HomeMy WebLinkAbout020-1372-08-000~ ,
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
~~ ~
Permit Holder's Name: ^ City ^ Village ^ TiXwn of:
Miller, Sam Hudson Township
CST BM Elev.; Insp. BM Elev.: BM Desc iption:
TANK INFORMATION
TYPE MANUFACTURER CAPACITY
Septic (~ ~~
Dosing ~S`~.S
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO P/ L WELL BLDG. vent to
Air Intake ROAD
Septic ~ yo' 2 ~- r a a ~ NA
Dosing NA
Aeration NA
Holding
PUMP /SIPHON INFORMATION ~
Man ter Demand
Model Number GPM
TDH Lift Friction System TDH Ft
---
Ee~emain I Length I Dia.
SOIL ABSORPTION SYSTEM
To Well
I ? c~.ew~,.~li n ci± c,Q. J .~-ro. , x Q,
TRENCH width, Le t r N .Of trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIM DiM N 1 N
SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING Manu actur~~ ~ ,,
~
~
~
SETBACK t ~ `
t
~~-I
CHAMBER m
r
M
N
INFORMATION TypeO
^^~ ~
~~
~ .~,~,
OR UNIT :
e
o a
u
System: V,
DISTRIBUTION SYSTEM y~°~~
Header / nifold u
~
~ Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
r
~/ Dia.
Lengt ength Dia. pacing ~ 30
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.)
'i 1
Inspection #1: ~/ /~ /Ofl Inspection #2: / /
Location: 537 Raider Drive,~ud~s~o~n, YVI 5,4016 (M1SE 1/4 SW 1/4 21 T29N R19W) - 2129192228 Raider Estates -Lot 8
1.) Alt BM Description =-~ ,~,~
2.) Bldg sewer length = -~- 2~-•0'_~`p
-apm_o~unt of cover = > /8 " ~ ~~•
Plan revision required? ^ Yes (~, No ~ ~ I K
Use other side for additional information. p It Q'O J
SBD-6710 (R.3/97) Date Inspector's Signature Cert. No.
ELEVATION DATA
County:
St. Croix
Sanitary Permit No.:
363957
State Plan ID No.:
Parcel Tax No.:
020-1372-08-000
STATION BS HI FS ELEV.
Benchmark 5-, g~ /'DS. 8 ~ , t7 '
Alt. BM 3.~-O 102. !S~
Bldg. Sewer
St/Ht Inlet q 3~ ~Ifo•~'
St/ Ht Outlet ~j.(o a- qb, /B
Dt Inlet -~ ~-
Dt Bottom '~- ~~
Header /Man. lo•°'a cl s ~-~'
Dist. Pipe ~~ ~~ C)s;1o ~
Bot. System 1(.zS 9`f.(eo ~
Final Grade (~ cj~,~S'
St cover o(.2.p
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
:
} ~ t
' ~ ~ 53 ~-- ~~- !~R-111 E
Sanitary Permit Application Safety & Buildings Division
201 W. Washington Ave.
[n accord with Comm 83.21, Wis. Adm. Code
PO Box 7302
~s~a~s~~ See reverse side for instructions for completing this application Madison, WI 53707-7302
urposes
seconda
d f
b
ry p
or
e use
Personal information you provide may
Submit tom feted fornt to coup if not
04(I)(m)] ( p ty
Oepertment of Commerce [Privac
I5
Law
s
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,
y
.
state owned.
Attach tom lete lans to the coun co onl for s n r not less than 8-t/2 x 11 inches in size.
k ~f ~o application State Plan I. D. Number
State Sanitary Permit Number
c°ra~ ST ~ ,e.o i X 5 ~~`~
I. A lication Information -Please Print ail Informatio Location:
Property Location
/
`~
Property Owner Name t
c~ ~ ~/~ L~C~ r- 1/451/4, S T G /,tv, R~ tE W
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rty/Owner's Mailing Addrtiss r~ ~ ~~ ~.
