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HomeMy WebLinkAbout024-1026-20-000 0 g r 0) ° 2 § ■ ( ( J ■ , u ( 7 (ft) m / 0 $ & CD 8 ° C.0 0 @ S § § w ^ \ / G § § c D CO § _ ( d c 2 E § C § ° > % k a \ / $ \. 9 0 CD z § §f 0 0 0 , n 0 ■ _; ® ° -0 -0 -v o o o $ : 7 § 2 2 § 2 O 0T / a m �§� k � � � § [ 0 1 CD 2 + G \Q/ m (oaf 3( . C CD CD CL \ � (D § k \ U) 0 -, CL � t f /ei �. % j E ■ m § CO CD 2) CL �z A k % \ 7 m / / ® C) ƒkE§( // ) CD (Q t� Xf ©f ® § /(i2i\F R NB&§g ;E f T ;> :E o�i *a% \ R / \] /� » ]G(2} ]e - e\s J 22§ §me JEE /(i / /ƒ$kk% � E M i2 2 5D \' { : � ° § § § 0 � . / PRIVATE ONSITE WASTE T TM REA y lViscon rc ( P OWTS) � S : Count , c- ( Department of Co INSPECTION REP T Sanitary Permit No: Safety and Buildings Division N �R- TTO PERMI 4 L T !f q GENERAL INFORMATI (Nll�'� � 23� C ff - � I Personal information you provide may be used for second u o 15.04 (1 )(m Permit Holder's Name: LJ City LJ Village Town of: Jacobson, Clarence ft - 77 — CST BM Elev: Insp BM Elew BM Description: r -- I •� f l CSL l�C� -{-��5 Sec. 19 T a N -R W TANK INFORMATION ELATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic W &t Sc- Benchmark 2 -45 - 1 ` - .0 Dosing Aeration Bldg. Sewer Holding St /Ht Inlet - 4 - o S r TANK SETBACK INFORMATION St / Ht Outlet 5 TANK TO I P/L WELL BLDG VENT To ROAD Dt Inlet AIRINTAKE Septic > �' (¢ I 5' NA Dt Bottom Dosing NA Installation r Contour I Aeration NA Header / Man. r Holding Dist. Pipe PUMP / SIPHON INFORMATION Infiltrative Surface Manufacturer Demand Final Grade Model Number GPM TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia Dist. To Well DISPERSAL CELL ORMATION DIMENSIONS Width Length No of Type of System Manufacturer: !!5� SETBACK P / L ell OHWM of Nav INFORMATION Waters odel Number: CELL TO DISTRIBUTION SYSTEM X Pressure Systems Only Header / Manifold Distribution (s) X Hole Size X Hole Observation Pipes Length Dia Length - Sp ac Spacing ❑ Yes ❑ No SOIL COVER Depth Over Depth Over Depth of Seeded / Sodded Mulched Cell Center Cell Edges Topsoil ❑ Yes 13 No F-1 Yes 11 No COMMENTS: (Include code discrepancies, persons present, etc.) �C 6-nj c Y tjj- Plan revision required ?❑ YesKNo , 2 ? b Use other side for additional information �TS In ector's Signature Cert No �J RRn -A71n /R 4 /Ml Sakty sad Buildings Division Count NVI sconsin 201 W. Washington Ave.. P.O. Box 7082 5T C e-o I x Madison, W[ 53707 - 7082 Sanitary Permit Number (to be filled is by Co.) De artment of Commerce ( 261 -6546 3 0 fo 1 Sanitary Permit Application State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide MAY be used for Pei Law. s 15. 1 y 1 vaeY 04( xm) Project Address (if different than mailing address) I- Applkstioa Intormntioo - Please Print All Info Property qwnWs Name RECEIVED Al Parcel # Lot t+ Bbc=Na r'e �' f^ ©� � L.. - to 7- 4P 2 > - (M0 .153 B Property Owner's Mailing Property Location C' State � J V 'V � � �4 Section 'u�r' Ile 4) IL 1� Type of Building (cheek all W T & N that apply) R E or� ;11 r 2 Family DwaWg— Number of Bedrooms Subdivision Name CS Num ber 0 Public/C.omtamial — Describe use - 0 State owned — Desaibe use Ocity_❑winge browasbip of S'Q HL Type of Permit: (Check only o box on line A. Complete line B if applkslae) VIC &41 ~ ❑ New System 0 Replacement System TraomeaMoWumg Tank RepWcenmeamt Only Other Modi to g _ r � - e oil. �,/ O r t� H• 0 Permit Renewal 0 Permit Revision 0 Chaogs of 0 Permit