Loading...
HomeMy WebLinkAbout020-1287-30-000 Wisconsin,Departmentof Industry, PRIVATE SEWAGE SYSTEM County: Lobar and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION Holder's Name: city Village Town of: State Plan o.: Permit ❑ LUNDELL,ERIC/MILLER, SAM _ _ CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax o. TANK INFORMATION ELEVATION DATA °i TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. r Septic Ud- , Benchmark I6 Dosin D a ,'9 3, !03 63 9/,7 Aeration Bldg. Sewer Holdin St/~k Inlet TANK SETBACK INFORMATION St/ hW Outlet e 97, 7/~ TANK TO P/ L WELL BLDG. ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Do ' NA Header? ar: - 2,011 iZ / Aeration A Dist. Pipe 27, How n-gBot. System 916, PUMP/ SIPHON INFORMATION Final Grade & Zz' 1ja Manufa Demand Model Number M TDH Lift Fri n em JTDH - JA Forc Length FD'ia. Dist. Towel SOIL ABSORPTION SYSTEM BED/TRENCH width/ Length~j r No. Of T enches PIT No. Of Pits Inside Dia. epth DIMENSIONS DIM N I N SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHI nufacturer: SETBACK INFORMATION Type O e,.c t , ER -Model Num System: ,~ec✓ 37 r s / I OR UNIT DISTRIBUTION SYSTEM Header / ~r Distribution Pipe(s) x Size x Hole Spacing ent To Air Inta i Length ~ Dia. Length 7 Dia. Spacing LO SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Sys my Depth Over q „ Depth Over v xx Depth Of x Seeded /Sodded hed Bed /T nter ~7 - ~ BedfT4s*h Edges ! T Topsoil C] Yes E] No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: UDSON. 21 29.19W,SE;W OT 3'PRAIRI LANE, C• Plan revision required? ❑ Yes No n - Use other side for additional information. /~p 1 T 2L SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: . e J 1 i BENCHMARK: Ta? OF Z P/PE `jT S~ L4]r~o~fNLe /00,00 = 7.20 ALTERNATE BM: 'Jot' eF /3/0~ F~UA/!~ AT/O N E/ ~S SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Wm,( Sca_Y" Liquid Capacity: / d o O. Setback from: Well, r House Other 19 T ~~~s~ Pump: Manufacturer--- Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length 11-f 0~ Number of trenches -rte ,A Distance & Direction to nearest prop. line: Z~S ~1~5 - t-07 t;h Setback from: well: S House 3; "7 ~ Other / 3 9 L= ELEVATIONS Ah14a/- z 2i4jr S(pa Building Sewers ST Inlet O Z-- ST outlet / T Z- PC inlet PC bottom Pump Off Header/Manifold 1,76 Bottom of system Existing Grade 90 Final grade . $ y DATE OF INSTALLATION: o:- PLUMBER ON JOB: r LICENSE NUMBER: INSPECTOR: 3/93:jt 3 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER Si4M LLEjL /r Ile- L L L ADDRESS_ r3 OX z g 14 U S n N c UZ s5/016 SUBDIVISION / CSM# Wf-tL 5 f,446o ~,q f/dam LOT # SECTION z/ T,c7 N-R_Z? (Z)Town of 1{U D ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYST A t rEQ- N W, f-lfCrelt sEfICE NAT9 VEaY e 10.5 E Se,4LE 4y = /D a.4e ICF_ N~u3E l1~,~ x !L' a4 'X So ? S' ill Z WAS/ Vl/Ell bs~ ~ , 6' Y'- P lg A BtM IoPof l,e We 01 AT S INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. ShM M►LUE Z dell: I-&w E Wf-LLS _7426o LoT-f3 Se,aLE //►t = /d y STEM E I. .Vo R 7 H L07 L/ NE W v o ~oNDl~1~ F-4SFMEhIT h a ~ i I-oT 3 \ L~ I (1-,4 ~ i ~r ~t-1a--IS n E1.=9sgO / I NJ i A~ 4 ~ 90~--~ 19 ARAf,E ~~°~s~ ° ~j ► ' i ~ I a S x so I ,~L so ~ \ , Zy )e ~ A I v ~ lo' i v r=te IS"! B"I 1 Sob /~~A1R1~ L k"E 1 _ i -PRAZ 4T sc ,COT 60RIVF_2 SANITARY PERMIT APPLICATION COU In accord with ILHR 83.05, Wis. Adm. Code I r STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 Z)? `T0 b 8% X 11 inches in size. Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION FOIL L DELL SAM I ki-O 5E Y4 h/'/4, S Z/ T 2'7, N, R E (or0 PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # 50 X Z S Z CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER SO WT S38 2769 WF1_L, S 7AA60 II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned ❑ VILLAGE : p S Q N P2/a 11Z LA IYC ❑ Public ®1 or 2 Fam. Dwelling-## of bedrooms PAR EL TAX NUMBER(S) Ill. BUILDING USE: (If building type is public, check all that apply) D Z. $ 7 o 1 ❑ Apt/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 in line A. Check line B if applicable) A) 1.,m 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 Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 F Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 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 U REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 7 s~ L y$ 7 z 0 0-7 95-, YO /Feet 9 7~ 0o Feet VII. TANK CAPACITY Site in alIons Total # of Prefab. Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Se tic Tank orHoldin Tank /Oo0 / Y1(,c / SEC 1 El 1-1 F1 Lift Pump Tank/Si hon 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 Stamps) MP/MPRSW No.: Business Phone Number: / Zy7 323 DouG T~Qa}{QE Qtr~ Plumber's Address (Street, City, State, Zip Code): 41 $0 X*0 /Z z_ V e14 A4O)YD (.U S O/G IX. COUNTY/DEPARTMENT USE ONLY r ❑ Disapproved Sitary Permit Fee (includes Groundwater Date Issued Iss 'ng Agent Signature (No Stamps) Approved F-1 Owner Given Initial Surcharge Fee) ~ ~►~7 li Adverse Determination~~~llll X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber 3 - INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the! expiration date, and at the 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 & 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. Ill. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in 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 in ##1-7. VII. Tank information. Fill in the capacity of every new and/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% 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, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) k -7;u ti wf z w Z W oix ° w n, z m ~i ----4 1 Ll L ° F- x~ nl > w x w O Ia- 1► ° o ? o o I I wcL l i o1 w ate. J cJ i o U i i I L Z w i z~ i i 0 Us z I a t 1.0 a I 90 o I I I ~ o I ~ I ~ I I I ~ I I I a 1 I I 0 I I I 0 l~ ~,i - I I I w I ~ I ~ I ° I I F > I +m~ w j a U I / dO I Ra I I Z > 1 10 CT I I I ~3 /~j I w e I ~ I I I ~ I• w _ to V_ x.11 Wisponsin, Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of Labor." Human Relations Division of Safety & 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 PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION Al M /az IQ GOVT. LOT 75 E 1/4 tV LI/4,S T _&Z9 AR E (or) W AMECSM# 5> ' PROP - ~S ~MAILING J is Ak6.4 L # BLOCK # SW UBD.N (L " &.k C) CITY STATE ZIP CODE PHONE NUMBER []CITY VILLAGE OWN NEAREST ROAD ( New Construction Use [Aj Residential / Number of bedrooms Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow ~ gpd Recommended design loading rate .Z bed, gpd/ft2 O g trench, gpd/ft2 Absorption area required 6 A!!~ bed, ft2 5~S ench, ft2 Maximum design loading rate ~Lbed, gpd/ft2 C3 trench, gpd/ft2 Recommended infiltration surface elevation(s)'Se --Sec 4L oC ft (as referred to site plan benchmark) Additional design / site cohsiderations Parent material Flood plain elevation, if applicable It S = Suitable for system CONVENTIONAL NUND IN• ROUND PRESSURE. I T•GRADE STEM IN FILL HOLDING T K U= Unsuitable fors stem 2(S El U ® S ❑ U 451 S 11 U S ❑ U S ❑ U ❑ S U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trerxtt E3 -7 /INV P, 4/3~_ C Ground r l .7 C) elev. icl,G~ft. Depth to limiting Remarks: Boring # L c ©-13 /0 3 $ , 3" ov 3 S, i ab ° 1 0.2 0:3 37-/2 /Vy 3 r S 1 .7 Ground / Cll,ft. Depth to limiting factor Remarks: CST Name. Please Print 4R Sn Phone: YC~Y ~tN Address: 4~ 9 i l'I U~v ~l~ f Signature: Dater / g 93 CST Number: 3 PROPSM. OWNER SAM Mi LLB SOIL DESCRIPTION REPORT Page *Z of 3 PARCEL I.D. # L6-)' 3 w EL--S V1419-4 0 Depth Dominant Color Mottles . Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Treridi 0- 4 4, 7 m C r rn r -Z O S 4_ S; L / ELK C- z 3. Ground 16yoe 3 S 1,1 elev. i •Z Zft• Depth to limiting 7 `7 t~ Remarks: Boring # Q ® It~Y~. l I ~K mr C O Q. Ground N-40 6YA 2 ` S rh elev. Depth to limiting factor ' Remarks: Boring # 16YA 4L-:~ A, n LK e,!Fr 2-l1 lb 4 Ground elev kDi ft. Depth to limiting f for Remarks: Boring # 0-I~ V/ C Z ~ M r 7 j Ground elev. i 0 ft. Depth to limiting jfactorr Remarks: SBD-8330(R.05/92) o , ~La 60 .01 \ I Sys71~r►'. ~-t ~,/AT Ids /n1 ~i !t ' AREAS To 45.4o AN& 1 Pipe 9S p R-- •siE LzT CaPoj0: Etvt = /6n ,6o'- i - I U Sz 9Ey M„9V 5~, - c - 9 E0,9Z- I` 1A CIO CD y, i LLI --4 