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HomeMy WebLinkAbout020-1135-10-000 Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 299087 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: SLEETER, LYNN HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 020-1135-10-000 TANK INFORMATION ELEVATION DATA A9700405 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet verit irIto ntake ROAD Dt Inlet TANK TO P / L WELL BLDG. A Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Head Forcemain Length Dia. Dist. To Well I F SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Liquid Depth DIMENSION DIMENSIONS SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION TypeO CHAMBER Mode 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 Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 20.29.19.661,NE,NW 941 RIDGE PASS WILLOW RDG WT 52 Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH , SANITARY PERMIT NUMBER: .M Safety and Buildings Division ~•~i_~i SANITARY PERMIT APPLICATION Bureau of Building water systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. C 'r • See reverse side for instructions for completing this application state anI ary Permit Number 931061 The information you provide may be used by other government agency programs ❑ Check it revision to previous application (Privacy Law, s. 15.04 (1) (m)]. Sal • "v State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location ~r E (or(!~) r ~k174 N W 1/4, S ZdT Z°f • N, R j f Propert~ Owner's Maili g Address Lot Number Block Number 1;4 1 Z o.SS y, It to Zip Code Phon Number Subdivision Name o SM Number y , 171S 36 4 899 l OW II. TYPE BUILDING: (check one) ❑ State Owned C] ity Nearest Road ❑ Village of ~sd..~ r) 5 GSS Public 1 or 2 Family Dwelling - No. of bedrooms rs(T Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment / Condo RO' /Cf. &W r:>- 1/ 3,5 - w 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. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5 Repair of an System System Tank Only Existing System 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 1 eepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 1 Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 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/day/sq. ft.) .(Min./inch) Elevation L}~U 6y3 , 7 ?Z-0 Feet 9'6.0 Feet TANK Capacity VII. FORMATION in gallons Total # of Prefab. Site Fiber- Exper. New Existing Gallons Tanks Manufacturer's Name Concrete strutted Con- Steel glass Plastic App Tanks Tanks Septic Tank or Holding Tank t~ /bo'0 1 50 ❑ ❑ 1:1 1:1 1:1 Lift Pump Tank /Siphon Chamber ❑ 1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. roiNrnk er's Name: (Print) 's Signature: (No Stamps) MP/MPRSW No.: 7]]Buiness Phone Number: E&4 '7Y7d? 386 • Z/36 Milo (410.6.1 Rk"Yrber's Address (Stre City,State, Zip Code): / 0 Z 44 -7 6f • IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing A ent Si ature ( St ps) A roved ~ surcharge Fee) pp ❑ Owner Given Initial ~f Adverse Determination /v & X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to county, One copy To: Safety & Ruildings Div, ion, Owner, Plumber INSTRUCTIONS ' 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one online A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phor e number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or vvith complete' dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems,- replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C; complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E.) soil test data on a 115 form; and F) all sizing information. GROUNDWATIER SURCHARGE - 1983 Wisconsin Act 410 included the creation of surcharges (fees) fora number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of s andards. G. 114i iF,(e f-770x-) 74 ~X f ' Git /APO CES S' Wisconsin Department of Industry, SOIL AND SITE EVALUATION J 2 Labor and Human Relations Page of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. 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 5'r, ~l ~x percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. # 0 L-CJ J 33_- 10 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 G Y VA,,' S1C'E TER Govt. Lot IVE 1/4 VU) 1/4,S LO T Zy N,R /9 E (o W Property Owner's Mailing Address Lot # Biock# Subd. Name or CSM# Roa City State Zip Code Phone Number [B --Town ff vD.SO~ • Sggl& (?/S )3Fc0 •d ff! ❑ City El Village [B-Town j~/ 'E /~i~S ❑ New Construction Use: L25esidential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 7 gpd Recommended design loading rate ' 1 bed, gpd/ft2 ' 'r trench, gpd/f12 Absorption area required. _bed, ft2 ~4 trench, ft2 Maximum design loading rate ' ? bed, gpd/ft2~trench, gpd/ft2 QXiST1"Ja - , -Bscammepdecf infiltration surface elevation(s) .F&nll, yx ,,~f t pf• j z ft (as referred to site plan benchmark) Additional design/site considerations Parent material 51Ar e141 &&ZW S4!!DY 40402 Flood plain elevation, if applicable ft S = Suitable for system Conventional Moou In-Gro ressure SAT-GG de System in Fill Holding Tank U = Unsuitable for system S❑ U O's ❑ U [fl S0 U L S❑ U ❑ S ETU ❑ S u SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench . s 0 -If goy 31SiI a f sl,C~ ~G CS If Ground 6 Sl~ lTcs~!~ . Z, • 3 elev. 00 7- Depth to limiting factor 2-in. •S /P Q'C IOV~ v 0~S 7-- Remarks: Boring # / 6`-/Z 10 3 3 SQL Z-f S~iC' l? P /7C 5 ; • Co 2 Z - a 10 31.~- 51~1 2 fS A" e-5 if . -5:. Co Ground /~I/~ Z- 7 S )l/e Y~~P r~iL- l ~JrL~c.