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HomeMy WebLinkAbout020-1185-50-000 Q o ~ o o p °eog, I c 4 0 w I 0 o I N I o I L~ I ~ I ti I I i I ti I W (D I LL o c 7 CD I v N M I z w w E o ° I Z a m rn C4 _o I c o z c aoi z ° c o I NHS CD v ~ M I ww a~ ~ •9 o. ~ I J ° • N d (n O I O o y Q O I z m z ° N z Q ° I 'TVA ~ II tp ~ R ~ I !1l O CD v v `c~ ~r rG IL E N I d rn 4 w c z c 0 •rv ~aaa ~ o N fn J U p rn OOi Z U o o PV N O O 0 N (D 0 E C° co y I rD _ p o o to N c o ul ° c E to o LO r`0 ° T U ° L rn °o m l CD 0) S 0 LI? a C N \ LO CD CD y i..i N ry= o w a~ v H c m r C4 :3 o o in O E R U • O N 2 m 0 z N z ~q cn CC O .fir IL V dt EL : a rr`F~V o c`a 3 o ~1 A U0.2 ',Ov)0 LOCATION: HUDSON 21.29 19.1167,SW,SE,21, WAGON WHEEL CIRCLE Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations Safety an. kluildings Division INSPECTION REPORT ST- CROTY GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: 291 Permit Holder's Name: 14 4 ❑ City ❑ Village Town of: State Plan ID No.: BENOY, VERLYN E & CATHERINE HUDSON CST BM Elev.: Insp. Elev.: BM Description: Parcel Tax No.: 6) - 61 020118550000 TANK INFORMATION EL VATION DATA A9200135 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic, fl Benchmark ~tj l(S~ o , 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 irl Septic W1 5X Z y/C) + NA Dt Bottom Dosing NA Header/ Man. 1A -t 7,3 Aeration NA Dist. Pipe Holding Bot. System fJ PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand its o> Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Fi Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS / / DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER Mode Number: System: _I OR UNIT f fy 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:)~- , 3 eo wy Plan revision required? ❑ Yes ❑ No b Use other side for additional information. z _ io SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: DILHR SANITARY PERMIT APPLICATION c In accord with ILHR 83.05, Wis. Adm. Code ouNTY STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than /U /I -I q1 8% x 11 inches in size. 1:1 Check rev sio to r vious 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 '(4 Ze l7~ SGa % ji S 2 T ,Z , N, R If E (or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # G/ G' CITY, TATE ZIP CODE PHONE NUMBER SUBDIVISI AME OR CSM NUMBER / ell F-I TYPE OF BUILDING Check one CITY NEAREST ROAD ( ) State Owned O VILLAGE : daoaa~ K %^C /C QSW TAX . UM ) ❑ Public 5 1 or 2 Fam. Dwelling-# of bedrooms 3 PA L III. BUILDING USE: (If building type is public, check all that apply) 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 50 Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE PERMIT: (Check only one in line A. Check line B if applicable) A) 1. New 2.E] Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 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 L+1 Seepage Bed 21 ❑ Mound 30 ❑ SpecityType 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 12. 