HomeMy WebLinkAbout032-1065-50-156 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division Sanitary Permit No:
INSPECTION REPORT ,Z6 DZ?
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 Township Parcel Tax No:
Macanda Properties LLC TOWN OF SOMERSET 032-1065-50-156
CST BM Elev: Insp. BM Elev: IBM Section/Town/Range/Map No:
GI3 9 Description, ~ Co24.31.19.325B-26
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM ~j
ar ~ mod'
Aeration Bld ewer
Holding air f3.?
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic 3~ f Dt Bottom
rttw 6 LA
Dosing Header/Man.
Aeration Dist. Pipe
Holding Tot. System
Final Grade
PUMP/SIPHON INFORMATION
Manufacturer DeP and St Cover Ln
Model Number 7,44 c✓ 7,
TDH Lift Friction Loss System Head TDH Ft
rcemain Length Dist. to well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits nside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: k~ r UNIT Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution Ix Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia 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 Bed/Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 708 205TH AVE
1.) Alt BM Description =
2.) Bldg sewer length = 3C r W ~-k~ L14- „AS GcC
- amount of cover = f\
Plan revision Required? ❑ Yes ❑ No 1 S G
Use other side for additional information.
Date Insep or's Si ature Cert. No.
SBD-6710 (R.3/97)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
572887 0
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)I.
Permit Holder's Name: City Village X Township Parcel Tax No
Macanda Properties, LLC Somerset, Town of 032-1065-50-156
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No
f5 24.31.19.325B26
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER i.' j CAPACITY STATION BS HI FS ELEV
Septic p~ +1 Benchmark
(.N i crate. ~'t ~ ' /ODC) T Z. 165% t
Dosing J 4 660 Alt. BM / /il. 71 9 3• 9 j
0 .4
n Bldg. Sewer
SZ 27 4- ZZ~` e 17,9 q6. 4~q
!5
Pe, to Iz
F.4
Holding St/Ht Inlet
to l,5 t- A 7 ~
St/Ht Outlet
TANK SETBACK INFORMATION .~otr,•
TANK TO P/L WELL BLDG. Ven to Ai take ROAD Dt Inlet
Septic 5 Dt Bottomr ~[~C z
3b % ° I K*
Dosing ✓ 8 1 / to ~7 / Z_- Header/Man. 2 9-7-35
Aeration Dist. Pipe fl Z' C~ 7 3
Holding Bot. System /Z - Z7 7 (o • 35
PUMP/SIPHON INFORMATION Final Grade
Manufacturer Demand St CQ~er 7 3 g
GPM t CO I
Model Number I ! 4~
TDH Li 3 Friction Los System Hea ^ TDH /5.5 EL7 s
Forcemain Length f Dia. if Dist. to Well C.~/~
spa Z Ito
SOIL ABSORPTION SYSTEM
BED/TRENCH Width / Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia Liquid Depth
DIMENSIONS Z
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING manufacturer
INFORMATION CHAMBER OR At , t ~--(a1(-f~-
Type,OfSystem:;~ UNIT ModelN mher
DISTRIBUTION SYSTEM ils e7-
f( = 3Z ~st~.~
Header/Manifol~ 131strdwtion x Hole Size x Hole Spacing Wo Air I ke
Pipe(s) u
Length Dia Length n Dia Spacings -1 1
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Dep"q \of xx Seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil \ Yes ( ] No No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 1,30115 IInspection #2: J /
Location: 708 205th Ave Somerset, WI 54025 (SW 1/4 NW 1/4 24 T31N R19W) NAf Lot 1 Vlk.,4- 4" l/// Parcel No: 24.31.19.325B26
1.) Alt BM Description 0A_
/
2.) Bldg sewer length L t ~d rte 1- r ^
-amount of cover= ~0 5►~~d(
Qal..,s t
3~ `I Z if
Plan revision Required? Yes rNo5 4 3~ 7~j
Use other side for additional information.
