HomeMy WebLinkAboutSAN-2018-327Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
TJoe:Miller
older's Name: City Village Township
TOWN OF CADY
CST BM Elev: Insp. BM Elev. BM Description:
TANK INFORMATION ELEVATION DATA
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO
PIL
WELL
BLDG.
Vent to Air Intake
ROAD
Septic
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer Demand
GPM
Model Number I
TDH Lift Friction Loss System Head TDH Ft
Forcemain I Length IDia. I Dist to well
SOIL ABSORPTION SYSTEM
County: St. Croix
Sanitary Permit No:
SAN-2018-327
State Plan ID No:
Parcel Tax No:
004- 1 0 1 0-80-000
Section/Town/Range/Map No:
1
05.28.15.71
STATION
BS
HI
FS
ELEV.
Benchmark
Alt. BM
Bldg. Sewer
SUHt Inlet
ISVI-It Outlet
Dt Inlet
Dt Bottom
Header/Man.
Dist. Pipe
Bot. System
Final Grade
St Cover
BEDITRENCH
DIMENSIONS
Width
Length
No. Of Trenches
PIT DIMENSIONS
No. Of Pits
Inside Dia.
Liquid Depth
SETBACK
INFORMATION
SYSTEM TO
Type Of System:
PIL
BLDG
WELL
LAKE/STREAM
LEACHING
CHAMBER OR
UNIT
Manufacturer.
Model Number:
DISTRIBUTION SYSTEM
Header/Manifold
Distribution
x Hole Size
x Hole Spacing
Vent to Air Intake
Pipe(s)
Length Dia
Length Dia Spacing
SOIL COVER Y o.dhaaaa n Awatimme Onh. YY Uniend Or Ot�rade Svstams Onto
Depth Over
Depth Over
xx Depth of
xx Seeded/Sodded
xx Mulched
Bed/Trench Center
Bed/Trench Edges
Topsoil
[g Yes Fw-] No
0 Yes Q No
COMMENTS: (include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 557 CTY RD NN
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =-
Plan revision Required? W Yes F15-1 No
Use other side for additional information.
Date Insepctor's Signature Cert. No.
SBD-6710 (R.3197)
4
�545867
Document Number Document Title,-,�",\ TX: 4452707
1072656
St. Croix County 13ETH PABST
Non -Plumbing Sanitation A davit REGISTER OF DEEDS
ST. CROIX CO., WI
RECEIVED FOR RECORD
10/11/2018 11:30 AM
Name — (Owner) Typed or printed EXEMPT #:
being duly sworn , states, under oath, that: REC FEE 30.00
COPY FEE 2.00
He/she is the owner of the following parcel of land located in St. PAGES: I
Croix County, Wisconsin, recorded in Volume — Page
Document Number/46IO&St. Croix County Register of DeedsOffiCC: Recording Area
Name and RetuCnAddress
,To -C /1r
A parcel of land located in part of the 5W 1/4 of the *4"J '/4 of Section �, e � '41
15 , T 2-$ N — R 15 W. Town of C�1 q -, St. Croix
County, Wisconsin, being duly described as follo4s (include lot no.
and subdivision/CSM or detailed legal description): 60ji - /6/6 y T6 Odo
Parcel Identification Number (PIN)
I . A new structure on this lot will be used as a habitable dwelling. Occupants of said structure utilize a pit privy for disposal
of human waste, which was authorized by a non-plurnbing sanitation permit in compliance with Sections 12.A. Lg and
, 12.3a.2 of the county sanitary ordinance.
2. The contents of the pit shall be disposed in accordance with NR 113, Wis. Adm. Code.
3. This agreement shall be binding on the owner, their heirs, assignees and/or land contract purchaser.
I also acknowledge that I will disclose this information to any parties interested in purchasing this property in the future.
Dated this %day of ___ __
AUTHENTICATION
Signature(s)
authenticated this _, _ _ day of _
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not�
authorized by § 706.06, Wis. Scats.)
THIS INSTRUMENT WAS DRAFTED BY
St. Croix County CDD
Staff
(Signatures may be authenticated or acknowledged. Both are not
1%
ACKNOWLEDGMENT
STATE OF WISCONSIN )
)SS.