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 ~d 720 a Feet lbw. Feet VII. TANK CAPACITY Site in gallons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concret Con- Steel glass Plastic App Tanks Tanks structed C Septic Tank or Holdin Tank Jpv~-_ 4,090 1 /'4.39xeAc* ~Tr I _T7T_1 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. P ber'a Name (Print): Plumber's Signature: (No Stamps) MR/MPRSW No.: Business Phone Number: -e r ~r 3 & r6 4CU Addra (St rest, City, Sthte, Zip e . cas3 INTY E PA ENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Sign ture mps) J2/Approved ❑ Owner Given Initial _c Surcharge Fee) / Adverse Determination 14T E I , 11, g, X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber A INSTRUCTIONS r, 4 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 (SEC) 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. N. Type of building being'served. Check on+y ane 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 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 al/ septic, pump/siphon and holding tanks for this system. Check experimental approval only if ranks 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'h x 11 inches must be submitted to t' e county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, !ocation 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 point:.; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump perforn-Lance 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) R APPLICATION FOR SANITARY PCRHIT 9TC-100 This application form Is to bo c:onplntod In full and signed by the ovntr(s) of the ptoperty being developed, luny lnadoquacles will only result In delay: of Litt p I t n I t Iseuanco. -Should this development be Intended for raaalt by ovner/contractot,(epac houoe), titan a second form should be tetalntd and co■pl■ted when Life property is sold and submitted to t h I a afllca with the ■ppropclate deed recording. gvnttt .of property /.Z Location of property Sit) 1/4 -SE- l/le 8actlon 21 T M-A l Township 1_"G( D_S U Kalling address ft~UtJ CT Address of site subdlvislon me"_ ~i47Y2~f~ S 1 41 Lot number Prtrlous owner of property Total /l:e of parcel Data parcel vas created Ate all cotnsrs and lot llnsa ldentlllable? Yes _yo is this pro patty being developed lor resale (spec house)? x _Yas No V.I... 7:3.5 and page [lumber 1 ss raCorded with the 11491etat of Dads. l L A V ARANTr DASD whlchInncludes WITH a 1(DOCU){RHT CNUNOTR1 VOL OUMIt A(DIPAot )4LXjjR, and the a9KL or TIM RBOI©THR Or DERDS. In addition, a rectified survey, if available, would be helpful so as to avold delays of the tevlevlnq process. it the deed description taterencas to a Cattillad Survey Nap, the Cattlfled Survey Nap 'shall also be tcqulred, PROPERTY OV119R CHRTIPICAT10N I(vs) c1tLity that all eLALemente on title form are true to the bast of my (our) knowledge/ Chit I (ve) am (are) Lila owner(a) of the property described In L h I a Inlat mat Ian Iarm, by virtue of a warranty deed recorded in the office of Lhe County RtglsLet of Deeds ae Document 11o. Yip Ityf presently own Lhe o ) and that I (we pr posed alto for rho news a die l obtained an easement to g petal ayaten (or I (ve) hews r run With the above descc b consttuctlo l ad co a r the n of raid nyrtatn, and the same )tee been duly raca rrdeid Inytheto of ,ths County Reglrt.c of Deada, as Document No Of t l c a d / Yip Yes 7 A.. signs t. of Owner SLynature of Co-ovner (II' hpp IcaDtel I-X Data of signature uat:a oc elgnat re 1 01, DOCUMENT NO. STATE BAR OF WISCONSIN FORM 5-1982 THIS SPACE RESERVED FOR RECORDING DATA y PERSONAL REPRESENTATIVE'S DEED • 410421 Harry J. Stewart ri ri CO" as Personal Representative of the estate of 1.:.' pl rsrE if b 31st JOhn• Aldro_ Myren_.Larsep,,__a/k/a-_John..Afdro.-Larsen._ - March A.t 1986 . a/k~a Aldro Larsen ........................en..