Date Insepct s Sign a Cert. No
SBD-6710 (R 3/97)
m
Cl)
J ❑ C ti m m
° m m
- U fD - - U CG C
[6
Z Z z Z) cz
° W 3 [6 m m
O _Z O O ma) a m - N
y C N
U Q Q `o o m 2 m
r W F_ Z m o c c
m `o
m i~ °
Z Cli m
Z ° r m Cl)
° c m m r
m
O Z {4 co
~U O LJ m o c o p ti a m `m
rl z 3 m ° o a~ E CC
a) Q E m m
w W
> m o m m m
° m m
m_° 3 m m m G~ cc~ F-
M -E
f
c E m S a o `o 0
m
N - o r N
Cl)
m N
a o m° - c a
a
o `m ~ N~ m S
L) _
-X
0) `m
r 3
m W
o `m v cc m En m m~
O -
m E ti - `o o a m ~ m o m i
> z_m m3 O f-
co C)
° c ° m m m ° m m in
0
o ? m n ay T ;;7 ti U 3p
M. cf) F-
m m o m(D ° Q m W
' m r _ -
a m m m m W
CD NI f-
.z L W CD z
Q L W ~O
CD Q~ 4< pv
U
0 r-K D
LL~
LLI
z Q c()
z° z ° D O Z
CO LLJ
~U
o W C~
r''1 C) F- 6 z
Q Q o
U C O
o N ~p
U D
~i <
n Z
Q i' V\ W
•..r 0
~ m
m
C
o >
C, Ir U ` w
W
}
i
W
LL
v ~ LL O
CL
Ln Cot 0 a v
YV- o18-oaa
,4d County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN
ccord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT
Persona information you provide may be used for secondary purpo, s ST. CROIX COUNTY GOVERNMENT CENTER
[Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road
Hudson, WI 54016-7710
LID
A~03~ (715)386-4680 Fax (715)386-4686
Alta H'omplete plans for the systP- ZJ an 8-1/2 x 11 inches in size.
•a1>sFn anitary Permit # - A0101 . Lo previous application
G Zb! - dZ
I. Applicatioia.lnformatinn - Please Print all Information fLocation:
Property Owner Name 1/4 1/4, Sec
T ' N, R C E (or
Property Owner's Mailing Address Lot N e Block Number
City, State Zip Code Phone Numer Subdiv ame or CSI M Number n" 2
S
; amity ❑ Village Town of
II Type of Building: (check one) L A r`
1 or 2 Family Dwelling - No. of Bedrooms: &Zs a` w JL
❑ Public/Commercial (describe use): {pl~~• Je?> i" ;c 'S %7
❑ State-owned Nearest Road
IL Type of Permit: (Check only one box on line A. Check box on line B if applicable) ' v
Parcel Tax Number(s) ,
A) I.[] Repair 2.~ Reconnection 3.❑Non-plumbing 4. ❑Rejuvenation
a
Permit Number Date Issued
B)
❑ State Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply)
X Non-pressurized In-ground ❑ Mound ? 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
V. Dispersal/Treatment Area Information:
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevatio 7. Final Grade
Required Proposed (Gals./day/sq.ft.) (Min./inch) Elevation
VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete strutted glass
Tanks Tanks
/Z El 13
7 ❑ ❑ ❑ ❑ ❑
iy
VII. Responsibility Statement
1, the undersigned, assume responsibility for repair/reconnenaion/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A
license is of required for terraiift repair or the installation o n-plumbing sanit tion ystem.
Plu is NZa iht) JPlumber's i re o MP/MPRS No. Business Phone Number
2~, 7/ LL 7
Plumber's Address (Street, ity State, Zip )4e) tl'
VIII. County Use Only
Sanitary Permit Fee ate Is ued lssu Agent Signa (N S)
Approved Owner Initial A s
Determination ~•G~
IX. Conditions of Approval/Reasons for Disapproval: ~f
ZYa 4-a& O" 6 14- r yr I
ciblcya mi oeN must do } "ill, it.
as per : wApment plan pro sided by plumbef.
