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HomeMy WebLinkAbout026-1013-20-000 0 O Ge N y Op 04 U O 1 O w o c m E O U) L Co W N U N d o 3 w 'v M p 0, a m q O CL U-0 C N m U) 01 O .r OO in C O N O X y N O L O X O N E N W N X 0 'O X a) O. N O Z c D N 3 c 3 LL O ON U t0~ N ~ c C ~ i E Q N N m N U Co m v ~ a' y co ~ 0 O z d d Cl) w a Co v H z c C7 o z v o N d Z c to P r O N c E ~ W a) co N co U) ) t C C Q z~z o N N C ~ N m E 7 O N R J LO d 0..M w m N o o a` 2 Cl) E c H F- F- 3~3 °-U) r O O O •ti u a a a a ry 3: 04 N fA J U z rn rn 7 } (3) 7 > v Cl) "1 M O Q O O_ y ~ 6) E N O O n O N ~ N O a N N ~ co co O N C N O c H N C o0 3 c of c E cn r_ © o w I-c o nilii c w O a CL -0 11 0 24 N 0 0 O c0 O N c N O M N ty~, O co 04 N D E U o~ a o N H ~ cn ~'V O O L O O O Z U O O o ~ E d CD m d 7 EL L d ~ a d .V N Y C CU o ca w O tnv A Ua~ 0 R AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP < S-x4.11( ! 61/ SECTION-_:~_T -?d N-R W ADDRESS _11 35 -6x Ai< e; ST. CROIX COUNTY, WISCONSIN SUBDIVISION_ ✓V/ LO OT SIZE=5)j C!h,6 PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 13°~ r y0 . INDICATE NORTH ARROW ILI BENCHMARK: Elevation and description: f_Dd ~~J``~~~~~~ S W• cf,yyt_ Alternate benchmark SEPTIC TANK:Manufacture : 4t/, Liquid Cap. T66tr'2~ 3 Rings used:/' Manhole cover elev: Final grade elev: Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front "t4-, Side , Rear Ft. lr'D From nearest, prop . 1 ine : Front , Side , Rear Ft . _--mod No. of feet from: Well l!Q~ Building: (Include this information in the above plot plan) 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Si on Manufact.: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.: mp off elev.: Gallons/cycle: Alarm: Man.: Switch Type: Location Distance fr nearest prop. line: Front_, Side_, Rear Ft. Distan from: Well Building SOIL ABSORPTION SYSTEM Bed: Trench: Seepage Pit: Width: S Length Number of Lines: Z Area Built J~la Exist. Grade Elev-76, / Proposed Final Grade Elev. g~ Fill depth to top of pipe: No. feet from nearest prop. line:Front Side, Rear Ft No. feet from well: No. feet from b HOLDING TANK Manufacturer: Capacity: No. of rings used: Elevation of bottom tank: Elevation of inlet: No. feet from ne rest prop. line:Front , Side , Rear Ft. No. feet from' Well building , nearest road Alarm Manuf cturer: INSPECTOR: / Z PLUMBER ON JOB: DATE : S ~i7/.~~'C~SGI/ S LICENSE NUMBER: 6/90:cj I i LC~CATI~N: RICIMQND 4.30.18.47E,NE SW, 175TH AVE. isco m epart mento In ustry, PRIVATI! SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST, CROIX Safetrj and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION 175662 Permit Holder's Name: ❑ City ❑ Village [X Town of: State Plan ID No.: PETERSON, JOHN T & JUDITH RICHMOND CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 14d,, dZ1' SGT-rrrQ GAS 2 026-1013-20-000 /40 21 Q Z TANK INFORMATION ELEVATION DATA A92003 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic K~,S VC, AN. Benchmark Q 7~ 111~,G'~1 ng- Dosi / Aeration Bldg. Sewer Holding St / F)f Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic >So' oo 14 NA Dt Bottom NA Headers Aeration IJIA Dist. Pipe 90.36 Holding Bot. System Z,ZI PUMP/ SIPHON INFORMATION Final Grade Manuf Demand 3:7~`"~~ Ca, t 29, ot/ Model Number GPM TDH Lift Friction 5 stem TDH Ft Loss ad I Forcemain Length Dia. Well SOIL ABSORPTION SYSTEM BED/TRENCH Width ' Len tl No. Of Tenches PIT o. Pits Inside Dia. Liquid Depth DIMENSIONS 5 ~ 9S DIMENSIONS LEACHIN Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM pe z , CHAMBER Num er: INFORMATION Ty O OR UNIT 7R System:el~,Gt25 (Z DISTRIBUTION SYSTEM Header/ N U&4814 Distribution Pipe(s) x Hole Spacing V r e Length JL Dia. Length 26-0Z Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Sy s Only Depth Over „ r Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center 2I "32 Bed/ Trench Edges z Topsail' ❑ Yes E] No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc/.) i417" Plan revision required? ❑ Yes 240 Use other side for additional information. 