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HomeMy WebLinkAbout020-1113-50-000 F — Wisconsin, Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safgty and Building Division INSPECTION REPORT Sanitary Permit No: DO 21 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: Gilbertson, Cecilia Hudson Township 020 - 1113 - 50-000 CST BM Elev: Insp. BM Elev: BM Description: kVAAP CT$ul TANK INFORMATION ELEV N DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic T B96chmark _ , 35 �. 0 f S Dosing AL BM Aeration Bldg. Sewer Holding St/Ht Inlet S. a5' `12- ' SVHt Outlet / TANK SETBACK INFORMATION g • 3 �?'�3 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic 1 1 > / Dt Bottom So ? 5D 2 8 --- Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUM /SIP ON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift riction Loss System Head DH Ft Forcemain Lengt Dia. Dist. ell SOIL ABSORPTI N SYSTEM BED/TRENCH Width X gth No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. T id Depth DIMENSIONS SETBACK SYSTEM P/L JBLDG IWELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type System: UNIT Model Number: DISTRIB ION SYSTEM Header /M ifold Distribution x Hole Size x Hole Spacing I Vent to Air I e Pipe(s) Leng Dia Length Dia Spacing IL COVER x Pressure Systems On xx Mound Or At - Grade Systems Only Depth Over Depth Over pth of xx Seeded /Sodde xx Mulched D O Bed/Trench Center Bed/Trench Edges 1 7., , PDe so [m] Yes DN No [W Yes :X No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: 0 aZ- / 0 Inspection #2: 'TT Location: 1030 H[ghw 35 Hudson, WI 54016 (SW 1/4 SE 11412 T29N R20W) NA Lot Parcel No: 12.29.20.459D 1.) Alt BM Description = r r r _ _ _ 2.) Bldg sewer length = C" 3 3 {n kAUAe_ - amount of cover °` c�"s ►`rte p�� c.o�nect�mK . 3� tall Plan revision Required? ❑YesNo Use other sidetoradditional inf /� SBD 6710 (R. C 45tr �� n tors Sign refit. Cert. o il, .S Tl c ?'o /Se- 1'Y13/tv0V_0xW 4ojae-- 93 C3 CY R.tit . County Sanitary Permit Application ST CROIX COUNTY WISCONSIN In accord with 15.04 St. Croix County Sanitary Ordinance ZONING OFFICE Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER G [Privacy Law. S. 15.04(1)(m)) 1101 Carmichael Road ot Hudson, WI 54016 -7710 (715)386 -4680 Fax (715 386 -4686 Attach complete plans for the system on paper not les9 - x 11 Inches in size. County Sanitary Permit # ❑Check If revisi t\ 00ous appfi . yo I. Application Information - Please Print all Information ` tion: Property Pr Owner Name. L �,` y . � ` "� 1l4 1/4, Sec l C,re / /i¢ �r /G,d TS© �V 1 01 T Zi N, 2-� R E (or Property Owner's Mailing Address 1 S��vNIN�tiGt Lot Number Block Number 103 //W;/. 3 2 �~N� N 1 ._ i City, State Zip Code Phone Numd Subdivision Name or CSM Number Rio • //vpso -J G� /. syoi� 7�,5' • 20 m j �, /�¢.. r 11 Type of Building: (check one) Z• amity []Village Town of l 1 or 2 Family Dwelling - No. of Bedrooms:���Q ❑ Public/Commerclal (describe use): ❑ State -owned Nearest Road ��. •� �+ II. Type of Permit: (Check only one box on line A. Check box on tine B if applicable) Parcel Tax Num A) 1.)(Repair 2. ❑ Reconnection 3, ❑Non - plumbing 4. ❑Rejuvenation ICA Sanitation do.