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HomeMy WebLinkAbout022-1067-50-000 P Viscongin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety hnd Building Division 1 0 INSPECTION REPORT sanitary Permit No: 487951 0 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: Jacobson, Harvey etal I Kinnickinnic, Town of 022 - 1067 -50 -000 CST BM Elev: Ins BM Elev: BM Des tion: f/ _ Section/Town /Range /Map No: . (� /�� a §d Vl 24.28.18.372 TANK INFORMATION ELEVATIONtATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic W tb 12. C�7lU��osb Benchmark ^v a pq 3" / 00-6 Dosing N .. Alt. BM Aeration Bldg. Sewer (5 � St/Ht Inlet / *Ink l o t-01, 11. / TANK SETBACK INFORMATION et, D- outlet • If St) �9• q TANK TO P/L W9LL BLDG. Vent to Air Intake ROAD Dt Inlet Septic _ Dt Bottom DD Dosing nA Head Man. Aeration L 4 7 Dist. P' • q H9Jdin �+� Bot. System Final Grade PUMP /SIPHON INFORMATION 411, I / / Manufacturer n Demand over i c� r dC GPM / COY 3,0 13 tn Model Number a I l / TDH Lift Frich'on�L, Syste He d TDH Ft 615 1 d �S Forcemain Length Dia. Z V I Dist. to well SOIL ABSORPTION SYSTE 17- BEDITRENCH Width I Leng No. Of Trench 0s PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS / p Z SETBACK SYSTEM TO YY11a P/L B DG WELL LAKE /STREA LEACHING a acturer.� � t i INFORMATION CHAMBER R t�IL, Type Of System: ( / UN Model M J DISTRIBUTION PYKEM 4-c> Head /Ma ifold Distribution J x Hole Size x Hole Spacing Vent to Air Intake r�` Pipe(s) Y/w" Len h � Dia Lengt Dia Spacing S IL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only De ver L Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center - T/ Bed/Trench Edges Topsoil Yes No Yes q J No CO Z S: (Include code discrepencies, persons present, etc.) Inspection #1: �� • ? / Inspection #2: 7/ —" Lod tion:: 11 Oak Drive River Falls, WI 54022 (SE 1/4 NE 1/4 24 T28N R18W) 40 acres Lot : arcel No: 24.28.18. 72 1.) Alt BM Description - ` k • ( / /�� T / � JyAC.v� 2.) Bldg sewer length - amount of cover = IErs I �a c Ali.. 7 Use other side for additional information. �hl Plan revision Required? I. Yes "I No SBD -6710 (R.3/97) �� / Date insepctor s Signature Cert. No. r7 Am Build on Canty ` 201 w in n , P. _ ,o, ���, tNnuber(tobe6lladin Co.) Isconsin Dep artment of Commerce 8) 1-6546 Sanitary Permit App 'C n state LD ' N a In accord with Comm $3.21. Wis. Adm. Code, personal �p�'! may be used for secondary purposes privacy m) ZON�oi'� �, UUrJ r Pro Addreu (if diffetan than mailing addreas) I. Appttcatim InforM*ttoa — Please Prier I Piulict Owner's Name Parcel N Lot I Block p / ; 1)e sec A 6 er0 - lo6 7 -s0 -also Property •s Mailing Address Property Location e, � t s `Vi `, section Cp 7 Ci State Zip Cods Phone Number T � � pa tcl re T N; R v E il. Type of Btdlditsg (check all that apply) ` id or 2 Family Dwelling - Number of Bedrooms Subdivision Name tSM Number 4�/� ❑ Pubes - Describe Use ❑ State Owned - Describe Use ❑City ❑ ( ' p of III. Type of Permit: ( x an A. Complete life B U appU=bic) A . ❑ Now Systere Replacement Systern ❑ TastmaWH ofdiag Tank Repb>amrot Only ❑ Otter Modification to Fig System B• ❑ Permit Renewal ❑ Permit Revisim ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date issued 9 ��� Befae �p� Plumber Owner ! n„ �,f ,/ N. of P0W1g Cbedc aB tbat _ e )KNon - Pressurized b4mund ❑ Mound 2:24 in. of suitable soil ❑ Mound < in suiublc soil ❑ At ❑ Single Pass r Conshtrcted Wetland ❑ Preasrized ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating S Media Filter Chanaber ❑ ❑ less ❑ Od- V. DkiiiftiaMentmwit Area Information: Desip Flaw (awn Deaiga Snit 7 icMien " � � Area (M �� VL Tank Info Capacity in Total Number Mmufiacom Prefab Site Stud Fiber Phistie C>alloas - Gallons of [hits Concrete Constructed Gloss New I Existing Tarim Taalm Septicer TaRk y Od0 rt' t°Y` AereMeTiesum"Udt Dodagt .caber v W ) b k— VII. Statemtmt- 4 the asiderftned, for WTS shows on the attached purrs. Plum Name ( ) P.— RS Business Phone Number � 99 s Address (Straw, Ci tj 06 )d eAP) vet van. t vac oar ❑ Disapproved Sanitary Permit Fee (mckides Groundwater FL2, ate Issued 4:17=! ApM igtauure (No ) ❑ Owner Givers Reason for Denial see Fee) fQT% 3 y !/v !�% %1PM8°OV2Ulte2soas for Disapproval /, � olk � _� Septic tank, effluent filter and (�_' %/ ��� j dispersal cell must all be serviced / maintained as per management plan provided by plumber. 40 ! / 2. All setback requirements must be maintained as per applicable code /ordinances. oj� �5� ^� oil Attaeb ea 11111" pi— (a tle Gauuy «elf) far tle syw... lea than tll s l l laehea le titre J SBD -6398 (R. 08/02) �I > jv t- frt n -L<— 91 eV 4 7 0 A7 x ss 4,- d !.,? L /6ketL 1 �tptk FO > 79 `;h. Sc4cd4O pvc cham /, K ,� � �'. � f,.,� f ,sy s �e •', �Io+ Ph.. 7 OP r bdsct -r1 t.oh p.jJC s pre,,, d� i•,.h s „� -� � At.+ to aOl to 91.7 �,h.pvc slo�?ed taway i �,wt�� ctia fah f Se - f fU rz A - Al•�”. " -2 J 1r ,1 e" V cdps d. / ��-/ Page Of �sn e -.t.�r Steed 40 (No Scale) P� -'jr :� re#r P.pe� >/0J't Approved Locking Manhole Covers �, v e, J � o` � � With Warning Labels Attached Weatherproof Approved^ _ d 7 I t '' 1 ke Junction Box Vent Cap 12" Minimum Fea /G.,+a�Q A;!t � 4" Minimum t Quick 18" Minimum Disconnect I NC 1 /4" Weep 8". .P f1/y.r. 4 j � a /% AeJ, C'evo4 Hole �Q/'�'�_. Baffle � A Alarm Qy On 61, B 1 C P"o , g: -c-4 *APPROVED Off S oF<dYe} to JOINTS WITH / d«'s APPROVED PIPE D 3' ONTO SOLID SOIL Conc. Block 3 of Bedding Under Tank —/ s'w w�mp cz�1a^m ®�j S�� ct"'f'� Number of Doses: S_ o2 Per Day Gallons Per Day / fi_Doses: 6 Gallons Volume of Backf1 ow::� °�+ ���9 Gal l ons Tank Manufacturer: ui.ese, Total Dose Volume: ........ = 116 Gallons Tank Size-Septic/Pump: ( -vv ! e! .S Ga 1 ons Alarm Manufacturer: Model Number: Capacities: A ) - o inches or ?4 Gallons Switch Type: + B a inches or 3 + Gallons Pump Manufacturer: 6"-1 d + C inches or 136 Gallons Model Number: 6 PO 4- + D g inches or 13 Gal 1 ons Minimum Discharge ate: 2 O GPR Total ..... = 3 8 inches or 6 Gallons Yertical Difference Between Pump Off and Distribution Pipe: u Feet �,nimum Required Supply Pressure: ......................... + ? ` Feet 3 c , r_) Feet of Force Main x 0 - 7 - �L Friction Factor /100 Feet: + � Inch Diameter Force Main Total Dynamic Head: ... = -8 Feet vernal Tank Dimensions: Length Width 8 Liquid Depth �8 -- _ It EPO4 EP05 APPLICATIONS a Fasteners: 300 series • Fully submerged in high ■ Motor Housing: Cast iron Specifically designed for the stainless steel. grade turbine oil for for efficient heat transfer, following uses: • Capable of running lubrication and