HomeMy WebLinkAbout020-1359-18-000 ' Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count
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. 1 5.04 (1)( m)j. 363894
Permit Holder's Name: ❑ City ❑ Village ❑ Aown of: State Plan ID No.:
aCasse Richard I Hudson Township
CST BM Elev.: I Insp. BM Elev.: BM Description: Parcel Tax No.:
D ,. m .0 `jE e# 020- 1359 -18 -000
TANK INFORMATION ELEVATION DATA /6t(.
TYPE MANUFACTURER CAPACITY STATION JS oa FS &4V.
Septic t1&'dAA)e IZwr8tu, Benchmark
Dosing �,(, Alt. BM 35
E Bldg. Sewer y. ei It St /Ht Inlet o.s3 Of Y/ /
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet
Air I
Septic ��f Z�( NA Dt Bottom �IG3S ` .&S7'
Dosing J 7 ( ` NA Header/ Man. t, �a f iTf 5.5D 9 0 • ��
Aeration NA Dist. Pipe o G I
Holding Bot. System
PUMP/ SI HON INFORMATION Final Grade
Manufacturer $ d St cover ' r
Model Number p q PM
�+ DH Lift?'5 Lriction'� System TDH
!O • Forcemain Length Dia. 2 Dist. To Well
SOIL ABSORPTION SYSTEM Z J,
RENCH Width , Length No. Of renches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN 3 �5
DIM ENSION S
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Ma�nu� cjrer: n
INFORMATION Type Of r CHAMBER M odel Number:
System: C't , (5 + g OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold u Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia- gth Dia. pacing
> 9
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 E] Yes E] No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) In fection #1: 0�/ 0:1 Inspection #2: / ' —
Location: 937 Meadow Lane, Hudson, WI 54016 (W' 1/4 SW 1/4 16 T29N R19W) - 16.29.19.2114 Parkwood Meadows -
Lot 18
1.) Alt BM Description
2.) Bldg sewer length= n
- amount of cover = Hf� C9 • ASS
Sez- S
Plan revision required? ❑ Yes No y Use other side for additional information. �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
SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue
Visconsin P O Box 7162
Department of Commerce In accord with Comm 83.05, Wis l e 2 Madison, WI 53707 -7162
• Attach complete plans (to the county copy only) for the Sys pap j no ounty
than 8 112 x 11 inches in size.
RECEIVED - Sanitar ermit Number
• See reverse side for instructions for completing this appliE- a'tibn y P
3 6 3i1
Personal information you provide may be used for secondary purposes s` k 'f ' 200 k if revision to pre" ts application
(Privacy Law, s. 15.04 (1) (m)]. Ian Review Transaction Number
ST Cfox wp
I. APPLICATION INFORMATION PLEASE PRINT AL
04f 0
Property Owner Name
�j(,h 6' 1/a T , N, R E (or )R
Property Owner's Mailing Address Block Number
/�Q4n0.Q Y L 9 m 1,
City, State Zip Code Phone Number Subdivision Name or CSM Number
E -5-53 (1 ) 6 �
II. E BUILDING: (check one) ❑ State Owned ❑ It Nearest Road
E] Village
Public 1 or 2 Family Dwelling - No. of bedrooms jilL OF
111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) �(,
1 ❑ Apartment/Condo G 0 — 1357 -119 -w
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. V1 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
______System ________System _____________ Tank Onty______________ ExistinQSystem_________ 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 14,14 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Weepage Trench 5( 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System -In -Fill 1 / - y !
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
Z , b eet 99, Feet TANK Cap acity
VII. I NFORMATION in g a llo n s Total # of Manufacturer's Name Prefab. ion steel Fiber- Plastic Exper.
New Existing G8110nS Tanks Concrete structed glass App.
Tanks Tanks
Septic Tank or Holding Tank 1 ZQ O La cilb I mj0&_es - ,nz), f 91 ❑ ❑ ❑ 1 ❑ ❑
Lift Pump Tank /Siphon Chamber 8W &o 1 r ❑ I ❑ 1 ❑ 1 ❑ 1 ❑
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plu is Sign ture: (No tams MP /MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip C )de):
i 4 2 tol
IX. COUNTY/ DEPARTMENT USE ONLY
Q Disapproved itary Permit Fee (Includes Groundwater D atelssued Issuing Agent Signature (No Stamps)
V Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination �a V� ZZ2
X. C TI
DIONS APPROVAL.
OF APPRO L / REASO S FQR DIS:
\I �,,; (owe
SBD -6398 (R.12/99) 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 maybe 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 plumber requires a Sanitacy 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) rrrust 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, 608 - 266 -3151.