Transfer to N List Pievioas Permit Number and Date Isillied Exp + Plumber owner 4 3 G � r � fJ('i DN tt of POWTS C heck am Nat a pply) Ali Non — Prsssuriaed ht4winnd ❑ Mound 2:24 in. of suitable soil 0 Mound <24 in. of suitable sot? ❑ At4n& ❑ Single Pass Sand Fiker ❑ Ceasameted Wulaod ❑ Pressurised In- Ground 0 Holding Tank ❑ Peat Filter ❑ Aerobic Trestment unit ❑ Recirculating Sand Filter ❑ Recirculadag SpdMk Media Filter OLeachingChainber ❑ Drip Lase 0 Gravel -mess Pipe 0 Odmer ( lain V. Dispendfrreatationt Area Plow Ioioorrnation: Desi gn �� Sed1 J iplication ��tpp � (td) 2 Proposed (� SY� ' VI. tank Info Capacity in Teual Neater Maatfar err r Prefab Site Steel Film Plastic Gallons Gallons of units Concrete Constructed Glass New Tewke 71111112 f . Septic alloWaaTank 'a i Awabie Twounu IMit I own VII. &atement- %the aade-kned, aaame reWassidbilky for lmb& WTS shown on the attached plains. 7 's Name (Prim) gaatiue M RS Business Phone umber P s Addmn (sttext, a Zip vin. Coca t u:c ,„,,, ved 0 D Sanitay Ferric Fee (includes Gmwndwater z e Issued Istuia Agene sii,aature (No saw") /� " surrbaree Fee) 12S 2l)D -e M Conditions of Approval/Reasons for Disapproval ❑ Owner Given Reason for Denial SYSTEM OWNER: 3) E-� ('j 1 1 L e Se tic tank effluent fuent filter and dispersal cell must all be serviced / maintained as per management plan provided by plumber. I Z'a 't 2. All setback requirements must be maintained �. as per applicable code /ordinances. Attaele e..ptete ptaea (u ere Gaa/y ouely) feu the syutaa oa paper nor leas rtuw Stn :11 nacres t■ doe SBD -6398 (R. 08/02) 7A1 W. Washington Ave., P.U. Box 7162 NVh4coiisin Madison, WI 53707 - 7162 Site Address Department of Commerce Sanitary Permit Application Sanitar Permit Number ` In accord wlth Comm 83.21, Wis. Adm. Code, persoosl infomtation y ou provide 0 ateck iE Revision my be used for Law, s15. 1 m L Apron Information - .Please Print All Information State Plus I.D. Number Property Owner's Name Pared Number Property Owner's Mailing Address Property L.00ation if i4 • S T N.R. B City, State Zip Code Phone Number Lot Nmmber Block Number Subdivision Name CSM Number II. Type of Building (check all that apply) city 0 1 or 2 Family Dwelling - Number of Bedrooms iilaga 0 Public/Commercial - Describe Use �. 0 Spate Owned Nearest Road III. Type of Permit: (Check only one box on fine A (numbering scheme for int ). Complete line B if applicable) A. 10 New 2 0 Repiiceoaent 4" '3 0 Replacement of 6 0 'Addidoa to For County use.. stem Tank Only Exisft System B. 0 Check if Sanitary Permit Previously Issued Permit Number Date Issued N. Type of Permit: (Check all that apply)(numbering scheme is for interned. use) . _ ....... . 44 0 Non - Pressurized In-Ground 210 Mound 47 0 S Filter 50 0 Constructed Wetland 22 0 Pressurized In- Ground 410 Holding Tank 48 O ogle Pass 510 Drip Line 45 0 At-Grade 46 0 Aerobic Treatment Unit 49 QRccirculating 30 0 Other V. ' 1/Treattnent Area Information: ' Design Flow (gpd) Dispersal Area Dispersal Area Soil 4plication PercAhtion Rate System Elevation Final Grade Required Proposed Ra Gals./Days/Sq.FL) (Min. b) Elevation VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel 'Fiber Plastic Gallons Gallons of to Constructed Glass New Existing Tanta Tanks Septic or Hok tag Tanis _ Daft Clnmbec VII. Responsibility S'tateoant-1, We $1211101106 responsibility for o Wl'S on the attached plane. Phmmber'a