HomeMy WebLinkAbout020-1332-80-000
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ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT , RLU-!'+fW_~ J
d 1998
Owner cct/
S'Te.e ST CROIx
Address
COUNTY
'r
City/State ZONINGOFFICE
.~/•l- d sd,✓ C~ ~ ,
Legal Description:
Lot -,f Block Subdivision/CSM #
t/4A2jj t/4 AW, Sec. ~2?, T21 N-R_YW, Town of PIN # OZD• 1332-- 'O'aa--i
SEPTIC TANK DOSE CHAMBER HOLDING TANK INFORMATION:
Tank manufacturer 92 , ' d W e 't Size ST/PC Setback from: House Well P/L
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: ed.AJ Width ,5- Length / IS Number of Trenches ~
Setback from: House 34 , Well SD , PAL 4 Vent to fresh air intake
ELEVATIONS:
Description of benchmark Elevation / e o ,
Description of alternate benchmark Sid 6 Elevation
°e-e- «
Building Sewer 9q ST/HT Inlet ST Outlet • 2- PC Inlet
PC Bottom Header/Manifold 97•~f Top of ST/PC Manhole Cover ~g
Distribution Lines q?- Z!;- ( )
Bottom of System ( ) q1.3 7 { ) ( )
( ) ( )
Final Grade ( ) /00
.7v
Date of installation/0 /Permit number State plan number
Plumber's signature L✓.•~=-~4`~ License number 7.-/,1Jf~2-Date
Inspector //V Ac
Complete plot plan Or
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. - 7o p o-F C- wtc-~l 5/c44
PLAN VIEW
V
INDICATE NORTH ARROW
Wiscensin Department of Commerce PRIVATE SEWAGE SYSTEM county
'Safety and Buildings Division ST. CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanital"W"-:
Personal information you provice may be used for secondary purposes [Privacy Lily, s.15.04 (1)(m)].
STOUTolde slN~p1 RD [A frb~~.illage ❑ Town of: State Plan ID No.:
CST BM Elev.: ri( Insp. BM Elev.: BM Description: ?ora p✓ l t-~ S Parcel T32b:),;13 3 2-80-000
100 t o o " (51"
TANK INFORMATION ELEVATION DATA A9700252
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic J~ ~/a (psp Benchmarlo 3 /oy /60
Dosing 414,13M '124 3 I'll
Aeration Bldg. Sewer 1/,5~5 C7,7. V5--
Holding ]4t/ Inlet ~.q7 9X F3
TANK SETBACK INFORMATION S *Outlet 5,SY,, 9T -y2
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic ,!'2( NA Dt Bottom
Dosing NA Header / Man. ~l
Aeration NA Dist. Pipe m11 7 057 9741 97 25"
Holding Bot. System 92> 9-7-37'
PUMP/ SIPHON INFORMATION Final Grade [~.3 1OO-
Manufacturer Demand tMo~ ~N r Co
Model Number V GPM
TDH Lift Friction S stem TDH Ft
Forcemain Length Did. Dist. To Well
SOIL ABSORPTION SYSTEM
BED P TRENCH Width Length No. Of~renches PIT No. Of Pits side D Liquid Depth
DIMEN l i DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Man acturer:
SETBACK _
INFORMATION Type O ,1 CHAMBER i M de Nu ber:
System' k1,w- I6 r 5 n a OR UNIT
DISTRIBUTION SYSTEM ~\<,-Tv-
Header /Manifold Distribution Pipe(s), ► x Hole Size x Hole Sp g Vent To Air Intake
Length Dia. Length -s2 Dia. Spacing ..c /S
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth 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 27.29.19,SW,NW 770 WILFRED RD A&B LOT 8
~'►nzl. 1(-Z.O- q7
/
Plan revision required? ❑ Yes /ati o d-7
Use other side for additional infor n . /
SBD-6710(R.3/97) Date Inspector'sSigna ure ert No.
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 sar.ita erm4uTIFF er
The information you provide may be used by other government a ency programs ❑ Check(/it revision to previous application
(Privacy Law, s. 15.04 (1) (m)]. -770 IA lil rCd l State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
c 1rs( 5'T~ , w 114*4J 1/4, S g-? T 2 q , N, R E (or
Property Owner's Mailing Address Lot Number_ Block Number
-T- 3 Cpwa to k~~ 7_11611`
City, State Zip Code Phone Number Subdivision Name or CSM Number
11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Ity Nearest Road
❑ Village
14,s ~.-,e v~7 tt
❑ Public 1 or 2 Family Dwelling - No. of bedrooms Town OF
Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo a7• c? 9. /9. ! 7 g SO
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. EI 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 Weepage 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
/(.Is- S I O &je" - ~Fe • S Feet /do, ° Feet
VII_ TANK Capacity
gallons Total # of Prefab. Site Fiber- Exper
n Gallons Tanks Manufacturer's Name Concrete Con- steel glass Plastic
INFORMATION App
New Existin strutted
Tanks Tanks
>e °~GY.G!
Ki7 Septic Tank or Holding Tank El E] 11 E]
Lift Pump Tank /Siphon Chamber. ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se ge system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No Stamps) P PRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code : t -
u j::2 1
IX. COUNTY / DEPARTMENT USE ONLY
ssue Issuing A nt Sign re (No S
❑ Disapproved Sanitary Permit Fee (Includes Groundwater L7/~
roved ❑Owner Given Initial Surcharge Fee)
pp Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05194) DISTRIBUTION: Original to County. One copy To: Safety & Buildings 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.
