HomeMy WebLinkAbout038-1164-50-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
216
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:
Home Tec Rentals I Star Prairie Town of 038-1164-50-000
CST BM Elev: Insp.BM Elev: BM Description: n (� Section/Town/Range/Map No:
' 4lko l a 30.31.18.779
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ? th Benchmark
2660 $ $ �G lam• /��
J J
Dosing Alt. BM
v
Aeration Bldg.Sewer
Holding St/Ht Inlet
/
TANK SETBACK INFORMATION St/Ht Outlet G. 73 g3. 7
TANK TO P/L WELL BLDG. _Yeat&Air Intake ROAD Dt Inlet 7-15 °IZ-7
Septic Dt Bottom J
7B
27
Dosing / Z�t Header/Man.
Aeration Dist.Pipe
Holding Bot.System
PUMP/SIPHON INFORMATION Final Grade 15. 3 $5.35
Manufacturer / l Demand St Cover ` 5* G �si(
GPM , ` lA,pn.
Model Number
rForc'em!ain Friction Loss System Head TDH Ft
Length Dia. Dist.to well /
SOIL ABSORPTION SYSTEM f 3.�� �~ 3,
BEDITRENCH Width Length No.Oy�Tren s PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth
DIMENSIONS P
SETBACK SYSTEM TO P/L JBLDG IWELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Ty T7nf System: UNIT Model Number:
oj.�
DISTRIBUTION SYSTEM �`•
Header/Manifold Distribution x Hold,811ze x Hole Spacing ivepoAir Int ke
Pipe(s)
Length Dia I 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 Bedrrrench Edges Topsoil R Yes No ® Yes]�:No]
COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2:
Location: 1911 A&B River View Lane Somerset,WI 54025(SW /4 SE 1/4 30 T31 N R18 ) Crestview Addition Lot 15 Parcel No: 30.31.18.779`
1.)Alt BM Description= ' '` rQ. �4 D CJQ„��n rtvlI -
2.)Bldg sewer length=
JJJ
-amount of cover=
3.)Contour=
Plan revision Required? ❑ Yes No 5
Use other side for additional information..
Date Insepctor's gnature Cert.No.
SBD-6710(R.3/97)
44 9Y0-7 y�
County San ication ST.CROIX COUNTY WISCONSIN
In accord with Chapert 12 St.Croix County Sanitary Ordinance PLANNING&ZONING DEPARTMENT
Personal information you prove may us o r secondary purposes ST.CROIX COUNTY GOVERNMENT CENTER
[Privacy taw.S.15.04(1)(m)] 1101 Carmichael Road
$T.C Ox V��EN1, Hudson,WI 54016-7710
(715)386-4680 Fax(715)386-4686
Attach complete plans for the system on paper not less than 8-1/2 x 11 inches in size.
County Sanitary Permit# ❑ Check if revision to previous application
STL- 07-1(6
1. Application Information-Please Print all Information Location:
Property Owner Name
1/4 1l4,Sec
Home Tec Rental 31 N, R 18 E(or)
Property Owner's Mailing Address Lot Number Block Number
P>O> Box 48 15
City,State Zip Code Phone Numer ubdivision Name or CSM Number
New Richmond Wi. 54017 7��_��d -.�g CrestView Add
II ype of ui ding: (check one) MkY ❑Village (Town of
IX 1 or 2 Family Dwelling-No.of Bedrooms: n 3 `' - a
❑ Public/Commercial(describe use): v Star Pralrrle
❑ State-owned Nearest Road
1.Type of Permit: (Check only one box on line A. Check box on line B if applicable) River View Lane
Parcel Tax Number(s)
O
A) J1.[XRepair ❑ Reconnection ❑Non-plumbing ❑Rejuvenation 038-1164-50-000
Sanitation
B) Permit Number wf- a4tc Date Issued //
State Sanitary Permit was previously issued $gN7� 6 p<rultdk (�- Q co
IV.Type of POWT System: (Check all that apply)
❑ Non-pressurized In-ground � Mound z 24 in.suitable soil ❑ Mounds 24 in.suitable soil ❑ Mound A+0
❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line
❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Other
❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating
V.Dispersal/Treatment Area Information:
1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application Rate 5.Percolation Rate 6.System Elevation 7.Final Grade
Required Proposed (Gals./day/sq.ft.) (Min.Anch) Elevation
I. Tank Information Capaicty in Gallons Total #of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete strutted glass
Tanks Tanks
❑ ❑ ❑ ❑
11.Responsibility Statement
I,the undersigned,assume responsibility for repair/reconnenction/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A
license is not required for terralift repair or the inst latio f non- m sa 'a" system.
