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HomeMy WebLinkAbout024-1034-60-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 569558 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: French, Troy W. & Dawn Pleasant Valley, Town of 024-1034-60-000 CST BM Elev: Insp. BM Elev: BM Description: Me Section/Town/Range/Map No: 16 -'k- ~a GO.J 29.28.17.223B TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. I-10 We-'j 3 3ood Benchmark Dosing Alt. BM Aeration Bldg. Sewer `t 9 7• S Holding St/Ht Inlet 5 $ ci- St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/y WELL BLDG. ent SI) Air Intake ROAD Dt Inlet Septic z5 ~ ` g J y5 ® Dt Bottom C9 Dosing Header/Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Rover GPM Kew- /6119 /1 Cl lea Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dist. to Well SOIL ABSORPTION SYSTEM BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SY EM TO P/L BLDG ELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type CHAMBER OR Of UNIT Mode DISTRIBUTION SYSTEM Header/Manifold §Distribution x Hole Size x Hole Spacing P Air In ke Length Dia Spacing a p g Ge SOIL COVER ressure Systems Only Mound Or At-Grade stems Only Depth Over pth Over xx Depth o xx Seeded/Sodded xx Mulched Bed/Trench Center nch Edges Topsoil Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 103 165th Street River Falls, WI 54022 (SW 1/4 SE 1/4 29 T28N R17W) metes & b nds Lott \ Parcel No: 29.28.17.2238 1.) Alt BM Description = / $ >Sle CI ia,(~~p 1 C~ a~~~ 2.) Bldg sewer length= :Z17 Q+~ l J~Q ` O'( `A ~..1! - amount of c over a = QD'~ ~ Lo c.~„ •„1 Plan revision Required? ❑ Yes No ~tF Us e other side for additional informationZ' I SBD-6710 (R.3/97) Date Insepctor's ignatur Cert. No. i ~ I a•°i o I a~i oo Q 3 64 03 eon m v, 4 0 0 0 E O c.. y N O Y O O O O C O L C N 4) O M 'a C N ~p N +a a N C O _ Y fa O c 7 a7 U .O-• > CO C C 0 3 ~ ~ U L j 0 Z W C N L a N a) N w a} C O Z 3 my z U -Fu 4),2 LL - 0 0 LL C j C _ O «f M O O N 3 0 3 N~ E a H t U) ~ ¢ !E 11 ~,I v I I `V C N Ili z i/1 ~`O (D > w E E fn p 0 a c z 'O O O O d d d co d a m a co > 0) -q- N F- U) Z rn N w ~ I Y Co O Z d c w`0 v o Y C..mc o a> 2 c c (D 0) N H C (ci r 0 y E. L ~^/J = :3 ) a) T N U) N V! C C L Q. L O _ O Q 2 Z z O z z z O U O rn N N `0 B 10 ca CL M m 0 ~I 'co` ooa h N LL fn V) V~ E O N fA m N ~ "ooo am I`O a= 00 0 •►v a ~aaa 13aaa a N vi om U)" ) o f6O0 o z N W V z LL CD CF) r- C> ~ o y v M O - O E 0 0- o a o o v CO° c d co a a, v rn m 3 0 d ¢ n U) L ? ¢ z in 0 r.+ O m N ~ O Gj M ~ N N E aD M~ V (14 O a) r U a 0 0 0 ~ N~ N C € a) N € E ~ U N N N O M H c 9 a) J c a~ a~ c w 00 o as t ~C poi, m c~ d m O v c y a~ v v ao v co 4 o o y m o o N o o ru- • ' o N a LL LO o z y a z o o z y z z uJ e~ IL € • a d (D dad` rr~~ c m c ~1 A c°~ai..2 0 U~) ci l0 U)0 & unty < Safety and Buildings Division Co~ } a . P v : ~ ~ i on Ave., P.O. Box 7162 Sanitary Permit Number (to be filled " by Co.) 53707-7162 q 6 &P1FNftA'q~.,,-X Sanitary P It 1Cati0Il SST In accordance with SPS 38321(2). Wis. s~ a1~Yaf M to the appropriate governmental unit is required prior to obtaining a sanitary p b41~aK1 ned POWTS are submitted to Project Address (if differan than i44 address) the Department of Safety and Professional Savies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law s. 15. 1 m Stats. L Application Information - Please Print All Information Property Owner's Name e__ Parcel 4 U 1- e- 4 Property Owner's Mailing Addres/ Property Location d 3 6 ~T Govt Lot r 2 Z 3 f~ 1 City, state Zip Code Phone Number S '/4,, Section zJ 1fiUf 611-1) 7b2.2- le-Vy II. Type of Building (check all that apply) Lot # T N; R E W 1 or 2 Family Dwelling -Number of Bedrooms Subdivrs )on Name, t~ Block # y 6~~-YtJ ❑ Public/Commercial - Describe Use ❑ City of ❑ State Owned - Describe Use CSM Number ❑ Village of XTown of 110 l/ III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and 994"asued Before Expiration Owner kq 67, f j7 IV. Type ofPOWTS System/Component/Device: Check all that apply) ❑ Non- In-Ground ❑ Pressurized in-Ground ❑ At-Grade ❑ Mound 2:24 err. of suitable soil ❑ Mound < 24 in_ of suitable soil t ing Tank 11 Olber Dispersal Component (explain) ❑ Pretreatment Device (explain) reatment Area Information:. Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation VL Tank Info Capacity in Total # Of Manufacturer Gallons Gallons Units $ New Tanks Existing Tanta QQa° T 2 _9 P~rV Cn~ N rLL P. Septic or Holding Talc Dosing Chamber VII. Responsibility Stateragalt- >y the undersigned, ass possibility for installation of the POWTS shown on the attached plans. Plpkb 's Name (Print} Plum gnatrm MP/MPRS umber Business Phone Number Plumber's Address (Street, City, State, Zip 2- /fib z-_ %C VIII on evartment Use Only su /Issuing t S' ` proved ❑ Disapproved Permit Fee Date 0,4 ~ U9 ❑ Owner Given Reason for Denial S DL Conditions of Approval/Reasons for Disapproval r ~ "SYSTEM OWNER: 1. Sepoittank, e#iawpom~e*e- d ps~eet~eelI must be s rvi d /maintained ~ ~ / 3 3 as per management plan provided by plumber. 2 All setback requirements must be maintained as per applicable 04 for the system and submit to the county only OR paper not less than g to :1 m sae SBD-6398 (R. 11/11) PLOT PLAN PROJECT Trov French ADDRESS 103 165th st. River Falls Wi 54022 SW 1/4 SE 1/4S 29 /T 28 N/R 17 W TOWN Pleasant Valley COUNTY ST. CROIX SYSTEM ELEVATION TBD BEDROOM 3 CONVENTIONAL AT-GRADE CONVENTIONAL LIFT OLDING TANK XXX MOUND SAC TANK SIZE DOSE TANK SIZE HOLDING TANK SI 3000 _ LOAD RATE *ABSORPTION AREA # of chambers BENCHMARK V.R.P. Bottom of siding ASSUME ELEVATION 1001 ❑ BOREHOLE O WELL *H.R.P. sameasbenchmark Property Line Future Garage overflow Huffcutt 3000 gallons holding \ tank T 30' <25' 15' Existing 3 30' Bedroom House driveway B.M.* 10' 35' 75' Well 35' 165th St. Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 5/8/13 Owner: Troy French Location: SW1A SE1/4 S29 T28 N,R17W103 165th St. Pleasant Valley System type: Holding Tank Manuals Used: Holding Tank Component Manual Version 1.0 Page# 1. Cover Page 2. Holding Tank Plot Plan 3. Holding Tank Cross Section 4. Maintance and Continge Plan 5. Holding Tank service c(.) act r Signature License number 26!~~ 0 MOLDING TANK CROSS-SECTION - - I Approved Weather Proof -Vent Cap Junction Box Approved Locking Manhole Cover 4" With Warning Label Attached Vent Pipe Minimum 12" /Final Grade 4" Minimum Approved Joint. f 18" Minimum Water Tight r-4 Seal Nigh ' Al a M Swi te`7r t SPECIFICATIONS TANK New Existing Approved Join Manufacturer: w/ C.I. Pipe Blind C.I. Tank Size: 3 Gallons Extending 3" Plug Onto Solid So ALARM Manufacturer: Model Nu►pber: Switch-TYpe a _ - NUMBER OF BEDROOMS,- GALLONS PER DAY: ,j 6TJ 3" of Bedding Under Tank Owner's Name : Address: Legal Discription: Township/Municipal ty: County: U-1"2/'~ PLUMBER/DESIGNER Signature: License Num er• Date: HOLwli-j SANK MANAGEMENT PLAN System pOWTS) has been designed. and is to be installed and This private Onsite Wastewater Treatment the Holding Tank Component Manual (SBD-10511-P Wis. Admin. Code, maintained according to Comm 83, County Sanitary Ordinance. 6/1111999), and the . This POWTS is designed to accommodate estimated domestic wastewater flow of tThe owner of this POWTS is responsible for system operation and maintenance, including all provisions in 2. the attached Holding Tank Servicing Contract and Maintenance Agreements. inlet 'nvert (at which 3. Each time the wastewater in the second tank reaches a level of 12' below t be called to empty the time the alarm will activate), the pumper fisted in the current Servicing Contract must tank's contents and dispose of them in accordance with NR 113, Wis_ Adm. Code. 4. At each service event, the service provider should visually inspect the condition of the tank. risers"e ad manhole cover(s) and verify that the alarm system functions and manhole locking devices are present. and Comm 83 and 84 Wisa Adn'ti- AlCode a actior,.s Discrepancies are reported to the owner shall comply with the county sanrtary ordinance 5. All service events or inspections of this POWTS shall be reported to the county within 10 business days. 6. The owner may not remove any of the wastes from the holding tank(s), or cause such wastes to be removed by any person not authorized to do so under Ch. 281, Wis. Statures. The discharge of wastes by and disch from this holding tank to the ground surface, including 9 intentional ~~rrecti orders ~ o~ won by the neglect, cones a failing pOWTS and may county or state. r -eason without being l 7. No one should enter a holding tank for any. within these tanks may contain lethal gases, and rescue of aor entering a confined space. 