Name (Print) ",Ke4 1 _ � aa� 6 � ��1� �(F l Plumber's Address (Street, Cifyo s 010D Zip U001), 77dz/e ge V13L /De use 0 Approved 0 Disapproved SattWcy Permit Fee 0aclodes Gronothower late hood Issuing Agent Sigmtare (No Stamps) Surcharge Pee) ❑ Owner Given Initial Adverse Determination EL Conditions of Approval/Reasons for Disapproval At tad► complete Puns W the C002V aab) for tha aystms os papa sat ka than sf/2 :11 iM&W to sise SBD -6398 (R. 051011 'M y t- _ f s � r 'Pam Guinn Subject: Tom Wang emergency tank replace Location: 238 Cty. W, Pleasant Valley Start: Wed 8/4/2004 11:30 AM End: Wed 8/4/2004 12:00 PM s Recurrence: (none) Clarence Jacobsen Sec 19 Ne /SW Near Oak Drive / County W et Tom know when you're headed south 715- 821 -0 4 2 . 44, a ' i S n LEGAL ST. CROIX COUNTY, WISCONSIN OLD TXSCR02 REAL ESTATE TOWN OF PLEASANT VALLEY COMPUTER NUMBER 024 - 1026 -20 -000 Parcel Number 19.28.17.153B OWNER NAME: First CLARENC & HELEN JACOBSON E Last J PROPERTY 1/2 PD -- Street Name -- Type SD Apartment 238 CTY RD W SECTIO W '/4160 %40 Line Description Line Description TOTAL ACREAGE 1.030 PLAT LOT BLK 01 SEC 19 T28N R17W IN NE SW 15 02 COM 312.8 FT S CEN SEC 19, 16 03 TH W 225 FT, S 200 FT,E 225 17 04 FT TO C L HWY, TH N 200 FT 18 05 TO POB TOWNSHIP PLEASANT 19 06 VALLEY. 20 07 21 08 22 09 23 10 24 11 25 12 26 13 27 14 28 F1- General, F4 -Prev. Parcel, F5 -Next Parcel, F7- Valuations, F8- History, F10 -Exit o " f i jO� S 7 Pam Ouinn Subject: Tom Wang emergency tank replace Location: 238 Cty. W, Pleasant Valley Start: Wed 8/4/2004 11:30 AM End: Wed 8/4/2004 12:30 PM Recurrence: (none) Clarence Jacobsen Sec 19 Ne /SW Near Oak Drive / County W Please call and let Tom know when you're headed south 7 - 821 -0424 f ?i 2� � i /-- F d Z4 e, :P; lit r � N M 3 � Gaw 4ge ��, �,, �•M: System Management Plan • PuFsuant to Comm 83.54, Wis.Adm. Code • Sectr_ 'c Tank . The septic tank shmlfbe maintained bY an . SeR� tank 3tia8 to�fied to service s eptc tanks under s. 28 Stars. The contents of the �sposed of in acc irdance with NR 113. Wm Adm. Code. The operating condtion of the septic tank and - Collet Ater shat be assessed at least once eierl 3 years by inspection. The outlet lifter shall be cleaned as necessar/ to ensure proper operation. The filter cartridge should not be removed unless provislons are made to retain solids in the tank that MY slough off the filter when removed from its endcsure. If the filter is equipped with an al- rm , the futer shall be serviced if the alarm is acbated continuously. tnteni ttent filter alarms may k dmte surge flows or an impending continuous alarm. The $eptic tank shall have Its contents removed when the volume of a and scum in the tank exceeds 113 the volume of the tank. If + Me pntertts of the tank are not removed at the lime of a ttiemtlel assessme% ingintenance shell advise the'owner of when ttte next service needs to be performed to ata;cd less than mminum scum and sludge won n the tank The axiditar of bbbgkai or dwnicw edditves to stance septic tank pedam ante is generJy not required. However, if such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and ifu�ng Division. . Pum Tan T PWW (003ing) tank shall be kmpecWd at least once every 3 years. Al awes, alerrns. and pumps shaft be Wdkd to ! Y PWW fin• it an smuert tier is instaw win the tank it shaft be inspeded and servk ed as necessary At- tads Com onent and Pressure