HomeMy WebLinkAbout012-1013-50-100 ST. CROIX COUNTY ZONING DEPARTMENT
r AS BUILT SANITARY REPORT
Owner
Property Addre s S a
City /State
Legal Description:
Lot ` Block Subdivision/CSM #
'/411 1 /4, Sec.S , TJN -RAW, Town of PIN # D doe ,. j a 3 - Sa-/ on
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer l.J �- Size ST/PC _ Setback from: House
— 3a Well 94 P/L ,
Pump manufacturer Model
Alarm location —�
(HOLDING TANKS O Y)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of system: Width 3 Length 7 .S Number of Trenches
Setback from: House YS Well N f P/L 6,10 Vent to fresh air intake / y R
ELEVATIONS /
Description of benchmark A At (1) , & PO C £ /0� - i Elevation /
Description of alternate benchmark Elevation
Building Sewer ST/HT Inlet ` / - 6*5 ST Outlet 43 - PC Inlet
PC Bottom - ---- Header/Manifold ` Top of ST/PC Manhole Cover 4 d 9 3
Distribution Lines ( ) ! �� g- � 6.)
Bottom of System(/)
Final Grade
Date of installation �- / Per it number State plan number
Plumber'=s*gnature 0 ,&L-. License numbe> - Date / / Q a
Inspector
Complete plot plan Or
xt
NOTICE: Please provide the following:
• A plan view sketch showing everything within 100 feet of the,systein. ,
• Two horizontal reference points to center of septic tank manhole cover.
• Slkow alternate benchmark; if applicable. "
PLAN. VIEW
INDICATE NORTH ARROW
Wisco%Wn Department of Commerce PRIVATE SEWAGE SYSTEM Count y
Safety and Buildings Division
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)l. 353321
Permit Holder's Name: ❑ City ❑ Village ❑ ToWn of: State Plan ID No.:
Alderman, Heather Erin Prairie Townshi
CST BM Elev.; Insp. BM Elev.: BM Description: < Parcel Tax No.:
cm . a' 100 .'0 ' Nc 012- 1013 -50 -100
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic O Benchmark ( 2 3 .O
Dosing Alt. BM c� Z
Aeration ,'� Bldg. Sewer
Holding St /Ht Inlet
TANK SETBACK INFORMATION St /Ht Outlet �p� ct. q '
TANK TO P/ L WELL BLDG. Air I ntake ROAD Dt Inlet
Air
Septic 1 �' ' NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe "J 7- Z $(
s It q 98.
Holding Bot. System V, q;-,5o r
PUMP/ SIPHON INFORMATION Final Grade - �,.' S. Z� �D�, 02'
Manufact n St cover '
Ze 02.0
Model Number GPM
TDH Lift Fric ' System Ft
Forcem Length Dia. H Dist. To Well
SOIL AB RPTION SYSTEM Z 5 U J,
�€B AT NCH Width Leng _ No.Of T enches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSION
SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer,
SETBACK
INFORMATION Type Of CHAMBER M del Number:
System: c i > L o I , - — OR UNIT
DISTRIBUTION SYSTEM
Header/ Manifold , Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length %� ( Dia Leng ing p
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: DS/ DZ/ab Inspection #2: - --/—/
Location: 1677 County Road K New Richmon WI 54 17 (NE 1/4 NE 1/4 5 T3QN R17W) - 5.30.17.61B
1.) Alt BM Description = 5 ( l w•� k °` �`"`- 5k4_Q_
2.) Bldg sewer length = �j D
- amount of cover = SYL
Plan revision required? ❑ Yes No Z
Use other side for additional information. 1 0 - 7 p I p
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: ,
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Safety and Buildings Division
V SCO/1SII1 SANITARY PERMIT APPLICATION 2 1 Box Washington Avenue
Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8112 x 11 inches in size. Sri C. M t
• See reverse side for instructions for completing this application State sanitary Permit Number
Personal information ou provide may be used for seconds
y p y second purposes ❑Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION I —
Propert wrier Na a IV Property Location
P%_ !Q C- - A W -o r ry\o 9A f4e 1/4, S � T 30 , N, R l Vr) W
Property Owner's Mailing Address Lot Number Block Number
Ci , Stat C. �. Zip Code Phone Number Subdivision Name or CSM Number
(71 ) %-
11. TYPE OF BUILDING: (check one) ❑ State Owned cit P Nearest Road �f I/
`* ❑ VII age
Public 1 or 2 Family Dwelling - No. of bedrooms own of ��
III. BUILDING USE (If building type is public, check all that apply) arcel Tax Number(s)
4/a • /d /3 - 9� -moo _ /po
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
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
______ ly______________Exi iq ----- ________ 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
12 ZSeepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System- I n- F i I I (Qq� W_0_�J&
VI. ABSORPTION SYSTEM FORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sg. ft.) Proposed (sq. ft.) (Gals/d y /sq. ft.) (Min. /inch) Elevation,�/./
7S� ; (6 / .?1.5 Feet Z po ? Feet
VII Capacit
TANK in g all o ns Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer Name Concrete Con steel glass Plastic App
New Existin structed
T nks Tanks
Septic Tank � Wil ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber El El 1:1 El 1:1 1:1
VI11. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installtlLon of the onsite sewage system shown on the attached plans.
