HomeMy WebLinkAbout020-1353-44-000 Wisconsioa Department of Commerce PRIVATE SEWAGE SYSTEM Count :
Safety and Buildings Division St. Croix
INSPECTION REPORT
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)]. 363826
Permit Holder's Name: ❑ City ❑ Village ❑ *own of: State Plan ID No.:
Delong, Andrew L. l Hudson Townsh
CST BM Elev.:, Insp. BM Elev.: BM Description: Parcel Tax No.:
020 - 1353 -44 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 0 J2 I dpt) Benchmar�,� l I CO 0
I
Dosing - 6 Alt. B -
Aeration Bldg. Sewer . 3"7 70 3
Holding -------- �� St /Ht Inlet 8, 68 , S --—
TANK SETBACK INFORMATION St/ Ht Outlet 8.52 ' . 28
TANK TO P / L WELL BLDG. Ae Intake ROAD Dt Inlet - ��
Septic NA Dt Bottom -
Dosing NA Header / Man.
Aeration NA Dist. Pipe 1 ,(o0 04/ 01-. 20
Holding Bot. System )/' Ii S$ ;G Q
PUMP / SIPHON INFORMATION Final Grade
Manufacturer Demand St cover 5.0 , (3/.8/3 r
Model Number GPM
TDH Lift Loss Friction System TDH Ft Head
Forcemain Length Dia. Dist. To Well
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 Manufacturer:
SETBACK CHAMBER
INFORMATION Type Of Model Number:
System: OR UNIT
DISTRIBUTION SYSTEM (ttr -I' 3. 2 ) _ '.
Header / Manifold Distribution Pipe(s) 1 x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. I 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 TopsoilYer__TrI ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: / / 13xspection #2: / /
Location: 868 Alex Lane, Hudson, WI 54016 (SE 1/4 NW 1/4 36 T29N R19)-29.19.2044 Conwood Ridge - Lot 44
1.) Alt BM Description =
2.) Bldg sewer length = `-t. s
-amount of cover = n , t
3 5t"'^' d^ae- ° D wit( si c,. r e,.r�s o ,, �a cT�� -
Plan revision required? RYes ❑ No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
1
ADDITIONAL COMMENTS AND SKETCH j '
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
�■ .
��SCO/1S //1 SANITARY PERMIT APPLICATION \ 201 W. Washington Avenue
P O Box 7302
Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
Y p
than 8 1/2 x 11 inches in size. d� .)(
• See reverse side for instructions for completing this application State Sanitary ermit N mber
Personal information you provide may be used for.secondary purposes ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)).
State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Prope y Owner Nam // Property Location
) 4 — e . ---- ,,Je- ; . 1 /4 N� 1/4, S al T 79 , N, R l) (ore
Property Owner's Mailing Address Q Lot Number .i 1 Bbocumr
�nls , V
City, S : to Zip Code Phone Number Subdivision Nam • : C Number
i _ _. , _ ( ) , r
II. TYP • F B ILDING: (check one) ❑ State Owned v • ■ ity Nearest Road
❑ Public CO ru
1 or 2 Family Dwelling - No. of bedrooms 3 Town OF ..,�„J l ' re is,txv yP�, -/
.
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Nu ber(s 1.444
, /,
1 ❑ Apartment/ Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
1 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining
4 ❑ Church / School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash
5 ❑ Hotel / Motel 9 ❑ Office / Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1.j2f New 2 ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Exist ngSystem 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,E Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑Seepage Pit ` C.6"•11021-5
� 43 0 Vault Privy
14 ❑ System -In -Fill ('
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min./inch) ch) y/ ,9 3 Elevation
s'r; _S"'G_� ...g,? 7' . g A/h ? 93,3 Feet p90f1 Feet
Ca acit
VII. INFORMATION in gallo Total # of Manufacturer's Name Con- Steel iber- Exper.
Gallons Tank concret Prefab. F
glass Plastic App
New Existin.
strutted
Tanks Tanks
Septic Tank or Holding Tank .140 pliey,., / 77L- //),)-,Se 151 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber I ( ❑ I ❑ ❑ ❑ ❑ I ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for instal : ion of the onsite sewage system shown on the attached plans.