Distribution System 0-trees .or shrubs s ou ve ante b e made around p or allowed to grog on the component. Plantings may y the perimeter imeter and the component shall be seeded and mulched as necessary s r to prevent erosion and to y than for vegetative maintenance) on the p component is not r alloa d. Cold weather f install- ations require the component to be heavily mulched for frost protection. Influent quality into the at -grade system may not exceed 22Omg /L BODS, 150 mg /L TSS and 30 mg /L FOG. influent flow may not exceed the maiizia design flow specified in the permit for this installation. be system is p vh a Aushinp point at the end of each lateral, and k is teGUa NNW heat sac's soft at least Once every 18 amts. When a pressure test Is perbmed it should be req V W b hest when the sysh m was t ubi1ed b determine P orifice doggtn t �x p has occurred and s cleaning is squat disOibuBan v#ft the ceL Observation pipes within the dispersal cell shall be* chocked for effluent ponding. Ponding levels should be reported to the owner and any levels above 4 inches considered' as an impending hydraulic 'failure requiring additional, mote frequent monitoring in accordance with Comm 83.52 (2). ' General ° mss system shall be operated is accordance with Comm '82-84 Wis.Adm and shall be maintained in accordance with it!s component manual SBD 10570- P•(B.6 /99)'and.local and state rules pertaining to system maintenance and maintenance reporting.. No one should suer enter a septic or tank _ ASP since emus � � �► be present that � ruse deaat. Septic and PUMP fS� � shy be In a VAh Comm 83.33. W& Adm. Code when the taft ace no knger used as . . Septic or pump tank manhole risers, a=ess risers and covers should be inspected for water tightness and soundness. Access openings used for swvk:e and assessment shall be sealed �raxd, defective. or subject b failure must be � upon the aunpletlan of service. -Any opening deemed be smxued • Exposed a=m openings greater than 8 $r diaMOW shag ..._boll t�ttive loddng device io prevent accidental or unaufhorized entry into a tic or comp men L If tbe:apffc tank or ?nY o a s coatpoct became defectva On t& or component shall be repaired or re#ced to keep the Ne w pump. pimp controls, alarm or rehied wiring becomes die the dekdive shah be �!I t ot of ft aam® or equal pwftmncL _ If th sat -glade componeat to accept naafi atei'oi tieris"Trdisc rge wastewater to the gionad surface, it tray be necessary to install arc aerobic pre - treatment unit or - replace the component. Additional site and soil evaluations may seed to be done and additional plans may to be prepared and appioved by the Department of Conmerce,• Safety and Buildings Division. . Questions about the operation or aaiatenanee of this system should - be directed to :� The County Office at • =1 lS - Z 6 PtQ `� - T J���f'dix The system installer at 1lS— �l2$- °tgSR h3'A'fll� The tank manufacturer at app- 3ZS -$yS, h]tESt The effluent filter' manufacturer at k)b - ZZ,L.. 57112. ST CROIX COUNTY SEPTIC TANK MAINTENANCe AGREEMENT . AND OWN CERTIFICATION RORM wn uycr � G, b Mailing Addrem 3 � C J a , Property Address (Vcnficatioa tr"md from Pb Amg DVatmeat for acw coastruc(ioa) aty&uc e� X 12.. I . Pam Idea on Number der lee --ao ; � r A.L DE N Property Location y., S �S y sm. W. Town of LOS, LI subdivision Lot # CCxtifica Stunt y Map # vok me page # WamaOr Dena # Volume p age # Spot. bom ❑ yes D no Lot tiros ida iftlo 0 yes a. no Gial�IC b�CatiIC�C « � • �J S `".wQlCii 1c im, b $*adrt* SL Gbooc?t jL sig�ood by8reovmecaadi�y s IaGctodpb«-a (i�t5cocteuocirutc asst �s sum oc aoa�'lid�anaadla(� air �mdpm (� the o I=A mWA aft -� �Lrneoadbaabore . �foeb.