HomeMy WebLinkAbout020-1332-70-000
' ST. CROIX COUNTY ZONING DEPARTMENT -
AS BUILT SANITARY REPORT R[avk:;ve
v
Owner A c A u r sTo T J t S 1998
ST CROIX
Address AC.1ec.7u Ae G COUNTY
City/State l2 _S-yd l~ ZONIMrOFFICE
Legal Description: ` ' ..i....'.
Lot Z_ Block Subdivision/CSM #
X 20 -13~i2 -70 - DO p
'/4 "'/4 ,,yA), Sec. 07 , TAN-RAW, Town of PIN #
SEPTIC TANK DOSE CHAMBER HOLDING TANK INFORMATION:
Tank manufacturer Size ST/PC / &T 5 Setback from: House X P! WellSa t P/L .5-4-1
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: t- BAJ Width 25- Length Jl3 Number of Trenches 2
Setback from: House YD Well o f P/L r4 Vent to fresh air intake
ELEVATIONS:
Description of benchmark ? e- Elevation P O , o
Description of alternate benchmark SX Elevation
Building SewerloaS &ZST/HT Inlet 99.ci 3 ST Outlet 99 •sS- PC Inlet
PC Bottom Header/Manifold 'f7-(-C. Top of ST/PC Manhole Cover /003
Distribution Lines T1. 36 f ( ) ( )
Bottom of System ( ) q L , 3 6 ' ( ) ( )
Final Grade 11, {v ( )
101
Date of installation / /f / Permit number 2lcN*2S-- State plan number
Plumber's signature License number VDate
Inspector R/F
Complete plot plan
1
NOTICE: Please provide the following:
• A plan view sketch showing everything within 100 feet of the system.
• Two horizontal reference points to center of septic tank manhole cover.
• Show. alternate benchmark, if applicable.. - 76R o , e4,.4 S/--b
PLAN VIEW
o
d _
v : y
INDICATE NORTH ARROW
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
Safety 9nd Buildings Division
'ST. CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) SanitarMr tA.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
~~irritlio,lefidN&RD [~eib46 /illage E] Town of: State Plan ID No.:
CST BM Elev.: + Insp. BM Elev.: BM Description: Parcel 19,2b:,,;1332-70-000
10I /0/,(", lt. Ate --o0T 2" Pit
TANK INFORMATION ELEVATION DATA A9700251
TYPE MANUFACTURER CAPACITY STATION BS Hl FS ELEV.
Septic M Cho ~C~ Benchm I& • Y 105' /D/ 6-,C~
Dosing /a-(,<_&m- 1U, 2•S')6 1021
Aeration Bldg. Sewer y. 10015./oo.b
Holding P /Ht Inlet 5_-07 017.53
TANK SETBACK INFORMATION ISt Ht Outlet 1 -y, 99 Ss
TANK TO P/L WELL BLDG. Ventto Air Intake ROAD Dt Inlet
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe -7 .(-Z cl -7 3V
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade S V qq.
Manufacturer Demand Ma IrI - 7,07 1d/f,
Model Number GPM
TDH Lift Friction stem TDH Ft
Forcemai n Length jia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED TR NCH Width SIP Length No. Of Trenches PIT No. Of Pits Insi a Di Liquid Depth
DIME ) 2_ DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHING Ma acturer:
SETBACK
INFORMATION TypeO f / M Number:
System 101-r nii-j R - V) j/ OR UNIT CHAMBER
DISTRIBUTION SYSTEM 14ST vA Z7 Z
Header/Manifold Distribution Pipe(s) , x Hole Size x Hole Spacing Vent To Air Intake
Length Dia- Length 115 Dia. K Spacing & 'fi 4-6
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over x epth Of xx Seeded /Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges T soil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 27.29.19,SW,NW 774 WILFRED RD A&B LOT 7
Plavi vir'> revl,51,oh 5 jMee S~S~u►~ We Ih5~a
.
hr,rwe-c°-d1 Z.
Plan revision required? Yes ❑ No
Use other side for addition I information. - / 7
Cert. (R.3/97) Date Inspector's Sig ture Nom.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
Safety and Buildings Division
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.
