HomeMy WebLinkAbout008-1072-95-000
Slgsconsin Department of Commerce PRIVATE SEWAGE SYSTEM -Ou^h St. Croix Sanitary Permit No
Safety and Builcing C,Vq%iOr INSPECTION REPORT 589704
GENERAL INFORMATION (ATTACH TO PERMIT) Mate Plan ID NC 2699204
Persc)ai information you provide may be used for srcondary pu•poses I.Privacy Law.. s'S C4 (1)i;mjl Parcel Tax No.
city 'village Township 008-1072-95-000
Pe-^'t Holders Name'. TOWN OF EAU GALLE
Jeffrey & Candace Schmitt sect cn,TowMRanie!MaPNo,
CS' BM File,, Insp RM Flev: BM Description: 25.28.16.381 B
ELEVATION DATA
TANK INFORMATION STATION BS HI FS ELEV.
TYPE MANLFACIURFIR r CAPACITY
Benchmark !A ! JDa
Septic l 1Z~~ l
t C AN. BM
gr~C~ I~r... Go ~.6
Dosing r•
Bldg. 5 ~9. 35
n v-~1 bc~
L Sewer 7. i5 16 3
;;Z~ C' SVHt Inlet q • °t 12-
Holding
StlHt Outlet \
TANK SETBACK INFORMATION
VdELL Vent foAir Intake ROAD DI Inlet
TANK TO P!L BLDG
Dt Bottom (Z '~j . S
Septic / ~c_, r r', • J X771 - -
Header!Man 3 •$z 97
Dosing - -
Dist- Pipe 35 "11 r"'
Aeration
act. System • 5~ y~ • _
Ho'.ding _
r
Final Grade Z `3Z cj `p
PUMPISIPHON INFORMATION ' Y Demand St Cover ~l /'65 h4anufactt,rer GPM
Model Number Z+ r
i G p v p
`7 S•3
T- 1 -DH Lift Qy Friction Lo ss System Head r iDH'r L~ t J~ I
Forcema Length , D,a. C ;t to '.^den
r
SOIL ABSORPTION SYSTEM PIT DIMENSIONS No. Of Pits inside C'a. Liquid Depth
ncnes -
RFDITRENCH Vvrdth Le,)ct^ No, Of 71e
DIMENSIONS r'
'STREAM LEACHING h<anu`acturer
SETBACK SYSTEM TO + P!L V BLDG' b'JELL LAKE
CHAMBER OR
INFORMATION f UNIT Model T, Number
e Of. S.Ystem.
P --7lC~a
DISTRIBUTION SYSTEM x I lore Si: e S x Pole s:>a .cg v r to Air I ke
Header Mavtold f; Distributicn
Pipes; ~1 t' t l r 3 z
Length Car Lergth /L, Dra St:ao Ig_ S v-
SOIL COVER x Pressure Systems only pund Or At-Grade Systems Onty
Depth Over h of xx seeeed~Sodded t~ulcned
epth C' ' I•-j, Yes - No `.y r'es No
Bed!Trerch Center ! * Bedjrench Edces t- I -
/ Inspection #1: ZZ Ce inspection #2'
COMMENTS: (Include code discrepencles, persons present. etc.) ~o S o v`
Location: No Address Available G ~Z ~ P ! d w ~CdJ
1 ) Alt BM Description = ` ' t ~ C_ C. j -~77
2) Bldg sewer length = L C_ l~G,:~ S 1
- amount of cciter = nl 't^ Sd-~l I I
?Ian revision Requ rod? 1 Yesr •No Lp I ZZ I \
Use other side for additional information Ce t No.
