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HomeMy WebLinkAbout032-1037-90-400 ^ a °o I O E» Zr O o M N O O-O10 O N O V N X y ~ N ~NiO O y N O ~ OL L C N m 3 Z N U w- O E C L > N c 3 In O N N ry E N o ° C a N Y C Oo.Z a0 N cE"a_ ~ ~ a O c > d = O 3 (CS O U- 0 U a N C Y '0 co ,.a Q Q C C o N cc > > z N w E z w o v L 0 M M a co F- cn C O C z O U O Z :!t c _ fA F- m o z c E a N M a) a a) C m N a~ • AV a` L 'o c C O m O O N Q w Z F- z o . z 00 C N d C o E N Lo N R E ~i M R O) N N N a Q O c0 C O `O W i N C O 00 00 o G a m N N 7 U V Z co i 0 3: 3: 3: Z o o 0 0 0 0 d w •N i E a a a a ~ m v) U rn rn Z W °o O 0 0 ~ r C N O 00 N• o d Q Z u O O C N N C "T W =3 04 t O F- U N U) = C- m O O O 0 O) - a O - N (D In E m (D w M N C N = O N 0 Iz a0 O E (D N F- Z N ~ M E N Q N E p cLj U) C~ N O z y O m Cn t a a w • co a a~ c 4 E C.1 c O ~T_1~11 O O 1~0 O ~i « A V a 2 l 0 (n 0 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 268692 Permit Holder's Name: ❑ City ❑ Village 41 Town of: State Plan ID No.: GERMAIN, MIKE SOMERSET CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA Aagniniqarz TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet rl 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 oss Forcemain Length Dia. I( Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits inside Dia. Liquid Depth DIMENSIONS DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM INFORMATION TypeO CHAMBER Model 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: SOMERSET.13.31.19W, SW, SE, 210TH AVENUE i Ai a 2- e- 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: vi~'r'■ i SANITARY PERMIT APPLICATION BureaSafetyu o oand ff BuilBuildinWater Systems ng Water . 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. S-L , (2, b/OI • See reverse side for instructions for completing this application State Sanitary Permit Number &F-6 91. The information you provide may be used by other government agency programs ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Pro erty Owner Na a /n / KjC coq 2M 00111 V Property Location 71 W D W1 /4 5,i 1/4, S 13 T 3 , N, R E (or) W Property Owner's Mailing Addr ss n /3OX 6 p Lot Number Block Number City., tates'd/K4~Ipf-- Zip Code S 025 Phone Number o Subdivision Name or SSM um er =ttigaj) -4& eSM YI Ip - 30 II. TYP F BUILDING: (check one) ❑ State Owned ❑ City Nearest Road ❑ Village E] Public 1 or 2 Family Dwelling - No. of bedrooms ,3 Town of '56 Vm 11?li- t o~/G _ (,►e: III. BUILDING USE: (If building type is public, check all that apply) arcel Tax Number(s) ` 1❑ Apartment/ Condo 0 3 -2 -/0 37-- 7 0- 75 V 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 12WSeepage 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 150 Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation Sio3 570 • S ,N,4 Feet /OS, Z Feet VII. TANK Capacity glloacit5 Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin strutted Tanks Tanks Septic Tank or Holding Tank '4 11r/ulJ I~ECALI s ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ LJ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) I Plu ber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: ~►.z"~f°- Plumber's Address (Street, City, State, Zip Code): _ J IX. CO NTY / DEPAR MENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater at Signa ture (No S m s) harge Fee) Approved ~ Owner Given Initial Surc Adverse Determination C NDI~IONS OF APPROVAL/ REASONS FOR DISAPPROVAL: J Si (105194) DISTRIBUTION: Original to Caur,t y. One copy To: Safety & Buildings Di-ion, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe 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- I1. 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 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- A/I E ,t'c.~•iJ sal ~ sr" Ile diP -Xlc 55 j v)ovsc Co a &A p{ c`~ 'ppQ ON "lay S 11 %Y. Oil P~o-r- Al PLA7e'~~ ~M 33' ~/!J Ad N/l X~c-5 . Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of man Relations . Labgj a=u Division afety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION VIEWED/(~~77 E J' PROPE WNE PROPERTY LOCATION qp • f ' v~►s (or)~' GOVT. LOT 114 • 1/4,S IT . PRO RTY OWNER': MAILING ADDRESS LOT # BLOCK # SUB . NAMEOj~I~ y ~ G Opp .1 CITY STATE ZIP CODE PHONE NUMBER ❑CITY _EIVILLAGE OW NEAR New Construction Use Residential / Number of bedrooms [ J Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate _bed, gpd/ft2_,,_~trench, gpd/ft2 Absorption area required 1~s bed, ft2 Z~x h, ft2 Maximum design loading rate ._bed, gpd/ft2_trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / site considerations Parent material 4,z&seZ 416 &E - Flood plain elevation, if applicable fi It S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE 7AT-GRADE SYSTEM IN FILL HOLDING TANK U =Unsuitable for s stem !81 S ❑ U ~I S ❑ U E RS ❑ U S ❑ U ❑ S 91U ❑ S Mtl SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Bouriclay Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Pont. Color Gr. Sz. Sh. Bed Trench 7 vv....