'T"ri~`atrnos. person from the interior of the tank may be difficult or impossible. 8. the event that this POWTS falls and cannot be repaired, a code co spy $ ~ e h of ing tank a b be installed in the same location (a new sanitary permit is required deemed available to the properiY- municipal.servic es would also be considered at this time if they are 9. If this POWTS is replaced, or its use discontinued, components no longer in use it shall be abandoned in accordance with Comm 83.33 Wis. Adm. Code. 10. If there is a problem with, or question about thi installation, the flowing persons should be contacted J~ I/ a. installer Phone: Phone: b. Service Provider Phone: c. County Zoning or Health .Dept.-- 11. Project a Transactiw. Number: z ppppp, SEPTIC or HOLDING TANK SERVICING CONTRACT Contract Date Mpg 165- 9-it- elil r4Z45- W1. J ~4D4-,O This contract is made between the Tank Owner(s) Name(s) and Pumper's Name i2~c/Cdl' 111.49Kv S PG"6G ~'lA rt yrive We acknowledge the installation of (a) septic/holding tank(s) on the following property: (Provide legal description): cS~~ ag 70?SAI R17W S 8 RDS OF w__ S-owS OF t.S W 5E T to N SHIP P4ZASAAa7 Amy P~RL~L c~li -!o3'f - 60 ' o©oa 1. The owner agrees to file a copy of this contract with the local governmental unit (St. Croix County Planning & Zoning Department) to document maintenance by a certified septage servicing operator as required in Comm 83.52(1)(c)2. Wis. Adm. Code and the approved Component Manual. 2. The owner agrees to have the septic/holding tank(s) serviced by the undersigned pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the septic/holding tank(s). The owner agrees to maintain the access road or drive so that the pumper can service the septic/holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the septic/holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the local governmental unit (St. Croix County) a report for the servicing of the septic/holding tank(s) on a monthly basis. The pumper further agrees to include the following in the monthly report: a. The name and address of the person responsible for servicing the septic/holding tank; b. The name of the owner of the septic/holding tank; c. The location of the property on which the septic/holding tank is installed; d. The sanitary permit number issued for the septic/holding tank (if known); e. The dates on which the septic/holding tank was serviced; £ The volume in gallons of the contents pumped from the septic/holding tank for each servicing; g. The disposal sites to which the contents from the septic/holding tank were delivered. 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract, the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the local governmental unit named above within ten (10) business days from the date of change to this service contract. Owner(s) Name(s) (Print) Owner's Signature(s) Subscribed and sworn to me on this date: RLV / Today's Date Pumper's Name (Print) Pumper's Signature Notary Public Signature Pumper's Registration Number Commission Expiration II IIIlllli lillilllllillilllli 8 1 5 6 2 3 7 Document Number Document Title Tx :4127502 978967 St. Croix County BETH PABST Ho/ding Tank Agreement REGISTER OF DEEDS ST. CROIX CO., WI IVA: RECEIVED FOR RECORD State Plan Transaction Number - _y 05/20/2013 4:35 PM EXEMPT Name - (Owner) Typed or printed REC FEE: 30.00 Being duly sworn, states, under oath, that: PAGES: 2 1. He/she is the owner/part owner of the following parcel of land located in St. Croix County, Wisconsin, recorded in