• See reverse side for instructions for completing this application state sa~tary Permit Number
The information you provide may be used by other government agency Pro9~,/ rams E] P Check If revision oaPPlication
r
[Privacy Law, s. 15.04 (1) (m)]. 774 VI /T>VV 4~
'TT Nr State Plan LD. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Property Lo ation
yam( a `,r 1/4 /~1/4,S 0-7 T N, R/ E(or)
Property Owner's Mailing Address Lot Number Block Number
City, State Zip Code Phone Number Subdivision Name or CSM Number
.4 S-Alel_ a ;7 51
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ Cityyage Nearest Road
~
Public 10 1 or 2 Family Dwelling - No. of bedrooms ❑ Vill Town OF IA J 1r`T
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/Condo 017. a9. 1q. /797 Oa?v 33,3 -7 U
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
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 12 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
C K.2 Feet 10®. ;aeet
VII. TANK Ca
in galloacitns Total # of Prefab. Site Fiber- Ex per.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic AppNew Existing strutted
Tanks Tanks
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
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:
Ibra=`:~5~t3
Plumber's Address (Street, City, State, Zip ode): 1 ~
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issue Issuing A ent Sig ature (N St ps)
Approved E] Owner Given Initial Surcharge Fee)
Adverse Determination (J
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Di-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 pumperwhenever
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 on line 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 phone 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; Q 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.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for 'nonitoring groundwater contamination investigations
and establishment of standards.
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION 1 3
Labor and Human Relations Page of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than S 1/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. #
020- 1076-9v
APPLICANT INFORMATION - Please print all information. Reviewed by Date
Personal infomnation you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
Richard Stout Govt. Lot SW 1/4 NW 1/4,S 27 T 29 N,R 19 K(or) W
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
1353 Awatukee Trail 7 Badlands Prairie
City State Zip Code Phone Number ❑ City ❑ Village U Town Nearest Road
Hudson WI 54016 (715) 549-673 Hudson State Hwy 12
® New Construction Use: ® Residential / Number of bedrooms 6 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 9 0 0 gpd Recommended design loading rate • 7 bed, gpd/ft2. 8 trench, gpd/ft2
Absorption area required _L2_$6-bed, ft2 1 12 9 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2. 8 trench, gpd/ft2
Recommended infiltration surface elevation(s) 9 6 . 7 0 ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material Glacial deposit 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 [3 s ❑ u ERS El u ®S ❑ u ® S ❑ u ❑ S ® U ❑ S ® 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
1 1 -6 7.5yr2.5/ none L 2mabk mfr cs 2m .5 ;.6
2 -24 10yr3/4 none sil 2mbk mfi cw if .5 '.6
Ground 3 4-9 10yr4/6 none ms a> ml cw .7 ..8
9 9 : 4e~' ft
Depth to
limiting
factor
9 6 in.
Remarks:
Boring #
1 -8 7.5 r2.5 none L 2makb mfr cs 2m 15
2 8-- 10yr3/4 none sil 2mbk _mfi cw If .5 6
2 u- - - - -
3 8-9 10yr4/6 none ms ps ml cw .7 -.8
Ground
elev. 99.24 ft.
_Depth to
limiting
factor
96 in. Remarks:
CST Name (Please Print) Signature Telephone No.
/•'a r.2 C -A cc n. cc fees F6 - 7i17
Address ' Date CST Number
S 7~ s~i.v ,r D! 7 ?79 d
.?ROP.ERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D.#
3oring # Horizon Depth Dominant Color Mottles Structure G~pjft2
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed Trench
3 0-10 7_5)jr2_5Z] none L 2mabk mfr cs 2m .5 .6
2 10-2 10yr3/4 none sil 2mbk fi cw if .5 '..6
around 3 28-89 1 0yr4/6 none ms "it 05 1 cw .7 ' . 8
;lev.
9 8 . eft.
)epth to
imiting
actor
in.
Remarks:
3oring #
1 0-14 7.5yr2.5 1 none L 2mabk mfr cs 2m .5 .6
2 14-40 10yr3/4 none sil 2mbk mfi cw if .5 ,.6
4 3 40-82 10yr4/6 none ms wi QS' all cw .7 :.8
around
alev.
97. 14 ft.
Depth to
imiting
actor
8 2 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
Boring# 1 0-1 7.5yr2.5 1 none L 2mabk mfr cs 2m .5 ' .6
5 2 10-38 10yr3/4 none sil 2mbk mfi cw if .5 '.6
3 38-96 10yr4/ none ms X61 ml cw .7 .8
Ground
elev. -
96 ._14 _ft.