rop
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State Zip Code d' Phone ~1r6 Subdivision Name or CSM
City
,
v sort ~1~ s'y®/~
^ City
II. Type of Building: (check one) (, ^ Village
^ 1 or 2 Family Dwelling - No. of Bedrooms :~ own of ~(./ jJ~ S 0
^ public/Commercial (describe use):_
^ State-0wned Nrarr_ct Rnad .. .. ,
I e of ermit: Chet onl one box o A. Check box on line B if a lica e 5 6. ^ Addition to
p) 1. New 2. ^ Replacement 3. ^ Replacement of 4. Existin S stem
stem S stem Tank Onl Date Issued
PeRnit Number
B)
^ A Sanity Permit was reviousl issued 'T- L ff E ~,
IV. Type of POWT System: (Check all that apply) 3~- Q l~ ~~I ~V Std S 3 " 2 EN
Non-pressurized In-ground ~. ~ !~ G f'~ t] Mound ^ Sand Filter ^ Constrocted Wetland
^ Iioldin Tank ^ Single Pass ^ Drip Line
Pressurized In-ground g ^ Recirculatin ^ Other:
^ At- de ^ Aerobic Treatment Unit
V. Dis ersal/Treatment Area Information:
I Design Flaw (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation Elevation rode
mJlnch
Required Proposed Rate (GalsJday/sq. ft.) (M~ ) ~ ~' ~ /
VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Ft ass Plastic
Gallons Gallons Tanks Con- Con- g
Information Crete strutted
New Existing
Tanks Tan1s ^ ^ ^ ^
~ ( ~T.~ fZ- Z ~ ~ / D
VIII. Responsibility Statement
I, the undersi ed, assume res onsibili for installation of the POWTS shown on the attached lans. Business Phone Number
Plumber's Name (print) Plumber'~S' ature nos s): MP~'~ °' ~ ~ / ~~ / ~ Z
-` oN G ~ l~~jjjj (p fo
Plumbee's Address (Street, City, Slate, Zip ode) ~ /
a a v ,~' ~f~~9~ vd ~/
IX. County/Department Use Only
Sanit Pemut Fce (Includes Gramdwater Date lssued Issuing Agent Signature (No stamps)
^ Disapproved ~'
~ Approved ^ Owner Given Initial Adverse S rcharge Fee)
~aa5• ~ ~-- z~-z6oo
Determination ,~ep n
X. Conditions of Approval /Reasons for Disapproval: ~ "a ~,~ rQO.!lt~tl~4~- L°,~ `
~, c.QBSt._ '~ ~ ~ ~~.~+.~ ~' w~1Cl u~.UMti ~.w~.uiSp r ~ ~ itibri i~S ~--~c ~0
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i Dif f user S ecif ications s .~ s,-~ ~, ~' = 9 y, s
Bo p
3 -- C ~f f('h~t '~ i2 TbT ~ ~ ~ -Tiz,~ N c {~,~ ~' l z- _ ~c H /~ n~ ~
~ 76"
coo aC~ oo i~~ oo two 00 00 00
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OD DD DO CEO OD C~C~
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o~ oo ao 0o Q~
00 00 oa o0 0~ oo ~o 00 00
DD OO DD OCR DO OO OD OO DD
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OCR Old DO OO CEO 00 CEO OO OD
All three BioDiffuser sizes Gt~n;
withstand H-10 loads when
installed with properly graded
and compacted soils. A mini-
mum of 12" of cover is requt~ed
for H-10 loads, ThQ 14" High
Capacity BioDiffuser is
designed for H-20 Ipad&.
A minimum of 1$" of cover is
required for H-20 loads.
~~ ~ a--~4/y,,L~.,
~~"~ ~ ~
Available Sizes
Chamber
Height
- ~
' ~ Chamber
Height
i
,' End View
34"
4" Knockout
Universal End Cap
Length 76" 76" 76"
Width 34" 34" 34"
Height 11" 14" 16"
Invert 6.5 9 11.3
Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
Attach tinplate site plan on paper not less than 8%: x 11 inches in size. Plan must
include, but not limited to: vertical and hor¢ontat reference pant (Bll~, d'iredion and
percent slope, scale or dimernsions, north arrow, an~i.ler,~iorr~td distance to nearest road.
APPLICANT INFORMATION - Prase print all information.