Plumber Name: (Print) Plu er' Signatur : (No S mps) MP /MPRSW No.: Business Phone Number:
o as '3 1s - a
Plumber's Address (Str et, C , Sta , Zip Code):
pto
s� N.-w t on s' o
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved nitary Permit Fee (Includes Groundwater ate ssue Issuing Agent Signature (No Stamps)
❑ Surcharge Fee)
Approved Owner Given Initial
Adverse Determination P r �
1 3--6
`z�
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 4/99) 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 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,plufnber 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 mairitained. *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 f608- 266- 3151. - - - - -
- 1
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. 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, eta.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only. ti
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 boss; 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 1'15 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.
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Wiseonsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor and 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 St. Croix
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distan t road. 012 - 1013 -50 -100
APPLICANT INFORMATION— PLEASE ' *'TION
MEW Y � AT !sq
PROPERTY OWNER: PROPERTY LOCATION
'r GOVT. LOT 1/4 1 /4,S T ,N,R or) W
Heather Alderman / -' Y ` ,i ° ° °� NE NE 5 30 17
PROPERTY OWNER':S MAILING ADDRES . LOT # BLOCK # I SUBD. NAME OR CSM #
2312 60th. Ave. t - na na na
CITY, STATE ZIP CODE ❑CITY VILLAGE MOWN NEAREST ROAD
Osceola, WI. 54020 X OAfa�i -3578 Erin Prarie C "
[x] New Construction Use Ix J ResideiltigtZ/,,Number of be fire [ J Addition to existing building
(] Replacement [ ] Public or co real d6 ri
Code derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd /ft .8 trench, gpd /ft
Absorption area required 858 bed, ft 750 trench, ft Maximum design loading rate gi bed, gpd /ft . 8 trench, gpd /ft
Recommended infiltration surface elevation(s) area A= 99.20 B= 97.50' It (as referred to site plan benchmark)
Additional design / site considerations nn
Parent material outwasr Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem ® S ❑ U NI S ❑ U ®S ❑ U ®S ❑ U ® S ❑ U ❑ S [11
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 Trench
..................
.................
..................
.................
1 0 -7 10yr3 /3 none 1 2msbk mfr gw 2f .5 .6
2 7 -23 7.5yr4/4 none scl 2msbk mfr gw if _ .4 _ .5
Ground 3 23 -96 7.5yr4/6 none co s Osg ml na na .7 .8
elev.
10 ft.
Depth to
limiting
factor
+
v
`►6
Remarks:
Boring #
1 0 -8 10yr3 /3 none 1 2msbk mfr gw 2f .5 .6
2 2 8 -24 7.5ry4/4 none scl 2msbk mfr gw if .4 .5
3 24 -90 7.5yr4/6 none co s Osg ml na na .7 .8
Ground
elev.
1 03.5 ft.
Depth to
limiting
factor
+90" S�.v
Remarks:
CST Name: -- Please Print Gary L. Steel Phone: 715 -246 -6200
Address: 1554 200th. ve. New Ric mond WI 54017
Signature: Date: 4 - -99 CST Number: m02298
i
I
PROPERTY OWNER Heather Alderman SOIL DESCRIPTION REPORT Page? o
PARCEL I.D. # 012 - 1013 -50 -100
`I
Depth Dominant Color Mottles Structure GPD /ft
Boring # Horizon Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends
« 1 0 -13 10yr3 /3 none 1 2msbk mvf gw 2f .5 .6
................ 2 13 -30 7.5yr4/4 none scl 2msbk mfr gw if .4 .5
Ground 3 30 -40 7.5yr4/4 none co E Osg mvfr gw na .7 .8
elev.