~/ • Z '3 elev. AS/ /zw Sly .S d, S GQ~ - - . ? Depth to limiting ;7 g ffactor in. Remarks: 9^';0Ai'eA0 Phi S 7~ %v 4 0 j» CD~Y /i ,uT S~i~L--S CST Name (Please Print) Signature Telephone No. 8013'ei. i -7 IS • 3<?6 ' SOPS -"4 Address i , LA Date CST Number SS ~ Nom"/G • fj~191>SOJ •~`falCo ~ -7- t? CS]'~c.~'f~ SOIL DESCRIPTION REPORT PROPERTY OWNER Page of PARCEL LDI Boring # Horizon Depth Dominant Color Mottles Structure 2 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground elev. ft. • Depth to limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Structure GPD/ft2 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Ground elev. tt Depth to ; limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. . Remarks: ' ,Z,- o i S2- , .S C.4 L~ = / ` 30 Cyr 31, ~z- l~v ~v 9 -2 3 , J I W~~L ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the L.~, N µ Sleet{cr residence located at: Sec. Zo T Z.!I_N, R__L5i_W, Town of St. Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced --t ) q(. Did flow back occur from absorption system? Yes No-X- (if no, skip next line. Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete X Steel Other Manufacturer (if known): Age of Tank (if known) : ~1 rye-^-_ ~..1 j(Y'1 cv~ a..a ( ignature) T (Name) Please int ouz'w~/ ![Y~rtc.'~CJ 1;"% ~C~IAN{~I a 1~11twA)L~ 1-7 (Q (Title) (License Number) al-1101-1 (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name Signature MP/MPRS ST. CROIX COUNTY WISCONSIN - ZONING OFFICE 1 " ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 AFFIDAVIT OF SYSTEM REJUVENATION Property owner: L.I HN Sl-csL~-c[' Address: q `t '~1 l 1cc~2 ~1 c, s~ Day time phone: (77) Parcel I. D. 1135- la Legal Description of property: _&E_; 4Q Sec. Zo , T. Z01 N., R. 1~L_W. , Tn. of ~ LaGc d , St. Croix County, WI As owner of the above described property, I aaknowledge that the septic system serving this residences s no undersized by current code standards. I understand that the issuance of a sanitary permit to allow the attempted rejuvenation of the septic system does not imply that the system meets current code sizing requirements, nor does it imply that the proposed procedure will be successful. I also acknowledge that I will make this information available to any future parties interested in purchasing this property. Signature: Date: 26 ~Q~ 5/97 8 T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. owner of property L„ "hJ% Location of propertyjA.F_1/4 MW 1/4, Section Za T Zy N-R 1_a_W Township Mailing address C1,41 Z`IIAJ)_. Address of site Subdivision name W'~~a~ 2\ -jam Lot no. 5 Z Other homes on property? Yes__')( No Previous owner of property Total size of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes _No Volume 18o and Page Number 10il as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. _ y;yaay4 , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. ya~Z~ Signature of Applicant Co-Applicant '7 Date of Signature Date of Signature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER L s/ N jo St e t~ -c- r ~G c . "I a~ S S MAILING ADDRESS q4 j PROPERTY ADDRESS PA J. booo l.-) s (location of septic system) Please obtain from the Planning Dept. CITY/STATE 14 PROPERTY LOCATION IV E 1/4, ~ 1/4, Section ?U T 761 N-R /of W TOWN OF 14 df nti ST. CROIX COUNTY, WI SUBDIVISION \,V ; ) d,_j LOT NUMBER S 2 CERTIFIED SURVEY MAP , VOLUME AIL PAGE, LOT NUMBER 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED:. cy DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 DOCUMENT No. STATE BAR OF WISCONSIN FOkW 1 - IM TNU •/AC[ scsUlvcn .oft 11[CORDIN0 MAYA WARRANTY DEED 420294 7~Of IS"1 R`GISTERS OFFICE This Deed, made between . Arne B. Thomsen, Jr. and ST. CWIX CO., WIS. barbara_>I.. Thomsen Recd. for Reocrd M 1st day of June A.D. 1987 Grantor. -"A and Michael _R. Sleeter and, Lynn L.. Sleeter, husb.3nd and. wife Grantee, Witnesseth, That the said Grantor, for a valuable consideration - ~ RETURN TO conveys to Grantee the following described real estate in - .Ft.. Croix County, State of Wisconsin: Lot 52, Willow Ridge 2nd Addition to the Town of Hudson. Tax Parcel No: FEE This deed is given in fulfillment of a certain land contract executed between the above parties on April 15, 1982, recorded in the office of the Register of Deeds for St. Croix County, Wisconsin as Document Number 377134 in Vol. 645, Page 321. This is homestead property. (is) (WWX Together with all and singular the hereditaments and appurtenances thereunto belonging; And. .granto,rs,-Arne-.B.- Thomsen, _.Jr.- and Barbara J. Thomsen------ - - _ - warrants that the title is goad, indefeasible in fee simple and free and clear of encumbrances except easements, covenants and restrictions of record, if any, and liens or encumbrances created by act or default of grantees and will warrant and defend the same. day of May 9 Dated this u (SEAL) (SEAL) Arne B. Thomsen, Jr. (SEAL) '.e 1k„-n•.- .(SEAL) Barbara' J. Thomsen . AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN 88. .ti..Cl~oJ4?4--------- County. / authenticated this da- of.-_ 19...... Personally came before me this.--.~l-..... day of 1W_Y.......... 19A.... fhv'above named Arne E -'fho t en and • -------------------Barba;a_,~hbsnY~~-----•-- TITLE: MEMBER STATE BAR OF WISCONSIN - - - _ . x f (If not, . - authorized by 3 706.06, Wis. Stats.) S, to me snow-n to be the person vbo'~,4K.ted the fore~ing instrument and acknLwledgg t~# Ntene. THIS INSTRUMENT WAS DRAFTED BY , - .