HomeMy WebLinkAbout028-1021-90-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
514964 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:
Weber, Lloyd I Rush River, Town of 028- 1021 -90 -000
CST BM Elev: Insp. BM Elev: BM Description: SectioniTowniRange /Map No:
ld /0 � , 0 S �n 4, 14.28.17.121
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benc- ktmark
2•1 X0 10a Z)
Alt. BM
Aerati 7 d Bldg. e^we i:�v U I /
Hold' St/Ht Inlet /„""" �' X A „
St/Ht Outlet "
7
TANK SETBACK INFORMATION 7 (, y
TANK TO P WE BLDG. �at-to Air Intake ROAD Dt Inlet /
h
Septic W rL7 Dt Bottom
Dosing lJ Header /Man.
��� �Hi� g•r q� o
Aeration yL Dist. Pipe
Holding Bot. System / y3
9 9'
Final Grade / 6 7
PUMP /SIPHON INFORMATION
Manufacturer Demand S ve
GPM OC2
Model Number
TDH Lift Frictio s System d TDH Ft
Forcemain Lim Dia. Dist. to Well
SOIL ABSORPTION SYSTEM 2
BED /TRENCH Width 3 ► 1 1-ength 1 No. Of Trencb�s PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ( 12—
SETBACK SYSTEM TO P/L BLDG WELL ILAKE /STREAM LEACHI G anufff
INFORMATION Typ System: _ n J p CHAMBE OR
%�Qr� UNIT Vodel N r:
DISTRIB T N SYS
Heade anifold IDistribution f x Hole Size x Hole Spacing Vent to Air Intake
N Pipe(s) f T I— \j �
Length Dia Length Dia Spacing �—
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over / 1/ Depth Over xx Depth of xx Seeded /Sodded Mulched
Bed /Trench Center -3 �( - Bed/Trench Edges Topsoil D Yes TN,7 ❑ Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:� Inspection #2:
Location: 323 192nd Street Baldwin, WI 54002 (NE 1/4 SW 1/4 14 T28N R17W) N� Parcel No: 14.28.17.121
1.) Alt BM Description = 4 . 5 lS V5 �1 V -
2.) Bldg sewer length = q I ' � �[
- amount of cover = `f Z s� w� in
J o Plan revision Required? El Yes No (� o7 Use other side for additional information. � O I SBD - 6710 (R.3/97) Date Insepctor's Signature
Cert. .
It COMMOVOO .W1.90V Safety and Buildings Division County
i epartment r 201 W. Washington Ave. . Box 7162
sco s i Madison, WI 53 716 Sanitary Permit Number (to be filled in by Co.)
of commeroett tt 5 / I V / 40
Sanitary Permit Application tateTransactio b r
In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate govemm �
unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Project Address (if different than mailing address)
submitted to the Department of Commerce. Personal information you provide may be used for secondary n ^j 3Z3
p urposes in accordance with the Privacy Law, s. 15.04(1 )(m), Stats. �F J"t✓
I. Application Informatio - Please Print All Inf9M i,toon
Property Owner's N me Parcel #
lat� ep '
Property Owner's Mailing ddress L AUG r) 5 2008 Property Location
Q G t /
City, Stat r Zip Coe S C tfr /1f y, /., Section
t
V N N circle one
1. Type of Building (c eck all that apply) Lot # T N; R E W
I or 2 Family Dwelling - Number of Bedrooms Subdivision Name
Block # ��
❑ Public /Commercial - Describe Use t�U,�2
❑ City of
❑ State Owned - Describe Use CSM Number ❑ Village of a /J, r
r r Z_,KYz0 �Townof �? Ald6/
1 6 _ u
III. Type of Permit: (Chec my one box on line A. Complete line B if applicable)
A. ❑ New stem Replacement System Re S
( f/y p y ❑ TreatmentlHolding Tank Replacement Only ❑Other Modification to Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New
List Previous Permit Number and Date Issued
Before Expiration Owner
IV. Type of POWTS System/Component/Device: Check all that appl Lai
N on- Press urized In- Ground 11 Pressurized In- Ground ❑ At -Grade [I Mound > 24 in. of suitable soil ❑ Mound.< 24 in. of suitable soil G
❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) E5
V. Dispersal/Treatm It Area Information:
Des k Flow (gpd) Design Soil Application Rate( so DispersalA ea quired (sf) Dispe Area ropo ed (sf) System Elevation
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units ;
New Tanks Existing anks
g
pti Holding Tank
D4 c
Dosing Chamber
VII. Responsibility Statement - 1, the undersigned,assuipe responsibility for installation of the POWTS shown on the attached plans.
