L, T N R_ISQTown of . Subdivision Plat: , Lot # . Certified Survey Map # e Volume _ , Page # . Warranty Deed # ` �' '7 7, ` (before 2006)Volume , Page # . Number f bedrooms Sec house E3 es ®'no Lot lines identifiable es 0 no • b r y Y OFFICE USE ONLY New Property Address (Verification of new address required from Community Development Department for new construction.) (Staff Initials) (Date) This form must be submitted with all Private Onsite Water Treatment System (POWTS) applications. New System: Include with this form a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. Community Development Department — Land Use Division 715-386-4680 St. Croix County Government Center 715-245-4250 Fax cdd o ccwi ov 1101 Carmichael Road, Hudson, WI 54016 www.sccw[.aov a r !III 824867 State Bar of Wisconsin Form 3-2003 2 IIIIIIiIIIIIIIiIIIIIIiIIIi Tx:4203242 QUIT CLAIM DEED Document Number Document Name THIS DEED, made between_ Mark L. Jensen, a married person as individual property ("Grantor," whether one or more), and Mark L. Jensen as Trustee of the Mark L. Jensen Revocable Trust dated July 29 2014. ("Grantee," whether one or more). Grantor quit claims to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ("Property") (if more space is needed, please attach addendum): SEE ATTACHED ADDENDUM Dated July 29. 2014 999779 BETH PABST REGISTER OF DEEDS ST. C RO IX CO., W I 08/07/2014 12:00 PM EXEMPT#: 16 REC FEE: 30.00 PAGES: 2 Recording Area Name and Return Address Jennifer A. O'Neill O'Neill Elder Law, LLC 900 Crest View Drive, Suite 220 Hudson, W154016 042-1060-20-000 Parcel Identification Number (PIN) This is homestead property. (is) (is -not3 (SEAL) (SEAL) * Mark L. Jensen (SEAL) (SEAL) AUTHENTICATION Signature(s) Mark L. Jensen, a marriedperson as individual proyeM a ntica ed on u 14 Jendifer A. O' e' TLE: ME ER STATE BAR OF WISCONSIN (If not, authorized by Wis. Stat. § 706.06) THIS INSTRUMENT DRAFTED BY: Jennifer A. O'Neill, O'Neill Elder Law, LLC 900 Crest View Dr., Ste 220, Hudson, Wisconsin ACKNOWLEDGMENT STATE OF WISCONSIN ) ) ss. COUNTY ) Personally came before me on the above -named to me known to be the person(s) who executed the foregoing instrument and acknowledged the same. Notary Public, State of Wisconsin My Commission (is permanent) (expires: (Signatures may be authtaticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. QUIT CLAIM DEED C 2003 STATE BAR OF WISCONSIN FORM NO.3-2003 * Type name below signatures. St. Croix County 999779 Page 1 of 2 ADDENDUM TO QUIT CLAIM DEED GRANTOR: MARK L. JENSEN, A MARRIED PERSON AS INDIVIDUAL PROPERTY GRANTEE: MARK L. JENSEN AS TRUSTEE OF THE MARK L. JENSEN REVOCABLE TRUST DATED JULY 29, 2014 PI N: 042-1060-20-000 LEGAL DESCRIPTION: Part of the Southeast Quarter of the Southeast Quarter (SE1 /4 of the SE1 /4) of Section Twenty-one (21), Township Twenty-nine (29) North, Range Eighteen (18) West, described as follows: Beginning 401 feet North to the Southeast corner of the Southeast Quarter of the Southeast Quarter (SE1 /4 of the SE1 /4) of Section Twenty-one (21), Township Twenty-nine (29) North, Range Eighteen (18) West in the center of the highway; then West 203 feet; then North 168 feet; then East 203 feet; then South 168 feet to the point of beginning and including a part described as commencing as the Southwest Corner of said parcel, then West 100 feet; then North 168 feet; then East 100 feet; then South 168 feet to the point of beginning. Town of Warren, St. Croix County, Wisconsin. St. Croix County 999779 Page 2 of 2 Wis. M�pt. 4Safety aid)Prost�i 0 642 /Services SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with SPS 385, Wis. Adm. Code County St Croix Attach cor> Pie ?'s 'p gt _ r� bi ss flan 8 112 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. 