HomeMy WebLinkAbout020-1062-10-080
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) SAN-2018-097
GENERAL INFORMATION 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:
Nor Flex Inc TOWN OF HUDSON 020-1062-10-080
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
23.29.19.235A-35
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION
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
Final Grade
PUMP/SIPHON INFORMATION
Manufacturer Demand St Cover
GPM
Model Number
TDH Lift Friction Loss System Head T DH Ft
Forcemain Length Dia. Dist. to Well
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 Manufacturer:
INFORMATION CHAMBER OR
Type Of System: 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: 720 NORFLEX DR
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Plan revision Required? ❑ Yes ❑ No
Use other side for additional information.
Date Insepctor's Signature Cert. No.
SBD-6710 (R.3/97)
G 1A - I re, ' aLyx - tit. ) NV - 3 0 I ~ - O c.
County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN
11 Q I . accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT
erso al information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER
S [Privacj, Law. 04( m)] -ff 11 1101 Carmichael Road
r Hudson, WI 54016-7710
`101 (715)386-4680 Fax (715)385-4686
977
A ac complete plans for the s~ is an 8-1 x 11 inches in size.
Cr~+ Permit TM ❑ Check if revision to previous application
Sti. x, zv 5A6U-~ 26 1-6'- dq
t. Appiic io rmation - Please Print all Information Location:
Property Owner Name
-i 1/4 1/4, Sec -
v M i T^ N, R E (or W
roperty Owner's Mailing Address Lot Number Block Number
> /I
City, S` to Zip Code Phone Numer Subdivision Name or CSM Number
II Type of Building: (check one) amity ❑ Viliaae own of
❑ 1 or 2 Family Dwelling - No. of Bedrooms: 661A&* A.e C-A
17 Public/Commercial (describe use): &Lc"'
❑ State-owned Nearest Road
il. Type of Permit: (Check only one box on fine A. Check box on line B if applicable; _L
Parse! Tax Number(s) , • 1^ jIf
A) 1.❑ Repair 2. Reconnection 3.❑Non-plumbing 4. ❑Rejuvenation
Sanitation: t ~iS/ . ~Vt
B)
❑ State Sanitary Permit was previously issued Permit Number Date Issued
IV. Type of POWT System: (Check all that apply)
Non-pressurized In-around ❑ Mound ? 24 in. suitable soil ❑ Mound 5 24 in. suitable soil ❑ Mound A+0
❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line
❑ Pressurized In-around ❑ Hoidino Tank ❑ Sinale Pass Otherr
❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating
Y. DispersaVTreatment rea Information:
Ii. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade
Requireedd1 Proposed (Gais./dayisq.ft.) (Min./inch) - Elevation
Vl. Tank Information Capaitty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete strutted glass
Tanks Tanks
'z' C3
VIt. Responsibility Statement J
i, the undersigned, assume responsibility for repair/reconnenttion/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A
license is not required for teraiift repair or the installation of non-piumbine sanitation system.
Plumber`s Name (print) Plumber's Sianatu e, (nc stamps) MP/MPRS No. Business Phone Number
Plumber's Address (Street,-.Cj'ty, State ZipCode)
Vill. County se Only
ved Sanitary Permit Fee Date Is ued issui gent Signatur sta s)
Approved Owner itiai Adverse -y Q~
etA nation ~JJ
IX. Conditions of Approval/Reasons for Disapproval:
SY$TRA OWNEW,
1 tank, etl *wker voi
c ispem:,i cell must all be sjitifcas'r,,. uitenec„
ea per macayement plan proliaeri by plu,nber.
2. AY eetMak rcruiwer;°ems rn~~st c E rr::t;rt; n:e
as per #Vp&etbiq rcx6: i :.rdu n,tar i o
Rev: 8/C5
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SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
STATE SANITARY PE
-Attach corgpiete pans (to the county copy only) for the system, on paper not less than
8%x 11 inches In size. ❑ check rriaion to avian applic"on
-See reverse side for Instructions for completing this application. STATE PLAN I.D. NUMBER
L APPLICANT INFORMATION - PLEASE PRWT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
rc% a 11x4 114, S i2-' Wt N, R lit E or
PROPERTY OWNER`S MAILING ADDRESS LOT # ~BLOCK*
726
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
IL TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE : NEAREST ROAD
M Public ❑ 1 or 2 Fam. Dwellin" of bedrooms . FAMCF-L TAX NUMBER(S)
NI. BUILDING USE: (if building type is public, check all that apply)
Q' ~ d " jdG'~•'~ G~
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Nome Park 12 ❑ Service Station/Car Wash
5 D Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B If applicable)
A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously Issued. Permit Cate Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 ❑ In-Ground . 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VL _ A RPTION S TEMINFORMATtON:
1. GALLONS PER DA 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PE RATE SYSTEM ELEV. 7. FINAL GRADE
REQUIRED {sq. ft.} PROPOSED {sq. ft.} (Galslday/sq. ft) (MiRC. n.tinch) d+~ ~0 ELEVATION
.1;?0 4 17 '7./t Feet fQ:%,GD Feet TANK CAPACITY
VII' INFORMATION in allons Total #of Manufacturer's Name Prefab. Con,- Steel Fiber- Plastic Exper.