St. Croix County.
Personally came before me this day of
FF Fr
C, 0 the tve named
f1A
Pt t 11
A
A 11-z-
to me'l&ovn
-to
the person(s) who executed the foregoing ins"95 t yin c-L-Vickriqw1e the
same.
fn
N
Notary Public, State of Wisconsin L4
My Commission is permancril. If not, state expiration date -
Date:
"THIS PAGE IS PART OF THIS LEGAL DOCUMFST - DO NOT REMOVE"
This information must be completed by submitter: docume
nt title. name & return address and PIN (if required). Other information such as the granting
clauses, leagal description, etc. may beplaced on thisfirst page of the document or may beplaced on additional pages of the document. Note.- Use ofthis
cover page adds one page to your document and $2,00 to the recording Lee. Wisconsin Statutes, 59.43.
St. Croix County 1072656 Page 1 of 1
-'l-lop-County Sanitary Permit Application
ST. CROIX COUNTY WISCONSIN
Or -.wd with Chapert 12 St. Croix County Sanitary Ordinance
personal
PLANNING & ZONING DEPARTMENT
crt X�
55:�, inf rmation you provide may be used for secondary purposes
[Privacy Law. S. 15.04(1)(m)]
ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, Wl 54016-7710
Fax
(715)386-4680 (715)386-4686
t'IIc to plans for the system on paper not less than 8-112 x 11 inches in size.
ermit Check it rev"-`s o to previous applicat . ion.
1. Application infoon - Please Print all InformatiW
1Location:
Property Owner N6-me
440* UZ 114 W1 /4, Sec
Property Owner`s Mailing Address
ILot Number
Block Number
City, State
Zip Code
I Phone Numer
Subdivision Name or CSM Number
S' 0 1-7 Wl '
11 Type of Building: (check one)
Comity 0 Village own of
r% r
%W1 2 Family Dwelling - No. of Bedrooms:
ED Public/Commercial (describe use):
Nearest Road V -Z-41 W-1
E3 State-owned
box line A. Ch k box fine B if
It. Type of Permit: (Check only one on on apphcaf e)
Parcel Tax Number(s) (,b 016. 1 1 1
A) I.E3 Repair 2.13 Reconnection 3. Non -plumbing ED Rejuvenation
0 0 o --(,)0
Sanitation
B) Permit Number
Date issued
[3 State Sanitary Permit was previously issued
IV. Type of POVVT System: (Check all that apply)
ED Non -pressurized In -ground ❑ Mound 2! 24 in. suitable soil ❑ Mound 24 in. suitable soil ❑ Mound A+0
ED Sand Filter ❑ Constructed Wetland F7 Peat Filter 71 Drip Line
0 Pressurized In -ground El Holding Tank 0 Single Pass Other
❑
E3 At -grade 13 Aerobic Treatment Unit Recirculating
V. Dispersal/Treatment Area Information:
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area A. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed (G a I s. /d a y/s q. ft.) (Min./inch) Elevation
V1. Tank information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete strutted glass
Tanks Tanks
E3 11 13
❑
0
E3
1:1
❑
V11. Responsibility Statement
[, the undersigned, assume responsibility for repair/reconnenction/rejuvenationfinstaliation of non -plumbing for the POWTS shown on the attached plans. A
i'llcense is not required for terraiift repair or the installation of non -plumbing sanitation system.
Plumber's Name (print)
PI Sig (ryo s��erXs):
MP/MPRS No.
Business Phone Number
P
V --------
Plumber's Address (Street, City, State, Zip Code)
VII[. County Use Only
D'I s
:Sanitary Permit Fee
is
Date Is ued
Issui Agent Si atur No s ps)
Approved
Owner en �Iniftt�ia�verse
Z
25
/49
Determination
Conditions of Approval/Reasons for Disarr at:
go
L
.54TOC —ul c-,
.
