HomeMy WebLinkAbout038-1059-10-100
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PAGE 1 OF 1
Parcel 038-1059-10-100 038 _ TOWN OF STAR PRAIRIE
ST. CROIX COUNTY, WISCONSIN
Alt. Parcel 14.31.18.256E
Current X Application # Permit # Permit Type
Creation Date Historical Date Map 00 SalespArea owner(s):
O = Current owner, c = Current Co-Owner
Tax Address: O - CERNOHOUS, KENNETH J & AUDREY M
KENNETH J & AUDREY M CERNOHOUS
956 S STARR AVE
NEW RICHMOND WI 54017
* =Primary
SC = School SP = Special Property Address(es):
Districts: ~
Type Dist # Description
C
SC 3962 NEW RICHMOND
SP 7060 STAR PRAIRIE SAN DIST #1
SP 1700 WITC
Legal Description: Acres: 1.150 Plat: N/A-NOT AVAILABLE
SEC 14 T31N R1 8W LOT 1 OF CSM 6/1562 Block/Condo Bldg:
40 1/4 160 1/4)
1.15AC EZ-UT-1226/265 Tract(s): (Sec-Twn-Rng
14-31 N-1 8W
Parcel History:
Notes: Date Doc # Vol/Page Type
/ 01/05/2000 616528 1482/168 LC
1065/522 QC
07/23/1997
07/23/1997 1059/439 WD
07/23/1997 1059/421 moDJ
Bill Fair Market Value: Assessed with:
2008 SUMMARY 0
Last Changed: 10/13/2004
Valuations:
Class Acres Land Improve Total State Reason
Description 26,100 127,800 153,900 NO
RESIDENTIAL G1 1.150
Totals for 2008: General Property 1.150 26,100 127,800 153,900 Woodland 0.000 0 0
Totals for 2007: General Property 1.150 26,100 127,800 153,900 Woodland 0.000 p 0
Batch
Lottery Credit: Claim Count: 0 Certification Date:
Specials: Amount
Category User Special Code
Special Assessments Special Charges Delinquent Charges
00
0.00 0.00
Total
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Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SEC. ) T_N-R W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i ~ ly
i ~ ry
i
j
z
t1 4
i
5V /
7~
i
INDICATE NORTH ARROW
r ~ ~ ~ III
' ~ III
j
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: Proposed slope at site: u`
SEPTIC TANK: Manufacturer: Liquid Capacity: y/
J
Number of rings used: Tank manhole cover elevation:-7
Tank Inlet Ilevation:l Tank Outlet Elevation: 77 a3
Number of fEet from nearest Road: Front,~Side,0 Rear, 0 4L feet
From ti Barest property line Front, oSide, 0 Rear,O feet
i
Number of feet from: well building.
(Include [his information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORBTION SYSTEM
Bed: Trench:
Width:z Length: Number of Lines:~ Area Built:,
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side Rear,O Ft.
Number of feet from well:
tf>'
e
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: Plumber on job: License Number:
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707.
XXICONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number
❑ Holding Tank El In-Ground Pressure ❑ Mound (If ass,9nedl
NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER: INSPECTION DATE.
Robed Dosedet R. R. 2, New Richmond, W1 54017 t1" °.,?6 --Sy -
BENCH MARK (Permanent reference pomtl DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.. CST REF PT. ELEV.
NE!,- o~ SE% o6 Section 14, T31N-R18W, Lot #1, Town o~ StaA PAaiAi.e
Name of Plumber. MP/MPRSW N... County. Sanitary Permit Number.
Cat Powers 1563 St. Cnoix 49499
SEPTIC TANK/HO ING TANK:
MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELE V.. WARNING L
ST
OV ABEL JLUCKIPG P IDED PYESLINO : VENT DIA.. VENT MATL. J HIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING. JVENTTOFRESH
ALARM FEET FROM I LINf• AIR IN LET.