9 1,23 9~ b SBD-6710(R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH e SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION aDILHR COUNTY In accord with ILHR 83.05, Wis. Adm. Code St. CRoix STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 8% x 11 inches in size. Ch k i re on t previous a plication -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 John T. Peterson NE '/aSW '/4, S 4 T30 , N, R 18 f (or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # 1135 175th. Ave. n/a n/a CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER New Richmond Wi. 5401 7 715 246-4804 n/a r175t REST ROAD II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLAGE ; Richmond h. A ve. ❑ Public ®1 or 2 Fam. Dwelling of bedrooms 3- -PARCEL AX N III. BUILDING USE: (If building type is public, check all that apply) D a / /Q 13 - a Q 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. El New 2.ZI Replacement 3. ❑ Replacement of 4.E1 Reconnection of 5.E] 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 El Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 El HoldingTank 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 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 450 825 850 .53 27 92.32 Feet 96.17 Feet VII. TANK CAPACITY Prefab. Site Fiber- Exper. in allons Total # of Manufacturer's Name Con- Steel glass Plastic App INFORMATION New istin Gallons Tanks Concrete structed Tanks Tanks Septic Tank or Holdin Tank Lift Pum Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for instal of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plum ature: (rmPs) I*MWPRSW No.: Business Phone Number: -620 Ga L. Steel 3254 Plumber's Address (Street, City, State, Zip ode 1554 200th. AVe. New Ric and w'. 54017 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date ssue Issuing A en C_u tamps) Approved ❑ Owner Given Initial Surcharge Fee) j1 $ 3/ gZ Adverse D termination 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 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 (SE31) 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumpec 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. M. 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 lumber of tanks and manufacturer's name. Indicate prefab or site constructed and tank material, Comp ete fo, 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) I S T C 100 This application form is to be completed in full and signed es the OMIct(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Shou development be intended for resale b ld this house), then a second form should be retainedrand nc mp eted when the property is sold and submitted to this ,`spec appropriate_deed-recording_------ office with the Owner of property John T. Peterson ~ Location of property NE 1 4 SW / 1/4, Section T 3O N_R_jjLW Township Richmond Mailing address 113 ~ Address of site Subdivision name n/a Lot no._ n /a. Other homes on property? yes x _ No Previous owner of property Dennis Schultz Total size of parcel _5 acres Date parcel was created 1-15-74 Are all corners and lot lines identifiable? x Yes No Is this property being developed for (spec house)?,_Yes No volume 507 and Page Number 181 as recorded. with the Register of Deeds. 114CLUDE WITH THIS APPLICATION THE FOLLOWING: A WARIUUITY DEED which includes a DOCUMENT NUIWER, VOLUME AND PAGE. 11U1•tUI R & THE SEAL or THE IMGISTLIt of DEEDS. certified survey, if available* ;would be helpful so asdto oav~oid delays of the reviewing process. d references to a certified survey Map,Ithe hCertified Survey Map shall also be required. P PROPERTY OWNER CERTIFICATION 10qe) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am the property described in this information form b e owner(s) of warranty deed recorded in the office of the county Regis of a Deed; as Document 11o.320200 , Y ter of own the proposed site £or the sewn e' and that I stem presently dispos obtained an easement, to run the above describe property, I (we) the construction of said system, and the same hs beduly No. y recorded in the office of county Register of deeds as Document agnature of ap~l cant c appl can ~J i • Date of ignature ~ •//y.L~ Date fps gnature Aarmaty Dwi--Short Fora STATE OF WISCONNIX) PaD11W6M M 1u CWn 540 ~ Matlwq ok (am 236.16. WL Statut.a) Form No. Y 32000 Z1;0' 3dien#um Madeby Dennis W. Schultz and Rachael Schultz, husband. and wife, grantor s , of St. Croix County, Wisconsin, hereby conveys andwarrantsto John Thomas Peterson and Judith Ann Jean Peterson, husband • and wife as joint tenants, grantee s , of St. Croix County, Wisconsin, for thesumof Three Thousand and no/100ths ($39000.00) Dollars the following tract of land in St. Croix County, State of