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HomeMy WebLinkAbout020-1332-60-000 ~4L.. /S, srL. e-~ ` ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT` ~ELLI~ED EI J Owner ~Qi,-Ag rj sr c olx"r Address wa 7~ e Tim ~r COUNTY r r ZONINGOFFICE City/State A/& d so iui Legal Description: Lot Block Subdivision/CSM # &,4 CX~ t/4 t/4 Ayw, Sec. ,?7, TAN-R /,I W, Town of & A y o.~ _PIN # /)Z0-)33Z-4P6-6 SEPTIC TANK DOSE CHAMBER HOLDING TANK INFORMATION: Tank manufacturer ~e,'d rv e yr" Size ST/PCl Setback from: House Well P/L -Sa 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: Copt) Width S Length Ili Number of Trenches - 7-Setback from: House Se' Well 31 ~ P/L ~ Vent to fresh air intake ELEVATIONS: Description of benchmark 2 ` `pvG Elevation l~~ a Description of alternate benchmark 5'~4 a h Elevation -5- G ti e-- o R e/rJ6 Y Building Sewer /17 9 ST/HT Inlet Cf7.31 ST Outlet .9 PC Inlet PC Bottom Header/Manifold ~~i• G S Top of ST/PC Manhole Cover Distribution Lines ( ) #,r ( ) ( ) Bottom of System ( ) ~5~5 ( ) ( ) Final Grade ( ) O ( ) I~ Date of installation Permit number Z'91 41,3 State plan number Plumber's signature License number Date / / Inspector /(1 45- Complete plot plan 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. PLAN VIEW r/ 0 s- x j l3 TYeiU s 0 _ v d ~R INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM CountyST. CROIX safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarpjfg4y4t±13.: Personal information you provice may be used for secondary purposes [Privacy LsAv, s.15.04 (1)(m)]. gTe3b~~de i4RD [ t illage ❑ Town of: State Plan ID No.: ii I CST BM Elev.: Insp. BM Elev.: BM Description: ~}vYV~ ub S 5 Parcel TOE►115-1332-60-000 100 loo Ion +0 c).F V, *-OoLetivif. TANK INFORMATION ELEVATION DATA A9700250 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic M W ((o Benchmark /07-, / bU Dosing Aeration Bldg. Sewer Uo7 X11 ' 979 dD4vt Inlet .(Pq~ (7731' Holding TANK SETBACK INFORM ION (jE>1 t Outlet -5 02 9(0 TANK TO P/L WELL BLDG. vent to AirIntake ROAD Dt Inlet Septic +(Pp q' 7 JD' NA Dt Bottom Dosing NA Header Man. yr/A Aeration NA Dist. Pipe 35 55 9f. q~ ~fS Holding Bot. System G ` cls_ 5- 5 PUMP/ SIPHON INFORMATION Final Grade 2 CO•b Manufacturer Demand s 61 U.,, W-{(ev 311 V~~ l Model Number GPM AI_ g X/ 6 TDH Lift Friction s m TDH Ft Loss ea Forcemain Length Dist. To Well SOIL ABSORPTION SYSTEM Liquid Depth BED THE tH Width Length , No. Of Trenches PIT No. Of Pits gManurer: DIMEN 113 DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING INFORMATION Type O CHAMBER er: System m' J / + `T~ n7i OR UNIT DISTRIBUTION SYSTEM -,J45 Header J Manifold Distribution Pipe(s) x H Size x Hole acing Vent To Air Intake Length ~ Dia. Length 03' Dia. Z4 Spacing SOIL COVER x Pressure Systems Only xx M nd Or At-Grade Systems Only Depth Over Depth Over epth Of xx Seeded / Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Aoil- ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons prese t, etc.) LOCATION: HUDSON 27.29.19,NW,NW 778 WILFRED RD A&B LOT 6 Z,0f -4 rdvw( Ir l9-cf? Plan revision required? ❑ Yes No Use other side for additional infor a 'on. 11/111 171~gj SBD-6710 (R.3/97) Date Inspector's Si ature rt. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Sa fety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water Systems (Ei 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 1/2 x 11 inches in size. T etlw I X • See reverse side for instructions for completing this application State Sanitary PPermjt Number 99 3 The information you provide may be used by other government agency programs E] Check i1 revision to previous application [Privacy Law, s. 15.04 (1) (m)]. 779 Wfl fred Rd State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Propert y Owner Name Proper tion t 1/4 /4,S.27 T q, N, R 147 E (or Property Owner's Mailing Address Lot Number Block Number 1353 a4LI'c Ac c T ; City, State Zip Code Phone Nu a Subdivision Name or CSM Number c~.L G.S --S',lQ1G (7iti > ~?3l ,C3actl~.~.~✓~ a^~'G II. TYPE F BUILDING: (check one) ❑ State Owned ~!ty Nearest Road p Village 10 Public 1 or 2 Family Dwelling - No- of bedrooms own OF H,.,40, III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) a7. 1 ❑ Apartment/ Condo 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_____________TankOnly 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 fK 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. Sy _stem Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation 7®© t ' Feet Feet VII. TANK Capacity sate in allons. Total # Of Prefab. Fiber- Plastic Exper. INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- steel glass App. New Existin strutted Tanks Tanks I 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: (No slam s) P MPRSW No.: 7;T, hone Number: Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/ DEPARTMENT USE ONLY Disa roved sanitary Permit Fee (lndudesGroundwater ate Issue Issuing Agent Sig ature (N to s) ❑ Pp ..~5. Surcharge Fee) Approved ❑ Owner Given Initial ✓e ,~jc?J s-~ Adverse Determination 18e 7~ ll X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SRD-6398 (R. 05/94) DISTRIRUTION: Original to County, One copy To: Safety & Ruildings Division, 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 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 8 112 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with 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. 