New n Gallons Tanks oncre structed glass App.
Tanks Tanks
Segfic Tank or Holding Tank sZ G ti
Lift Pump TankCSl hon Chamber f+~3't? ( ,iFt r`.at' X,
VIN. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) .s PRSW No.: Business Phone Number.
l~r o~..,~• S'e~i 4 d~ ^ Fr..T .3 3~ 3/R l
Plumber's Address (Str t, City, State,~ip Code):
c
IX. UNTY EPARTME USE ONL
to Date tssu Issuing Agent n cure Mft)
Disapproved nary Permit se (includes surcharge Fee)
Approved ❑ Owner Given Initial l tom.'
LJ[ J "B'
Adyng
X. CONDITIONS OF APPROVALJREASOfNS FOR DISAPPROVAL:
SBD-8398 (formerly Plb-67) (R. 11 /88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
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NORFLEX INC., 720 NORFLEX DRIVE, HUDSON, WI 54016
INSPECTION STATEMENT FOR USE OF EXISTING SEPTIC SYSTEM
i
The existing septic tanks will be pumped and inspected. One boring was conducted
to verify that the drainfield is functioning properly. There was no sign of
failurejbiomat. The system is correctly sized for the planned future addition.
Y
y
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Keith Haring, MPRSW # Dated
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) located
at:; _')'/4~kj 1/4, Section -j-, , To N, Range- W,
Town of , 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 SPS. 384.25, 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
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capacity:
Construction: Prefab Concrete } S el Other
Manufacturer (if known): k 'Y1
Age of Tank (if known):, ~Permit number (if known)
(Li6 e sed P1 mber Signatur) (Print Name)
SQ
s-- ctu
(Title) (License Number) MP/MFRS
(Date)
Form to be completed by licensed plumber (Dept of Safety and Professional
Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer
(NR 113 Wisconsin Administrative Code)
Rev. 2/2012
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S T C - lay
SEPTIC TANK MAINTENANCE AGREEMENT ~
St. Croix County
OWNER/BUYER Norf lex, Inc. 1 Andpr.Aon Holdings. Inc
ADDRESS'?20 Norflex Drive FIRE NUMBER ' 20
CITY/STATE Hudson. WT 54016 ZIP 5401.6
19 W
PROPERTY L4CATZON: 1/4, Shi 1/4, SECTION 23 , T29 14-R
TOWN of Hudson r St. Croix County,
SUBDIVISION r , LOT NUMBER NA
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, iP needed by a licensed septic tank pumper. What
you put into ttie :system can affect the :Function of the septic tank
as a treatment stage in the waste disposal, system.
St. Croix County residents may be eligible to receive a grant
for a maximum of 60t of the cost of replacement of a failing
system, which was in operation prior to July 1, 1973. St. Croix
County accepted this program in August of 1980, with the
requirement that owners of all new systems agree to keep their
system properly maintained.
The property owner agrees to submit to St, Croix Zoning a
certification 'form, signed by the owner and by a mater plumber,
journeyman plumber, restricted plumber or a licensed pumper
verifying that (1). the on--site wastewater disposal system is in
proper operating condition and (2) after inspection and pumping (if
necessary), the septic tank is less than 1/3 full of sludge and
scum.
I/We, the undersigned have read the above requirements and
agree to maintain the private sewage disposal system in accordance
with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your sep.'c has been maintained must be
completed and returned to the St. Cr ix Co. Zoning officer within
30 days of the three year expiration ate `
SIGNED:
r President Norflox,
Inc.
DATE*
Fresi.dent Anderson
St. Croix co. Zoning office Holdings, Inc,
911 4th St.
Hudson, WI 5401.6
STC - 100
This application form is to be completed in full 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/cohtractor,(spec
house), thenta 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 Norfl px, nc. 1Z Anderson Holdings, Inc.
Location of, propertysF 1/4 X1/4, Section 23 T_2.2_N-RAW
Township giirisap
Mailing address 122 pa Clnndyi ew Ave, N . , 'White Bear Lake, MN 55110
Address of site ?20 NQr"l _x Drive, Hudson ''VJl X4016
subdivision name ,,„A Lot nos NA.