•.t.vvv, Ground - - - elev. Depth to limiting factor ~9l Remarks: Boring # / 5-,11 22~ Zf _~2_ 1 Ground elev. J~ft. Depth to limiting factor >9l Remarks: CST Name:-Please Print Phone: Address:o , Signature: Date: CST Number z- ~Ie PROPERTY OWNER SOIL DESCRIPTION REPORT Page.,~of _s PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench }.v $.u•} vvr ~yv'•* ti F:v\: .vi4f _ Ground elev. /~L ft• _ _ Depth to limiting factor aAL Remarks: Boring # { Ground elev. AIZ 1~1 ,r3. s - - 8 -t Depth to limiting factor ~yG Remarks: Boring # Shc / Ground elev. AZO ft. Depth to limiting fact 7 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) ~a81,9 3J~+lcS 7© , Q~ 3-7 OEN® ATE M 3 ......jam.................... ............k................ a a ( d . Q . -iP v 13 1~ T. I I .............................F:................. 1 ~ . t . a . o....U............ r. 'x ..~...x . ..........X. I"" V1~ r O WE S TB URNE' SUPPLY INC. BLAINE • BURNSVILLE • CHASKA • MAPLEWOOD MINNEAPOLIS • ROGERS PLUMBING COST. SERVICE (612) 551-2900 PLYMOUTH HEATING CUST. SERVICE (612) 551-2899 n1:i % I 1 1I (j 7 1 9 ; ;f,'7^ RFI.,Ia*,4 TFAM 1 RFAI TY PAGF n7 /;z cwot-~- ~ A ~ o rt FILED " 9 1996 Bearings are referenced to the 10 APR 2 9 south line of the SEk of section H KA1~ N Wes{ 13. assumed to bear 589'09102"E 01 Remor ofrt 3 ~,~VYM O R ~ M a r•f GJ CL Qc !f O N A Ih' 3 K A f7 o w O us M In d~ TED CO LANOS A r+ m o o,~ $01-071501-W 545.361 m N co 33.00! 512.96 A' N H In r • to N r.. X C s o O r- r r w r to M r 1-~ S +y O _ W o ' I N W ~ o A I,t N -30.81:' 512.96' vi w w c Q ; 501 °07'50"W 547.77' m y$ 7~~ 0 m C7 O fJ O V ff A F+ ^I _ T 0 17 Z 1! Ft I i 1( r*~ N ~j vf . x -36.63'. C N > L) N 512.96' i-I % x g (n 89*09'02"W N01°07'50"E 549.591 1 0° 66.001 S01 °07'50-•W 550.06'' f m < w Q b ~ C 0 ~ - , J µI J w W o a C6 -37.10: 512.96 o g N 3 ~ ~ o c, ~ 6 ~ O vw ~ ao n H ~ d ' s I Ln N W w ► k.► x H - K 0 Ir) Ir -38.89.1 513.211 N N0202115211E O 552.101 n r 1A „ ~Gl I~ I iD u.' Y ED- N a L 52~ apgyp- ~ ~R ~A~ r+ STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER _ryl MAILING ADDRESS _ d 3 - y PROPERTY ADDRESS ~[p al ri{ (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION Sl~3 1/4,_ 1/4, Section )3 T N-R_J_I_W TOWN OF ST. CROTX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP , VOLUME, PAGE 30%%,LOTNUMBER. -3 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: q 2~ - °l V St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 f)I D J~- 03a - 107,7 -90 - X16 0 F S 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. _________T_____________ Owner of property Location of property 1/4_1/4, Section_[_ ,T~_N-R~_W TownshiMailing address 9 0 370 Address of site '1 off` Lot no. Subdivision name Other homes on property. Yes_ _No Previous owner of property Total size of property 3 , 2 AG Total size of parcel _0 Date parcel was created H 25 Are all corners and lot lines identifiable? '_Yes No Is this property being developed for (spec house)? --11K-Yes No Volume -J~- and Page Number 6_ as recorded with the Register of Deeds. WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE In addition, a NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. 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.`'i 1 and that I ( ) P own the proposed site for the sewage disposal system or I (e) obtained an easement, to run the above described property, for the asduly DocumendedNon construction of said system, and the a of has Deeds been the office of the County Register o 5 35T71 o . Sign ture of Applicant Co-Applicant ~a v r-1 4- r- C' 4 WARRANTY DEE~---~ DOCUMENT NO.. Vol. 114 1 PAG- ~ REGISTER'S OFFICE ' ST. CROR CO., WI Lyle P. Klink and Marie A. Klink Rec'dforRacotd husband an w ' e, N_OV 2 1995 tit 11:15 A. M conveys and warrants to Michael Germain and Od4 I Michelle M. Germain, husband and wife, Regil wa00001 THIS SPACE RESERVEO FOR RECORDINGeTA NAME ANO RETURN ADORESS~ the following described real estate in St. Croix County, State of Wisconsin: (Parcel Identification Number) S SW1/4 of SEl/4 of Section 13-31-19, St. Croix County, Wisconsin. SUBJECT TO a 66 foot easement for ingress and egress over the above described parcel, at a location to be determined and described by a surveyor within one year of the date hereof. The Grantor and Grantee hereto agree to execute an amended easement, if necessary, upon surveyor's completion of the legal description for such easement. This is homestead property. (is) XIKY4X Exception to warranties: Easements restrictions and rights-of-way of record, if any. , Dated this ~ L day of October 19 95' ~ (SEAL) (SEAL) Lyle P. Klink Marie A. K1' k (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) Lyle P. Klink, STATE OF WISCONSIN ss. Mariie,,'~A. Klink County. authenticated t4 6' y of October 19_L5 Personally came before me this day of 19 the above named Kristina Ogland ~ ~ , es' C-- 2_s i ~ ~ a ~ ~ U ~ ~ ~ 6 D o