Plumber' ame (Pri • v ' Plumber' . i s - • • o ' • rry{�s MP /MPRSW No.: Business Phone Number:
,
Al ..� 0 m _. - - / ��I f _ L i of � s_ - -
Plumber's Address Street, Cit State, Zip Co. .
vi ea e _ .4 i% Lf,
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
roved Surcharge Fee)
pp ❑ Owner Determination Initial 0 C a) L/ 4 - t 1 /
Adverse Determination T �(
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -6398 (R. 4/99) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner Plumber I
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 be 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 completedimensions, 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 w hich can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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Visconti Department of Commerce SOIL AND SITE EVALUATION Z
Division of'Safety and Buildings Page of J
Bureau of Integrated Services in accordansa-rRffi s-. g Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 irfehe?�th size, Plar�ytnust .'n, County •
include, but not limited to: vertical and horizontal reference"point (BM), directional* 4-. Cro 1 )/
percent slope, scale or dimensions, north arrow, and locatj�riand distance to neatest road. \ Parcel I.D. # r
APPLICANT INFORMATION - Please print akl,information, , .. l Rev' wed by A Date J4l
Personal information you provide may be used for secondary purposes (Privac ? v Law a6tp4 -(1) (m)). A/I �
/ 1 �f(/�r7 ( , 'l �yo1 1
Property Owner `,,, 1� ` , �P erty; 'oc on
QtC` X� .Sl (�l ` �� / r ( `� t � e % r CSM# � T Z s ,N,R !Gl E (or) 1�/
Property Owner's Mailing Address ... V; , , Block# Subd.
1353 A ; VNee -r. y `1 C'at4or\ wood P►d
City State Zip Code Phone Number ❑ City El Village [y Town Nearest Ro
kAudSon 1 \tl 1f -IO1to x(115 )5LIq -4131 +-Judson 1 C-1-y Rd N
73-New Construction Use: N.Residential / Number of bedrooms 3 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow LQ o(3 gpd Recommended design loading rate • 7 bed, gpd /ft • 3 trench, gpd /ft
Absorption area required 5(51 bed, ft 2 150 trench, ft 2 Maximum design loading rate • 7 bed, gpd /ft • 5 trench, gpd/ft
Recommended infiltration surface elevation(s) 7 Gower 1 m3, 33c-.- ft (as referred to site plan benchmark)
Additional design /site considerations i5 � / 9'S Z 0
Parent material (Zt &(I j dl t-6w4f_5k Flood plain elevation, if applicable /./c✓L gGy/D ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system RI S ❑ U I s ❑ u ® s ❑ u ®s ❑ U ❑ s ®U ❑ S ® U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
1 0 lUyf^ 3/2 -- t._ S 1 m5c m-Pr CS 1 - C .1 . • S'
2 6 - 109 IL) yr 1 -0_0 — YYiS m1 Cs - . 1 ; - g
Ground
elev.
—ft.
Depth to '
limiting
factor ,
ICq in. 007 ,
Remarks:
Boring #
0 10 y 3)2 — LS I n--) 5 M-Pr C5 1-? , ; •
a 15-3z_ gu 4-1-4 _ � L l rn a bk ,-r,Pr CS — H .5
3 3 Ia yr Lt/Lo fi-)5 0 Se Yr I C. S — , - 7 .
Ground _ ,
elev.
/ft. .
Depth to ,
limiting
factor
tbi in. Remarks:
CST Name (Please Print) Signature Telephone No.
Adavin Sc11,0rV\O�. .7 __=may_ 7/..C--= - 4/DO(--
Address Date CST Number
1 1 0 k &dt rS/ d y So/IA -a - s-eI W / . ,S '� V,5 - 9 r "S ?
C f-- SOIL DESCRIPTION REPORT
PROPERTY OWNER Page 2 of 3
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Structure D /ft2
g G Texture Consistence Boundary Roots P
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
3 1 o - 1'2- Ib yr. 312- LS I n m - 5 IC •`1 ;• g
2- t L -32 16 '-L IL) 'I_ \mGb r r 5 — L{ . 5
Ground 3 32:I04„ iL \ir LI/co (o 1^(m 5 0`-35 ry )i C - . 1 .
elev. .J
9118 ft.
Depth to
limiting
factor \C-9 Il� (pin.
i 0.\(°9 \ \h
Remarks:
Boring # _
0-12 10 yr 30- LS ms m-Pr c 5
4 IZ -yD Ibyr I-114 mfr C S — - `-( • 5
Stu i 1 yr Loo
--- r s m I c s " • - 7
Ground
elev.
91.94 tt.
Depth to
limiting
factor
1Ggin.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GP, D /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring# 0 -13 to \f, )2 _ L5 1 rn55 rn-P- CS I.0 - - 1 . $
5 2 13 -2q 11� r LI I L I 51 -- ) mctbk (r S - y • 5
3 29 -116 l0yr 4/6 rnS sr ran I C S ` • �(
Ground
elev.
%5
Depth to "\
limiting If6 a�
factor
110 Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R. 07/96)
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND •
OWNERSHIP CERTIFICATION FORM
OwnerBuyer _Vi t •
M ailing Address .L . L.! : A! • .' -. s L 0
Property Address " — ' ►i: =.:" : .
(Verification required from Planning Depa ent for new construction)
City/State 1D1/l W �
/State
Y I'k1 ‹.3` Parcel Identification Number 02-0' 110 ' RC' COO
LEGAL DESCRIPTION 11
Property Location ,s5 '/., il') '/., Sec. 3 (0 , T c M kN -R 19 W, Town of , \ •
Subdivision COROYMark Italy. , Lot # 44 . Certified eritfied Survey Map # ,Volume Page #
Warranty Deed # X (roO54(DEJ , Volume / ?A , Page # <, ?le •
Spec house D yes 1331 no Lot lines identifiable 2 yes D 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.