Plu a Name (Print) Plu er ignature MP /MPRS Number Busis Phone
s
Plum er's ddre�(Street,City,State,�iRC e) ^ � ����
VIII. County/Department Use Onl /1\jD
Approved isapprov Permit Fee Date Issued Issuin ent Signatur
❑Own rven Reason Denial
IX. Conditi 8Weasons for Disapproval 1 I f
3
1. Septic tank, effluent filter and �� 'J
dispersal cell must all be services / maintained
as per management plan provided by plumber.
2. All sAwkrequitements must be maintained 1
48 OK Attach to complete plans for the system and submit to the County only on paper not less than 8 to x 11 inches in size
SBD -6398 (R. 01/07) Valid thru 01/09
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County
Attach complete site plan on paper not Tess than 81/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. A p — D — - 000
Please pri Revie by Date C �(
Personal information you provide may be u ed for s�j acy La , s. 15.04 (1) (m)). ✓ 8
Property Owner rope Location
Llo 1le e AUG 2 5 2008 Govt. Lot Nr 1/4 S W 1/4 S T a6 N R 17 � W
Property Owner's Mailing Address Lot # Block # Subd. Name CSM#
3 Z 3 / 7 _ - � V ST. C�(tX-( OUNTY
City State Zip C ❑ City ❑ Village own Nearest Road
G,riT i S - 4 6,, >- (713 -36 1 R u.s 9 a A oL _S7�t-
❑ New Construction Use:% Residential / Number of bedrooms .7 Code derived design flow rate � �� GPD
Replacement ❑ Public or commercial - Describe:
Parent material 4.izs'- soy �ZArC �'i! Flood Plain elevation if applicable A/A ft•
General comments X pe pia f d P t �7 3Gf o
and recommendations: p, ,, ClIsy. CS = C
F-/ I Boring # Boring
N Pit Ground surface elev. ft. Depth to limiting factor 7 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
,r
- 20'� O
Boring # Er�] Boring
Z Pit Ground surface elev. I� ft. Depth to limiting factor O 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
4 cL s Z 61.E /, 6>
9 - -Zv /0 413 - s - k C s 0 - . 9 , v
ri
3
* 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
eG� s isle d s c� / 2� v 6 73
Address Date Evaluation Conducted Telephone Number
41Y 1 30
7 70
R
Property Owner 4 4 G/ Parcel lD # – 0 j ?� � ` O - 0 Page of
F 31 Boring # ❑ Boring
Pit Ground surface elev. 74 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 I *Eff#2
/10
a} 32 -74' zS R5� �s a�l� �S LL - - O• d
F-1 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/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
F-1 ❑ Boring
Boring # Ground surface elev. ft. Depth to limiting factor in.
Pit
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
* 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.
$BD -8330 (R.07 /00)
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cuasuant to Gomm 83.54, Nis.ddm. Code
Becht Tank
The septic tank shaft be maintained by an indivit i certmed b service
septic tank shall be of is �'•k5 tetdet s. 287 48. �. The canW tg d ft outlet UK did lredar>ce vatlt AIR 113, Wis. J1dm. Code. The ttDeag cartdttiort of the
enstue prrtperopemp •The 3 yem by n. The outlet t s�� t o C.taned as n srr�
�f $k"* off the M* VAM a sitadd Wt � reRgwrd are awe 10 retaa solids in the tank that
. the ala ism. . d ds Via. tf the Mw is WM as . me Mw Ad be sanice!1 if
Ott Mw dorms may ipdtcW strpe G= or an in ng c abiwota warm. Tne
tmttc shat bane its OMoved � be voktne of sludge gad scorn kt ate tsa t 1 A the irtaid volume of
Ole medr. >rt a of the tank are ad rmnaved ere tlam of a trteairsi
the ofwbm ere pew M*S b be did Sefte
the tank. The addition of P b at®inmh ktas thsrr atdnwm s arnnWion in
i ec. ifsnCt poduc'.s or addttires b eramrtco a ydee * ked.