%O • /// 3 B) N EF 1 1 0 KE .S.7 Permit Number Date Issued ❑ State Sanitary Permit was previously Issued /9. IV. Type of POWT System: (Check all that apply) % - -Ap 0 bV r/Jtox ❑ Non - pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Weiland ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ 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 Required Proposed (Ga dal /sq.ft .) � (Min.finch) " Elevation 3 6-0 VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks yyC Concrete structed glass Tanks Tanks /ESC /� Aa G-- 17 5 0 .A ❑ ❑ ❑ VII. Responsibility Statement I, the undersigned, assume responsibility for repair/ reconnenction /rejuvenationfinstallation of non - plumbing for the POWTS shown on the attached plans. A license is not required for teralift repair or the installation of non - plumbing sanitation system. PI tubers Name (print) Plu s Signatur mno m p : MP/MPRS No. Business Phone Number *7 0 Plumber's Address (Street, City, State, Zip Code) S ©r •/ A.4P 1142p /'40,J 401' s VQV VIII. County Use Only i Disapproved Sanitary Permit Fee Date Issued Issuing Agent Signature (No stamps) Approved Owner Given Initial Adverse Determination `i� 2 '� Z U0[ IX. Conditions of Approval /Reasons for Disapproval: 5 ` f S ko'k, zjkk - 5s t S _ COO& c Ct ' f . �. . tAAAA s ►� P - -A- J 114 w y 33 W O 5 Co ' 1 y� i6d,o � E z 30 � - A) < r T i ID LID 1 r 0 � S ysT gg �► 0 c 13ILY Tor o "= Z AggOe p UIbrlCh S ?(% !,A i Rd. g01g 655 0 Wi 5 Hudson. C�3 MQ Hwy 3S W O o 0M 5(p Z X6 0,0 E p 3 0 00 - i 0 � S ysr• to I o gg �► Tap 0/0= �y sgOe �on�ultants Vlbricht Se a9 priva0 t4all Rd 16 6 vdts 5A0 2 Hudson, � ✓ M� r � l Wisconsin Department of Commerce SOIL EVALUATION REPORT Page ! of Z Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code ; Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must County ST C-ROf X- Include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. 020 ' Z percent slope, scale or dimensions, north arrow, and location and distance to nearest road. O ). D • // 3 50 19 eb Please print all information. a ewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). I Property Owner Property Location Ck-e / i4 6' G 13ERT50,) Govt. Lot 5 4) 1/4 59 114 S /Z T 29 N R 20 45, (or) W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# / //w)/ 3-5 City , State Zip Code Phone Number ❑ City ❑ Village 0 Town Nearest Road ,11 �/ Sya /� ( �lS, 3962 57 HLIPSa.) 17tu 35 ❑ New Construction Use: Residential / Number of bedrooms Z— Code derived design flow rate 6Z7 GPD [Replacement ❑ Public or commercial - Describe: Parent material 4,d DV Apt Flood Plain elevation if applicable W n, General comments and recommendations: v-I iU C��M �3- 0 .SA' �"% /� � Ta /t'c 4 �A��� / 5��Ez SEPT /c -r4,u& . �X /• s % /ylr �j2�/W.e� / s /,v cD�E ��/J� �N % so/ � -S �� o © Boring # ❑ Boring b b > / / O Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 "Eff#2 7 7 SYRy Zz /P c 5 — �. Z o,+ ffS.D F Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 "Eff#2 7 Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 _< 150 mg /L " Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L CST Name (Please Print) Signature CST Number ?? 043 42 Z/ /6�c'�•Cti 7 z ze 3 7 5' Address Date Evaluation Conducted Telephone Number 0144/ ��S•3��•d' /�S Uibricht & Associates Private Sewage Consultants 655 O'Neil Rd. Hudson, Wis. 54016 49A ) f'7- u&v o v Ly 2 -3 ter" Ce FI-ve- v • A/b sl' ivs o� s I A l7 �' OUP /at,�,iu G— • ��'y tv�e� /VAFB 725 �U,VG T /o.✓ �:v 1 Property Owner Parcel ID # Page of F-1 Boring # ❑ Boring ❑ Pit Ground surface eiev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fl In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 2 F F ❑ Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Cons tence Boundary Roots GPD /ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ❑ Boring # ❑ Boring El pit Ground surface elev. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft In. Munsell Qu. Sz. Cont. Col r Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BOD a > 0 < < _ 220 m g/L. and TSS >30 _ 150 m g /L 'Effluent #2 - - < BOD < 30 mg/L and TSS 30 mg/L The Department of Co erce is an equal opportunity service provider 4nd employer. If you need assistance to access services or need mate al in an alternate format, please contact the department at 608 -266 -3151 or TTY 608- 264 -8777. SBD -8330 (R.6 /00) �w y . 3.S O � E R 30 S Tic 'ry � y , (3 0 s y ST o gg �► F ' - rap D� A4 7 ulbticht & pssoe " $ewa9 ptivateN011 R 5 A016 65 Wis. �1 7 Hudson �2 1 M� �� , 2 v ��- ST CROIX COUNTY SEPTIC 'TANK MAINTENANCE AGREEMENT �,- AND �- OWNERSHIP CERTIFICATION FORM y C'�c/ / /,� �ri �,6�ti'T5'o,�t� 3 �6 ^ 2-f5 Uwtler /Hu er Mailing Address / 3 d I lw . 3 5 7ze - / 'P oso,L) t!!1 /• I 5� Property Address Ste (Verification required from Planning Department for new construction) ©3 D � ��� �-' �4 • Ada City /Stags' Parcel Identification Number 4.;L0 • ll'l3 o • lc r;m LEGAL DESCRIPTION Property Location 56k) 1 /,, S � /A, Sec. ! 2 , T 2f N -R 2.0 W, Town of Subdivision ,Lot # Certified Survey Map # N/ , Volume Page # Warranty Deed # W ( Volume S D S Page # 5� , Spec house O yes [ Ino Lot lines identifiable yes Ono 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. Croix 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 wastewaterdisposal 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 ' Slating 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. e 1 o SIGNATURE OF APPLICANT O RIGINAL DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) 9m (are) the owners) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE O APPLICANT DATE DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this Applicatlon: 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 File All Copies and S10 Fee with Register of Deeds 3 1 , 100 1 APPLICATION FOR TRANSFER OF JOINT PROPERTY TO SURVIVING SPOUSE Under Section 867.045, Wisconsin Statutes Decedent Date of Ucath Sr11.101 S•cuf iiy Number ?tort Fdwnrd Gilhertsen — .�_.4_!�r�1._ ? - ��33_ Address of Decedent at Date of Death City Statr Zip Cede pll2_KY_ 5" `Twiscn, `• A01 � � 'iec tL ^1F Surviving Spouse Address ^Fc ilia ^. "ilbertson n #P rr.. jr "' 'i �c THE FOLLOWING (DOES, DOES NOT) CONSTITUTE THE TOTAL PROPERTY IN WHICH THE DECEDENT POSSESSED ANY INTEREST AT DATE OF DEATH Serial or Account Full Value at Date N of Death 1. U. S. savings bonds, savings and checking accounts: ' i i j REGISTERS OFFICE BT. CROIX CO.. WIS. Recd for Record this - dey of_.Liil titctr__AD.19:L� Pt SW SB Sect.i.on 12, Tvm. 29 Rance 20 r 1% NW-RF SAntAmn 12, Two 29 20 -- tea star oleos i Total value of bonds, savings and checking accounts. $ 2. Real Estate: Assessed Valuation Equalized Value Recording Data 61Lt,800.00 , �31< 10 13 -3 , < ( and L�90 -586 DECLARATION I declare that on the date of death the above named ere husband and wife, that this application is, to the best of my know- ledge and belief, true, correct and co m the provisions and limitations of the Wisconsin Statutes. SIGN Spou - - - - -- -- - - - Date HERE -_ _ 11✓3�L7.1_ _. r � a s•* I certify that 1 have mailed or delivered copies of this Sworn to before �» b�j r )k' " application as provided ins. 867.045 (3), Statutes, on 30 1973 Register of Deeds 't Date County of " ►, Register of Deed- y- �- enor< 5.PASE5 ". i