Other homes on property? yes x No
Previous owner of property _Dayid & Julie Waldro_'L
Total size of parcel 68.4 acres
bate parcel,was created 4- ~-9 "3 recorded
Are all corners and lot lines IdeYit:is iable? Yes No
j
Is this property being developed for (spec house)? Yes X No
Volume 1000 and Page Number 349 as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARIWITY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER & THE SEAL, OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
.references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I(we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of
the property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No.4;~6~66 , and that I (we) presently
own the proposed site for the sewage disposal svstpm nr T (--N
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and Human Relations E SEWAGE SYSTEM County:
atetyandBuildings Division INSPECTION REPORT
(ATTACH TO PERMIT) sanitary r it
GENEW INF RMAfiION
)C_ I Permit Holder's Name: ❑ City E] Village Town o : State Plan i o.:
e Insp. BM E ev.: BM Description: Farce Tax No.:
TANK INFORMATION ELEVATION DATA A9300256+
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Verit
TANK TO P / L WELL BLDG. A
irito ntake ROAD Dt Inlet
Ar
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP! SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction 5 stem 7DH Ft
Loss 1-
Forcemain length Dia. Dist. To Weil
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits inside Dia. Liquid Depth
-DIMENSIONS DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manu acturer:
SETBACK
INFORMATION ype CHAMBER model Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header / Mani o d Distribution Pipes x Hole Size { x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing I[
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded I Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 23.29.19.235A rv(, /x~
.c
~
Plan revision required? /yes ❑ No 1 /
Use other side for additional information. 'I
1 Il?] TI
SBD-6714 {R 05191} Date Inspector's Signature Cert. No.
r-
Parcel 020-1062-10-080 Valid as of 05/07/2018 04:05 PM
Alt. Parcel 23.29.19.235A-35 TOWN OF HUDSON
ST. CROIX COUNTY,
WISCONSIN
Owner and Mailing Address: Co-Owner(s):
ANDERSON HOLDINGS INC %NORFLEX INC
%NORFLEX INC
720 NORFLEX DR Physical Property
HUDSON WI 54016 Address(es):
* 720 NORFLEX DR
Districts:
Dist# Description Parcel History:
2611 SCH DIST OF HUDSON Date Doc# ValfPage Type
1700 WITC 09/25/2014 1002Q87 26/6043 CSM
04/12/2004 759109 18/4728 CSM
Legal Description: Acres: 35.149 07/23/1997 1000/357 WD
SEC 14 T29N R1 9W PT SE SW & SEC 23 T29N 07/23/1997 806/286
R19W PT NW NW & PT NE NW FKA PART OF LOT more...
2 CSM 10/2778 FKA CSM 18-4728 L... more...
Plat Tract (S-T-R 401/4160'/4 GL) Block/Condo Bldg
6043-CSM 26-6043 020-014 23-29N-19W NE NW LOT 01
4728-CSM 18-4728 020-2004 23-29N-19W LOT 8
2018 Valuations: Values Last Changed on
11/03/2017
Class and Description Acres Land Improvement Total
G3-MANUFACTURING 35.084 0.00 0.00 0.00
Totals for 2018
General Property 35.084 0.00 0.00 0.00
Woodland 0.000 0.00 0.00 0.00
Totals for 2017
General Property 35.084 542,300.00 0.00 542,300.00
Woodland 0.000 0.00 0.00 0.00
2018 Taxes
Taxes have not yet been calculated.
Key
Primary
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Cy) AS BUILT SANITARY SYSTEM REPORT
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SUBDIVISION / CSM#/~sp~}`~e~ Y LOT # l
SECTION T N-R W, Town of ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
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INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK :
ALTERNATE BM:
SEPTIC TANK j PUMP CHAMBER j HOLDING TANK INFORMATION
Manufacturer:Liquid Capacity:
Setback from: Well r y.-- House Other
Pump: Manufacturer Mode I# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Lengt< Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: House Other
ELEVATIONS
Building Sewer ST Inlet; ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION: 14""
PLUMBER ON JOB:
i
LICENSE NUMBER: i
INSPECTOR:_
3j93:jt
NORFLEX INC., 720 NORFLEX DRIVE, HUDSON, WI 54016
STATEMENT FOR CORRECT SIZING OF DRAINFIELD FOR ADDITION TO
EXISITNG BUILDING
The system is correctly sized for the planned future addition. There are currently
30 employees and an additional 30 future employees are planned. The system was
originally designed for 100 employees.
Mary ]o HuppW 3~signer *1859-007
ON,
MARY .ID•~ r
HUPPERT w
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