Wisconsin: I Commencing at a point 660 feet East of the Northwest corner of the Northeast Quarter of the Southwest Quarter (NE4 of SW4); thence South 660 feet; thence at right angles West 330 feet; thence at right angles North 660 feet; thence at right angles East 330 feet; to point of beginning, all in Section Four (4) Township Thirty (30) North, Range Eighteen (18) West, totaling five (5) acres more or less TRANSFER REGISTERS OFFICE $3,000 ST. CROix CO., WIS. FEF Recd for Record this-X7tb_ day of-January---_A.D.19_14 8s 41 Rs N of ~'liedt Jn IMitntoo Mlertot, the said grantor s hevlereunto set their hands and seal g this 15th day of January , A. D., 19 74. Signed and Sealed in Presence of . Sem)) Sad) i _ Eric J. Lundell ..r(Seal) Frances Van Nevel .._..(SeaJ) !!lift of ~mti,rcon~in~ St.Croix as ..Conarty. Personally came before me, this 15 day of January , A'19 - ~t,,• theabovenamed Dennis We Schultz and Rachael Schultz, husband and'..' -t • . to me known to be the person swho executed the foregoing instrument and ac owled A t t4 `'va~L e Er c J • Lundeg Notary Public, Ste Croix Cou , ls. My commission ammbwpermanent,Ac%k)Mx Drafted by Kaiser, Law Offigg, New Richmond, Wis ri 1 BOOK 5,07 ..:3..bna.a7wU.n=ass. swea+a=er==-s;. t.r SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County John T. Peterson OWNER ADDRESS: 1135 175th. Ave.. New Richmond, Wi. FIRE NO: 1135 LOCATION: 1/41 1/4, SEC. T N-R W, TOWN OF: Richmond ST. • CROIX COUNTY SUBDIVISION: n/a LOT NO. n/a 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: ~ 2z I. DATE: - r vZ - St. Croix County Zoning office _ 911 4th St. Hudson, WI 54016 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, - DIVISION -LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 76 N WI 53707 HUMAN RELATIONS (ILHR 83.0911) & Chapter 145) LOCATION: SECTION: T0WNSHIP/Mj&,4t§btWTY: LOT NO.: BLK. NO.: SUBDIVISION NAME: NE ~/4SW 1/4 4 /T30 N/R181fK(or)W Richmond n/a n/a n/a COUNTY: OWNER'S/RSty NAME: MAILING ADDRESS: St. Croix John T. Peterson 11135 175th. Ave., New Richmond, Wi. 54017 USE DATES OBSERVATIONS MADE CAL NO. BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence 3 n/a 1:1 Newteplace Il 7-28-92 7-29-92 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) ®S ❑ U QS OU QS OU ❑ S ~A ❑ S 6M conventional If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5) (b), indicate: n/a Floodplain, indicate Floodplain elevation: n/a PROFILE DESCRIPTIONS page 27 SaB 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-1 90 96.17 none >90 0-12, 10yr4/2, L.; 12-28, 10yr4/4, sil.;- B-2 88 96.17 none >88 0-11, 10yr4/2, L.; 11-24, 10yr4/4, sil.- 95.32 0-b, lUyr4/Z, ; si B-3 84 none >84 28-84, 7.5yr4/4,sl. B- B- B- decimal' PERCOLATION TESTS TEST WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER D H ~ AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P- 1 3.8 none 30 11-1 U, 1124 P- 2 3.85 none 30 11-1, 11-1 11-1 24 P- 3 3.00 none 30 1% 11/8 11/8 27 P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 4,v 92.32 3 tit r 3 I _E N 1h rt- ~ 1 E E E E E C e E 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: Gary L. Steel 7-29-92 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): -6200 1554 200th. Av.e New Richmond Wi. 54017 2298 7 CST SIGN DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) OVER - Ai t 'HE i i $ f T T H I priv . STEEL'S SOIL SERVICE Gary L. Steel 988 N. Shore Drive C.S.T. 2298 New Richmond, WI 54017 MPRSW-3254 John T. Peterson NE 4 SW y S . 4-T30N-R18W (715) 246-6200 Richmond, township dll 1-14-1 176 of ji, br1 0 Pe , teoc~ A1.-,e, 1 \a / I 9'u) C~ p ft a7a-1 10 3,1 c«C '9* Gary L. Steel 8-21-92 REPT131 RICHMOND ST. CROIX COUNTY ZONING PAGE 1 .•'09)Q2/92 16:59 REQUESTS FOR INSPECTION WORK SHEETS FOR: 9/ 3/92 AREA: JT Activity: A9200321 9/ 3/92 Type: CONVSEPT Status: PENDING Constr: Addregs: RICHMOND 4.30.18.47E,NE,SW, 175TH AVE. Parcel: 026-1013-20-000 Occ: Use: Description: 175662 Applicant: PETERSON, JOHN T & JUDITH Phone: Owner: PETERSON, JOHN T & JUDITH Phone: Contractor: GARY STEEL Phone: 246-6200 Inspection Request Information..... Requestor: GARY STEEL Phone: Req Time: 13:01 Comments: Items requested to be Inspected... Action Comments Time Exp 00012 FINAL INSPECTION --------------------------------------------y+---------------------------------- Inspection History..... Item: 00012 FINAL INSPECTION