HomeMy WebLinkAbout182-1016-10-075
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
GENERAL INFORMATION (ATTACH TO PERMIT) lb L41 ~v se:_ 218
State Plan I No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City X Village Township Parcel Tax No:
Skifstad, Jamie Village of Star Prairie 182-1016-10-075
CST BM Elev: Insp. BM Elev: BM Descri tion:, Section/Town/Range/Map No:
D V 1 17W_ _6
D /115'v 31.18.01.2101010
TANK INFORMATION ELEVATION ATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
5{ ~ ~n lb-713 9g, 6 /
Dosing r Alt. BM L ~bdL S,JIp 1 Z •3
Aeration Bldg. Sewer
D~.S ~,5 161.3
Holding StfM Inlet
TANK SETBACK INFORMATION SUHt Outlet
-
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet _
Septic Dt Bottom
Dosing Header/Man.
Aeration Dist. Pipe
Holding Bot. System
~
PUMP/SIPHON INFORMATION Final Grade
Manufacturer Demme St Cover
M L f !55 lU z
Model Number
TDH Lift Friction Los System Head TDH Ft 98.
Forcemain Len Dia. Dist. to Well N wine S. r-*!:U4n59
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING fillanufacturer:
INFORMATION CHA OR
System: UNIT Model Number:
DISTRIBUTION SYSTEM
Header/Manifold jLergW tribution x Hole Size x Hole Spacing Vent to Air Intake
Length Dia _ 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 Bedlrrench Ednes 0 Yes ~ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 517 5th Street Star Prairie, WI 54026 (NE 1/4 NW 1/4 1 T31 N R1 8W) NA Lot 1 Parcel No: 31.18{..01.2101010
1.) Alt BM Description= 51~~(
2.) Bldg sewer length = q 5Ir 1W SVILC~ W 0 -fVA ✓ l
- amount of cover = 1 3$ 5
. 5' belaW r~.de. C>'~2" c~~l~
Plan revision Required? Yes X No 7 h
Use other side for additional information. l(/ (J~
SBD-6710 (R.3/97) Date epctors ignature Cert. No.
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RECEIVED I
County Sanitary Permit ApplINURIUM ST. CROIX COUNTY WISCONSIN
ST. C INW M~(~ I accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT
E 0 "Perk nal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER
[Privacy Law. S. 15.04(1)(m)] Carmichael 110 1 1
Hudson, WI54016-770
(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 Permitt## 2-' ❑ Check if revision to previous application
1. Application Information - Please Print all Information Location: i \l q-4t -5 1-7
Property Owner N me 2/ lD/6 )
1JL~' (Q S A.) 25 1 , G~(L(1 /4, Sec /
C. 4 N, ~ R E (or) W
Property Owner's Mailing Address Lot Number Block Number
City, State F~ , Zip Code Phone Numer Subdivision Name or CSM Number
5 S yaa~ 7/s- J 3 _ $ y l0 4133U~ V~ Is' =10y6
1t Type of Building: (check one) Mity Village ❑Town of
1 or 2 Family Dwelling - No. of Bedrooms: C~ n 4 /
❑ Public/Commercial (describe use): 44~ J
❑ State-owned Neat Roaad~
II. Type of Permit: (Check only o n line A. Check box on line B if applicable) ~ _
Parcel Tax Number(s)
A) 1Repair Reco nection ❑Non-plumbing 4. ❑ Rejuvenation
Sanitation ! -l0~ ' 07~
B) Permit Number c~ Date Issued 2-60
State Sanitary Permit was previously issued :3 OJ /
IV. Type of POWT System: (Check all that apply)
A Non-pressurized In-ground ✓ ❑ Mound z 24 in. suitable soil ❑ Mound 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
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
y D Y/ //V
1. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete structed glass
Tanks Tanks
tp 57: DOO /000 1 ❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
VII. Responsibility Statement
1, 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 installation of non-plumbing sanitation system.
Plu LA e rint) Plumber' igna a fi#MPRS No. Business Phone Number
0-35"7 -It"
j 1 17/
Plu er's Addr (Street, City, State, Zi Code)
b r ' E s'
VIII. County Use Only
roved Sanitary Permit Fee Date Issued Issuing ature o stamps)
Approved Owner Gi I Adverse Z5~ q 7
Dete urination
zb
14
IX. Co ditions of Approval/Reasons for Disapproval:
CC~ccn ~ - vs~- b~ ~'osI- S(CWe_d a Code
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8307945
Document Number Document Title TX : 4253879
St. Croix Coun 1013502
ty BETH PABS
BST
REGISTER OF DEEDS
Accessory Structure Affidavit ST. CROIX CO., WI
RECEIVED FOR RECORD
06/10/2015 11:59 AM
° EXEMPT
Name - (Owner) Typed or printed REC FEE: 30.00
being duly sworn, states, under oath, that: COPY FEE: 2.00
PAGES: 1
He/she is the legal owner of the following parcel of land located in St.
