HomeMy WebLinkAbout032-2000-40-000
t Wi'sconsinDepartment of Commerce PRIVATE SEWAGE SYSTEM County:ST. CROIX
Safety and Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) SanitarI990W
Personal information you provice may be used for secondary purposes [Privacy L s.15.04 (1)(m)].
Permit Holder's Name: ❑Si ELVjjlaaa Town of: State Plan ID No.:
FAGNAN, MARTIN SVM L-RSET
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tic (Vi_2000-40-000
TANK INFORMATION ELEVATION DATA A9700495
TYPE MANUFACTURER CAPACITY STATION BS HI FSELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
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
os' Forcemain Length Dia. H Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMEN 1 N
LEACHING Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION Type O CHAMBER Model Number:
OR UNIT
System
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: SOMERSET 36.31.19.468B,SE,SW 734 PARENT STREET
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
Date Inspector's Signature Cert No.
SBD-6710 (R.3/97)
ADDITIONAL COMMENTS AND SKETCH T
SANITARY PERMIT NUMBER:
and
SANITARY PERMIT APPLICATION 201eE W shnlgtonAve sion
Wisconsin In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Department of Commerce Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 81/2 x 11 inches in size. S-/ ` ~D
• See reverse side for instructions for completing this application State Sanitary Permit Number
2.R9 Ile
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)]. sWTI& State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Property Owner Na e,,, Property Location /
1 /4 A, S 3 b T N, R E (or
Property Owner's Mailing Address Lot Number Block Number
-3 4
City, State Zip Code Phone Number Subdivision Name or CSM Number
,5'o,-r. ~e z~ lJ ; _ 0C) 1~5- (7 /S' s/6 3y -6 ~
II. TYPE F BUILDING: (check one) ❑ State Owned City Ne st Road
Village
S
Public jjj~l or 2 Family Dwelling - No. of bedrooms own of b
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo 98 0- _ 00° y~
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.eplacement 3. E] Replacement of 4. E] Reconnection of 5, E] 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 1,;E3-teepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
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 S. Perc. Rate 6. System Elev. 7. Final Grade
1~ Required (sq.ft.) Pro osed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ~ Elevation Feet
7', 1~ V~ Y. P ~ i Feet 12 U
VII. TANK Ca
in alaclttos Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existin strutted
Tanks Tanks J# I
Septic Tank or Holding Tank El ❑ 11 ❑ ❑
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 S n ure: (No Stags) f*F/MPRSW No.: Business Phone Number:
Plumber's A( dress (Street, City, State, Zip Co e): i-
IX. COUNTY / DEPARTMENT USE ONLY
012
❑ Disapproved Sanitar Permit Fee (Includes Groundwater ate ssue Issuing ent Signature (No Stamps)
urcharge Fee)
Approved ❑ Owner Given Initial
A Adverse Determination. D
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
I -
r
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, 608-266-3151.
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 narne, 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 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.
PLOT PLAN
PROJECT Martin Faanan ADDRESS 734 Parent St. Somerset Wi 54025
SE 1/4 SW 1/4S 36 /T 31 N/R 19 W TOWN Somerset COUNTY ST. CROIX
11/17/97 3
MPRS Shaun Bird 3532 , / 4~i/ DATE BEDROOM
CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 648 BED SIZE 12'X 54'
BENCHMARK V.R.P. Bottom of Siding ASSUME ELEVATION 100' VENT
12" GRADE
❑ BOREHOLE (DWELL *H.R.P. Same as Benchmark
q COVERING
SYSTEM ELEVATION g3.4 R
3' 3'
110' Property
40' 20' 15' -1
ST - Vent
a64 onr.4 5'
25' ?e f C 04t, 30, I I nt Slope
I I
Well 12' X 54' Bed
, 0'
25' B- I Neighboring
house with
basement
Pro 3 Bedroom I
House
Note: A existing trailer is in the pro
house area and is to be removed. 15' ST 10' 25'
B-3
o Existing
Driveway
0
r
CD Pro
Driveway
Parent St.
Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page of
Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code
/
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and , r
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
J3a-a o -
APPLICANT INFORMATION - Please print all information. R~ew by Data
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ZS
Property Owner Property Location
Govt. Lot 1/4 ,d/4,S 3 T 31 N,R E (or)(&
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
7-3
City State Zip Code Phone Number El city [__1 Village Ej Town Nearest
&;t Yoas S .A e
❑ New Construction Use: ,Residential / Number of bedrooms Addition to existing building
Replacement ❑ Public or commercial - Describe:
Code derived daily flow gpd 7 Recommended design loading rate -L--2 -bed, gpd/ft2 trench, gpd/ft2
Absorption area required _ 6 ~3 bed, ft2_ 4' Ltrench, ft2 Maximum design loading rate bed, gpd*_/2- , gPd*
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material Flood plain elevation, if applicable ,&,ZAI ____ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
U= Unsuitable for system 2f S ❑ U as ❑ U ELS ❑ U Ms ❑ U ❑ S tau ❑ s .ru( )
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
1 o- 1 a ~ f a 5
l~ h124,- -51~1 2,77
Ground n/) 14- g
elev.
9~ft.
Depth to
limiting ;
~ 3
Remarks:
Boring #
123 h~"' -55
Ground
ev. ft '
Cfepth to
limiting
,,7 ~Cl/y
-in. Remarks:
CST Name (Please Print) ' nature Telephone No.
Address Dat CST Number
r ~a 0 - 917
C ll SOIL DESCRIPTION REPORT - '
PROPERTY OWNER Page of
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
.13
elev. Ground 1 ~1 / 1 d
Depth to
limiting ;
f
'7in.
-S S Remarks:
Boring #
vim. ,
Ground
elev.
ft.
Depth to
limiting
factor
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 # ;
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBD-8330 (R. 07/96)
Soil Test Plot Plan
Project Name Martin Fagnan Shaun ]W/0'
Address 734 Parent St.
Somerset Wi 54025 CSTM #3922
Lot Subdivision Date 11/16/97
SE 1 /4SW 1/4S36 T 31 N/R19 W Township Somerset
FlBoring ()Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Bottom of Neighboring House Siding
System Elevation 93.4 * H R p Same as Benchmark
110' Property Line
40' 20' 15' -1
ST
65'
25'
30' 0% Slope
Well . 0
25' B- Neighboring
house with
basement
Pro 3 Bedroom
House
Note: A existing trailer is in the pro
house area and is to be removed. 25' B.
B-3
o Existing
Driveway
0
r
cu Pro
Driveway
Parent St.
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE S
PROPERTY LOCATIONS 1/4,,yc Section , T _N-R112-W
TOWN OF ~z ST. CROIX COUNTY, WI
SUBDIVISION 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 (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
+ 5-1 c -toD
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
Location of property~1/4_S'GVl/4, Section s-~ ,T3IN-RW
Township Mailingaddr ss,~~
sue-,
Address of site
Subdivision name Lot no.
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 _Z_No
Volume I and Page Number 4~L.~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 ~o 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 ljn the off' e 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
~of ice_ of the County Register of Deeds as Document No.
Signature of Appl ca Co-Applicant
Date of Signature Date of Signature
• 00cm ENtNO. STATE BAR OF WISCONSIN FORM 2-19a THIS SPACE RESERVED FOR RECORDING DATA
WARRANTY DEED
401495
40L 710mt stets
"I I
Jeffrey R. Fagnan, a single man I ST.CAODtGO n
Ule& fW R~oord fhth
d
ay G#L.Uril A.o, l 5
conveys ow warrants to Martin J. Fagnan and Mary a. 1'00
Fagnan. husband and wife
RETURN TO
the following d scribed real estate in St. Croix County, I
State of Wisconsin:
Tax Parcel No:
The E 134 feet of W 433 feet of N 128 feet of S 161 feet
of SO of SW} of Section 36-31-19. 'SFM
T FEE
This is not homestead property.
(ia) (is not) f
Exception to warranties:
Dated 19th day of A o r i l 19 85
Z4. , j 10 APO
3=9w;19 440C I- -4Rj'0r"!;X (SEAL) (SEAL)
J re D. Fa nan
(SEAL) (SEAL)
!1
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
aa.
St. Croix County.
authenticated this day of 19 Personally came before me this 19th day of
Apr i 1 19 _$5 the above named
_7Pffrey D. Fagnan
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to he person- who executed the
authorized by § 706.06, Wis. Slats) fore g i str owledge the same.
THIS INSTRUMENT WAS DRAFTED BY
nrOOKI DCAI Tv