2. AN FA&W* bemrtrire,i
Rev: 8/05
4il
''JJ
~mr~seJ
i.J ~'r
~s mss'
n
C~ ~ - fyjc,, .I fmtS /fjc~+v3~a? - li~BfGS
1 -7.0~ GYJ•D '
Q~~s -
m
Izo~ 1
i
,r r
COPY
'i~ v A
x o /ov 5~ 2 sus
I
91
OLO
sc~
' p t f f
~ - F>S'e,~ ~L4inES /~johsfS6~.' - /s~BfGS'
Iz
r
i
i
VIED
[ED' ~
I I I I N I I I I I I I I I I I I I I I I I I I I I I I I
Document Number Document Title 2 F 8 jx94 9 5 0 9
o ray
St. Croix County ' 1061577
I'v opr,P
BETH PABST
Affidavit for a single POWTS y v nt
servicing Two Structures via P r to In er for Main REGISTER OF DEEDS
7 ' ST. CROIX CO., WI
' RECEIVED FOR RECORD
Name - (Owner) Typed or print d 02/26/2018 04:25 PM
being duly sworn , states, under oath, that: EXEMPT
REC FEE 30.00
He/she is the owner/co-owner of the following eel of lar ocated in St. Croix COPY FEE 2.00
W , Wi consin, recorded in Volume , ag Document Number PAGES: 1
St. Croix County Register of Deeds Office: Recording Area
0~I~~ Name and Return Address
A parcel of land locate in the, I / 1/< of the W'/< of Section, T9tN,R/JW, k~~ ~.JC_ kzr
Town o s St. Croix County, Wisconsin, being duly described as 76 4 20
follows (include lot number and subdivision/CSM or detailed legal description):
n 5 a ti~~-e-+ ~ 5~16 z5
Va-.f ~0 l 2 Z
o 3z o 0- so 1S
5 3 2 5 Parcel Identification Number (PIN)
As owner of the above described property, I acknowledge that a Private On-site Wastewater Treatment System (POWTS) serving the
primary residence is sized for .3 bedroom(s) with a design wastewater flow of l&d gallons/day (DWF is based on 150 gpd /bedroom @ 2
persons per bedroom). A maximum of (0 occupants are permitted; if the number of occupants exceeds the maximum for POWTS
design, the system will be undersized to accommodate increased wastewater flows and/or contaminant loads and may be subject to
premature failure. An accessory structure NOT to be used as a 2"d dwelling has been connected to the POWTS via Private Interceptor
Main Sewer (PIMS) in compliance with SPS 382.30(12). I understand that disclosure of this information will be made to any parties
interested in purchasing this property in the future.
Dated this Z ~day of
*
A THENTI ATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
)ss.
St. Croix County )
authenticated t fis day of Personally came before me this I-'"ay of
(year) (year) the above named
C />r//Z-
* to me known to be the
TITLE: MEMBER STATE BAR OF WISCONSIN person(s) who executed the foregoing instrument and
(If not, acknowledge the same.
Authorized by § 706.06, Wis. Stats.)
THIS INSTRUMENT WAS DRAFTED BY
(Signatures may be authenticaited or acknowledged. Both are Notary Public, State of iscmlSm ~ f6 y ,
not necessary.) My Commission is permanent. If not, state expiration d te:
Date:
ow~
GREC,010 J. HICKS
r2a%C
"THIS PAGE IS PART OF THIS LEGAL DOCUMENT - DO N0 An.3
tAY CA~fi.
This information must be completed by submitter: document title name & return address, and I . (f requt is : as the granting
clauses, legal description, etc. may be placed on this first page of the document or may be placed on addition a document. Note: Use of this
cover page adds one page to your document and $2 00 to the recording fee. Wisconsin Statutes, 59.43.
St. Croix County 1061577 Page 1 of 1