Croix County, Wisconsin, recorded in Volume - Page =_Document
Number R71 ` %S St. Croix County Register of Deeds Office, Recording Area
being duly described as follows (include lot no. and subdivision/CSM or Na me and Return Address Lj--T
detailed legal description): o , P ~✓-``'f ~tlvz G
S-T - Sr 57-AA- 1'& f
oee-5 ~ ~ ~ Parcel Identification Number (PIN)
As owner of the above described property, I acknowledge that the Private Onsite Wastewater Treatment System
(POWTS) services both an existing principal dwelling and an accessory building on this lot and is sized for a • Lre-(a)
bedroom home, or a design flow of q!56 gpd. This accessory building may not be used as a second residence on this
parcel. I also acknowledge that I wilt disclose this information and stipulation to any future parties interested in
purchasing this property.
Dated this l y of ~`Le 20/S7
•Yt t~
di%
17 AUTHENTICATION ACKNOWLEDGMENT
O C Agnabbk(s): M STATE OF WISCONSIN )
rT ' 0 : W
)ss.
" f ( St. Croix County. )
u`, gthdr [ ated this day of Personally came before me this day of un 1 S
C-11 ; the above nam Tow
to
TITLE: MEMBER STATE BAR OF WISCONSIN me known to be
the person(s) who executed the foregoing instrument and acknowledge the
(If not,
same
.
authorized by § 706.06, Wis. Stats.)
THIS INS UMENT WAS DRAFTED BY
k w YadYt`•^~) 41-
Gra : x C resan~-4/ ~tr :~.ke~ 'F L r ~c~ e Orr-
Notary Public, State of Wisconsin
(Signatures may be authenticated or acknowledged. Both are not My Commission is pe anent. If not, state expiration date:
necessary.) Date: O a
"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 granting
clauses, legal description, etc. may be placed on this first page of the document or may be placed on additional pages of the document. Note: Use of this
cover page adds one page to your document and $2.00 to the recording fee. Wisconsin Statutes, 59.43.
ai
State Bar of Wisconsin Form 3-2003 8 1 2 5 1 5 0
QUIT CLAIM DEED Tx : 4100727
971883
Document Number Document Name BETH PABST
REGISTER OF DEEDS
THIS DEED, made between Dennis J. Skifstad and Linda S. Skifstad, husband and ST. CROIX CO., WI
wife and Jamie L. Skifstad-Powell, fka Jamie L. Skifstad and Joel Powell, husband 01/23/2013 09.41 AM
and wife ("Grantor," whether one or more),
and Jamie L. Skifstad and Joel Powell, husband and wife, as survivorship marital EXEMPT#: N/A
property REC FEE: 30.00
("Grantee," whether one or more). TRANS FEE` 215.70
Grantor quit claims to Grantee the following described real estate, together with the Recording Area PAGES: 1
rents, profits, fixtures and other appurtenant interests, in St. Croix
County, State of Wisconsin ("Property") (if more space is needed, please attach Name and Return Address
addendum): Jamie L. Skif ad f~ Q
L~
517 50, St. 1 1, T,
Part of the fractional Northeast Quarter of the Northwest Quarter (NE Y. of Star Prairie /M 54026
NW of Section One (1), Township Thirty-one (31) North, Range Eighteen
(1 B) West, in the Village of Star Prairie, St. Croix County, Wisconsin, described
as follows: Lot 1 of the Certified Survey Map filed April 20, 2001, in Volume 15
of Certified Survey Maps on Page 4067 as Document No. 643302. 182.1016.10.075
Parcel Identification Number (PIN)
This homestead property.
(is) (is not)
it
Dated
(SEAL) (SEAL)
*Dennis J. Skifsta * Linda S. Skifstad
,-;;7m ~L J7~~G(LLL~ (SEAL) (SEAL)
Jamie L. Skifstad Powell J owell
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF t ,Nl;~G 04 6'1A
)
Authenticated on [ 1 ) ss.
~T l _ to i COUNTY )
Personally came before me on o//' /1g
TITLE: MEMBER STATE BAR OF WISCONSIN the above-named Dennis J. Skifstad and Linda S. Skifstad,
(If not, husband and wife and Jamie L. Skifstad, fka Jamie L.
Skifstad-Powell and Joel Powell, husband and wife. to me
authorized by Wis. Stat. § 706.06) known to be the same person(s) who executed the foregoing
instru /acknowled d the same
THIS INSTRUMENT DRAFTED BY: ~s-o
Dennis J. & Linda S. Skifstad
702 County Line Ave.; Star Prairie, WI 54026 Notary Public, State of Wisconsin
My Commission (is permanent) (expires: _,~ql 4K )
(Signatures maybe authenticated or acknowledged. Both are not necessary.) T-
NOT£: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED.
