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HomeMy WebLinkAbout020-1353-17-000 5, rrn IA Wisconsin Department of Commerce PRIVAT SEWAGE SYSTEM 619 Safety and Buildings Division Count y INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 370268 Permit Holder's Name: ❑ City ❑ Village Down of: State Plan ID No.: Steffen, Merl I Hudson Townsh CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 1 CD •D /CD . D CS% - $ -Ih-1 020 - 1353 -17 -000 TANK INFORMATION ELEVATION DATA 3 ' - Z F. / g -20 TYPE MANUFACTURER \ CAPACITY STATION BS HI FS ELEV. Septic ( ( _f /2-gp Benchmark 0,e, (, /oo,9G /OD, O Dosing - Alt. BM & - --) l o-o, 8O' Aeration Bldg. Sewer e.. .e6 q Holding St/ Ht Inlet S 44 95 TANK SETBACK INFORMATION St/ Ht Outlet 5;95 75 - . o / • TANK TO P/ L WELL BLDG. v Ai e r nt to Intake ROAD Dt Inlet —_-- • Septic qp' (*) 2a" NA Dt Bottom �— Dosing NA Header / Man. 9i0 . . 9/• SC Aeration — — ,NA Dist. Pipe c •9 3 9/, 4 ; c k Holding ` Bot. System = . y (, Z i—_ � 1 z 29;v PU P/ SIPHON INFORMATION Final Grade , 3 93• G. 2.. 4 %fo 92' s(,, Manua - -r D- .• . . St cover Z.oR i8. 88 Model Number GPM M TDH Lift Loss on _ Head TDH Ft F main Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM( ( „Lt., P),-c-Q. 4 ,vva_.. MO/ RENCH Width , Len s No T enches PIT No. Of Pits Inside Dia. Liquid Depth DIMENS NS 3 TS (OS. DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING ^ ^.1 tur —c_►�CRa,0t INFORMATION Type Of CHAMBER £ (7 — 5:01.1.-Man Number System: t), > 4D ' ) - � OR UNIT 4{-i - 6,p, „4 DISTRIBUTION SYSTEM Q Header / Manifold Distribution P e(s) x Hole Size x Hole Spacing I Vent To Air Intake Length Dia. gth 7 9 O t SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over I xx Depth Of xx Seeded / Sodded xx Mulched Bed /Trench Center Bed /Trench Edges f l Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COM MENTS: (Include code discrepancies, persons present, etc.) Inspection #1:Qu.6,!2; /odInspection #2: -/ / 1 Location: 654 Hillary Farm Road, Hudson, WI 54016 (NW 1/4 NW 1/4 36 T29N R19W) - 36.29.19.2017 Cottonwood Ridge - Lot 17 1.) Alt BM Description = bef o`"^ 15• a vQf "r 2.) Bldg sewer length = 20 - amount of cover = > t 6 ” Plan revision required? ❑ Yes No / Use other side for additional inform� 4 on. 083/ 00 / S � ----�■ SBD -6710 (R.3/97) Date Inspecto s Signature Cert No ■ ` SANITARY PERMIT APPLICATION Safety and Buildings Division VA 201 W. Washington Avenue scons,n P 0 Box 7162 Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7162 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 1/2 x 11 inches in size. 5T t✓ • See reverse side for instructions for completing this application State Sanitary Permit Personal information you provide may be used for secondary purposes ❑ Check i r vision to previous application ' [Privacy Law, s. 15.04 (1) (m)]. State Plan Review Transaction Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION . Property wnet: Name __ _ Property Location // F L S i h 1- FE N wt./1g hi W U 5 3 T ,p 7 , N R I `l Alork9 Proper#y O l a F s Maiii4 g A,dd Lot Number Block Number cit . State yf • / o 4 (, 4 Zip f P ho i tk, visipn u ber 0 0 KAJ o o II. YP • B LDIN : (check one) ❑ :o7 ''4 ,,p,2� a Nearest Road • Public ki 1 or 2 Famil Dwellin• - N TALM�1E 74:MAI ; a i of , w Ot SGT Corew wfacht Tie III. BUILDING USE: (If building type is public 3 �� f‘nV ) _io.