efficient strength, and durability. • dry without damage to heat transfer. ■ Motor Cover. Thermo las- • Homes components. systems components. Available for automatic and tic cover with integral handle • Farms Motor: and float switch attachment • Heavy u sum • EPO4 Single phase: 0.4 HP, manual operation. Automatic points. � � p 115 or 230 V, 60 Hz, 1550 models include Mechanical • Water transfer RPM, built in overload with Float Switch assembled and ■ ewer Cable: Severe duty • Dewatering preset at the factory. rated oil and water resistant. automatic reset. ■Bearings: Upper and lower SPECIFICATIONS • EP05 Single phase: 0.5 HP, 115 V, 60 Hz, 1550 RPM, FEATURES heavy duty ball bearing Pump: EPO4 built in overload with m EPO4 Impeller: Thermo- construction. • Solids handling capability: automatic reset. p Semi -open design 1 /4" maximum. • Power cord: 10 foot with pump out vanes for AGENCY LISTING • Capacities: up to 55 GPM. standard length, 16/3 SJTO mechanical seal protection. SP• Canadian standards Association • Total heads: up to 24 feet. with three prong grounding n EP05 Impeller: Thermo - • Discharge size: 1 NPT. plug. Optional 20 foot p (CSA listed model numbers length, SJTW with • Mechanical seal: carbon- lastic enclosed design for „ g improved performance. end in "F" or "AC .) rotary/ceramic - stationary, three prong grounding plug BUNA -N elastomers. (standard on EP05). ■ Casing and Base: Rugged • Temperature: thermoplastic design provides 104 °F (40 °C) continuous superior strength and 140 °F (60 °C) intermittent. corrosion resistance. • Fasteners: 300 series METERS FEET stainless steel. 10 • Capable of running��� dry without damage to s 30 I components. Pump: EP05 s �! I • Solids handling capability: c 7 25 /4 maximum. w • Capacities: up to 60 GPM. _ • Total heads: up to 31 feet. 6 20 ; I • Discharge size: 1 1 /2 " NPT. z 5 �-- -- l Mecha - r i sea carbon e rotary/ceramic - stationary, j 4- 15 BUNA -N elastomers. - 0 • Temperature: *' 3 10 104 °F (40 °C) continuous ; �1 140 °F (60°C) intermittent. 2 — T 5 ' 1 j i i I I I `"✓ � �' / /�✓ ZU�` �°p 10 20 30 40 50 GPM + 0 2 4 6 8 10 12 W/h CAPACITY ©1995 Goulds Pumps, Inc. Effective May, 1995 B3871 7� tet W t7 1 )0 3 i. R Cd - P, vc c r., ass. llp- 7 /- aid � � � f 1. poi. zk,� � - -rr.- r � : � O/e 16ket > toe, At- ppf�p /,I 11y1A i Wisconsin Department of Commerce SOIL EVALUATION REPORT Page / of Division of Safety and Buildings a dance with Comm 8:,, Fn!?(!lt tt Attach complete site plan on paper no 11 es in A� , St Ck -,X CV include, but not limited to: vertical and horizontal reference int (BM), Parcel'[. . percent slope, scale or dimensions, nertl� on and dista .4 a /p 6 0V Please print all information. eviewe Date Personal information you provide may be used for secondary purposes (Privacy NTY , r Property Owner yj �ve� hs - "' t ,.T./ , .SJ� G&A. hot SF 1/4 AIE 1/4 S �4 T N R W Property Owner's Mailing Address Lot # E ock = Subd. Name or CSM# C l v d 1< 1?� -s`Y� -- City State Zip Code Phone Number ❑ City [ Village JK Town Nearest Road )T, "vcr f'd //s W s'4 oa 1 (7 13 42.x- &8 73 K ;., h ; c k in 4 i c Ud k p i.: r e ❑ New Construction Uselgf Residential / Number of bedrooms Code cerive.