To be complete and accurate this sanitary permit application rryust include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to oe 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, 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 1/2 x 1 t 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 contamination investigations
and establishment of standards.
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- -•N• _.wn tKOSS SECTION AND SPECIFICATIONS
4" CI VENT PIPE 12" MTN. ABOVE GRADE E WE ATHER LATHER PROOF
t 2s • FROM DOOR 9 N
INDOW OR JUKCTION BOX
FRESH AIR INTAKE APPROVED CONDUIT
MANHOLE c
FINISHED GRADE 4" CI RISER W/ PADLOC
7 6 MIN. WARNING l
A80VE G ADE _ -- _4" MIT
18" IN. 6" MAX.
INLET -
WATER TIGHT SEALS GAS -
4" TIGHTi ;
BAFFLE APPROVED
CI PIPE -j-- SEAL � , (,M JOINTS V/
8
3' ONTO PIPE 3' 0
S OLI D C + ON SOLID SOI
PUMP OFF ELEV. — FT. -
-- OFF " RISER
D PERMITTED
IF TANK
MANUFACTU!
3" APPROVED BEDDING UNDER TANK HAS APPRO'
SPECIFICATIONS CONCRETE PAD
SEPTIC I DOSE
TANK MANUFACTURER: 3 -
NUMBER DOSES PER DAY:
TANK SIZES: SEPT
�.� IC
- -._._. GAL. DOSE VOLUME INCLUDING
DOSE _ioxrT_ GAL. F LOWBACK : �� L
ALARM MANUFACTURER: CAPACITIES: A :
MODEL NUMBER :�BINCHES =
SWITCH TYPE:
B = _?,_ INCHES = �Q C
t'UMP MANUFACTURER:
MODEL NUMBER: C : _&PINCHLS z
SWITCH TYPE: D
INCHES = _ r
REQUIRED DISCHARGE RATE _a 1 GPM PUMP 6 ALARM WIRING AS PER ZLmR
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRI Of
• MINIMUM NETWORK SUPPLY PR BUTION PIPE (J
..1 _ FEET FORCQiAIN X /FT/ 100 • FT. � • FRICTION FAC �— FEET
'2-b
-FEET
TOTAL DYNAMIC HEAD �FEI='I.
INTERNAL DIMENSIONS OF PUMP TANK: LENGTH
WIDTH _ — DIAMETER
LIQUID DEPTH Q k
IGNED :
LICENSE NUMBER:
n ••ww.
• 1 MO
• • '0' '0
Su bmersib l e Effluent Pump
GOULDS
ec 11 au
N ,w-' } METERS FEET
1Jp O )t r ,o MODEL: 3871
Disc l r ge i 1 1 i x 9 30
(�S . �e ",maXlm0M
5011 i w 8
Motor 25
Single phase: 115V
Materials of Construction 6 20
Brass/thermoplastic a 5 15
4 EPOS
Features and Benefits
!/
0
•Top suction eliminates C3 3 —
impeller clogging. 2-
M •Corrosion resistant , , 5
construction.
0 00 10 20 3 40 50 US.GPM
*Float actuated switch. 0 2 ; 6 8 ;o 12 odn,r
CAPACITY
METERS FEET
25 Pump Specifications Features and Benefits
MODEL DVP03
0 5 °ha and' /2 HP •EPO4 impeller- semi -open design
5 Up to 60 GPM with pump out vanes to protect
1s Maximum head to 32' mechanical seal.
< 4 Discharge size 1 NPT • EP05 impeller - enclosed design
0 3 ,o Solids: 3 /:' maximum for improved performance.
2 • Rugged glass - filled thermoplastic Motor
' S All motors feature ball casing and base design provides
° 0 5 ,o ,5 20 2s ,� o.s.cPM bearing construction. superior strength and corrosion
Single phase: 115V resistance.
2 CAPACITY s a ���` Materials of Construction *Cast iron motor housing for
Cast iron efficient heat transfer, strength,
Thermoplastic and durability.
Stainless steel • Corrosion resistant threaded
stainless steel shaft.
*Available for automatic and
manual operation.
•CAA listed models available.
e
All Models are designed for continuous operation and feature stainless steel hardware.