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION
LabpG and Human Relations
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code Page 1 of 3
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
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. St. Croix
Parcel I.D. #
020 - /070 -g0
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 SW 1/4 NW 1/4,S 27 T 29 N.R1 9 9(or) W
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
1353 Auatukee Trail 8 Badlands Prairie
city State Zip Code Phone Number ❑ city
Hudson WI 5401 6 549-563 ❑ village Q Town Nearest Road
(715) Hudson State Hyw 12
ER 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, 8
9P~t2 ' trench, gpd/ft2
Absorption area required 1 2 R h bed, ft2 trench, ft 2
Maximum design loading rate • 7 bed, gpd/ft2 • 8 trench, gpdfft2
Recommended infiltration surface elevation(s) 96.5
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 Hof din Tank
U = Unsuitable for system [N ❑ U ] S ❑ U 0S ❑ U E] S ❑ U ❑ S L] U ❑ S ] U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure
in. Munsell Qu. Sz. Cont. Color Texture Consistence Boundary Roots GP.D/ft2
Gr. Sz. Sh. Bed , Trench
1 0-14 7.5yr2.5/1 none L 2mabk mfr cs 2m .5! .6
2 14-3 10yr3/4 none sil 2mabk mfi cw if .5- .6
Ground 3 36-8 1 0yr4/6 none ms -wi d .5Y ml cw .7 .8
elev.
100.0 ft.
Depth to
limiting
,
facW'4
n.
Remarks:
Boring# 1 0-14 7.5yr2.5/1 none L
2mabk mfr cs 2m .5 .6
2 2 14-38 10yr3/4 none sil 2mabk mfi cw if .5 .6
3 38-84 10yr4/6 none ms M•6519 all cw .7 .8
Ground
Depth to - - - -
limiting
faqt~r-in Remarks:
CST Name (Please Print) Signature Telephone No.
Address Date ^CST Number
e 7a S'C_v¢ ' , 'Y Ar %L2 T7 ~7 QO
?ROPERTYOWNER Ric-hAr(7 qtnut- SOIL DESCRIPTION REPORT 2 3
Page of
PARCEL I.D.#
3oring # Horizon Depth Dominant Color Mottles Structure 2
in. Munsell Gu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed Trench
3 1 0-14 7yr2.5/1 none L 2mabk mfr Cs 2m .5 .6
2 14-36 10yr3/4 none sil 2mabk mfi Cw if .5 .6
around 3 114-36 10yr4/6 none ms I* 009 ml CUT .7 .8
elev.
10 0 , 1 ft.
)epth to
imiting
actor
84 in.
Remarks:
3oring #
1 0-1 7yr2.5/1 none L 2mabk mfr Cs 2m .5 .6
2 12-36 10yr3/4 none sil 2mabk mfi Cw if .5 '.6
4 _
3 36-84 10yr4/ none ms 84 05 ml Cw .7 , . 8
-found
elev.
100.4 ft.
Depth to
inviting
ator
4 in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Boring# 1 0-1 7yr2.5/1 none L 2mabk mfr Cs m .5 .6
5 2 16-`6 10yr3/4 none sil 2mabk mfi Cw if .5 '.6
3 36-E6 10yr4/ none ms ~Ua o59 ml Cw .7 .8
Ground
elev.
100.2 ft.
Depth to
limiting
factor
2-6-'n. Remarks:
Boring #
Ground
Jlev.
ft.
Depth to
limiting
factor
in.
Remarks:
SBDW-8330 (R. 08/95)
~ X33 ~
o ~
e 1\1S
a
a~
ps, • ~y
~ . P X12
~h1_ l_1 ',`,D®c y boa ~l ~.r_T z ~eo /D0 4
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS \ SS 3
PROPERTY ADDRESS 7 61 l~.'~ c ~ cti e~ S A~ ~I 4,e
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE S, W S ~1 Q 1
PROPERTY LOCATION S~ 1/4, /V W 1/4, Section a T cal N-R ct
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION 1Z LOT NUMBER
CERTIFIEDSURVEY 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.
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:,
DATE: -
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
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 1` ~~`a ~z O S~ u
Location of property 2'Uj 1/4 n U-) 1/4, Section a -1 , T21 N-R-)
Township '~t~1ucl~S c~ Mailing address _ 135-3
~}c~, ►(~Q L
yAddress of site 7'70 ,~~J',f""rcd rQ
Subdivision name ~c L ~ S Sum i rc' e- Lot no. O
Other homes on property? Yes No
Y Previous owner of property
Total size of property Lo O C ~2
Total size of parcel 3 '~C (t-~ s
Y Date parcel was created
Are all corners and lot lines identifiable? _.X-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. , 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.
+Q hAa~ o
Signature of Applica_ntyl Co-Applicant
Date of Signature Date of Signature
SS3584 ~y
STATE BAR OF WISCONSIN FORM 1 - 1982 /
WARRANTY DEED
DOCUMENT NO.
vat IZY4 PAcE442
This Deed, made between The NGL Coro kiCGlS I c. , ,
a Wisconsin cor oration organized April 1, .1996 and uT CFiCG, r.)., ~';j
Recd for Rewra
e w t t o scons n Secretary of State on
pr DEC 2 0 1996
and Richard 0. Stout Grantor, i`
3:30
j ~ •at 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, Stale 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 nn-nnn~ non ln~ 4n_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.
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
(SEAL) The NG Cor oration (SEAL)
♦B %t/
(SEAL) Robert Romeo
• (SEAL)
'its: VP R ('nntrnll~
ACKNOWLEDGMENT
Signature(s) Minnesota
State of 'Aft taudn,
ss.
authenticated this day of 19 Count . li
personally came before me this day of
voc 17M PAA 43
r
EXMIT 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-t
AV
toot :214PA 444
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