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HomeMy WebLinkAbout006-1076-60-000. ,,~ Wisconsin Department of Commerce Safety and Buildings Division GENERAL INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: ^ City ^ Village ^ 7sown of: Cvelson, Jarnes Cylon Township CST BM Elev.: Insp. BM Elev.: BM Description: ~ . ~ ..~ a'~ e~ TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~ SI~.ti ~r~s~~ OC'Z~ Dosi Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. vent to Air Intake ROAD Septic ~~~ •~ '3 NA D Aeration ~ NA Holding- PUMP /SIPHON INFORMATION M cturer and Model Number G M TDH Lift ~ction S stem TDH F Force Length Dia. Dist. To SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. CTO1X Sanitary Permit No.: 363918 State Plan ID No.: Parcel Tax No.: 006-1076-60-000 STATION BS HI FS ELEV. Benchmark ~/~( Alt. BM S ~ Bldg. Sewer L sa St/Ht Inlet ~-~ ~ St/ Ht Outlet Dt Inlet Dt Bottom Header /Man. Dist. Pipe Bot. System Final Grade St cover y. ~ a ~ BED /TRENCH Width Length No. Of Trenches PI No. Of Pits Insid ~ Depth DIME I N `- - '- IM N 1 SYSTEM T P / L BLDG WELL LAKE /STREAM LE Manu acturer: SETBACK AMBER M INFORMATION Type _ - oe er: Syst m: fC~ar~ _ - OR UNIT DISTRIBUTION SYS~I`E~M~ Header / Mani old Distribution Pipe(s) x Hole Size x Hole Spacing Vent 7o Air Intake Length Dia. Length i 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.) Inspection #1: ~ l..S'1oa Inspection #2: / / Location: 1827 County Road O}} New Richmond, WI 54017 (NW 1/4 SE 1/4 33 T31N R16W) - 3331165150 1.) Alt BM Description = ~e'p nt 3o c~~~Ns~~~G~r, - _ ~ y---- ,~grou.~ 2.) Bldg sewer length = ~ s0'' z o' u~~r s~' tra;J,,, s+ Zo ~ ..,,~, ~ ~ ,~ ~ -amount ofcover = >/p'r zo ~r s~(~,f~c( ~w~~(~~d . ( .,t ( ,[ ~1usC w~ a S ~ C ouC ~~ ~~ir4~lri L,~~t S `col SPA ~/ r l ~-i a~ (cap-5f `Kn~S ~b~h f Plan revision required? ^ Yes (~ No Use other side for additional information. ,S dV SBD-6710 (R.3/97) D . e Inspector's Si ature Cert. No. ~~ ~~isconsin Department of Commerce SANITARY PERMIT APPLICATION In accord with Comm 83.05, Wls. -.. ~ ~ Safety and Buildings Division 201 W. Washington Avenue POBox7162 Madison, WI 53707-7162 • Attach complete plans (to the county copy only) for the syst ape` notless ~ `b 4 unt y ~~ than 8 vz x 11 inches in size. o - ~ 'v~ El~~E f t Sanitary Permit Number st~ • See reverse side or instructions for completing this appl . r P l i f i id '~ `~ ~~~~ _ 3 / ~ (( { ersona n ormat on you prov e may be used for secondary purposes '~~`~ ~~ [] k if• revision to previous application (Privacy law, s. 15.04 (1) (m)]. ~f~_ _ ~t - Xwrt~C ;~T ~,~iOtX State an Review Transaction Number I. APPLI ATION INF RMATI N -PLEASE PRINT ALL N~ RM .•i `' Property Owner Name otati tia "3 T 31 , N, R ,~E (or) Property Owner's Mailing Ad~ ss ~ U o'tbluim ej- L r- Block Number ~ City, State Zip Code Phone Number Subdivision Name or CSM Number @.t.J _ 1 / ) . ~ r 9 ~~ II. PE F 6 IL ING: (check one) ^ State Owned ~ Ity ^ Village Nearest Road Public or 2 Famil Dwellin - No. of bedrooms wn of s._,_ CT / III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Nu er(s /- lto_ S~S 33. ~ ~ '` ('~ b r- ~ v / (~ d 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 S ^ Hotel !Motel 9 ^ Office! Factory 13 ^ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box online B, if applicable) ~~ RPCOnnection of 5. ^ Repair of an A) 1. ^ New 2. ^ Replacement 3. ^ Replacement of ` ' C Existing System ________ Existin~System ______System ________System _____________ TankOnly_________~__ _ 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 ^ Seepage Trench 22 ^ In-Ground Pressure 42 ^ Pit Privy.. 13 ^ Seepage Pit t 43 ^ Vault Privy 14 ^ System-In-Fill d ` VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Pert. Rate 6. System Elev. 7. Final .Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Edon ~ "~ ` eet eet ~ Q -- ~-- ~ VII. TANK INFORMATION Ca tit in ~all0 S g Total # Of r Manufacturer s Name Prefab. Site con- l st Fiber- Plastic Exper. N i i E Gallons Tanks Concrete ee glass App ew n x st strutted Tanks T nks eptic Tank ~-- ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for ' stallation of the onsite sewage system shown on the attached plans. Plumbe~Name:(Print) w Plumber ig e: tamp MP{MQR~(No/:~ x~ ,[ ~ { '` BusinessP~e~mbe~:~ ,r . / SS ~ mot _~- l J V C/ j U Q,,iI~~/ „ C/ i Plumber's Address (St~ d City, tate, Zip Code) ~ N IX. COUNTY/DEPARTME T USE ONLY ^ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issui gent Signature (No Stamps) A roved pp ^ Owner Given Initial , surcharge Fee) (~ r7~25 4 Adverse Determination - O X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: ~ ~~~ ~` ~Lrcr~ ~E,a~ ~f~ ~ ~. v r^~f i~~Ci` rti f~ p~~s {ham 5 Y s {cam ~~S SBD-6398 (R.12199) DISTRIBUTION: Original to County, One copy To: Safety a 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 ($BD-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 2to 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: I. 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. Bui-ding use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one online 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. `JII. 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 experimenta! product approva! from DILHR. ~~III. 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 mode{ 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 j 1983 Wisconsin Act 410 included the creation of sdreharges (fees) for a number of regulated practices whichtan effect groundwater. ~ ' The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. ~. 3r .s PLOT PLAN PROJECT James Nelson ADDRESS 1827 CTY RD O New Richmond Wi 54017 NW i/4 SE i/4S 33 /T 31 / 16 W TOWN Cylon COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE6/17/00 BEDROOM 3 CONVENTIONAL XXX IN-GRO ND RESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE •7 ABSORPTION AREA # of chambers ,BENCHMARK V.R.P. Base of Shed Siding ASSUME ELEVATION 100' ^ BOREHOLE O WELL '"H.R.P. Same as Benchmark SYSTEM ELEVATION 94.3 Alt. BM 150' 60' O 0 Top of Well Qa 104.5' Rail Road Tracks B-1 12°Io Slope Vent 0 " 20' 20' ~/'r•aR . Ca ~~ ~ ~t.t a~ ~ ~• Q~ 7, 6 20' M. ~~ Assumed Drainfield Location 8 , Please note: plumber is responsible for Shed building sewer only, no work is to be done the septic tank nor the soil Tank absorbtion system 50' appears to be a Weiser 15' 1000 Gallons T After 30', building sewer is to be insulated 50' as Per code Alt. 50' ~ .M. Well 15'_ 10'_ 3 Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Bureau of Integrated Services 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 percent scope, scale or dimensions, north arrow, and location and distance to nearest road. parcel I.D. # Page of ~! c ~ nP7` APPLICANT INFORMATION -Please print all information. Revie y Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ~ / Property Owner ~ Property Location l0 ~_ ~~ Govt. Lot 1/4 ~1/4,S T ,N,R~~ E (o Property Owner's Mailing Address Lot # B ock# Subd. Name or CSM# ~ ~~ City State Zip Code Phone Number .(~ Nearest Road ^ City ~+ ^ Village /~' Town A ^ New Construction Use: residential /Number of bedrooms ~ Addition to existing building ~fieplacement ^ Public or commercial -Describe: Code derived daily flow l' gpd Recommended design loading rate ~ ~ bed, gpd/ft2 ~ ~ trench, gpd/ft2 i Absorption area required `~.~ bed, ft2 ~'~ .~ trench, ft2 Maximum design loading rate ~ ~ bed, gpd/f12~ trench, gpd/ft2 Recommended infiltration surface elevation(s) ,~~ ~ ft (as referred to site plan benchmark) Additional design/site considerations _ .~ F` it.r Parent material t~,c.C.~~r,_,r lc ~~-~ Flood plain elevation, if applicable /l.~/~ ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system ~ ^ U ^ U - ^ U S ^ U ^ S ^ S~ U Boring # Ground ~ev~ ~"~- . Depth to limiting ,r; ~Qr , SOIL DESCRIPTION REPORT Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench ' ~ w v ~jL ~~ ~ /n ` ~ ~ ~ r 1 'iii ! / ~ `/ ~ V A ~t~v ..