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HomeMy WebLinkAbout018-1060-90-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 154 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 X Township Parcel Tax No: Eggen, Luke & Becky Hammond, Town of 018 - 1060 -90 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: 100 GAA 1 baihlivb aF 5 26.29.17.413B TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. E . Septic Benchmark s� EX■b4":n. G -7 •8Z /K6 /62. Dosing \ Alt. BM Aeration Bldg. Sewer Holdin St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet //43 96 . cry TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Gentet Leg I 1.. 12. zt 56 . 41 Septic �/ l0 7 / ( D�B tom Z TIC. 1135 16,17 JBesiacy / / / tk wa. 1 412 $5 3& — — br Z b 4— !LIZ 16 . a / / 1 Disf.'Pipe w Z Z /DO 56 Holding Bot. System J . . - _ IV .•— Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH ILi Friction Loss System Head DH Ft C "----- Forcemain Leng - Di . Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIME SN IONS 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: nn /5 , a / ' ,� / �� UNIT Model Number: 6.0141 .• 7 DISTRIBUTION SYSTEM 1,X4) Header /Manifold Distribution x 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 >o< Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes a No ®Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 720 200th Street Baldwin, WI 54002 (SE 1/4 SE 1/4 26 w T29N R17W) metes & bound Lot Parcel No: 26.29.17.413B � 1 1.) Alt BM Description = C rrt.., P- t l red'�OJ II 6 S . L V _.r... I p � 2.) Bldg sewer length = • t �� t W a(6e. 19/ [ t /..� 4v K,Q. i 4 Ar z . - amount of cover = 1.t 5r A 0 ✓14e,i -- oT- u AA . Z 1 / 1 1i As'. / h 1 / f a� (D 5 &ft "9R Plan revision Required? Yes o / 11 Use other side for additional information. cow/ . ins= Emma Date In !.ctor's '' atur W Cert. No. SBD -6710 (R.3/97) /� hl O County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN 0 p In accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT Ott. GI Personal information you provide may be used for secondary p ST. CROIX COUNTY GOVERNMENT CENTER All, $ 00- [Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road Hudson, WI 54016 -7710 ,,,��,.. (715)386 -4680 Fax (715)386 -4686 Attach complete plans for the system on pa r ne legr iaf n 8-1/2 x 11 inches in size. County Sanitary Permit # ❑ Check if revision to previous appl.tion 0/5 —~• I. Application Information - Please Print all Inform .- Location: .• . Property Owner Name 1t� ^ C 1/4 5q.. 5q.. 1 /4, Sec O W ' QJ.. w -e T P1 N 1 1 R E (or) W Property Owner's Mailing Address . 4 kal '' N AG Lot Number Block Number Cit , State Zip Code Phon y ' Subdivision Name or CSM Number (b F YI w\ 5 cAL 1 6 j %u 4 '6l d_ / e of Building: (check one) f amity j ❑ Village n wn of 1 or 2 Family Dwelling No. of Bedrooms: '1,�� 1 Y i d Public /Commercial (describe use): ❑ State -owned Nearest Road II. Type of Permit: (Check only one box on line A. Check box on line B if applicable) Parcel Tax Number(s) L1�� A) 1Repair 1 2. ❑ Reconnection I3. ❑Non- p lumbin g 4. ❑ Re I uvenation I 0�� , ��� 6� ° l 11 }� `- -� Sanitation B) Permit Number Date Issued ❑ State Sanitary Permit was previously issued 1 14- ilik IV. T of POWT System: (Check all that apply) 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 Elevation 7. Final Grade 1 150 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 structed glass Tanks Tanks ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ VII. Responsibility Statement I, the undersigned, assume responsibility for repair /reconnenction /rejuvenation /installation of non - plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installation of non - plumbing sanitation system. Piu, is Name (print) Plumb Si ature (no to ) MP/ PR No Business Phone Number .. DK� �c iliyl r �' .7. 