- design flow rate IS GPD ❑ Replacement ❑ Public or commercial - Describe: N A Parent material C ";L - r i / Flood Plain e eva _ - -, on if applicable /V 2 4 ft. General comments Sw y / sa�.. ti.�. / cf 6 /.pcs��8c / iKF'lt�df�cs c,. /7."'%ir and recommendations: 6 F 1-1 Boring # Boring Pit Ground surface elev. 9S: ft. Depth to lic .Inc ` 2ctor > 7 s in. Soil A I'�, =lion Rate Horizon Depth Dominant Color Redox Description Texture Strua_ Consistence Boundary Roots GPD /ff in. Munsell Qu. Sz. Cont. Color 1 Gr. Sz. Sn. 'Eff#1 - Eff#2 o -6 1O ! R 31 - "_ S'.' F Z r., r �r c S -4 0- j; c _ 6-10 leY94 13 - S Z .,dblC C- s .? 19 0 , 6 0•' fit ,� � fi � l C fEa °� c� d � se- �'• a e•, 1"S. !� /L g n � Boring # Boring > 1 0 0 Pit Ground surface elev. g✓� 7 ft. Depth to lim.tinc factor 0 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure ; Consistence Boundary Roots GPD /ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 - Eff#2 5 / . 0 .7 4 t] A Irl, S o- C w 2 �' o.� o 0 r P < /o Cod�sn d nsE�Ts ' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg /L ' Ef=vent #2 = BOD < 30 mg /L and TSS < 30 mg/L CST Name (Please Print) Signature CST Number Charm /e 4.. W' e 122 © 6 73 Address Date mwation Conducted Telephone Number W /S` 7 70 t4 Sh , Z ;j'w � " s; -r �...��1� / ' / 7 /0 7IS 27S'- �Q I Property Owner Parcel ID # O .�.Z ' f 6 7 �"�� Page of a Boring # ❑Boring Pit Ground surface elev. " ft. Depth to limiting factor Ey in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fP Fin. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 At K C w r r. l- d F-1 Boring # ❑ Boring W ❑ 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 /ff� in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 i Boring # ❑ Boring _ ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Appheation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fg in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 • Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg /L • Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 - 264 - 8777. 0 7 iool 4 o F t �Jkn � i } � 3 i i t' � ! ! t 'j s 4e-o( U M OL1 � p y r G- y � old JODI oie — �•S3.33 yro�a PY !�� 1' r ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Ta4so/, L- 31 Mailing Address Property Address (Verificati n required from Planning & Zoning Department for new construction.) �� i City /State Vibe( Ell S / '0/ 1 . Parcel Identification Number EP- /0 - 521 - QQQ LEGAL DESCRIPTION Property Location I/ , V., Sec. o� t , T d N R�W, Town of 16'Ah��C`,C Subdivision , Lot # Certified Survey Map # Volume , Page # Warranty Deed # 6 p , Volume G' , Page # Spec house 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. 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 Planning & Zoning Department within 30 days of the three year expiration date. Uwe 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 i 'I'L, � +SINATURE OF APPLICANT( 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) VOL 1683NG 24:3 651 S6o KATHLEEN H. WALSH Document Number QUIT CLAIM DEED REGISTER OF DEED RECEIVED FOR RECORD Harvey R. Jacobson, in his own right and as Trustee for Sandra L. RECEIV 9:30 AM Nelligan, Cheryl L. Bessette, Julie Ann Geddes, and Pamela M. Jacobson, an undivided one -fifth interest each, quit -claim to the Raymond O. OUIT CLAIM DEED Jacobson and Olive L. Jacobson Irrevocable