QUIT CLAIM DEED 92003 STATE BAR OF WISCONSIN FORM NO. 3-2003
• Type name below signatures.
tGlE$F
=O1 A,9
OF W0
111-111111511111%,
1 of 1
'b
FILED
643302 £ APR 2 0 200, ►
p~'L E&- q f, SH
Si C1oix Co.,
CERTIFIED SURVEY MAP.... _
Located in part of the Fractional Northeast Quarter of the Northwest
Quarter of Section 1, Township 31 orN
Range 18 West, V'illoge of Star Prairie, St- Croix County, Wisconsin.
NORTH 114_31-18
Prepared for and of the request of: SECTON 1-31_18
OWNER: (FOUND ALUM/NUM COUNTY MONUMENT)
Dennis Skifstad
702 County Line Avenue S8658.31'E
Star Prairie, Wl 54026 NCRTh UA/E C "nyE NH; -AV 2626.34'
Drafted by. Ty R. Dodge - - ' -
i
N 7NUEST CORNER -
S£CnON 1-31-18 N
(FOUND SP//CE BY BENT 1 IRON P/PEJ O
NOTES:
a: ?9y, e6y~°w • s~Y~aI
PARCEL IS ZONED R-4 /6/
F. SETBACKS VARY BASED ON BUILDING HEIGHT- Iv
J I CONSULT STAR PRAIRIE ZONING CODE
SECTION 13-1-45 FOR SETBACKS.
NO DRAINAGEWAYS OR BUILDINGS ARE PRESENT I co
ON THIS PARCEL AS TO THE DATE OF SURVEY. ,n
Sr t`• ~Ly UNPLATTED LANDS OF OWNER I - isl6=-+
I-33 ~ I
S86 58'31 -E 437.95' 20.29' ~~J` i I I
404.93• {
33.03'1-
! I I
I o
I o ` I
Ic
rz Z i a I~ I
LOT 1 o I
TOTAL AREA: to o y l I i in r-a
, ,1~ I y Ir
i° 167,592 SQ. FT. la
Ir 3.85 ACRES IV -0 v I p j0
C: V 1I/`w I V 1D
I~ IV 1
v ' I~ I v j~
~-1 ~ I~ 1i I - I~
rn IJ vll I~
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I~ -I I co
15' DRAINAGE AND PRIVATF UTJLITY EASEMENT I I I
AND PUBLIC EASEMENT FOR WATER, STORM
AND SANITARY SEHER + I I I rc
I ' Izz
VA RIA
R/GHT-Ole AY1 I I I•~ i~
I I I 10
33.031 33' I
398.87' ~ I ~ Ir
1V
8658'3i'
W431.90' jz
I ,o
14.24'~~ fN~ r ti IN
UNPLATTED LANDS_OF OWNER ~
. IN.i I
I~ ' I ^
I} ,
jjo I
i 1
/
Section Corner Monument
of Record SOUTH 1/f CORNER O0
• Set 1" x 24° Iron Pipe weighing s£Cnan/ >-31-18
1.13 pounds per linear foot (IN R1lESTABLISHED d►
T>POM RES£s)
DWG # 1192 11 00
Prepared by. fao NO TH
JECI Consulting Group Inc- GRAPHIC SCALE
LAND SURVEYING & CIVIL ENGINEERING SCALE IN FEET: 1 inch = 100 feet
Phone No. (715) 246-4319 BEARINGS ARE REFERENCED TO THE NORTH-SOUTH 1/4
109 East Third Street, P.O. Box 325 LINE OF SECTION 1, TOWNSHIP 31 N., RANGE 18 W.
New Richmond, Wi 54017 WHICH IS ASSUMED TO BEAR SOO'37'27"W.
Sheet 1 of 2
Vol 15 Page 4067
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) / 'S S7C--50 located
at: /'jF- 1/a, NW 1/a, ection , Town _N, Range l W.
Town of 6 St. 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 Comm. 84.25, and it (they)
appear(s) to be functioning properly.
Most recent date of inspection or service - / -
Did flow back occur from absorption system? Yes No_x_
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capacity: 060
Construction: Prefab Concrete Steel Other
Manufacturer (if known): t)uA
- 4U
Age of Tank (if known): '5--
Permit number (if known)
(Licens Plumber Signature) (Print Name)
(Title) (License Number)40/MPRS
(Date)
Form to be completed by licensed plumber (Dept of Commerce Chapter 5
and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin
Administrative Code)
Rev. 9/2008
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
~r
Owner/Buyer C' C_' c ~ ,
Mailing Address
Property Address
(Verification required from Planning & Zoning Department for new construction.)
City/State Parcel Identification Number y `Ad " OZ5-
LEGAL DESCRIPTION
Property Location J~ 1/4 , /Jlj'(1/4 , Sec. l , T3/ N R 18 W, Town of -
5,&A-Subdivision Plat: , Lot #
Certified Survey Map # 6 113-3 4 Volume /5 , age # ~ 06
Z Q 20 (before 2007)Volume , Page #
Warranty Deed # y7
Spec house ❑ yes $"o Lot lines identifiable ,yes ❑ 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.
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 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
3
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)
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