Date Insepctor's nature
✓r
l
SBr-67'C (7R 3/07)
1 RECEIVED
County -
t Safety and Sui ings Div s ,Sr ~~oiX
uS JUN 0 2 20165 201 W. Washington Av . Box 7 Sanitary Permit Number (to be filed in by Co_►
P l CROIX COUNTY Madison, WI 53707-7
- Q1~lMUN(TYDEVELOPMENT j 51Fy 764
Sanitary Permit Application State ftansaetionNumbet -
rn aceordance'.vith SPS 353 21(?), Wis. Adm. Code• submission of tnts ltwm to the appropristc govcmmcnlal unit (4j J O
equ;red prior to obtaining a sanitmv pe-mv Note: Application funs for sttuc-owned POWTS are Submitted to Pn,jcrl Adders i if do Tzrent tha minting address)
hr 1_>rpartment of Safety and Professions; Senses- Personal information you provide may be used for secondary ~j
,u,puses in accordance with the Privacy IaW, a 15,04( I )AM). SUS. C `
I. Appliention Information - Please Print-Info tion A f,
Property Owner's Name - - ' - - - Pa ccl v
F~L!!!!Lr r O b ' /6
:Imperty Owner's Mailing Addre~% U - - Ptvpcrty Loutiun G
a 5 O - b 39-f
4 ~l
L✓ 913 1/? CO, s?Q, L Ciovt. Lot
f it-V, State /ip Ctxle Phone Number EVE • sE s etn,n
7-4-
5-Y 7a( 7/S SS6-.?y4.2 teir~l~nn~
T WS N; R /G t ot~
11. Type of Building (heck all that apply) ~ Lot 4
56 or ' hanuly Duelling - Number of Hecnroms Subdivision Name
Public'Cnnunen ial Dcscrit+c L: sc 3 Block
11 M Q►' - Crab -
i- State OW'n-y- rkscrnbe Wsr C Number L,-vTtfnc of
Tosam of S-q a G/v L LC-
X
111. Type of Permit: (Check only one box on line (:omple[e line B if applicyble) - - -
vNew system Replacement Sy'stert 17 Treatment Holding Tank Replacement Only n (hher Mexltfication to Fxisting System (explain]
H• 11, Permit Renewal Permit Revision ❑ Change of Plumber ❑ Permit Transfer to Nrty Lt Previous Perm it numb r arid Date k%ued
Before Fxpiralinn Owner
-
IN'. Type of POWTS Svstem/Couiponent/U_evlce:(Chec-k all that apph) I~ p~ (F g
Non-Pressurized In-6toemi ❑ Pre;;utwcd In-(iround ❑ .At-Grade XMnund - 24 in- of suitable soil 1 Mound , 24 is of suilahl{1r. -il
holding Tank C Other Dispersal Component iexplain) r' Pretreatment Dcvicc (ex la r l
V. Dis ersalrrreat ent Area Information:
)csign Flow (gpol Octogn Soil Applicario ate( fi Dispersal Arca Rcquinc ~f,_ _ Distxrsai Arcs Pro ed '•:f Sy,tcm hlcvation e,,jr6-A
Goo / o Goo per- 96.V 95: 7'
V1. Tank Info Capacity in 'T'otal k of Manufacturer
Gallons Gallon; Urtit_v °
- L I j
New -1:A, Fximmg Tarts - u - y
is
tic ur wowwh+k• k D - - -
1--.,ing Chamber
171. Respoasibilih' Statement- 1, the uudrrsiKtrrd• assume e res responsibility for installation of the PO►V'lti shown on the attached plans.
I':cmbcr•s Name (Print) Plumber's Sieuat MP,~rtiai-S Numhcr tiusirress Phone Nnmlw•r
7s 67.x-8
('lumber's Address (Strecl, City, State. Zip Code)
~7~ ,OOQ4J/.1-1 I %/lL lG O. t AAnID, lJr SY736_
%'III.C'ounly/Department Use Only '
Appmvcd I Di ,pprnv; I Pennit Fee Dane wed Issuing Ag t tgnatu:e
fii, ;rt R, _,or IorDcuial $ A ,
I\. Conrlit~elMt')r axon for DiSapproval ✓ I (4,,
1. 5teptir. r~i)ertt f at10 I-
dispemm cell must all ¢setvices I •ng~ SV ! t/t%1 ~f Pr ~
as per RW&get plan pro' by plumber.
2 `#~s~l~ilihltiagf rt xdn priaait (lied
'L n~ oodm bYdlilatlCei. - - - - -~J''
Attach to complere plans for the system and submit to the County ~only un paper not k S N? I I inchM cj2~
S13D-6399fR 1111) l~,olr~e~ X414 r
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DIVISION OF INDUSTRY SERVICES
;t4'4T6fF~' 3824 CREEKSIDE LN
\J\ HOLMEN WI 54636-9466
Contact Through Relay
I` s P y http•ildsps.wi.gov/programs/industry-services
S. www.wisconsin.gov
Scott Walker, Governor
Dave Ross, Secretary
V av 1116
CUST ID No. 220654 AT N: POWJ-'1' Ir:.~pectr~+
CHRIS NI BAUER ZONING OFFICE
BAUER PLLJMBING AND SEPTIC SYSTEM TNC ST CROIX COUN"T"Y" SPIA
N6483 DORWINS MILL RD 1101 CARMICHAEL RD
DURAND WI i,,1736-4831 HUDSON V0 54016-7708
CONDITIONAL APPROVAL
PLAN APPROVAL. EXPIRES: 05/11/2018
SITE: Identification Numbers
Jeff Schmitt Transaction ID No. 2699204
12TH Ave Site ID No. 823333
Town of Eau Galle Please refer to both identification numbers,
St Croix County above, in all correspondence with the a?,encv.