1 4 40 -90 7.5yr4/6 none ms Osg ml na na .7 .8
Depth to
limiting
factor
+90
33 6
Remarks:
Boring #
1 0 -15 7.5yr3/2 none 1 2itisvic mfr yw 2f . .6
4 <' 2 15 -3 7.5yr4/4 no ne scl 2msbk mfr gw if .4 .5
3 30 -84 7.5yr4/6 none co Osg ml na na .
.8
Ground
elev.
100.8ft. —
Depth to —
limiting
factor
+8 4"
Remarks:
Boring #
1 0 -10 10yr3 /3 none 1 2msbk mfr gw 2f .5 .6
5 2 10 -22 7./5yr4/4 none scl 2msbk mfr gw if .4
3 22 -84 7.5yr4/6 none co s Osg ml na na .7 .8
Ground
elev.
10 ft.
Depth to
limiting
factor
+84 11
Remarks:
Boring #
Ground
elev. i
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel Heather Alderman 1554 200th Ave.
CSTM2298 NE4NE4 S5- T30N -R17w New Richmond, WI 54017
MPRSW -3254 town of Erin Prarie (715) 246 -6200
1
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1 =40'
BM.= top of 1 pvc pipe C el. 100
Alt. BM.= top of 1" pvc pipe @el.. 100.20'
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4 -8 -99
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer
Mailing Address CD ! f 6;(
Property Address l � 7
(Verification required fro tanning Department for new construction
City /State C Parcel Identification Number 0l a. -101 So - )0U
LEGAL DESCRIPTION
Property Location AAG '' /4, � '/4, Sec. 5 , T-30 N -R-12W, Town of P ra cL
Subdivision tO cvq , Lot # �—
Certified Survey Map # r Volume `—` , Page #
Warranty Deed # �u7 , Volume / S_ , Page # —5
Spec house ❑ yes W no Lot lines identifiable yes ❑ no
SYSTEM MAINTENANCE
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 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
master plumber, journeyman plumber, restricted plumber or a licensed 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.
I/we, 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
days f the three year expiration date.
GION 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
the pr perry described above, by virtue of a warranty deed recorded in Register of Deeds Office.
3 /
SI ATURE OF APP CANT 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
qq `a
y); . , 125PAGE 315
6[728'71
STATE BAR OF WISCONSIN FORM 2 - 1998 KATHLEEN H. WALSH
REGISTER OF DEEDS
ocument Number WARRANTY DFFD ST. CROIX CO., WI
This Deed, made between Kevin D. Schmit and Jacqueline K. RECEIVED FOR RECORD
Schmit, husband and wife.
05-14 -1999 10:04 AN
, Grantor, and Heather Alderman, a single
person, WARRANTY DEED
Grantee. CCQPY FEE:
Grantor, for a valuable consideration, conveys and warrants to Grantee COPY FEE:
the following described real estate in St. Croix County, State of Wisconsin TRANSFER FEE: 217.50
(The "Property "): RECORDING FEE: 10.00
PAGES: 1
Recording Area
Name and Return Address
KRL i 1TNA OGLAND
Zi1Z Estreen & Ogland
P.O, Box 359
Hudson, W1 54016
C>/ 1 —
012 -18i� -50- .00; 012 - 1013 -80 - old
Parcel Identification er (PIN)
,r�
This is not homestead property.
E1 /2 of NE1 /4 lying North of Railroad in Section 5 -30 -17 EXCEPT Certified Survey Map in Vol. "11 ", Page 3106.
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this Z 7 day of May, 1999.
* * n D. Schmit
* cq ne K. Schmit
*
ACKNOWLEDGMENT
AUTHENTICATION
STATE OF WISCONSIN )
Signature(s) Kevin D. Schmit and Jacqueline K. Schmit, husband ) ss.
and wife County )
authenticated this � ay of May,
1999. Personally came before me this day of
the above named
* Kristin Oglanj to me known to be the person(s) who
executed the foregoing instrument and acknowledge the same.
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by § 706.06, Wis. Stats.)
Notary Public, State of Wisconsin
THIS INSTRUMENT WAS DRAFTED BY My Commission is permanent. (If not, state expiration date:
Attorney Kristina Ogland )
Hudson, WI 54016
(Signatures may be authenticated or acknowledged. Both are not
necessary.)
*Names of persons signing in any capacity should be typed or printed below their signatures
WARRANTY DEED STATE BAR OF WISCONSIN
FORM No. 2 - 1998
INFORMATION PROFESSIONALS COMPANY FOND DU LAC, WI 800.655 -2021