Personal information you provide maybe used~or secondary p~pses (Privacy LavJ,,s. 15.04 (1) (m)).
Page 1 of 3
AC.E. Soil & Site Evaluations
County
Parcel I.D.#
t~~,ee 020-1056-10-000 LD.#21.29.19.209A
Kd.s~:...tl ~A~Qrrs~._ 19 t 2 `i -2~
Property Owner , .. ~•- Property Location
Miller, Sam r' _ . ,, Govt. Lot SE 1/4 SW i/4 S 21 T 29 N,R 19 W
Property Owner's Mailing Address i ~- - '' of # Block # Subd. Name or CSM#
P.O. Box 151 ~ °, ~~~`^
- 8 Plat OfRaider Estates
City ~ _ ~. ; ~"~
State ` ~ipCode P ^ City ~ Village Town Nearest Road
Hudson WI ~ ~ ~ 6-276~~` Hudson ~ Raider Drive
New Construction .~ , ....~.-- __.t 4 ^Addition to existing ilding
R t~rltia~% ~ rooms
^ Replacement Use:
[~ Public or ~ ~ la describe •2
Code Derived daily flow 600 gpd Recommended design loading rate •6 2 .7 trench, gpd/ftz
Absomtion area required 1000 bed, ftz g57 trench, ftz Maximum design loading rate .6 bed, gpolftZ .7 trench, gpd/ftz
fter~mmended infiltration surface elevation(s) 94.50' ft (as referred to site plan benchmark)
Additional design /site considerations 111 trenches using high capacity infiltrators.
Parent material Glacial outwash Flood ain e~vation, if icable NA ft
S=Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding lank
U=Unsuitable for system ®S ^ u ®S ^ U ^ S ^ u ®S ^ u ^ S ®u ^ S ® U
SOIL DESCRIPTIO N REPORT
Boring#
1
Ground
elev
99.98 ft
Depth to
limiting
factor
>102"
,2
Ground
elev
98.16' ft
Depth to
limiting
factor
95'
Depth Dominant Color Mottles Structure
i
t
C
Bounda
Roots GPD~
Horizon in. Munsell Qu. Sz. Cont. Color Texture ~.. Sz. Sh. ons
ence
s ry ~ ,Trench
1 0-10 IOyr4/2 None sl 2fsbk mvfr as 2f,lm 0.5 ! 0.6
2 10-21 10yr4/4 None sl 2msbk mfr as 21,1m 0.5 0.6
3 21-26 10yr4/4 None gr.ls Osg dl cs - 0.7 ~ 0.8
4 26-SO 10yr5/4 None ~. Is & s Osg dl gs - 0.6 0.7
5 80-102 10yr6/4 None ~. is & <. Osg dl - - 0.6 0.7
~ ~ Sa
bs •~~/~(. ~ ~
Remarks: H#4 & 5 contain a mixture of ed >s & s. Lo - rate reduced sli ht to tom sate for tennat stacxm or wirer at n-rer~ace or
trYfiiral rhanorc / <~..gyRS sot S
1 0-14 10yr4/2 None sl 2fsbk mv& as 2f,lm 0.5 ~ 0.6
2 14-26 10yr4/3 None is Osg ml gs 2f,lm 0.7 i 0.8
3 26-39 7.Syr4/4 None gr.ls Osg dl cs - 0.7 I' 0.8
4 39-95 10yr5/4 None s Osg dl aw - 0,7 _T_ OT8__
S 95-105 10yr6/2 m3p5yr5/8 ~.5. resit Om mfi - - NP 0.2
3.9L Y•9Z
Remarks: H#5 consists of sic]
to bedrock at l~~".
CST Name (Please Print) Signature. Telephone No.