NE 1A, SF 114, S25, 12 8N.1 R16W
FOR:
Description: Four Bedroom Mound System ! 6% slope (2) Bid-s.
Object Type: POWTS Component Manual Regulated Object ID No.: 1597920
System(s): MOtmd Component Manual - Ver. 2.0, SBD -10691-P (N.OP01, R" 10!12), Pressure Distribution
Component Manual - Vcr. 2,0, SBD-10706-P (N.01!01, R. 10112); Maintenance required, 600 GPD Flow rate:
Effluent Fitter
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed
and located in accordance with the enclosed approved plans and with any component manual(s) referenced above.
The owner, as defined in chapter 101.01 (10), Wisconsin Statutes, is responsible for compliance with all code CONDITION
requirements. ~1Pf~RflV
No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.0fbEPT OF SAF
slats. PROFESSIONAL
The following conditions shall be met during construction or uistallation and prior to occupancy or use: 15NISION OF INDUST
Reminders
• A sanitary permit must be obtained from the county where this project is located in accordance with the i/ ~A4r\ ~-e
requirements of See. 145.19, Wis. Stats. _
Inspection of the private sewage system installation is required. Arrangements for inspection shall be ~ewii~
the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats.
• A state approved effluent filter is required. Maintenance information must be given to the owner of the tank
explaining that periodic cleaning of the filter is required. Access to the filter for cleaning must be provided
per SPS 384 product approval conditions.
• The area within 15' dovnslope of the dispersal cell shall remain undisturbed. Vehicular traffic, excavation or
soil compaction is prohibited in this area.
• A copy of the approved plans, specifications and this letter shall be on-site during construction and open to
ins~)cc:'.er by :u'ithoE iz.ed rc rese'itativ~s of the. I k: ~~rtmer.t ~~hich rnav :ncludde local ins, tors.
CHRIS M I3ACLZ Page 2 5,11,x2016 WM"
Owner Responsibilities
• The current owner, and each subsequent owner. shall receive a copy of this letter including instructions relating
to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and
maintenance manual and/or owner's manual for the POWTS described in this approval.
• The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POXVI'S
occurs in accordance with this chapter and the approved management plan under s. SPS 383.54(1).
• In the event this soil absorption system or any of its component parts malfunctions so as to create a health
hazard, the property owner must follow the contingency plan as described in the approved plans.
• The owner is responsible for submitting a maintenance verification report acceptable to the county for
maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized
in the POWTS.
A copy of the approved plans, specifications and this letter shall be on-site during construction and open to
inspection by authorized representatives of the Department, which may inc'.ude local inspectors. All permits
requited by the state or the local municipality shall be obtained prior to commencement of
construction'urstal lation,'operaticn.
In granting this approval the Division of Industry Services reserves the right to require changes or additions should
conditions arise making them necessary fbr code compliance. As per state stats 101. 12(2), nothing in this review
shall relieve the designer of the responsibility for designnig a safe building, structure, or component.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and an,,,
others who are responsible for the installation, operation or maintenance of the POWTS.
Sincerely, Fee Required S 250.00
V2 I This Amount Will Be Invoiced,
r a r d Ito Swirn When You Receive That Invoice,
POWTS Plan Reviewer, Division of Industry Services Please Include a Copy With Your
(608) 7 89-7892, Mon - Fri, 7:15 am - 4:00 pm Payment Submittal.
jerry.swim(cilwisconsin_gov WiSR1<1RT code: 7633
cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am'To 4:30 pm
Note: Effective January 1, 2012, all codes wider the jurisdiction of the Division of Industry Service; (formerly
Safety & Buildings) will be modified. Code references with prefixes starting with "Comm" have been replaced with
"SPS" to recognize the relocation of the Division of Industry Services from the former Department of Commerce to
the Department of Safety & Professional Services. Additionally, all IS (formerly S&R) codes have been renumbered
and addressed in a "300" series. Tor future reference. the Wisconsin Commercial Building Code will he addressed
by SPS Chapters 360-366.
CHRIS M RAURR Paec 2 >>11:2016
Owner Responsibilities
• The current owner, and each subsequent owner, shall receive a cope of this letter includin,c instruc-ions relatin-2
to proper use and mairrtenance of the svstem. Owners shall receive a cope of the appropriate operation and
maintenance manual and/or owners manual for the POWTS described in this approval.
• The owner of a PONVTS shall be responsible for ensurmL, that the operation and maintenance of the POWTS
occurs in accordance with this chapter and the approved management plat under s. SPS 383.54(1).