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Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor an4iHuman Relations
, ion 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 sjn size. Plan must include, but St. Croix
not limited to vertical and horizontal reference poi �irleotiori, -J> rid 0 of slope, scale or PARCEL I.D. #
.... .
dimensioned, north arrow, and location and this e_�o earest road. ' . 020-
APPLICANT INFORMATION PLEASE �8j AL� ATIOtJ�`, R VIEWED BY 3 - D Ez�
PROPERTY OWNER: • P OPERTY LOCATION
T Custom Homes, Inc. `�1 f 1 5 mon - GbVT. LOT NW 1/4 SW 1/44 T 29 ,N,R 19 Y[(or) W
PROPERTY OWNER':S MAILING ADDRESS ST CP .LQT # BLOCK # SUBD. NAME OR CSM #
521 McCutcheon Rd. CC '18 na Parkwood Meadows
CITY, STATE ZIP CODE n � lGE CITY [:]VILLAGE MOWN NEAREST ROAD
Hudson, WI. 54016 C''1 381 -5. Hudson Meadowood Ln.
[:] New Construction Use Pc ] Residential/ Number s 4 [ ] Addition to existing building
I ] Replacement [ ] Public or commercial describe
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 • 7 bed, gpd /ft - 8 trench, gpd /ft
Recommended infiltration surface elevation(s) 95.50 ft (as referred to site plan benchmark)
Additional design / site considerations na
Parent material Outwash- -u Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE 7 SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem ®S ❑ U ® S El ® S El U 3 S ❑ U ® S ❑ U ❑ S 13U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
..................
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trerich
.................
..................
1 0 -19 10 r 2/2 none 1 2msbk mfr cs 2f .5 .6
..................
2 19 -29 10yr 4/4 none sil 2msbk mfr Qw 2f .5 .6
Ground 3 29 -96 7.5 r 4/6 none co s 0scr ml na na .7 .8
elev. —
9 9.7 ft.
Depth to
limiting
facto �6 • Sa
5b. 2 6 , z 3 • `1
Remarks:
Boring #
1 0 -11 10 r 2/2 none 1 2msbk mfr cs 2f .5 !.6
2 11 -22 10 r 4/4 none sit 2msbk mfr qw 2f .5 .6
Ground 3 22 -96 7.5 r 4/6 none co s Osg ml na na .7 i.8
elev.
9 9.7 ft.
Depth to
limiting
factor '
+96" 5V y
Remarks:
CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200
Address: 1554 200th. New Richm WI 54017
Signature: Date: CST Number: m02298
7 -6 -99
PROPERTY OWNER LaCasse Custom Hame § 1 69L DESCRIPTION REPORT Page _",.of 3
PARCEL I.D. # 020 - 1029 -30
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
..................
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed T
.................
3
1 0 -13 10 r 2/2 none 1 2msbk mfr cs 2f .5 .6'
2 13 -30 10 r 4/4 none sil 2msbk mfr 9w 2f .5 .6
Ground 3 30 -90 7.5 r 4/6 none co s 0sq ml na na .7 .8
elev.
99 ft.
Depth to
limiting ,
f +60" S,s
46.9 .8
Remarks:
Boring #
1 0 -18 10 r 2/2 none 1 2msbk mfr cs 2f .5 .6
2 18-35 2msbk mfr Qw 2f .5 .6
Ground 3 35 -84 7.5 r 4/6 none co s Osq ml na na .7 .8
elev.
99.3 ft. —
Depth to
limiting
factor
+84
Remarks:
Boring #
1 0 -12 10 r 2/2 none 1 2msbk mfr cs 2f .5 .6
i
";....5.....`> 2 12 -30 10 r 4/4 none sil 2msbk mfr gw 2f .5 .6
Ground 3 30 -84 7.5 r 4 6 none cos Osq ml na na .7 .8
elev.
9 9.4 ft.
Depth to
limiting
factor
+84"
Remarks:
Boring #
Ground
elev.
1
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(R.05/92)
7
STEEL'S SOIL SERVICE
Gary L. Steel LaCasse Custom Homes, Inca 1554 200th Ave.
CSTM2298 NW S16- T29N -R19W New Richmond, WI 54017
MPRSW -3254 town of Hudson (715) 246 -6200
lot #18- Parkwood Meadows
This soil evaluation was conducted to satisfy a zoning requirement, it may or may
not be suitable for your use. The location of the test may or may not be as shown
rmanent lot lines were not established at the time the test was conducted.