® l'I'Tax Number(s) 3 4 . Z,7_ f 9 d(7 . d a 1 ❑ Apartment /Condo � r 4, ,.t t3S3- i 00 2 ❑ Assembly Hall 6 ❑. Me i Faci it • i ,,c: �• 10 ❑ Outdoor Recreational Facility ) j'� 3 ❑ Campground 7 ❑ Me � • is al fly. rs/ ir 11 ❑ Restaurant /Bar/ Dining 4 ❑ Church / School 8 ❑ Mo • . e • 0 'N .? '\ 12 ❑ Service Station / Car Wash 5 ❑ Hotel / Motel 9 ❑ Offic '4%' • r `.,,, , 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box o ` ._._• • r , line B, if applicable) P. A) 1. N ew 2. ❑ Replacement 3. ;�•] ..FT.r nt of 4. ❑ Reconnection of. 5. ❑ Repair of an 'S ystem System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date 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 Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit ./ / /► / 43 ❑ Vault Privy 14 ❑ System -In -Fill - >L�477Cva di444 Cy,ace / �/ r` / 4 eG , ��„0 VI. ABSORPTION SYSTEM INFORMATION. 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Eleyyw�. 7. Final Grade / Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) V. I go. Z s/ Elevation Gv ? S6 ✓ 7(0 3 ./ 0.13 z B 4 .8 vreet q 3,2-Feet Capacity VII. INFORMATION in allon Total # of Manufacturer's Name Prefa Co n- Fiber- Plastic Exper. Gallons Tanks Concre Steel glass App. New Existing structed Tanks Tanks p ptic o ank / a9C 1 "" Ip t7G I ill" W {S Kid t ❑ ❑ 0 ' ❑ ❑ L er ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plui:;,iYnatu. Business Phone Numer: 1 9 II e l s e 1MP/Ai.W Apo SS I' 7,,c--- .1.2s - a 17-‘ Plumber's Address (Street, City, State, Zip Code): J oaa S.. YlLeu:•t. sY eLuee F:tls Li) 346P2 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Surcharge Fee) FApproved ❑ Owner Given Initial / Adverse Determination erZ 2_5":"0 �U 4/��7/D!1 ... OF APPROVAL REASONS FOR DISAPPROVAL: F APPR VAL / REAS N X. CONDITIONS F R : ( r O j 0, recow.n.en, / / ��o ; o *t• fY {o..� S4tl44w/ .4 // p r o�ef¢ 4<- - e/Ca. ./ .h 2 ,, I „ n aS f NLGY.,...'rae iff (/ Of cover Over 7 c deeS p ' /0 Lt -l) er3 >`,^ • .7Z- c' toa `,-i ".4-e SBD -6396 (R.12/99) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained: The septic tank(s) must be pumped by a licensed pumper, whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608- 266 - 3151. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to oe installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County / Department Use Only. X. County / Department Use Only. • Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. • GROUNDWATER SURCHARGE • 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. MERL STEFFEN PLOT PLAN LOT 17 CoTrON WooD RIDGE. 215 AcRe SCALE I ; 10' N , ' I G ASPElk - L, 106 0 arra sPita. ix i 2 OAK EL. 100.0 1200 GAL MIDWES7ERV PRECAST 5EP7IC 2 LZHigiy1_cAPAC4T_r_iALFA_LTR4TION C)4/1,1 BEg5 EACII TRENCJi FL I EL. 90.2. TRIENCIV'2 EL. 81.80 \ _- l■ N .N \ -(eAA- to jkv ‘Y 4 4) 0 5AteA . \ Q / 1 N T3: . ez. /f2. 47 .f . \ 120°041— . \ SErik<- „ 1I N (9 \A -------__ --C) - lq',R iLl'(' S Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page ! of Bureau of Integrated Services in accordance with s Wis. Adm. Code • Attach complete site plan on paper not less than 8 1/2 x 11 inches in Plan musty include, but not limited to: vertical and horizontal reference point (B L ?1}r'ection 91 `1p C ,r 6 t ,,z percent slope, scale or dimensions, north arrow, and location and ittance to ne resi tg";l Parc I I.D. # z.. APPLICANT INFORMATION - Please print all info 1 prlOn j Revi b {, �►/( Date Personal information you provide may be used for secondary purposes (Privy Law, s. 15.04 � i X i 4 ���r " iS 1 y /- ,'7 C1 Property Owner � \ \‚ r fi ation' • g ‘c.