❑YES LINO ❑YES LINO NEAREST
DOSING CHAMBER:
MANUFACTURER BEDDING. ILIOUID CAPACITY PUMP MODEL PWARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
❑YES LINO ❑YES LINO ❑YES LINO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMB 05 F P-11TV WELL BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN FEE LINE AIR INLET
PUMP ON AND OFF) ❑YES LINO e /1NE E
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing JOIAMETER MATERIAL AND MARKING;
or excavation. (If soil can be rolled into a wire, construction shall cease until F RICE
the soil is dry enough to continue.) AIN
CONVENTIONAL SYSTEM: % BED/TRENCH WIDTH. LENGTH NO. OF DISTR. PIPE SPACING COVER INSIDE DIA #P LIQUID
DIMENSIONS rRE9iC~fES angtkRlAL PIT > DEPTH
Vpo
t
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. 115 !IS R NUMBER OF PROPERTY WELL . BUILDING. VENT TO FRESH
HF LOW PIPFS ABOVE COVER ELEV. INL T ELEV Ef D, ] PIPE' LINt^ w AIR INLET
a ~ `;0 NEARESTO--s U 7
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for 1PROVI DE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it N REVERSE SIDE. SHOW ELEVA-
❑YES LINO meets the criteria f dium sand. TONS MEASURED.
SOIL COVER TEXTURE PM ARKERS OBSERVATION WELLS
ES LINO ❑YES LINO
DEPTH OVER TRENCH BED DEPTH OVER THENCH,BED DEPTH OF TOPSOIL I IDDID EDED MULCHED.
CENTER EDGES. f
❑YE LINO ❑YES LINO ❑YES LINO
PRESSURIZED DISTRIBUTION SYSTEM: !
BED/TRENCH WIDTH 7LENGTH TR EONCH ES LAT RAL SPACING GR VEL DEPT BELOW PIPE FILL DEPTH ABOVE COVER
DIMENSIONS.
MANIFOLD PUMP MANIFOLD ISTR{IPE MANIF IU ERIAL. NO. T/ DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV.. ELEV.. DIA. LEY. PIPES DIA.:
ELEVATION AND
DISTRIBUI ION
INFORMATION HOLE SIZE HOLE SPACING DRILLEDCOR CT COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑Y LINO ❑YES LINO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING.
FEET FROM LINE
❑YES ❑N ❑YES ❑ NEAREST
1(2
TO
Sketch System on
„ _.,fZe n'°rn-mUtrrlty-fTF~or audit.
Reverse Side.
sIGN~Ar ~ T ,
DILHR SBD 6710 (R. 01/82)
E APPLICATION FOR SANITARY PERMIT flte"
DILHR (PLB 67) COUNTY
DEVRRTmEnTOF UNIFORM SANITARY PERMIT #
InDUSTRY. LRROR 6 HUMRn RELRTIOnS
W499
=Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROP TY OWNER MAI N5ilADDRESS /
Jj 7
PROPERTY LOCATION CITY:
VILLAGE:
1/4, S Tom'; N, R (or) W TOWN OF:
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
7 cl)
TYPE OF BUILDING OR USE SERVED
l 1 or 2 Family Number of Bedrooms-. ❑ Public (Specify): , f
THIS PERMIT IS FOR A:
New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued
An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity Y
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of ivate sewage system shown on the attached plans.
Nam of Plumber (Pri Signa ~e: / MP/MPRSW No.: Phone Number:
P timber's Address: / Name of Designer: 11 COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
Disapproved
~ ❑ Owner Given Initial
Approved Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.);
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
I
APPLICATION FOR SANITARY PERMIT
This application form is to be completcd in lull and signed by the owner(s) of the
property being developed. Any inadequacies will only result in delays of the permit
issuance. Should this development be intended for resale by owner/contractor,("spec
house"), then a second form should be retained and completed when the property is
sold and submitted to this office with the appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property ~ Q ( ~7 F D-r
Location of Property Section '1 N - R W
Mai-ling Address
Subdivision NaW
Lot Number f
Previous Owner of Property 44 /^q ,F 47 N
- P-A)
Total Size of Parcel /
-A-C,/
Date Parcel was Created
Are all corners and lot :Lines identifiable? Yes No
Is t his property he Lug deve Loped i or re•sai c Spec house) ? -Yes No
VoIunit aHd Pate, NUIBIWt "n recorded with the Register of Deeds
iNCLUDF WITH THLS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed
C:: 2 _ :and Conti ict
3. Other recordings i 1 ed w i i n !h, Ke 9 i :;te r of laced;, 01 fice
in addition, a certified survey, it available, would be heI'piul so as to avoid delays
of the reviewing process. If the deed description refercaces to a Certified Survey
Map, the the Certified Survey Map ghali ills" he r-q"irwK
PROPERTY OWNER CERTIFICATION
I (we) ce tidy -that W UxtementA on this (roam ane We iu the bmt u~ my fault)
knowledge; Vat I (we) am (atte` the own.ea b) o6 the paopeAty descAbed in .th-M
06onmat%on loom, by v.ihtue of a watkan-ty rd"-uon gin- the 06lace 01 the
County Regimen of deed, an Moment No 54 c and that I (we)
~
v entt- p~ io, oaed sit( on the
1~ e~ y owv the p 1 ua.cge: s pow system (on I (we) have.