Dh h p +heft $flat be approved br septic tank use by the DVulmeatof CM=KM c•.afeitr mid
k_To c
> PUM go*w W* shat be krspecW j*lesetDace
!mil P oPer� ion. 0 an a Owl.$ itch W � ttte ft* itsh�� • and pumpri Ad be 0.t8d b
wed � ssrvkxd'as Beceawy.
At- Made G eat and Pressure Distribution S steza
o.trees .ors s a o
be m:de :roand.the Perimeter and to 'or _ to a rov on t the canponeat. Plantings Way
to prevent eroa3ga and to prorideaou protection from treated and mulched as necessary
than for Vegetative penetration. traffic (other
ationa some oa the comPonant is not.alloved
companeat to be heavily anl . Cold zeatber install-
require the ched far frost protection. _
Influent quality into the at -grade system nay not exceed ZZ
so thi s 3as ��ta�tion,flov mad not exceed the mat -m - design f1�ov and
for 8 s D5 pecffied In the
permit Thep gums &*jboom
thi
t
mpwtha
iater� be d p
so out Bt the and of eat feral, ad it b r ft It ena
rsd b Ore id6i ds at ie est y etru 18 moaete. Wha a pr - m watts
Rio mtei�ia � Vw b tt� aed r� is
Observation pipes within the di
apersal cell shall be for effluent
E levels Should be reported to the owner and nay levels above i Inches cons idered '
as an Upendi °rdanc C omm - 83 hydr nre requir3aa additional, more frequent monitoring in
- 6ameral •. -
' -SY 3 t 4 m shall be operated fa accordance with Comm 1s2 -$4 fFis.Adm.
maintained is accordance with it•.s coupoant annual SBD 1OSWr (,,.*Code and shall be and .local and
State roles per
t:�8 t o ayaten maintenance and maintenance reporting..
No ouesboaid evec�a0era - ...._
b Wig Codeieirea etemait: ire Dealt.
bagervs.das -
0r ttbc .s thetaaad sltouid dedtbcwater atd$od *Mw. /lm=
uieed ltorsert�lop gad atae 0esated
ar subj�t ebd bmuvtbe ' ��Wm!��oadst Jygope�9
��dnp devit:sb ac°°as°,paeendertbaa iod>$Im1
- ---,. P�aodderdsl oreatilMo a m�horcderpoaertt
_ ,ippt�� -���°'�detse.�sthe: ""'" �dnponartahelbarsrp�edorw�Cedbloeep ' : .
witirldot wpioedt° rid+" beoatwedeibc�rartn ilk tiU�etopipoaentsW be -
oot�oAetttd4esttrpeategnsitpedoraaaa.
If the_
• b t: tiasta+rattts
� stoma , it be = � w _ _. ursstaaates to
ssue�►►
aaaassa t o bssttail ap
- to ;Pn- tr!attoatt rnit or
�eamt. itiomal sits amp soil• _
8�fe tad P� SIW gaga Do . p trod sp*oeed�yt he Dip tUt o Commerce..
ti �'8ivisi�..
t>re eperatioa at aaiitenstece of this arstat should be 3�,:aetot�t
ikta Cemttyrnit Office at - %ys. 2�- �,.b��? P�L�t�;- .:�'•y/af 3$'d`yE��
The $"stew installer at - I ts_
!Le tarot agmataetarer as ��� - gyS�, hll@5t�tt
The effluent _filter' maaufactarar at km - Z21 S7�t 2. 2-fCS�
rte �, • .� . _ 6 3 p- _8?,O -y.�' �t F Gotn,..t�g .
SEPTIC TANK MAINTENANCE AGREEMENT
• AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer Q U
Mailing Addres
Property Address IX) 114 l.(/ ` en
(Verification required from Planning & Zoning Department for ne construction.)
City /State ��,\ : _ Parcel Identification Number
LEGAL DESCRIPTION
Property Location /4, S w '/4, See. _�, T 0(� N R W, Town of
Subdivision , Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # Volume �� , 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 §Gomm. 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
�%;j lav,
IGNATURE OF APPLICANT(S) 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)
ti DOCUMENT NO. -
WARRANTY DEED
II ::,;- seece oozgay¢a cos aeeo:eo+ne ow
!! <<
I ISTATE BAR OF WISCO FORM 2 -1882 li S ISTERS OFFICE
1 1t
ii � ti �_ t r��,i. �� ri Sr. c rix r' I . is
ABC - & for irXoPd this 11th
II _Norris_ -T . -.. Monicken, Rol - and L. Monickers, rtaioy ii da)*a` Feb
• .... ..... ... ..