Rev. 8/05 6-L. th 1 0 e6 t_e_4V
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Vacoled ROW
Railroads
- - �, j`_+:, iy'+i •jK#•, -5 -'1-` :.` � '.k ,Y+ •� ri t.:l.�r S.A-In "A. ,�1��1:" i. Soils
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Conveyance Division
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DISCLAIMER- This map is not guar�
te, correct,
1-tY.+tl a+:tlF'-�` t �'r• ' ° . rr r 1 ` [f ` 'iV1' 17`�3�•M�1 conclusionsa:• - respons
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Wis. Dept. of Safety and Professional Services SOIL EVALUATION REPORT Page Of
Division of Safety and Buildings "L�ancio
ew'Bith SPS 385, Wis. Adm. Code
County st croix
Attach complete site plan on paper not less thaw 8 1/2 x 11 inches in size. Plan must I include, but not limited to: vertical and horizontal referent*,polnt (BM), direction and Parcel I.D.
percent slope, scale or dimensions, r#Mh arrow, and location and distance to nearest road. e> 00
Please print all information. Reviewed y Date'
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
IProperty Owner JOE MILLER Property Location
I SW NW 5 T/ 2(—' 0
Property Owner's Mailing Address Govt. Lot 1/4 1/4 S N R 'E (or) W
569 CTY RD NN Lot # Block # Subd. Name or CSM4(
City WILSON State Zip Code Phone Number [lofty �Villa ge Ofown Nearest Road
W1 54027 na60th ave
— Cady
E) New Construction Use Residential / Number of bedrooms Code derived design flow rate GPO
0 Replacement OPublic or commercial - Describe:
Parent material Flood Plain elevation if applicable
General comments PRIVEY USE ONLY
and recommendations:
11 Boring
Boring #
13 Pit Ground surface elev.
Horizon
Depth
Dominant Color
Redox Description
Texture
in.
Munsell
tau. Sz. Cont. Color
A
0-10
10 YR 3//2
---- -- — ---------
SIL
E
10-14
e7.5 YR4/4
--------
SIL
B
14-22
7.5YR 4/4
— ------- — ---
LS
C
22-86
7.5YR4/4
S/CB
Boring# Boring
L� Pit Ground surface elev.
Effluent #1 = BOD 2 > 30 < 220 mg/L and TSS >30 < 150 mg/L
CST a (Please Print) Si ature
Address
Depth to limiting factor
in.
Soil Applicabon Rate
Structure
Gr. Sz. Sh.
I FBK
onsistence
MVFR
oundary
I CW
I
Roots
*
2M
GPD/ft 2
Iff#l- -
.4
tff#2
.6
IMABK
IFSG/CB
SG/CB
MFR
MFIR
CW
CW
CW
2M
I VF
.4
.7
.6
1.6
.7
1.6
Depth to limiting factor
icture onsistence oundary Roots
E. Sh.
Soil A Eplicabon Rate
GPD/ft 2
ff#1 *tff#2
LMuent #2 = BOD 45 < 30 mg/L and TSS < 30 mg/L
CST Number
Date Evaluation Conducted Telephone Number
SBD-8330 (RI 1/11)
8287934
State Bar of Wisconsin Form 2-2003
Tx:4236188
WARRANTY DEED
1008676
BETH PABST
Document Number Document Name
REGISTER OF DEEDS
ST, C RO IX CO - r WX
03/05/2015 11:34 AM
THIS DEED, made between Harold Halverson, aka Harold H. Halverson, a single
EXEMPT#: NA
RFC FEE: 30.00
person
TRANS FEE: 1350.00
("Grantor," whether one or more), and er.PAGES:
1
husband and wife, holding as survivorship marital property
("Grantee," whether one or more).
Grantor for a valuable consideration, conveys and warrants to Grantee the following
described real estate, together with the rents, profits, fixtures and other appurtenant
Recording Area
interests, in St. Croix County, State of Wisconsin ("Property") (if more
Name and Rentrn Address
space is needed, please attach addendum):
Thomas A. McCormack
Southwest Quarter Of Northwest Quarter (SW 114 Of NW 1 /4) and
PO Sox 2120
Southwest Quarter of Northeast Quarter (SW 114 of NE 114) and
Baldwin WI 54002
Southeast Quarter of Northwest Quarter (SE 114 of NW 114) of Section
Five (5), Township Twenty-eight (28) North, range Fifteen (15� West.
004-1010-80-0009 004-1010-30-0009
004-10 ■ 0-90-OOo
Parcel Identification Number (PIN)
This is homestead property.