Trust, dated 06 -01 -200 EXEMPT N 16 2001, Harvey R. Jacobson, Trustee, Sandra L. Nelligan, Alternate CERT COPY FEE: Trustee, both with full power of sale or encumbrancing, the following CORY FEE: TRANSFER FEE: described real estate in St. Croix County, State of Wisconsin: ty RECDRDIN6 FEE: 10.00 PAGES: 1 The NE'/. of the NE' /.. The SW% of the NE' /.. Recordi Area The SE'/. of the NE' /.. Name and Return Address The E'% of the NE' /. of the SE%. C. L. Gaylord Attorney at Law P. O. Box 46 All located in Section 24, Township 28 North, Range 18 West, Town of River Falls, WI 54022 Kinnickinnic. 022 - 1067 -10 -000, 022 -1067- 40-000, 022 -1067- 50-000. 022 -1069 -40-000 (Parcel Identification Numbers) This is not homestead property. Dated this 1st day of June , 2001. ` (SEAL) :/ -- (SEAL) "Harvey R. Ja obson (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature of Harvey R. Jacobson authenticated this 1 At STATE OF WISCONSIN day of ALW a 2001. COUNTY 'C. L Gaylord Personally came before me this day of TITLE: MEMBER STATE BAR OF WISCONSIN 2001 the above named to me known to be (If not, the person(s) who executed the foregoing instrument and authorized by g 706.06, Wis. Stats.) acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY C. L. Gaylord Notary Public, County, WI. P. O. Box x 48 Attorney Law My commission expires River Falls, WI 54022 *Names of persons signing in any capacity should be typed or printed below their signatures. INFORMATION PROFESSIONALS COMPANY FOND OU LAC, WI 800 - 055.2021 J Parcel #: 022 - 1067 -50 -000 10i21i2005 11:17 AM • P 1 OF 1 Alt. Parcel #: 24.28.18.372 022 - TOWN OF KINNICKINNIC Current ,X__; ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner HARVEY R ETAL JACOBSON O - JACOBSON, HARVEY R ETAL 6136 N PARK RD GLENDALE WI 53217 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 1482.OAK D R SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 40.000 Plat: N/A -NOT AVAILABLE SEC 24 T28N R18W SE NE EZ -UT- 1409/614 Block/Condo Bldg: EZ -UT- 1399/379 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 24- 28N -18W Notes: Parcel History: Date Doc # Vol /Page Type 07/19/2001 651559 1683/242 QC 07123/1997 495/60 2005 SUMMARY Bill #: Fair Market Value: Assessed with: Use Value Assessment Valuations: /-? Last Changed: 08/11/2005 Description Class Acres Land mi rove Total State Reason AGRICULTURAL G4 28.000 2,600 0 2,600 NO AGRICULTURAL FOREST G5M 10.000 25,000 0 25,000 NO OTHER G7 2.000 20,000 98,100 118,100 NO Totals for 2005: General Property 40.000 47,600 98,100 145,700 Woodland 0.000 0 0 Totals for 2004: General Property 40.000 37,600 74,900 112,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: 306 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 o C �1 -Z� ! c G; w K n N Z O O Oi II I A NO • -' (D 7 S. m D co -4 o p a .► 7 (D y N Q n {� 7 O > j do C) O m m r � O n c 2! C7 O - 4 R O 00 c c of -1 6 3 y m a O f/1 W CD N O -w v z CD ca D v' a CD W c 3 ° = o o 0 N N CL O �1 z v! ° v (A 000 z - �+ N C y y N 7 n I S,� y � I 3 -a Z N.Z ° n z � O o 0 CD ! ?' =r 0 U) N CD N 3 a ca o a 3 m 7 z CD tb -1 W C N O A Z CL c N w d A z 0 W G) (O� CO j j N N m m 0 A c p A Z z m y A m � I � A I w � I a m a � N c o a N I I I I � o I � c a I � I N N O H I ! A o °p p tv O ti 0 ti V CL