�3.rd S- U .A ' ,.Govt. Lot , , 1/4 NW 1/4,S 3 T ? ,N,R /q E (or)�V � Property Owner's Mailing Address 'Ldt # 4 s l Subd. Name or CSM# City State Zip Code Phone Number City ❑ Village gl. Town Nearest Road 1 � ❑ Ci }-�(t,AC SOrm I" \ 1 r 0t(p 1 (ii, ) {k {-l 31 0 LAC),‹ c ) I Co or we 0.� 4 ®-New Construction Use: Residential / Number of bedrooms 3 --14 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow t °C M) gpd Recommended design loading rate • 7 bed, gpd /fi • g trench, gpd/ft Absorption area required ft5 bed, ft -1 5C ) trench, ft2 Maximum design loading rate • 7 bed, gpd /f1 • trench, gpd /ft Recommended infiltration surface elevation(s) o,P{r (7 G W. d•Q ft (as referred to site plan benchmark) Additional design /site considerations ta g -? 90. gr.) l_� Parent material ( ��Cl.� t)1A4 \ Q.j) Flood plain elevation, if applicable A / //r ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system 4 S ❑ u I1 s ❑ u ©S ❑ u ®S ❑ u ❑ S ©u ❑ s El u SOIL DESCRIPTION REPORT Boring # H Depth Dominant Color Mottles Structure GPD /ft g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 1 b°15 10yr'3I 5L irr,abl{ i c5 (' . q . • 5 6 Lb yr i-i i - 2 - _ LS (- t mt 05 - -1 ; E Ground 3 Ao - ibis> I()'lir rnS 0 S3 l C5 — . , b/ elev. y3.2aft. Depth to e,9 limiting factor 10(0 in. a • ' 1 ' Remarks: Boring # 1 8 --( (_yr 5q2. - v SL 1 rnabk ne4 C5 1 • 4 ;..5 2- dq- its i0yr Ltlln _ m5 0 ml c__ — . 1 .. 8 Ground elev. ' 94.70 ft. Depth to , limiting factor 1 l g in. Remarks: CST Name (Please Print) Signature Telephone No. AdCt n SC der- 67 / s) 2� 7- -/ O O Address Date CST Number `-/D$ OeJer5 --/ Son- ,r°.rsc -, wt 5.i0 2.6- g 26-3369 PROPERTY OWNER S' v`f" SOIL DESCRIPTION REPORT Page 2 of PARCEL I.D.# Boring # H orizon Depth Dominant Color Mottles Structure G D /ft 9 Texture Consistence Boundary Roots P in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 3 1 OA g i r 3) 5 L mckhlc m Cr (5 I C - y :. 5 2 I� -ell ID / r n') 5 () 55 fl t C5 — Ground elev. q 3 ft. Depth to I r y , Z (s f 2 �� limiting factor / Z u 117 in. °1>J �' Remarks: Boring # I 0 - I9 tvyr312 Sr_ 1imvihlz mCr c5 ( ,•`j 2 l9 -I lU yhp ■r) oS.3 ml cS .S Ground elev. 9%7o ft. Depth to limiting N 19. go A. factor X09 in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # 619 )O r3I2 mail m-Py- L3 ) - 5 5 Z tq -no tC r y1( m s 0 j5 rn1 c • 8' ........................... Ground elev. 92.30 ft. Depth to limiting factor it in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) V e- 3c 3 siou+ 6.c5+ n Ces-f-l-cs4N-1.) ak. R ic _./e...Z/f4r.‘ .... nq ,•1 iz " g...I c( -ev• lo-v.o kto J 1 .. h G" PcfelcA 1 _ , ? , . 7 ( - e " . lbG. 6 fit UPP 4-4 7 0 . - 0 77 ,r.vf-ew► 4-l..a u 400 e t tq. - d > V 44 - ei - a,./ YZ• 60 _ ofEr` 0 b A ' 1 a 'SlrP st. P• a 1 • • ! el 43 e • • . iw C 1\d - x i -v, ✓c (ifi�,.. 