James K. Thompson a-- 715-248-7767
Address AC.E. Soil & Site Evaluations Date CST Number Ref #
340 Paulson Lake Lane, Osceola, WI 54020 4/19/00 3602 1202
.n
~-
PROPERTY OWNER Miller sam SOIL DESCRIPTION REPORT
• PARCEL I.D.# 020-1056-10-000 I.D.#21.29.19209A
3
Ground
elev
97.51' ft
Depth to
limiting
factor
92"
4
Ground
elev
ad ~n $
~zo2 Page 2 of 3
,4_C.E. Soil & Site Evaluations
Horizon Depih
~. Dominant Cobr
MunseB Mottles
Qu. Sz. Copt Color'
Texture Sfiuciure
Gr. Sz. Sh.
ststPatce
Boundary
Routs GPD/ttz
---._~ ____--
Bed ~ Trendl
1 0-10 10yr3/2 None sl 2fsbk mvfr as 2f,lm 0.5 0.6
2 10-19 10yr3/3 None sl 2msbk mfr as 2f,lm 0.5 0.6
3 19-25 10yr4/4 None gr.ls Osg dl cs - 0.7 0.8
4 25-29 Syr4/6 None gr.ls Osg dl gs - 0.7 0.8
5 29,92 10yr6/4 None is & s Osg dl aw - 0.6 ~ 0.?
6 92-110 10yr6l2 2mp5yr5/8 L.S. Om mfi - - NP 0.2
36.1 L~~Z. t
Kemark$: tliF J COritamS a mixture OI saatuteQ is ac S. I.oaatng raze reallce(t Sllgniry [O compensare IOi poLCnia'dt ic-ng uL wa,cr ea unciiaaz vi
1 0-24 10yr3/2 None sl 2fsbk mvfr as 2f,lm 0.5 0.6
2 24-32 10yr3/3 None is Osg ml cs 2f,lm 0.7 0.8
3 32-46 10yr4/3 None s Osg dl gs - 0.7 ~, 0.8
4 46-108 10yr5l4 None s & gr. Osg dl - - 0.7 ~~ 0.8
Depth to
limiting
factor
>108'
5
Ground
elev
95.98 fit
Depth to
limiting
factor
85"
Ground
elev
Depth to
limiting
factor
KetnarKS:
1 0-9 10yr4/2 None sl 2fsbk mvfr as 2f,lm 0.5 0.6
2 9-23 10yr4/3 None Is Osg ml gs 2f,lm 0.7 0.8
3 23-36 7.Syr4/4 None gr.ls Osg dl cs - 0.7 ! 0.8
4 36-85 10yr6/4 None s Osg dl aw - 0.6 ~ 0.7
5 85-101 10yr6/2 m3p5yr5/8 L.S. Om mfi - - NP ~ 0.2
~e eo~.,t~.~'e„ce po.s't.
^ 6~
o~e~:
S~ rn,-r/e ~
p. o. 8~x psi
S~lO/6
~.o Ca-~ i ~» .
/off ~'~ P/a~o,~'~aale~~S~s,
SEys!,5 ~yy, See. ,2I, T.29/!, ,P.i9uI,
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ST CROIX COUNTY
• SEPTIC TANIC MAINTENANCE AGRBEMENT
i AND
OWNERSHIP CERTIFICATION FORM
ownerBuyer S 64/1 r'1~ ` L ~-,~``~-..
Mailing Address ~ a ~ ~ / ~ /
property Address , ~ 3 7 ~ ~ { 4J~~- ~ 1L..1 / ~
(Verification required from Planning Department for new construction)
City/State ~ u 105 D N W ~ Parcel Identification Numb D ~' J~ ~ *~` ~ O g ~ 4 ~
LEGAL DESCRIPTION
property Location ~'/4,~ w '/., Sec. ~ ~ . Ta 7 N-R ~`~ Town of ~ U ~4 ~'`~
Subdivision ~ A (~ £ ~-- ~ 5 ~~ ~ ~ ~ .Lot # C~
Certified Survey Map # Cr ~ '~~ `~~ .Volume ~_ ,.Page #
i
Warranty Deed # ~ ~ ~ 7 s 3 _, Volume / Page #
Spec house ~ yes ^ 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
masterplumber, journeymanplumber, restrictedplumber or a licensedpumper verifying that (1) the on-site wastawaterdisposal system
is is 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
da of the ear expire ' n te.
~ i~`~i d~
AT[JRE PLICANT 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 ownet{s) of
rty described above, b virtue of a Warranty deed recorded in Register of Deeds Office.