~ ~ C ~ ~' y ~ ' p ']n 1 ~ ~~ i ~r ~ ~ ~ J ,'~ ,~. , Boring # Ground ' elev. , ft. Depth to , limiting factor in. Remarks: CST Name (Please Print) ~~ 'gnatu Telephone No. / ~~ f ~~©'~ ~~1~~ ~"b Address ~ _ ,~ - ~,,~ , , -~ Date CST Number ,, , Remarks: ~ '~ Project Name James Nelson Address 1827 CTY Rd o New Richmond Wi 54017 Lot ----- Subdivision NW 1/4 SE 1/4S 33 T 31 Soil Test Plot Plan Shaun CSTM #226900 ------- Date 6/17/00 N/R16 H/ Boring (~ Well PL Property Line BM or VRP Assume Elevation 100 ft. Township Cylon County ST. CROIX Base of Shed Siding System Elevation g4•3 *HRP Same as Benchmark Alt. BM Top of Well @ 104.5' ~t. ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the ~.-,..2.d N~ so•~, re/slidence located at : ~~1/,, ~1/,, Sec . ~~, T_~N, R~~W, Town of Cy~~,~. St . Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced cSe,~o-dr ' 9 Did flow back occur from absorption system? Yes No~ (if no, skip next line. Approximate volume or 1 ngth of time: gallons minutes Capacity: ~lj~j~ yt~~~ Construction: Pre ab Concrete ~ Steel Other Manufacturer (if known) : (.J a~1 ber Age o f an ( i f known) : / y y ~~.~ ature) (Name) Please Print r~/.~ r ~~~~~~ (Title) (License Number) ~3~-~ (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except o inspe 'on opening over outlet ba fle). t Nam / ~ Signature MP/MPRS ~ Jt. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer ~rY~ ~ c ~~r~' O Mailing Address Property Address City/State ~- ue1~u~ ~~-~-~- (Verification required from Planning Department for new construction) Parcel Identification Number ~ % / ~~ /_~~/~~~ LEGAL DESCRIPTION Property Location /4 r /~ >,~~ '/4, Sec.~~', T~~N-~`~ W, Town of ' ~i~ Subdivision Certified Survey Map # ~~ ,Volume ,Page # Lot # _/~ Warranty Deed # (9f y/l)X ,Volume ~~,3 ,Page # _~~~~~, Spec house ^ y~no Lot lines identifiable no SYSTEM MAINTENANCE Improper use and maintenanceof 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 a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a masterplumber, journeyman plumber, restrictedplumber or alicensed pumper verifying that (1) the on-site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 day of the three ye/ar expiration date. ~- / NA OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of th roperty described ov , by virtue of a warranty deed recorded in Register of Deeds Office. IGNATURE OF APPLICANT DATE ****** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ****** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed r L . 1r ~ 1 DOCUMENT NQ STATE BAR OF WISCONSIN. F'ORM3-1982 E~'r 1.91.08 ,~ _`~`~1 QUtT ('.LATVI I1EED KRTFILE'EN H, IiAi.Sti ti RESiISTER OF DEEt?8 ST. GftQIk. t:0>, it2 1"rar~cts M. Nelson quit.. claims to James R. Nelson the ~~ ~~ REt~ - ~Y ~ ,' fallowing described rest estate in St. Croix County, State 43~-~-~4oQ °30 t~! of Wisconsin: 9tSA CLADS DEE9 EXEt~P t Rlt CERi €OPY FEE: G~^t FfE: iRAtk~TER FEE: RE(S1RBT}i6 FEf: 14.04 PA6ES. t REMINGTON LAVE' 7FFICES P. O. Box Y7? New Richmond, VhI 54017 ~' .Tax Parcel No: 006-:076-6U } ,. All that part of the NW '/a of the SE '/. of Section 33-31-16, described. as follows: Commencing at the SW connct of the NW `/. of the SE '!. of Section 33-3I-16; thence N 353 feet; thence E 154 'Fi feet; thence S 122 feet; thence E 194 %3 feet; thence S 231 feet; thence ~ 349 feet to the place of beginning. Subject to recorded easements, reservations, and rights of way. .This deed is given pursuant to a judgment of divorce, entered in Washburn County Circuit Court on February 22, 2000, Case No.: 99 FA 33. i This is nut homestead property. E ~ Dated this 2ZZ day of February, 2000. k j r THIS INSTRUMENT WAS DRAFTED BY: Remington Law Offices James T. Remington P. O. Box 177 New Richmond, WI 54017 n't ~ tSEAL) * Frances M. Nelson _ ~" ACKNOWLEDGMENT STATE OF WISCONSIN ) SS. ST. CRODC COUNTY ) Personalty came before me this2?~y'of February, 2000, the above named Frances M. Notson to me rsrown to be the person who execute the foregoing instrument and acknowledge the same. .. ., Notary ' m ,Wis. My co ~"A: ~...,+,