0 7 (5 760 - © Y,6 Plumber's Address (Street, City, State, ' Code) 0/6 /Sere Uc So vii z- 7 - l-) —S vo ,s VIII. County e Only IN e':: _ - • -d Sanitary Permit Fee Da ssue Issuing ent Signature o stamp Approved , ■ Owner Giv- • n ' - Adverse zz S i iJ ation IX. Conditions of Approval /Reasons for Disapproval: i) c,..: r fer...."- 4--I 1(0,2_, 6454- , 'req,_ r' r P ,Ay G 6erke... 1 c4..‘.J 667 ive.t15 i t ll 3(o ,� ZS P IAA 2 2N` 4I 5 1 cl? 2,3 n( wed T.-;.,(e l z • 3 S a-; dv die , 3 OLALle,vt 2__ - P � �,.C, S Cp �' c" Gt1 0 rn b0 P' - nn�� W(a:Ac: CI, zee, - 6m r(e . :0 . I60 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFIICATION FORM Owner /Buyer UAL. Mailing Address —1 2D Property Address 1 L U Z s-- BcacLwin 1.-111)2 (Verification required from Planning & Zoning Department for new construction.) City /State t c- In \ Parcel Identification Number – 1 D 0 0 ODD LEGAL DESCRIPTION Property Location c3�. 1/4, '/4 , Sec. au , T N R t W, Town ofKIAA ► V1 Subdivision Plat: , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # (before 2007)Volume , Page # Spec house 1 yes ? no Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and /or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. 1 /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 Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my /our knowledge. I /we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms * , ll / � I D S NAT �� OF APPLICANT(S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) 07/16/2003 13:56 FAX 715 386 6560 1 2 3 �\ - 5 3 P 0 7 6 734 KATHLEEN H. WALSH REGISTER OF DEEDS STATE BAR, OF WISCONSIN FORM 2.1999 ST. CROIX CO. , MI Document Number WARRANTY DEED RECEIVED FOR RECORD 08/07/2003 01:00PN This Deed, made between LeRoy Van Heukelom, a single person, and Carol L. Reigottie, a single person, WARRANTY DEED EXEMPT # REC FEE : 11.00 Grantor, and Luke J. Eggen and Beckygen, husband and wife, TRANS FEE: 462.00 COPY FEE: CC FEE: PAGES: 1 Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St Croix County, State of Wisconsin (if more space is needed, please attach addendum): Recording Area The South 165 feet of the North 358 feet of the East 264 feet of the Name and Return Address Southeast 114 of the Southeast 1/4 of Section 26, Township 29, Range 17, Milo � '(S St. Croix County, Wisconsin. 3-kj 2 hie S 4(S. Vs SS`(O *This is not homestead property of Carol L. Reigottie. ` /(44.1 ' Metro Legal Services 018 -1060- 90-000 EDIRET 402490 A Parcel identification Number (PIN) 288657 WD 215643 This is homestead property. Os) iIEX0O Exceptions to warranties: Easements, restrictions and rights - of-way of record, if any. Dated this 17 _ day of July , 2003 .. % * _ _ * LeRo n Heukelom 1 * Carol L. Reigottie AUTHENTICATION ACKNOWLEDGMENT Signature(s) LeRoy Van Heukelom, a single person, and Carol STATE OF WISCONSIN ) L. Reigottie, a single person, ) ss. County ) auth ticate,hisraday of July 2003 i Personally carne before me this day of 01) / / / the about named L. /i' * Krishna O and J I TITLE: MEMBER TATE BAR OF WISCONSIN w - (If not, to me known to be the person(s) who executed the forego authorized by § 706.06, Wis. Stars.) instrument and acknowledged the same. i THIS INSTRUMENT WAS DRAFTED BY s Attorney Kristiaa Ogland Notary Public, State of Wisconsin Hudson, WI 54014 My Commission is permanent. (If not, state expiration date: (Signatures may he authenticated or acknowledged. Both are not necessary.) .. , r .) *Names of persons signing in any capacity must be typed or printed below their signature. information Proreaebneie canauy, Fond du lac, 1M STATE BAR OF WISCONSIN DO:14554021 WARRANTY DEED FORM No. 2 -1999 i