0422-1060-20-000 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 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 Mark Jensen Property Location' W I S SW 2 1 /4 l / Q4-)q T N R Property Owner's Mailing Address Govt. Lot 4"r4 �1 8E (or) IN 8 12 HNvy 65 Lot # Block # Subd. Name or CSM# na na. 1.66 Acres City State Zip Code Phone Number ity Village Roberts W1 54017 715-7604-347 1:1 [Drown Nearest Road I I I( Wnrrin I HNA-y 65 New Construction UseEl Residential / Number of bedrooms 3 Code derived design flow rate 450- GPD Replacement Public or commercial - Describe: na Parent material Outwash plains Flood Plain elevation if applicable na ft. General comments Verification Boring and recommendations: MBoringBoring #97.40 120 DPit Ground surface elev. ft. Depth to limiting factor in Horizon Depth Dominant Color Redox Description Texture in. Munsell Qu. Sz. Cont. Color 0-12 1 Oyr 3/1 11011C S'I 12-34 1 Oyr 4:14 none sicl 3 34-51 7.5yr 4/4 none Sl 4 5 1 -1 "10 7.5yr 4/6 none fils Boring # Li Boring Pit Ground surface elev. ft. Der Horizon Depth Dominant Color Redox Description Texture in. Munsell Qu. Sz. Cont. Color Gi Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L CST Name (Please Print) - ignature David J. Steel Address 1699 150th St NeNA- Richmond., W1 54017 Structure Eonsistence oundary Roots Sz. Sh. *1 2nisbk in fr CS I ",T Soil Application Rate GPD/ft 2 -ff#1 *1 .6 -'_ff#2 .8 2msbk in fr CS Ivf .4 .6 0111 osg m fr rnI CS na na 2 .6 na .7 1.6 ' Aructure Consistence oundary Roots Sz. Sh. Soil Application Rate GPD/ft ff#1 ffi#2 1=ttluent 92 = BOD < 30 mgA- and TSS < 30 mg/L CST Number 248956 Date Evaluation Conducted Telephone Number 8/23/2023 715-760-0347 -Sl3D-8330 (R 11/11) Wis. Dept. of Safety and Professional Services SOIL EVALUATION REPORT t 2 Division of Safety and Buildings Page of in accordance with SPS 385, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must I County St Croix include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. 042--1060-20-000 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. I Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Mark Jensen SW Sw 21 -)q M Govt. Lot 1/4 1/4 S T N R 18E (or) W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 8 12 1 lwy 65 na na I 1.66 Acres City State Zip Code Phone Number Roberts W1 54017 715-760-0347 I [:]City F-lVillaegE]Town Nearest Road Warren Hwy 65 New Construction Use[] Residential Number of bedrooms Coded 450 erived design flow rate GPD Replacement Public or commercial - Describe: na Parent material Outwash plains Flood Plain elevation if applicable na General comments Verification Borl'11cy and recommendations: 1-� Boring # E) Boring 97.40 Ij Pit Ground surface elev. ft. Horizon Depth Dominant Color Redox Description Text in. Munsell Qu. Sz. Cont. Color 1 0-12 1 Ovr 3/2 11011C Si 1) 12-34 1 Oyr 4,4 none sic 3 34-51 7.5yr 4/4 none 51 4 5 1 - 1'011-0 7.5yr 4/6 none 1 rn� Boring # Boring Pit Ground surface elev. ' Utluent #1 = BUD S > 30 < 220 mg/L and TSS->30 < 150 mg/L CST Name (Please Print) ignatu David J. Steel Z�pr Address 1699 150th St Neu- Richmond, W1 54017 nanth to liMifinri fnr,+^r 120 re Structure Lonsistence oundary Roots Gr. Sz. Sh. * Soil �Iication Rate GPD/ft 2 ff# 1 *1 ---ff#2 2msbk infi- CS -6 .8 2msbk in fr c S Ivf .4 .6 0 M m fr cs na .2 .6 osg rn I na na .7 1.6 Depth to limiting factor onsistence oundary Roots Soil Application Rate GPD/ft 2 ff# 1 *[:.ff#2 Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Number tk -? 2.4 8 9 5 6 Date Evaluation Conducted Telephone Number 8/23/2023 715-760-0347 SBD-8330 (RI 1/11) p14 2 cn � c3CD�.. E 1� CL C7 + im ., l< C�CO O r , ;saws .'A � o n Ick- I # Ia� N n. (.e r t � „ S fl , t w+ y r ly, r i rr' , n r t4 yy� r , + r r wif ' n Yn 1 I °0 i n , , yA ST. L��x couNTY 3&�,� No. 651272 1�ji Nellil mi; LA Bud] I ❑ TRANS FER/RENEWAL PREVIOUS NO. PLUMBER A# An 0 C'S# TOWN OF SEC ?1_,T_7UN, R /I E/16> EXPIRES BLOCK SUBDIVISION AUTHORIZED ISSUING OFFICER - CHAPTER 145.135 (2) WISCONSIN STATUTES (a) The purpose of the sanitary permit is to allow installation of the private sewage system described in the permit. (b) The approval of the sanitary permit is based on regulations in force on the date of approval. (c) The sanitary permit is valid and may be renewed for a specified period. (d) Changed regulations will not impair the validity of a sanitary permit. (e) Renewal of the sanitary permit will be based on regulations in force at the time renewal is sought, and that changed regulations may impede renewal. (f) The sanitary permit is transferable. History: 1977 c. 168; 1979 c. 34,221; 1981 c. 314 Note: If you wish to renew the permit, or transfer ownership of the permit, please contact the county authority. UNLESS RENEWED BEFORETH T DATE POST IN PLAIN VIEW VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION SBD-06499 (RI 1/20)