V A~ p lcj I Q) cl, Cc~ f O CIS 3 41 O I~ N M Lr) 7f m tnl ~ m v. H U W N N (G! N U 31 } V A~ ° N OI ---A V Q I 1J Z O I r N Ln N U), I ~ N r ' _ 1 I go. so- j f 6~ ° l ° w Cu ~:l, U1 (Y) _ ~ ;G b d {n ~ U L 2 U U / b L 1N M 1, p r- - r - - - - p N - - - .00 00,17 w 59 N ' - oo' FF : li I - i I ~ e~ Q Y a~ N o Uco r--1 U4 d . to N N I Z I~ t~ Cd i V) a _ Q to* cn 4-A T w UC U UO o ` - . - cO 1 m 0 !V i Od , SE . L ~ S STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER F (2I L LU N D F-LL /SAM M /LL912- MAILING ADDRESS &0 K Z 2 u 6 S c~ W S d PROPERTY ADDRESS S LO8 ?'R A I~ F L A K f- 44O D S n W W' - ~0 & (location of septic system) Please obtain from the Planning Dept. CITY/STATE U D S c-~ PROPERTY LOCATION S E 1/4, NU-) 1/4, Section 2, TV N-R TOWN OFV S D ST. CROIX COUNTY, WI SUBDIVISION VJ E L L S FA P. & O ETA T 16 ~ LOT NUMBER 3 CERTIFIED SURVEY MAP y 7f & Sg , VOLUMES_, PAGE, LOT NUMBER 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 maintaine be completed and returned to the St. Croix County Zoning Officer within 30 days of the thre ear expiratio ate. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 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. Owner of property It- 4-U M € L L A I-L- Location of property 4, Section T Z 9 N-R / W Township U [)5 O N Mailing address j30I( -*~rL 8 2- l au j T SAD/( Address of site SOg jPeRI CE LAM-: Subdivision name LA .S F/4 g- (op No N Lot no. ~ Other homes on property? Yes_j(_No Previous owner of property A n(/ r 4. k/EL L _S Total size of property 3.N A-C Total size of parcel _-/cl c_ T Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? X Yes No Volume"12-g 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. 7 7-0"q/ , 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. Signature of pplicant Co-Applicant ~ I Date of Signature Date of Signature • DOCt.1MENT NO. WARRANTY DEED THIS SPA,-E RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2 - 1982 47729 RAEGISTER'S OFFICE ST. CROX CO., W! Anita G. Wells, a single woman Recd for Record DEC301991 ~ J":2 :1440 P. M convr,vs and warrants to John- A. Elbert an CJ. ll, as. Tenants .in Common,. an undivided o Regeach . PET',; RN TO the following described real estate in St... Croix --County, State of Wisconsin: Tax Parcel No: All that part of the Northeast Quarter of the Northwest Quarter (NEJNW}) lying Southerly (Sly) of the Railroad Right-of-way; The Southeast Quarter of the Northwest Quarter (°EJNW}); The East Half of the Southwest Quarter (E}SW}), EXCEPT r part to Alfred L. Ekblad , in Volume 498, page 484; part to Leslie L. Swenson in Volume 498, page 504; part to Donald F. Johnsin, in Volume 500, page 525; and part to Donald L. Jordan, in Volume 580, page 354, all in Section Twenty-Onr (21), Township Twenty-Nine (29) North, Range Nineteen (19) West. This Warranty Deed is given in full and final satisfaction of chat original Land Contract between the parties, dated December 4, 1989, recorded December 13, 1989, at 11:30 A.M., in Vol.. 858 of Records, on page 633-634 as Document No. 454203, Office of Register of Deeds for St. Croix Co., WI. This is not homestead property. (is) (is not) Exception t- warranties: Easements, restrictions and rights-of-way of record. Uatcd tbi: 27th day of December . 19 91 (SEAL) f (SEAT.) Anita G. Wells (SEAL) (SEAT, AUTHENTICATION ACKNOWLEDGMENT Signa re(s) OF Anita G. Wells, a STATE OF WISCONSIN ' si pl woman s~ ......County. 27t1h Decerr.ber 1 aut a IT t a of_.--. , T~.. Personally came before me this day of 19 the above named Leo A. Beskar - - - TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by $ 706.06, Wis. Stats•) to we ki, -.cn to be the per-on who exccuted the fun^_uin, in>truvi,.nt and arknowl.d,_c the sanie. 71, S 1":5TR1_jh'ENT WAS DRAFTED BV Leo A. Beskar, Attorney ROM, Beskar 6 Boles, S:( 2219 North - Main St Cooiltv. ""is. (Ji~~ ~;rt.~ I fie au -ieht iced or sckm,w!ad;'ed. Loth M\ t "t. _1 <inn nct nL1,Ii not, staG t:n`nltiou are not nec(,ssary.) date: 1-6 ) •NamF nt prrsme signinK In ar; ~apn, itp <i i 1 WARRANTY DEED STMT: BAR OF 0.-[ICON StYA"-- - jai Plrw C^c FORM No 1 Al 11..4- ns