(is) (is not)
Exceptions to warranties:
Easements and restrictions of record.
f
J
Dated
AUTHENTICATION
Signature(s)
authenticated on
(SEAL) �' ' (SEAL)
* Harold H. Halverson
(SEAL)
(SEAL)
ACKNOWLEDGMENT
STATE OF WISCONSIN )
) ss.
ST. CROIX COUNTY)
Personally came before me on
the above -named Harold Halverson, ajeaHarAR Halverson
TITLE: MEMBER STATE BAR OF WISCONSIN It
(If not, to m known to be. e� person(s) hoc used the foregoing;authorized by Wis. Stat. § 706.06) instle
over .� �� 1�
THIS INSTRUMENT DRAFTED BY: * Thomas,A. IVI'cCormackf _
Thomas A. McCormack Notary Public, State efolVlisconsin
Baldwin WI 54002 . f, �^My commis ionj(.:s,Lne nn�r. ent),(ar
(Signatures may he authenticated or acknowledged. Bnrh°ari! not necessary.-M
NOTE: THIS IS A STANDARD FORM. ANY MODIFICATION TO THIS FORM SHOW D HENCLEARLY IDENTIFIED.
WARRANTY DEED 02003 STATE BAR OF VI'ISCON'SIN tr FORM NO.2-2003
*Type name below signatures. INFO-PROT'"wwwJnfoproforms.corn
St. Croix County 1008676 Page 1 of 1
ST* R X
T Y
-Wil
RE: Non -Plumbing Sanitation, privy
Community
Development
Government Center
1101 Carmichael Road Hudson WI 54016
Telephone: 715-386-4680 Fax: 715-386-4686
www.sccwi.gov
A sanitary privy can be installed provided there is no interior plumbing to a structure, but only
with an approved County Sanitary Permit, a recorded non -plumbing sanitation affidavit and
supplying a plot plan showing all setbacks are met.
Please be advised of the following requirements:
1. A Soil and Site Evaluation to be completed by a Certified Soil Tester in the state of
Wisconsin.
2. A copy of the recorded Warranty Deed is required at time of application submittal. If you
do not have a copy available, you can obtain a copy from the St. Croix County Register of
r)nnrlc =+- n minim=l fno Thic nfFrn is Inratorl arrncc tho hmil frnm the rnmrni inihi
1600 %. %.0 %A %J %A %. bl 1 1 1 1 1 1 11 1 1 bl 1 1 v. `. ■ 1 1 1 14 .0 V I 1 1 1 \/,rM 0 �r I. %A A• It v I / 1 1.1 I V v v 1 1 1 1 1 I" I I 1 4 •
Development Department office.
3. A Non -Plumbing Sanitation affidavit is required to be recorded with the St. Croix County
Register of Deeds; a $30 recording fee will be required. Staff will be able to help you fill
out the form. Please contact the main office at (715) 386-4680 to schedule an
appointment with a staff person to complete this affidavit when you drop off the
application.
4. A site plan must be included with the application with the following setbacks:
a. Well must be 50 feet from a privy.
b. Privy must be 25 feet from a dwelling, 25 feet from a lot line and 25 feet from any
slope 20% or greater.
c. Privy must be 75 feet from the Ordinary High Water Mark of a stream, lake or river.
5. Vaults must be 200 gallons or greater and a State of Wisconsin approved product.
6. Privy openings shall be screened and all doors self -closing.
7. Vent for the vault must extend at least one foot about the roof and be at least 3 inches in
diameter.
8. Owner must call for an inspection, 24 hours prior to requested inspection time.
Due to the amount of sanitary permits submitted to this Department every day, staff cannot
guarantee that a permit will be approved the same day is submitted. Please plan for
approximately one (1) week to receive your approval. Upon approval of the sanitary permit,
then you will be able to pursue approval with the Town for a building permit for a structure
intended for habitable purposes. Each Town contracts with a Building Inspector, it may be
easiest to contact the Town Chair to get this information. A driveway permit may also be
required if there is not an existing residential access, please contact the Town Chair regarding
this as well.
The Town Chair for Cady is Michael Tully and he can be reached at (715) 772-4578.