1t) ■ S'I' CROIK COUNTY SEPTIC 'TANK MAINTENANCE AGREEMENT AND OWNERSIi1P CERTIFICA'T'ION FORM Owner /Buyer Mt R L. SSE r FE Mailing Address I $o\ vJ , S tacK.SON :0ox V'∎11 C �c�t �sA ,5r1 l 3(o Property Address `�p 5 y }�5 ��� �— FAQ Rp t!tb (Verification required front Planning l)epaitment for new construction) /11 e. City /State t w� Parcel identification Number OaO' -1 35 3'" )76°O LEGAL DESCRIPTION Property Location Nw'A, NW 'A, Sec: '1' c�`1 N -R 19 W, Town of {1ubSo14 • Subdivision Co4o1.1 vi0®.1 __. 1�b� , Lot # 11 . Certified Survey Map It , Volume , Page # Warranty Deed if , Volume , Page # Spec house O yes [Milo Lot lines identifiable Eryes 0 no SYSTEM MAINTENANCE 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. The property owner agrees to submit to St. Cioix Zoning Department a certification form, signed by the owner and by a piaster plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (I) 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. I /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 Zoning Office within 30 days,of the three year expiration date. t i NATURE 0 fi LICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this fonu arc trite to the best of my (our) knowledge. I (we) am (are) the owner(s) c the property described a ttve, by virtue of a warranty deed recorded in Register of Deeds Office. „ 6, q,00 SI NATURE 0 T ,ANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Ine nde with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed • 1 ' , /O - 1518 STATE BAR OF WISCONSIN FORM 2 - 1998 624279 WARRANTY DEED KATHLEEN H. WALSH • REGISTER OF DEEDS Document Number ST. CROIX CO., 141 . . _ ' _•• RECEIVED FOR RECORD This Deed, made between RTC`HAPr) 0. ST0T1T and 06 -06 -2000 10:15 AN JANET P. STOUT, husband and wife, _ WARRANTY DEED Grantor, EXEINIT CERT COPY FEE: and u _ a e . _ , — COPY FEE: • hnshani and wife, TRANSFER FEE: 179.70 RECORDING FEE: 10.00 PAGES: 1 , Grantee. Grantor, for a valuable consideration. conveys and warrants to Grantee the following described real estate In St. Croix County, State of Wisconsin: Rernryir,g Area Lot 17, Plat of Cottonwood Ridge, Town of Hudson, St. Croix County, Wisconsin. Name and Return Address a1 Parcel dentificati Number ' (PIN) This is not homestead property. (is) (is not) Exceptions to warranties: easements, restrictions, rights -of -way and covenants of record. • Dated this 1 day of -*AT - Sun , 9 n n n . R tict4 © ,Sirx41 (SEAL) de/lAZ— — (SEAL) Richard n Ctnirt * .Tanpt P Stnut (SEAL) (SEAL) * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. St. Croix County. authenticated this day of Personally came before me this f day of - Diat.'Si)n. , 2000 , the above named Richard O_ Stout and Janet P Stcuit TITLE: MEMBER STATE BAR OF WISCONSIN to Of not, me known to b���a . - rl i [gcuted the foregoing authorized by §706.06, Wis. Stets.) instrument and }i6tAl - • • a r t.Ti CONSIN KE ON J. BAST THIS INSTRUMENT WAS DRAFTED BY Janet P. Stout 1151 AwatnkPa Tr_ Hudson, WI 5401 6 Notar ublic. State of W c nsin My ommissior is permanent. (If not. state expiration date: 1 1 . - - (Signatures may be authenticated or acknowledged. Both are not ^ ) necessary.) Names of persons signing In any capacity most be typed or printed below their signature. STATE BAR OF WISCONSIN Wisconsin Legal stank CO., Inc. WARRANTY DEED FORM No. 2 - 1998 Milwaukee, Wis. 1- A , -- - ----- • - -- -- -- ---------r"----:--1 cN,) ,S9'80S 3„6O,ES.1�0N w . 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