Depth to -
limiting
factor
.A in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
- Remarks:
SBDW-8330 (R. 08/95)
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STC- 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS i 5 w 2 C"
PROPERTY ADDRESS E( GJ, /may / f ~lc G~S®.c~ / 4. r
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE c~s~h , S 0 1
PROPERTY LOCATION 1/4, 1/4, Section 1` arI N-R Q
TOWN OF G S ST. CROIX COUNTY, WI
SUBDIVISION c~L A-v-4 S za *X lZ t LOT NUMBER
CERTIFIED SURVEY MAP , VOLUME_, 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 (I)
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: n
DATE _
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Iiudson, WI 54016 t ~1)3
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 ~Z" C;~rzx z) v
Location of property SL-) 1/4 A) LU 1/4, Section a-j T_2_~_N-R__A0
Township SUr Mailingaddress 13 53 Pw yq 4j )G e TR ',C
c~S~, Lv~ 5 ~{b I b
Address of site AV subdivision name L r4n,.~Q s 2 Lot no.-2--
Other homes on property? Yes ~ No
Y Previous owner of property
Total size of property 1 (v b L~Ze s
Total size of parcel 3 ►'-1S
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes ~_No
Volume and Page Number 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. and own the proposed site for the sewage ,disposal tsystem ) orr Ie(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.
p Applicant Co-Applicant
Date of Signature Date of Signature
: • . SS3584 ~y
STATE BAR OF WISCONSIN FORM 1 - 1982
WARRANTY DEED
DOCUMENT NO.
vonPacE442
IC"G. n
'i This Deed, made between The NGL Cornorati on uT. CROP%~
i a Wisconsin cor oration organized A ril 1 .1996 and `f ilec'~JtorRecora
e wit t o scons n Secretary of State on
Pr l DEC 2 0 1996
Grantor,
and Richard 0. Stout 3:30
ii ~ •.tt P.
Grantee,
_
Witnesseth, That the said Grantor, for a valuable consideration
conveys to Grantee the following described real estate in 3t . Croix THIS SPACE RESERVED FOR RECORDING DATA
County, State of Wisconsin:
'NAME AND RETURN ADDRESS
Richard 0. Stout
See Exhibit A hereto. 1351 Awatukee Trail
Hudson, WI 54016
020-1074 80-000, 020-1074-90-000,
020-1075-n -nnn, non ~ me ~n-000
PARCEL IDENTIFICATION NUMBER
$ TRANSFER
Grantor also quit-claims to grantee any reversionary right, title and interest to the
parcel described in Vol. 588, page 212, Doc. No. 354521, and in Vol. 588, page 214,
Doc. No. 354522.
I
This is not homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
See Exhibit B hereto
and will warrant and defend the same.
Dated this 4th day of December
,19_x_.
(SEAL) The NG Cor ration (SEAL)
(SEAL) Robert Romeo
(SEAL)
'Its: VP R f nn+-.,,,,.._
ACKNOWLEDGMENT
Signature(s) Minnesota
State of llts~taca[sti~t,
ss.
i
authenticated this day of Count , l
19 personally came before me this day of
vot 17214FAM43
EXHIBIT A
Legal Description
The NGL Corporation to Richard O. Stout
The South Half of the Northwest Quarter, the Northwest Quarter of the Northwest Quarter,
and the West Half of the Southwest Quarter of the Northeast Quarter of Section 27,
Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin.
Except that portion of the Northwest quarter of the Northwest quarter of said Section
27 described as follows: Beginning at the Northwest corner of said Section 27; thence
along the North line of said Section 27, South 88 degrees 23 minutes 58 seconds East
160 feet; thence, diagonally, South 29 degrees 07 minutes 38 seconds West 338.27
feet to a point on the West line of said Section 27; thence along said West line, North
0 degrees 54 minutes 02 seconds East 300 feet to the Northwest corner of said
Section 27 and the point of beginning.
Subject to the right of St. Croix County for highway purposes as established by deeds
recorded in the office of the Register of Deeds for St. Croix County, Wisconsin, in
Volume 257, page 118 and Volume 302, page 24;
Subject to the right of way grant to the Wisconsin Telephone Company, recorded in
the office of said Register of Deeds, in Volume 472, page 85, document 305105;
Subject to the existing town road along the North line of the Northwest Quarter of the
Northwest Quarter of Section 27.
220798-1
'Jim
foot fi214 PACE 4 4 4
Exhibit B
Liens and Encumbrances
The NGL Corporation to Richard O. Stout
(i) Municipal and zoning ordinances and agreements entered under them, (ii) recorded
easements for distribution of utility and municipal services, (iii) recorded building and use
restrictions and covenants, and (iv) general taxes levied in the year of closing.
220798-1