�++g.�soet tie iad e bm�m�epa�r�e =9s6ca�w�Qia�omd�s . ��, sa[ Ooavmr, �ce�radd�eDtg ,,�,o,��eofWmoonsta. &.WofsoQane da6c. a '?` ` odmn � cbcoom � i c�odmdr�cocuodtot 6 eS4Qvbc .Co=LyZ.00iag<)W=vca30 -11i��n OP DATE (irnRrr��nrgN Y (we) me* Qmt all mtmcots on this feat aae tme to toe bat of my (oo low I (wee) am (are) dw ow=(s) of t'�'oPY above, by victor of a wsmvqdoodm000dodinaofDoods DID DATE Azy iafo'mu dat is mis{Cpceseotodmiy tesalt is the unkw permit being wvaimd by d o ZnivS , ""* ** "� Inc[adc vr[th tbts appttcR&w a sb=pod wa=v1y dood fimu tba R haw of Doods oMft a copy of &c cediftod tottery coop if wcocaoc is made is the want* deod WARRANTY DEED.— i wband and Wife as Joint Tenants FORM 399 (Revlsed) q �_ _ — - i This I ndenture, Made this ... .-------------- ._... - - - ---- ._day of---- .- - - - - -- Apr?s- -. . - -- __ -- in the year of our Lord, one thousand nine hundred and -..... t4. ayanty.- thz 'ee ------- ..between...Clarence J. Jacobson I - .- -- -- -. -- - - -- . -- end Helen Jacobson, his Wife .............. ................... --- ---- -- - • - - -- - - - - -- ------------ - - - - -- -- -- ---- ---....- .......... -.. I li ....... • --------- . --------- • ...... ---• ----------------------------- ----------------------------- - - - - - -• ------------------------ Parties ----- of the first part, and ....... Kichard W. Jacobson and Dorothy J . Jacobson - - - -- - -- -- - -- - -- - ------- .... ... . -..- -- ..... -. - - -- - -., o f ... River Falls,. Wisconsin husband and wife, as joint tenants, parties of the second part. Witnesseth, That the said part ie.s. ....... of the first part, for and in consideration of the sum of .. .One— Thousand and no cents ($1,000,00) -- _ _ ._ _. _ _Dollars, to - -- -them in hand paid by the said parties of the second part, the receipt whereof is hereby confessed and acknowledged, ha Ve.. .given, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and by these presents do..... grant, bargain, sell, remise, release, alien, convey and confirm unto the said parties of the second part, as joint tenants, the following described real estate, situated in the County of._ .. St. Croix - - -- - - - -• - - ... - -.. _. and State of Wisconsin, to -wit: That certain parcel of land or tract of real estate located in the NE quarter of the SW quarter of Section 19, T 28 N, R 17 W, Town of Pleasant Valley, St. Croix County, Wis— consin, parcel to be conveyed more fully described as follows: from the Northeast corn— er of said SW quarter go South along the East line of same a distance of 312.8 feet to a point in the centerline of CTH "W °, said point being the point of beginning for parcel to be herein conveyed; thence West parallel with the North line of said quarter a dis— tance of 225.00 feet; thence South parallel with the East line of said quarter a dis— tance of 200.00 feet; thence East parallel with the North line of said quarter a dis— tance of 225.00 feet to the centerline of said highway; thence North with said centerline a distance of 200.00 feet to point of beginning, the above described parcel containing 1.03 acres, more or less.