Volume Page Document Number 9(,(,099St. Croix County Register of Deeds Office: Recording Area A parcel of land located in the Sf.J 1/4 of the SC '/4 of Section Name and Return Address 24 , T Z'S N - R 17 W, Town of 15900,? P~~~.sc... t<- 1s tll e_ , St. Croix County, Wisconsin, being 1001Y 3Sd R13WIX-19'T,S Zj1., duly described as follows (include lot no. and subdivision/CSM or detailed legal description): az'-f / 03 - Cob - cxs Parcel Identification Number (PIN) Agreement Date: ZD 13 c5~~ We acknowledge that application is being made for the installation of (a) holding tank(s) on the above described property or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage. Also, a municipal sewer cannot now serve the property, or any other type of private onsite wastewater treatment system as permitted under Comm 83, Wis. Admin. Code, or § Ch. 145, Wis. Slats. .'As.an inducement to the county to issue a sanitary permit for the above-described property, we agree to do the following: 1. Owner agrees to conform to all applicable requirements of Comm 83, Wis. Adm. Code relating to holding tanks. If the owner rails to have the holding tank properly serviced in response to orders Issued by the governmental unit or the Department of Commerce to prevent or abate a human health hazard as described in s. 254.59, Slats., the governmental unit (Town) may enter upon the property and service the tank or cause to have the tank to be serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.0703, Stats. 2. The owner agrees, pursuant to Comm 83.54(2) and Comm 82.40(3)(e), Wis. Adm. Code, to have a water meter installed In the structure. The water, meter shall be installed by a plumber authorized by the Department of Commerce to make such installations, with said installation complying with State regulations and manufacturers specifications. The owner. agrees to be financially responsible for the purchase, installation, maintenance, and repair of the water meter, and agrees to allow the governmental unit or the Department of Commerce to enter the above-described property on a regular basis to read and/or inspect the water meter. 3. Owner agrees to pay all charges and costs incurred by the governmental unit or county for inspection, pumping, hauling, or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank. The governmental unit shall notify the owner of any costs that shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all the costs and charges may be placed on the tax roll as a special assessment for the abatement of a human health hazard, and the tax shall be collected as provided by law. 4. The owner agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code, to have the holding tank serviced and to file a copy of the contract with the governmental unit. The owner further agrees to file a copy of any changes to the service contract, or a copy of a new service contract, with the governmental unit within ten (10) business days from the date of change to the service contract. 5. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code, who shall submit to the county on a semiannual basis a report detailing the servicing of the holding tank. The governmental unit or county may enter upon the property to investigate the condition of the holding tank when pumping reports and meter readings may indicate that the holding tank is not being properly maintained. 6. This agreement will remain in effect only until the county office responsible for the regulation of private onsite wastewater treatment systems certifies that either a municipal sewer or a private onsite wastewater treatment system that complies with Comm 83, Wis. Adm. Code serves the property. In addition, this agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 7. This agreement shall be binding upon the owner, the Off f the owner, and assignees of the owner. The owner shall submit this agreement to the register of deeds, and the agreement 1~9k r@pQ9~ Y y the register of deeds in a manner that will permit the existence of the agreement to be determined by