Plumber's Name(print) IPlu a ps): MP/MPRS N0. Business Phone Number
Keith Knudson 43 651-470-1737
Plumbers Address(Street,City,State,Zi Code)
927 150th St. Roberts Wi. 4023
111.County Use Only
Disapproved Sanitary Permit Fee Date Issued Issuing Agent Signature(No stamps)
( Approved Owner Given Initial Adverse 10 2- /
Determination Z7, fwd
X.Conditions of Approval/Reasons for Disapproval:
-trf -r�^6- of 2sPar2, PtccMB&f- MAW' co vryfcr cou AJi7 ft2 0alr4r()e-f_ F/ug770A) 6 J rJNr-
osl/_Pt7oA), SIZE, J�oC*-nOAJ/ 4 /hounrp vEFLtr-140770A� of eant?0-44X.E.
C SCjetj� 021 „vats (69m17- 6 d W-70 "-'o► QE loan miV
RAi mwsr BE eu^Wb 4a:De-D ppew-t'T Sugf&e' IN wmme r9F mR&C..
Rev:8/05 _)(-V P_i F y iF Dcz,"Pf9&ch' iN 6oAlea7EP /r/!;
GtSr�rb 65 FED ���
o � T� Reo L
IL W
cr pt. � 4Pt
• pe�la��e�.u7`
�'d E S LCI?1T �I W 4 KNUDTSON PLUM BING?;
CONTRACTING,LLB
W 150TH ST.648"7MPRS
yh, ROBERTS,WI 54023-8526
%v 6 Y, t�1�0 • '� c 1-470- 737
Octn
C�
� y
RECEIVED
JUN 01 Z01b
ST.CROIX COUNTY
;OMMUNITY DEVELOPMENT
i
I
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer Scott and Carolyn Counter d/b/a Home Tec Rentals, LLC
Mailing Address 2165 Goose Lake Road, New Richmond, WI 54017
Property Address 1911 Riverview Lane
(Verification required from Planning&Zoning Department for new construction.)
City/State Somerset, WI Parcel Identification Number 038-1164-50-000
LEGAL DESCRIPTION
Property Location '/4 , '/a , Sec. 30 , T 31 N R 18 W, Town of Star Prairie
Subdivision Plat:Crestview Addition , Lot 15
#
Certified Survey Map# ,Volume ,Page#
Warranty Deed # 875299 (before 2007)Volume 745 Page#09
Spec house❑yes Ono Lot lines identifiable❑+yesE]no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
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. Owner maintenance
responsibilities are specified in§SPS.383.52(1)and in Chapter 12-St.Croix County Sanitary Ordinance.
The property owner agrees to submit to St.Croix County Planning&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
wastewater disposal 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.
Uwe,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 Safety And Professional Services 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 Planning&Zoning Department within 30 days of the three year expiration date.
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
property described above,by virtue of a warranty deed recorded in Register of Deeds Office.
Number of bedrooms 6
Digitally signed by Scott J Counter 2015
!.DN:cn---Scott J Counter,o=Home Tec Rentals.LLC,ou,
Scott J Counter D all=scott�hometecbuilders mm,c 5 / /
Date:20 15.06.01 15:24:38-05'00'
SIGNATURE OF APPLICANT(S) DATE
***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning&Zoning Department. ***
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV.04/12)
63V- //64 - 56 —cCO ( 779.)
5¢-46(- Pr�,.,r.e., 3a .31 . l S
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
This is to certify that I have inspected the existing septic and/or dose tank
presently serving the following residence:
(Street address) /?7/ /' ► " er v,-iv- / , e located
at: 1A, 1/4, Section 4 0 , Town / N, Range /K W,
Town of t. Croix County Wisconsin.
Upon inspection, I certify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of SPS. 384.25, and it (they)
appear(s)to be functioning properly.
Most recent date of inspection or service cY 7 .
Did flow back occur from absorption system? Yes No'
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capacity: 61
Construction: Prefab Concrete V Steel Other
Manufacturer (if known): V s.Q 7
Age of Tank (if known):
Permi 0 ber,(if ►N� ,,
/�‘ /5 .14e. X156,-,
r icensed 1,umber Signature) (Print Name)
(Title) (License Number)MP/MPRS
64/(i.--
(Date)
Form to be completed by licensed plumber (Dept of Safety and Professional
Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer
(NR 113 Wisconsin Administrative Code)
Rev. 2/2012