• In the event this soil absorption system or any of its component parts malfunctions so as to create a health
hazard, the property owner must follow tine contingenc> plan as described in the approved plans.
• The owner is responsible for submitting a maintenance verification report acceptable to the county for
maintenance tracking purposes. Reports shall he subrrittec at intervals appropriate for the component(s) utilized
in the POWTS
A copy of the approved plans, specifications and this letter shall be on-site durin, construction and open to
inspection by authorizes representatives of the Department, which may include local inspectors. Al: permits
required by the state or the Iota: municipality shall be obtained prior to commencement of
constnlction'installationtoper ation.
In g anting this approval. the Division of industr Services reserves the right to require changes or additions should
conditions arise making Choir necessary for code compliance. As per state staLs 101.12(2). n0tllcng in this review
shall relieve the desiEmer of the responsibility for designing a safe building, smtcnire. or component.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at The address
on this letterhead.
The above left addressee shall provide a cope of this letter and the POWTS management plan to the owner and any
others who are responsible for tae installation, operation or maintenance of the POWTS.
Sincereh. Fee Required S 250.00
T
This Amount Wfll Be invoiced.
card ~1 Swim When You Receive That Invoice,
POWTS Plan Reviewer, Division of lndustiy Services Please Include a Copy With Your
(608)789-7892. Mon - Fri, 7:15 am - 4:00 pm Pavment Submittal.
jerry.swim~>,wisconsin Roy WiS1v1ART code: 7633
ce: Fdwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm
Note: Effective January 1, 2012, all codes unde- the jurisdiction of the Division of Indusm' Services (formerly
Safety & Buildings) will be modified. Code references with prefixes starting with "Comm" nave been replaced with
"SPS" to recom- ize the relocation of the Division of Industry Services from the former Department of Commerce to
the Department of Safety K Professional Services. Additionally, all 1S (formerly S&B) codes have been renumbered
and addressed in a "300" series. For future reference, the Wisconsin Commercial Building Code will ne addressed
by SPS Chapters 360-366.
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JKiahoma City, OK 73157-2;
hone: 1.800.701.7694
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r Document Titic fx:43lH9 i'
St. Croix County 1030220
BETH PABST
Accessory Structure Affulavit REGISTER OF DEEDS
ST. CROIX CO., WI
RECEIVED FOR RECORD
06/08/2016 11:15 AM
Name - (Owner) Typed or printed EXEMPT
ben,i duly sworn, states, under oath, that REC FEE:
30.00
PAGES: I
:
He/she is the Icgal owner of the following parcel of land located in St.
Croix County, Wisconsin, recorded in Volume rvA Pale AA Document
Number9~f(~ ~ St. Croix County Register of Deeds Office, kc: c!;ra: rrr; Area
being duly described as follows (include lot no. and subdivision!CSN1 or ~a c and Return :add ess
detailed legal description): 'n In ' h
Vt! ~t!~ ~ L e'r'r
J t -C 2-5 flZ A/ kl&td P r NC 5C D C 5C '45 QcG (lu 93,--/ -7 JL
~j 7 l k- , S (-.V / 55~ ~
l4C{ ` roP Or ~~1Fi 25 ~H ~i 1.305.72 Y7-1 r/-/' Parcel llcntifcationNumber (PIN
j
rbZ7' lru 7/a / ~36~. ~y >ct-~ t~{ oors- 1077-- 95 -ciao
S S 7' L-' ~2q ?'o /go's . J
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 ) I 'Y bedroom home, or a design flow of~)00 gpd. This
accessory building may not be used as it second residence on this
parcel. I also acknowledge that I will disclose this information and stipulation to any future parties interested in
purchasing this property.
DaV this - day of u n Q ZCj
5-C 6 -'h
Al l'FIIEN Y1CA'rioN AChNOW1,EDGMEN11Signature(s) STATE t--)F WISCONSIN
)ss
't. Croix Countv 1
authen[icated L'us da;: of 4
Peisom+lly carte before me [his day of
f) k the ah .vc named }
%
TITLE `.IENIBER STATI F3AR Ut i~'ISCONSiN r_ to.a7e knu~sri to be
(Irnvl, the person(s) who executed the foregoing i Utr hent'a ,~acknaivled(~ tx
authnnzcJ by J 706.06 , Wis. Scats) same' _
7NfS INSTRUMENT' WAS DRAFTGD BY
C7;
VWL
Notary Pubic, State ofwiseons' ~~I r('•,':'
(Sirna.mes may be authect.iea7ec c,r acknowledged Ruth are not h Commission is perimmert ff net, st;tte expirmiam,44c1
necessary' Da "C Io 3
Sr C,oix Ccun 1030220 Pace 1 of 1
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