7
�11 401
= top of SE lot stake C el. 100.00
Alt. EM.= top of 1 11 pvc pipe C el. 100.60
Q�f p
S �
GarytL Steel
7 -6 -99
t r tl � v�C1 -iIV�HY j LUUU. Z: J�FMLACASSE CUSTOM HOMES lEL:71S�$61 ^j�U 1133 Y 1��
■
t ST CRUIX Cf)tW'>E7f
t SU)TIC TANK MAGI MUNCS A43MA+ MU
AND
OWNERSW- CIR.MIC&TIQN UORM
Owner/Buyer
Mailing A.ddivall ..&1faA- :0!jaea�a eJ ��. - -- o4,�r:� gftz =gat
ilroporly Address :7 �-77
(vallieatiou lag0irad from htauelua-Dtpsrtment for new oanalrttctlon)
CRY/Stata 4r,r& _ Parcel rdenlificu on Number 0@2L- " /!2L-
rte`, r MMLMN
Itrupelly I.a�QtYoJt , . . `i`t, sm. .1 Town of
sabdivision JA
War rauiv Desa it �,�� 3 l , VOKUtta. S Ptlgo IF ^
Sp 40uda Q ye = Lot tines klvnttf ble Kyal ❑ rto
SYSTEM MAINIM
improper we w4tta feat anee of ymw ceptia &Went aouid math In Its Irranature fbllure talisn wae
dle lM PMM inebl F0
cotniats of pumplas 00 Ills Boole It"& evory aura* yaaw vt #00M. lf- N�+rhy ■ 1Ccastid pumps<r. Whit You put IWO the syttatn
can affbet Ilia haotion oPlho a*dcr ttlttktrr a ttzatruent rfte In the nva dbposat syatmi
into praprrix avver mea-to sulitaft to m. Croix Zeafitg De@ar4u W & cattgamil" Awn, ftmd by durowneraad -bX ■
mmstcrplumbcr. joutaipytnmnp wi=stdi kdplmnberoralicc2mvdputy '►l►_orvW4W dmt(gd a-etralt�aaAm�
In In ptepor vend etott- andlot:(2)- after - Itrspacllon atuLpu (iCerc �►rY �► aeptftl eetr%.i+l tier tlutf tttltrttuf alaAga�
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aa�foctlL ltereto eµsol��rtE�Ct�e�s- a�Nt¢nE�NN4leraEf�aeouroab ttt►iee[�ho �
atalingflint your a idc6ystcmLn ►*bC�aruatuta:aecttuuet Go cau>tiratedand.re mad to the $t. CMbtCmUt r
day* vo.tl� � ��rortplrstic+r
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tlta PTO ptrty da a alwve, br v ua cC a aratranty tleetk rieeatd�l Hs LEe let of pee�{4Oploe�
W143NA P zv DATR.
' * "" t t�site revoked Ilw '" �
Any lnfaematiart tltat M mb- retr"amdtt►.Y restrtt lit t santtary tit tt l►ir �� �
laelwl�wNhlblx wipp elent{ted Daada OBU -
a copy of tlta canit7isal eamay taap•`ICtagance is made In tho watnnly dppd
VOL 1511 PAGE 205
STATE BAR OF WISCONSIN FORM 1 — 1982 �� 0231 1 O
WARRANTY DEED KATHLEEN H. WALSH
REGISTER OF DEEDS
DOCUMENT NO. I ST. CROIX CO., WI
-- -... _ ..... . .:. .. ..... . . .: . _..:l� RECEIVED FOR RECORD
Howard LaVenture, three - fifths
This Deed made between ( 05-16 -2000 1:40 PM
(3/5) interest in and Arlene LaVenture, two fifths WARRANTY DEED
(2/5 ) interest in, as tenants in common. ' EXEMPT A 17
Grantor, CERT COPY FEE:
! and �• AC4S 5� - EkeTti.,:.S i N G ii TRANSFER FEE:
RECORDING FEE: 10.00
PAGES: 1
,Grantee, �
Witnesseth That the said Grantor, for a valuable considerati
I�
St . Croix I� THIS SPACE RESERVED FOR RECORDING DATA
conveys to Grantee the following described real estate in I -- -- - - -
County, State of Wisconsin: NAME AND RETURN ADDRESS
I-FVC, 465 f, 9L" a- B
_TDA� OF 4knsoN
LOT 18 OF PLAT OF PARKWOOD MEADOWS, I
ST. CROIX COUNTY, WISC !i 1�(t�,d S t W Sao'
�
.
PARCEL IDENTIFICATION NUMBER
i;
ii
!i
This deed is given in partial satisfaction of certain land contract dated February 19, 195,9
and recorded in Volume 1404 , Page 616 as Document Number SgRllb which was
subsequently assigned by assignment dated May 28, 1999 and recorded in VolumeL�,
Page 352 as Document Number 6043
This is not homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging I '
And
Grantor
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
I
anv liens or
ens
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