reference t`ti7V1+~®tJ~ Ing tank is installed. \ I ~~~y I Owner(s) Name(s) - Please Print - jVt7$crlbed and sworn to before me on this date: \~a z=~ a 4 i3 PUS Notarized Owner's Signature(s) ublic Governmental nit Official Name, Title - Please Print My Commissio Expires lee 19 ~S- - 51 . Ct o ,'.w J"e_. Govern taI Unit Officl ignat a Drafted by: /ersonal' formation you provide may be used for sec dary purposes [ rivacy Law s. 1,5.04(1)(m)) .THIS PAGE IS PART OF THIS LEGAL DOCUMENT- DO NOT REMOVE" This information must be completed by submitter., document title. name & return address, and PIN (if required). Other information such as the 0 ranting clauses, legal description, etc. may be placed on this first page of the document or may be placed on additional pages of the document. cover pace adds one narrp to your document and $2.00 in the recording fee. Wisconsin Statutes, 59-517- A parcel of land situated in the Southwest Quarter of the Southeast Quarter (SW '/4 SE '/4) of Section 29, Township 28 North, Range 17 West, more particularly described as follows: Commencing at the Southwest comer of the Southwest Quarter of the Southeast Quarter (SW %4 SE %4) of Section 29, Township 28 North, Range 17 West, thence North 8 rods, thence East 5 rods, thence South 8 rods, thence West 5 rods to the place of beginning, St. Croix County, Wisconsin. I I 2 of 2 8 0 9 9 3 4 1 State Bar of Wisconsin Form 6-2003 Tx:4077438 SPECIAL WARRANTY DEED 966099 BETH PABST DocumentNumber Document Name REGISTER OF DEEDS THIS DEED, made between Tony Peterson and Talgya Clark. joint tenants ST. CROIX CO., WI ("Grantor," whether one or more), and Troy French and Dawn French, husband and 10/25/2012 11:55 AM wife . ("Grantee", whether one or more). EXEMPT#: 14 Grantor for a valuable consideration, conveys to grantee the following described real REC FEE: 30.00 estate, together with the rents, profits, fixtures and other appurtenant interests, in PAGES: 1 St. Croix County, State of Wisconsin ("Property"): A parcel of land situated in the Southwest Quarter of the Southeast Quarter (SW '/4 SE ''/4) of Section 29, Township 28 North, Range 17 West, more particularly described as Recording Area follows: Commencing at the Southwest comer of the Southwest Quarter of the Southeast Quarter (SW '/4 SE %4) of Section 29, Township 28 North, Range 17 West, thence North Name and Return Address 8 rods, thence East 5 rods, thence South 8 rods, thence West 5 rods to the place of Thomas R. Schumacher + beginning, St. Croix County, Wisconsin. BAKKE NORMAN, S.C. PO Box 308 New Richmond W154017 This Special Warranty Deed is given in lieu of foreclosure and in conjunction with an Affidavit of Fair Dealing from the Grantor. This warranty deed is subject to the terms and conditions set forth in that affidavit, being recorded simultaneously with this deed. 024-I034-6044 Parcel Identification Number (PIN) This it homestead property. Grantor warrants that the title to the Property is good, indefeasible, in fee simple and free and clear of encumbrances arising by, through, or under Grantor, except: Subject to municipal and zoning ordinances and recorded easements of record, if any. Dated N' 14yr El 20 ID. (SEAL (SEAL) * Talava Clark * Tony Pe erson (SEAL) (SEAL) * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ) authenticated on ss. • (.._ry ~ X COUNTY ) * Personally came before me on QC kO?,(~ 1 uC)l a the above-named -AL-x-\ W ~~_~t~u~tttru~t.,~ TITLE: MEMBER STATE BAR OF WISCONSIN Tartu a Clo fk< ' SP ; ([f not, to me known to be the person(s) who executed the fo_t$~~`-405'9 OT A authorized A by Wis. Stat. § 706.06) instrument and acknowledged the same. THIS INSTRUMENT DRAFTED BY: B Thomas R. Schumacher, Bakke Norman, S.C. * mGI~SSa ra • u ~aKt' _ ' AV LAG,' Notary y2` PO Box 38, New Richmond W154017 My Commission (is permanent) (expires: s 'srFbF' 1NISG0`` H~~~~ (Signatures may be authenticated or acknowledged Both are not necessary.) 11iir.1mt NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. 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