~~ ~ ~
ATURE O P ICANT DATE
~ ««s«««
«««««« Any information that is mis-represented may result is the sanitary permit bciag revoked by the Zoning Departmen
•• Include vrlth this appllcatlon: 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
..^ , .
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Cc:.'„ ~~^.* rr^ ~ WF~itii•... i Y LECL~
~ 5": ... .. DARE' R't ~~ ,_.. .0; :'t 2-toga
' ! vol ~ 458~~r.E ~5 '~I
EXCEPT parcel conveyed to Donald F, Johnson in 'volume 500, page 515;
and EXCEPT parcel conveyed to Dc^aid R. Jordan in Voi;aoe 580, page 354;
and EXCEPT parcel platted as we " s =argo Sta*_ior, in Yolur! 5 of Plats, page
89, as Document A478658, ALL in _tction 11 (21 ), Township Twenty-nine (29)
North, Range Nineteen (19) West, T?wn of Hudson, St. Croi[ County, Wisconsin.
/a~`~
the following described rc:,i estate in ......S.ti,.,Croix. .....County, r -'-'
............ .........
Stale of Wisconsin:
The East Half (6h) of the Southwest Quarter (SNy) ExCEP7 parcel Ta: Parcel No: ~.~1~~0 ~Q
conveyed to Aifr~td L. Ekblad in volume 498 O '
page 484; and EXCEPT ~Q ~D~ 6
parcel conveyed to Leslie L. Swe^son in Volume 458 page 504• and
6.1075
kAlii~EEN H. WALSH
kr"ci;TEk Of DEEDS
3T. GhOIX CO., WI
RECET.vED FOR RECORD
09-22-1999 D:30 AM
iiARRANTY DEED
ExEftDT N
CERT CODS FEE:
~OG't FEE:
TRANSFER FEE: b17.50
RECIiRDIMG FEE: 10.00
RAGES: 1
I
....... .... .. .. .. .. ... .... ... .... U N
.........~...:...:.~::.:::...:~ .::.......:.::::.:.....::::::.~.. _: ::.::.::_::.::::.: f~~~
Subject to unrecorded agreement voted October 12, 1491 by and between Donald R. Jordan, Cail Gordan,
John A. Elbert and Eric J. Lunde~l regarding furore lano transfers and roadway conveyances.
Subject to covenants, conditions, -estrictions and easements created by preliminary plat of Nells
Fargo Station First Addition.
Subject to easements, restrict .^s, reservations, and r~;hts-of-way of record, if any
is not ~
Th;a ............................ >•cc^utcnd property.
(ydQ (is nnt)
h:xccptinn to wsrrnntics: as ^oted above
1)nled this .,...,..20th
......._..... ...... Jay ,:
_ ............._ ................ (SAL)
AUTHENTICATION
Signntura(s) ..........................
T1TL);: tifCrti3I:R S'C:LTE BAR 1£ 'NIA" ":~;:.
((f not .............................._....... .
authorized by b 7CG.06. W's. S:a:aJ
TNISINSTRUMENT `N,>^, :, R+~F'F') 8Y"
Humbird Land Corporat[,,n
(Signnturc3 may be nuhlentl~a'_ a ,r ylR^( Wic ll,•` '. .I.
sre not r.~ce~sarv.l
August......... ....................... 19.99
HUMBIRD LAND CORPORATION _ _„--...(SEAL)
Austin J. Baillon, Its President
... ............................................(SEAL)
ACKNOWLEDGMENT
STATE OF )Wm9~39~fISiIQ MINNESOT
ss.
Ransey
. .................. County. I
(~~.s::u::y «uw h•_iorc me ibis Zuttt.--.,.day of
.....
au_gust ..............._............. !!'39.... the above named
Austin J. Baillon President of
`~.:.c:bi.rd .Lacd. Cocancation...-• ..................••---.............
:c n•.c known to be tl•,e person ........... who t.•.ecuted the
:urc;~ie;: instrument anc 2c~wjcdytofihR•xa~uRv.~t~ti,.v;.,,
........
• Paul A. 3a.iJ.lrn. ~`:' 'i0yr.(~U~JTY
..„~
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