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 monitoring groundwater contamination investigations and establishment of standards. P c~ ~ BBD ~~a o /3? , a Dcap~~.~ u`~ ?G~ /=aeG~ zk s GJ~-'7`"~V' ja 4' r I T es t Wisconsin Department of Industry, SOIL AND SITE EVALUATION Labor end Human Relations Page 2 .Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 112 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. # 620- /07y- 9D 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 Richard Stout Govt. Lot NW 1/4 NVi7 1/4,S 2 7 T29 N,R 19 X (or) W Property Owner's Mailing Address Lot # BlockT bd. Name or CSM# 1353 Auatukee Trail 6 adlands Prairie City State Zip Code Phone Number ❑ City ❑ Village ❑X Town Nearest Road Hudson WI 54016 (715 )549-67311 Hudson S t Hwy 12 ® New Construction Use: K] Residential / Number of bedrooms fa 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 12 R h bed, ft2 1 12 5 trench, ft2 Maximum design loading rate. 7 bed, gpd/ft2_$,_trench, gpd/ft2 Recommended infiltration surface elevation(s) ~IJ~• li y 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 Fj de System in Fill Holding Tank U = Unsuitable for system ®S ❑ U ® S ❑ U R] S❑ U U I ❑ S ®U ❑ S 0 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles in. Munsell Qu. Sz. Cont. Color Texture Structure Sh Consistence Boundary Roots GPD/ft2 Bed Trench 1 - r L AAabk 2 -24 10yr3/4 none sil 2mabk mfi cs If .5 ;.6 Ground 3 4-9 10 r4/6 none ms os ml cs elev. 99.41 ft. Depth to limiting factor 9 6 in. Remarks: Boring # ma ek 1 31- none . L 2mfr r- 2m 2 -38 10yr3/4 none sil 2mabk mfi cs if .5 ~.6 2 3 8-9 10yr4/6 none ms osg ml cs .7 .8 Ground elev. 9 9 ._2.4-ft. Depth to - limiting factor _gL_5_in. Remarks: CST Name (Please Print) Signature Telephone No. Glf~' n- S'c - ?_r S - 3 PL 12 1 Address Date CST Number 4 ao w 6 ~7 o22T1? Richard Stout SOIL DESCRIPTION REPORT Page 2 of3 ROPERTY OWNER PARCEL I.D.# 3oring # Horizon Depth Dominant Color Mottles Structure 2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench 3 2mabk 2 10-2 10yr3/4 none sil 2mabk mfi cs 1f .5 ;.6 around 3 28-9 1 Oyr4/6 none ms osg ml cs .7 -8 8 3lev. 9 8 . D-tt. )epth to inviting actor , cLul_in. Remarks: 3oring # 1 0-14 7.5 r2.5 1 none L 2 2 14-4 10yr3/4 none sil _2mabk mfi cs if .5 .6 4 3 0-9 10yr4/6 none ms os ml cs .7 :.8 around Aev. 9 7 . 1-4---ft- Depth to miting actor 9.2-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 3oring # 1 0-10 7. 5 r2 . 5 1 none L 2mabk mfr CS 2m - 9 -6 5 - 2mabk 3 38-89 10 r4/6 none ms os ml cs Ground 3lev. 96. 14 ft. Depth to limiting factor U-in. Remarks: 3oring # around alev. ft. Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) Cie 62 Bi °lo a s Q11- . X33 A `as h 4 eel 06 7---~ ~a r 7 /119/ ?"/°dc.~~ AMA ;2 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 Location of property (V 1/4 tJ 1 1/4, Section T a I N-R 1Town1s`hip ~ a S a ~ Mailing address _ HS-3 Sb Uj Address of site 77F A Subdivision name a -~-rl!S za•, R- t Lot no. Other homes on property? Yes x No Y Previous owner of property Total size of property Ca O e_tz~ s Total size of parcel A- c.(L s Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes __y 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. (we) presently own the proposed site for the sewage ~diand sposal tsystem 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. Signature of Applicant Co-App1icant Date of Signature Date of Signature STC- 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County r- OWNER/BUYER F- C-~~ t2 p vT MAILING ADDRESS 3 5 s lti Vy 4y lC_e__e_ L PROPERTY ADDRESS a/, /rte d /Q~~tct-d A9ZA'5 (location of septic system) Please obtain from the Planning Dept. CITY/STATE L~`sU ~S G h W p 1 G PROPERTY LOCATION Ni-v 1/4, IV 4> 1/4, Section T d N-R J 9 TOWN OF cQS v~ ST. CROIX COUNTY, WI SUBDIVISION -S 2~ t LOT NUM13ER 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 (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. UWe, 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: DATE- _ Croix County Zoning Office St Govcmment Center 1101 C:arniichacl Road Hudson, WI 54016 11/93 553 584 ~y STATE BAR OF WISCONSIN FORM 1 - 1982 WARRANTY DEED DOCUMENT NO. vot Tff 4 PAcE442 bT VRVIJ11 V D.1 V11 This Deed, made between The NGL Corporation j 1 a Wisconsin cor oration organized A ril 1, 1996 and 4 Rec'dtorRecorfl filed witIll t o scone n Secretary of State on pr DEC 2 0 1996 Grantor and Richard 0. Stout tT 3:30 p• Grantee, Witnesseth, That the said Grantor, for a valuable consideration conveys to Grantee the following described real estate in St . 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, 020-1075-00-000, ~0-000 PARCEL IDENTIFICATION NUMBER `rRANSKER 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. 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 h (nntrnl~er ACKNOWLEDGMENT Minnesota Signature(s) State of mamrsaon, ss. j authenticated this day of 19 Count . Personally came before me this day of vot 17M PAc[443 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 comer 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 r • s . ~a~z14 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