T1he rees owner ro crty agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
p p s g p
master plumber, journeyman plumber, restnctcd plumper or a licensed pumper verifying that (1) the on -site wastewaterdisposal system
is in proper operating condition andlor (2) af1cr 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 maintaincd must be completed and returned to the St. Croix County Zoning Office within 30
days if the three , <xpira j n date.
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SINATURE OF APPLICA DATE
OWNER CERTIFICATION
1 (we) certify that all statements on this form are true to the best of my (our) knowledge. 1 (we) am (are) the owner(s) of
the property describe a ►.ve, by virtue of a warranty deed recorded in Register of Deeds Office.
.41► :.%r/ ti / /3 /ow . .
SIG ATURE 0 APPLICAI DATE
•••••• Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department.
•' Include with this application a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made to the warranty deed
' vol_ 1438P4G1340 [I)
STATE BAR OF WISCONSIN FORM 1 — 1982 6050965
' WARRANTY DEED KATHLEEN H. WALSH
REGISTER OF DEEDS
DOCUMENT NO. I ST. CROIX CO., WI
RECEIVED FOR RECORD
This Deed, made between 06 -30 -1999 11:50 AM
RICHARD 0. STOUT and JANET P. STOUT, husband
and wife, WARRANTY DEED
EXEMPT 11
Grantor, r, CERT COPY FEE:
j and ANDREW L . DeLONG and LAURA L. DeLONG , CORY FEE:
husband and wife, TRANSFER FEE: 164.70
RECORDING FEE: 10.00
PAGES: 1
Ii , Grantee,
Witnesseth, That the said Grantor, for a valuable consideration
i
I( THIS SPACE RESERVED FOR RECORDING DMA
conveys to Grantee the following described real estate in St . CrOix
County, State of Wisconsin: NAME AND RETURN
tut n To:
Lot 44, Plat of Cottonwood Ridge, Town of Edina Realty Title
Hudson, St. Croix County, Wisconsin. 400 South 2nd Street
Suite #115
Hudson WI 54016
n7n- 1108- Ro -noo .
PARCEL IDENTIFICATION NUMBER
.
i i
This is not homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And Richard O. Stout and Janet P. Stout _
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements, restrictions, rights -of -way and covenants of record,
and will warrant and defend the same.
Dated this 29th day of Jun ,19 99 .
Richard 0. Stout (SEAL) Janet P. St � o } �. u � t 4 .,.. (SEAL)
, * clux.a (7:1. Sitmt * dt4tz I (SEAL) (SEAL)
* *
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Wisconsin,
1. ss.
St. Croix
County.
authenticated this day of -, 19 Personally came before me this 2 9th day of
June ,n oa , the above named '
- — - __Ri 0. Stout and Janet P.
* Stout
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, -Bra* p0ulin
authorized by §706.06, Wis. Scats.) public to mel.wn to be tilt son S who executed the foregoing • j l0L " ..K T IS`---- g g
State instrun int and ackno - -dge t{ same.
THIS INSTRUMENT WAS DRAFTED BY /LWA fe ,
Janet' P. Stout (((///
1353 AwaLukee Tr. * V r
Hudson, Wi. 54016 Notary Public, " _ County, Wis.
(Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If ot, st a expiration date:
necessary) // (/ /J1crq .)
* Names of persons signing in any capacity should by typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc.
Form No. 1 — 1982 Milwaukee, Wis.
1
L
)OD RIDGE N
1/4 IN PART OP THE NE1/4 OP THE NI11/4, SW1/4 OP
P' THE ER1/4 AND IN PART OIP THE SW1/4 0 P THE SIE1/4
01
mi; szeRolz corm% iffscorisni. — MATCH LINE R2g
SEE SHEET 3
OWNER \ 1!
-- -3s--- ha RICHARD 0. STOUT WM 1.SW
.... ■441 ...'. Y FARM r AD • JANET P. STOUT PLATTM TO RETAIN OWNERSHIP OF OUTLOT 1.
--__ ____ :a •
ter 1353 AWATUKEE TRAIL OUTLOT 1 IS RESERVED 0R FOR TONN ROAD w ig
. .......... _ ... ,. , ,, - 41•444 04.• ..........„... op _ HUDSON. 51 54015 :E1 27 TO EASEMENT IR OT R
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0.453 ACRES
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123,155 SO. FT. 1 I 3.366 ACRES , i 37 1131PCOMIT CULAX--SIC EASSIENT k
14e.sse so. rr. I 1 3Si 3S i 1 :11,7 2 OE-SAC TO SE REMOVED I 1
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