----._.._..-•---.......---...........---------•••---•----•--•-----•--- 9:45 A C.~ - • . ("Decedent") for a valuable consideration conveys, without warranty, to ••Verlyn E. Benoy j and Catherine A,__Benoy1 as husband and wife as marital ~"ti~ aR . rr 10 coil property with right . of survivorship _ Grantee, RETU To the following described real estate in St._ Croix County, State of Wisconsin (hereinafter called the "Property") West Half of the South East Quarter of Section 21, Township 29, Range 19. Tax Parcel No: 'i i i :'1;1'•.X~ ter. ~ ~ i. Ii ii i~ ~i ~i I Personal Representative by this deed does convey to Grantee all of the estate and interest in the Property which the Decedent had immediately prior to Decedent's death, and all of the estate and interest in the Property which the Personal Representative has since acquired. Dated this 2-8t day of Mal"gh................................................ 19..86•.. i i• i II (SEAL) I L ------(SEAL) ' Harr J .Stew r - •--X-•..:._.. % 1 Personal Representative Personal Representative . AUTHENTICATION ACKNOWLEDGbilkk'NT~ n C::~I Q 4'7 Signature (s) STATE OF WISCONSIN r6~; . 2-- G-T • 47 41 s t...C> aiX---•-••....---..County. authenticated this ........day of 19------ Personally came before me this 28Ch...day of MarCll............................. 19-B-6--- the above named Hary-_,T, Stewart,-.as••Personal-_Representative . • #ox le estate.•gf- Johtl Aldro My en Larsen, TITLE: MEMBER STATE BAR OF WISCONSIN a/kZa__John-_Aldro__Larsen1__a/k_a Aldro (If not, Larsen authorized by § 706.06, Wis. Stats.) to me k own to be the person who executed the foreg g ime}~t and ack j1owledge the same. THIS INSTRUMENT WAS DRAFTED BY Lois A. Murray of HEYWOOD, CARI & MURRAY . . -----•---.-•-.-.v .F....,H r~? .~/~S ©r!•~--- - P-,D.._.Box-229•,-•13uchsan,.. ioIL.54QLh....•.•---........_ St._ Croix County, Wis. Notary Public ..St-- Croix (Signatures may be authenticated or acknowledged. Both MY Commission is permanent. (If not, st to expiration are not necessary.) date kn i •Names of persons signing in any capacity should be typed or printed below their signatures. SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER_ C- fi /`,e (/y r- l~ i~L~L tr 0 ADDRESS: FIRE NO- LOCATION: 54t) 1/4, S r 1/4, SEC. `T? q N-R TOWN OF: 1-1411 QS G 1J ST. CROIX COUNTY- SUBDIVISION: ~2 12 ( IX LOT NO. 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 a 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 to help with the cost of the 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 the St. Croix County Zoning a certification form, signed by the owner and by a master 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. Certification from will be sent approximately 30 days prior to three year expiration. 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 form must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: ~~..1_/.: i ✓,~~~.y~- DATE St. Croix County Zoning office 911 4th St. Hudson, WI 54016 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS DIVISION INDUSTRY, P.O. BOX 7969 LABOR AOD PERCOLATION TESTS (115) MADISON, WI 53707 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOT NO.: BLK. NO.: SUBDIVISION NAME: LOCATION: SECTION: TOWNSHIP/QTY: ` w '/a N/R E to COUNTYY- OWNER'S/B~7dIE: MAILING ADDRESS: 1.411A - C.t.. T USE DATES OBSERVATIONS MADE rr~-~L NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: ERCOLATION TESTS: L"fHesidence ~ eplace ~ O ~ 2 O RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND PRESSURE:SYSTEM-IN-FILL HOLDING TANK: ri=t M:(optional) CC'S DU CAS ❑U CAS ❑U CAS ❑U CAS - If Percolatio n Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- / 9. /Vpf t " 6 '3t L • l ' r w B- y 9a a o sr, e p 9 '8 s / . / ' N s / V. 8 ' ,res. B- 41 zfl NS/ V. B_ PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN -WATER LEVEL ES RATER INCH ES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD ? PERIOD 2 PER P- 3 5- r P_ P_ y !Sh locations ofpercolation tests, soil borings and the dimensions of suitable soil areas. Indicate r1n Describe what a the hori- Tna 3 levation reference points and show their location on the plot plan. Show the surface elevati nd the direction nd percent 't a LEVATION I, P6.I/ F. E t c ~ i r r 3 t _ b - 'e e. F z E 3 mm__ N 3 3 E , : ~e S i _ I I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: DAVE FOGERTY PLUMBING -1' ~Z ADDRESS: 3233 #3289 CERTIFICAT N N MBER: PHONE NUMBER (optional): Faartw i hts Road WISCON CST G URF~ &Mb 749-3656 TRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. 5 R. 10/83) - OVER - s~ I'd TO ^~O see(-e yo e SH► , i , p arl kSSNIK'r ~G~• o ~~2' X _ ~OrIN' © perk ;p Art • s• i • x zy ~ Oro ?.?4 DAVE FOMTY PLUMBING Licensed Perk Tester & Plumber #3233 #3289 Fogarty Heights Road RTSS, WISCONSIN 54023 ROSE 15FIti0 740-3686 e 3 L074 /o 3l3/ f Z ~o s► 40 °x r p I o o~ lift N W . _ . • ~ ;a. • ,r . ~ . i W ' ,R. . o ► n. n ~ Z • - O y ~ ~ P • i / ~ ~ _ . ~ o N . ~Zo °~R` W ~ = ~ . ~ ~ ~ r ~ ~ " - ~ ..,d - - I REPT131 HUDSON ST. CROIX COUNTY ZONING PAGE 1 09/14/92 11:03 REQUESTS FOR INSPECTION WORK SHEETS FOR: 9/14/92 AREA: MJ - - - Acttiivity: A9200135 9/14/92 Type: CONVSEPT Status: PENDING Constr: Address: HUDSON 21.29.19.1167,SW,SE,21, WAGON WHEEL CIRCLE Parcel: 020-1185-50-000 Occ: Use: Description: 149291 Applicant: BENDY, VERLYN E & CATHERINE A Phone: Owner: BENOY, VERLYN E & CATHERINE A Phone: Contractor: FOGERTY, DAVID Phone: 715-749-3656 Inspection Request Information..... Requestor: FOGERTY, DAVE Phone: Req Time: 15:09 Comments : 3:(45- Items requested to be Inspected... Action Comments Time Exp 00012 FINAL INSPECTION ---------------------------r-----.° Inspection History..... Item: 00012 FINAL INSPECTION 269.74' 209.79 209.79' 209.79 209.79 209.79 to So 23 r- 22 21 20 19 18 N co - 0 0 ~o it 0 1262 it I ~ . a) ~ \9 • _ 1261 1260 1259 1258 1257 NW/4-S !J4 209.84' 209.79 209.79 PRAIRIE VISTA 5 '`rcc~lc _ < ~`1 t- L~41iL V 209.98 209.98 350 VERLYN & Q CATHERINE BENOY 24 `i PHONE #386-4143 3. v3 Z 11-3V to ~o~ c+czc.,,~ N 1263 25 .26 .27 M 17 N LOTS FOR SALE ►0 ~ ~ ~ ~ M (p i~ 15,500 - 17,000 P.,. OD rd o .i 1256 • Located on Cty Trk UU ` ')3 miles East Hudson 1264 1265 1266 Easy access to I-94 Nat'l.gas available TERMS TO QUALIFIED BUYERS 247.88 235 210' ' 210' - m co 106 104X3'' 409.04 M LOT 9 -4, s 1255 . 5 0'A act 28. 1267 LOT - ~ - I0 436.37 LOT 8 m U9 S~ x 1168 N 1166 to t 1254 415.96 346`99 I ~wAGON~, 6 6' 349196 ~~E HEEL i CO LOT 7. LOT I I I 165 00 M W 114 -SE 1169 1170 ~IDI 0 9,56 LOT 12 ~r LOT 13 SOBS LOT * 6 .401 1 171 S01-0 1164 532.?T, i~~ , LOT 5 ' LOT 14 1163 - ,o y g 1 172 3 LOT I LOT 2 LOT 3 ' LOT 4 .N 0 6~3 212 C 212 D 2 12 E 212 B 'CERTIFIE_ URVEY MAP VO UME 6~ PA E 1768 ' . COUNTY _ TRUNK - UI7-~ S 1 /4 CO R. ' SEC. 21 " '