obtained an EasemaHt, to tun with the above Mcn bld,opeAty, boa the
con tauction o6 said system, and the same hat been duty aeeoaded in the OQice
o6 ,the C un tc Regis tea- o6 AM, an Document No. ) .
SIGNATURE OI OWNER Sl ATURE OF CO-OWNER (IF APPLICABLE)
677_915= -4
DA'L'E SIGNED DA'L'E SIGNED
cn
y
r
S'1' C- 105 r
y
H
SEPTIC TANK MAINTENANCE ACREEMENT o
St. Croix County
d
y
OWNER/BUYER-_
ROUTE/BOX NUMBER- ~1 Fire Number
CITY / S'1' A T E-.L__Y -'L i P_-y I -
PROPERTY LOCATI:ON:~~'4, Section T__:3(_ N, It _W,
St. Croix County,
'1' o w n o t 57AR_PRA -1 R 1 _C_. _
Subdivision Lot number_
I
Improper use and maintenances of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
it needed, by a licensed septic tank Rp per. What you put into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St. Croix County residents may be eligible to receivu a grant for
a maximum Of 607 of the cost of replacement of a failing system,
which wars in operation prior to July 1, 1578. St. Croix County
accepted this program in August: of 1980, with the requirement that
owners of all. new systems agree to keep their systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic tank is less than 1/3 full of sludge'and scum.
Certification form will be rent approximately 30 days prior to
three year expiration. Ho
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
r1
the standards set forth, herein, as set by the Wisconsin Depart- 'd
meat of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date.
1
SIGNED
U A T E -
St. Croix County Zoning Office
P.O. Box 93
Hammond, Wl 54015
715-796-2219 or 715-425-8363
Sign, date and return to above address.
,DEPARTMENT OF SAFETY & BUILDINGS
INDUSTRY; REPORT ON SOIL BORINGS AND DIVISION
LABOR AN.D PERCOLATION TESTS (115) P.O. BOX
MADISON WI 539069
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATION:` SE7/T_,~/ N: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
' I' 1/4 N/R (or) W
CQUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: /
'i.USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: r PROFILE DESCRIPTIONS: PERCOLATION TESTS:
❑Re lace
,Residence dNew p
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE:SYSTEM-IN-FILLHOLDINGTANK RECOMMENDED SYSTEM: (op ional)
S ❑U ❑S ❑U S ❑U El S y' U El S ❑U
If Percolation Tests are NOT requir d DESIGN RATE:
If any portion of the tested area is in the
under s.H63.09(5) (b), indicate: t ? Floodplain, indicate Floodplain elevation: „j7
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTHI'N, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- > ~?;1
B--1/
~7 97
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PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER lNe"n- AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PE I D3 PERINCH
I/ Z14 5-
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION
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I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (p t): i TESTS WERE COMPLETED ON:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
C y SIG ATURE:
AT /
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
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CroSS `Q~IUt'-) Or ~y15 (10~
Frelch Air Inlele And Obcsrvatlon Pipe
_ C~)--Appruvea Vent Cup
Minimum 12" Above
final Grade
20- 42" Above Plps _ 4" Cast Iron
To Final Grade Vsnl Pipe
Marsh Hay Or Synthetic Covering
Mm 2" Aggregate -
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MAXIMUM Dker►i OF F-XcAVAT1,00 FROM 01Wtv0a &KAK WILL BE IUCHES
MINIMUM OrPrH OF FAM/ATIIDN IFKO/A. *61WAL GRApF- WILL BE -3 7 INCHES
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