L_- _Mon ken
ic, Dorothy -- Sebion, a
�! a
f
Mart 1. - 1.... James O'Connell
11 - - -- - - - -
Y - • --' -•
II L1�; �; < �...i...Y �.r nd Cli �:.._ fton 8:30 A
n�r.. __ .::__ -�
cot,ce } =. and warrants ,to "`-"� -� - - -- - - -� --
II n
.._ - - - - -- - - - -- ---...... - - - -- - - - - --
Weber, his wife
li -- — �,
I Oe clty it
1 ...... -- -........ .......... ---• ------------ - ........ ...................... --
F`I .. -- II rseT.nw T.
--- - - - - -- ........... .
the following described real estate i . St - . . Cz'o_iX .. ............... •........ County,
-- - — --
+� State of Wisconsin:
n
Tax Parcel No- -------------------------
North I+
North one half of Southwest quarter (N'2 of S1-4) and North Half of
I
Southwest. quarter of Southwest quarter (Nkof SW4 of SW4) of Section
II
4 NT. .hPast quarter of Southeast quarter (NES
of SE4) and the North half of the Southeast quarter of the aouLUeaSL. II
1 I quarter (N- of SE I I of SE 4) of Section Fifteen (15)
I All in township Twenty -eight North (T28N), Range Seventeen West
(R17W)
f 'Phis deed is given in satisfaction of that certain land contract
between Lloyd J. Monicken and the grantees dated September 20, I)
1975, and Recorded in the office of the Register of Deeds for St. II
l Croix County, Wisconsin, on September 23, 1975, in Volume 528 of
Records, at Page 611, as Document No. 329346.
This .....
.- -___- - homestead property.
(Ys) (is not)
Ii J•:xcepLiol, W Wairaia 1 -
;es: IE'ns and restrictions of record and except
any liens or encombrances created or suffered to be created by I�
the grantees, their successors, or assigns.
Dated this _. ....... -,r - ---- -. - -------- day of ........ �Cn(va Ky ........ ............ .............. j 19. �.6
.dYLC�i�� ......(SEAL) �.. �... �f ) /..
- on � ten_ _ .- Mal .L,...Mon.icken...... .......
1
1 t /� `
- . ..� - ---- --- (SEAL) _(SEAL]
I l ! G - .... ........
Roland L. Monicken Dorothy Sebion
!
... ...................... ..
i1 O Mart
AUTHENTICATION ACKNOWE.FDGMENT
I Signature(s) JLt �DL ii_. / YI2 1c'_ k�. .,_IS <.ItcJ : .1i1:�,cc , STATE OF \WISCONSIN
f_ylti /i: _l : /Y1.1, „ <r.. _ Qbf�ltwt_ S L�f� y , �Q G�,F,- .'.t- 11f��t�✓ll sa.
_ - -........................ ------------ County.
i
__ '� Tdn.✓d
� autY.ent_ ted this ��.___.day of__.�__._.___ /. _.., 19?tEz_. Personally came before me this ................day of
�f -,-------------------------------------------- -_ - 19..U the above named -
TITLE: MEMBER STATE BAR OF WISCONSIN
`I ----- -- ---- -- ••_-
(If not. - -- - ------ - - --- -- - ..._.._
.....-- ..............
authorized by § 706.06, -W is. StatsJ to me known to be the
person ...... ..... who executed the
ji foreI:toing instrument and acknowledge the salve.
Ij THIS INSTRUMENT WAS DRAFTED BY
I Thomas A. McCormack __. _... _......... ..._.. _
.1 ---- -- -- --- -- - --------- ---- ..............
....
BaldW n� WI 5- - 002 -----._........ Not:,•} Public Ceun' }. Wis.
(Signatures may be authenticated or acknowledged. Both lI” Comm+`• °Inn is perr,elnent.tif not. state ext
are not necessary.) date:
-Names of persons SixninK in anY �n Dn�res' vv.u.•i d,.. r: F., .7 • ... •+. .-
WARRANTY DEED STATE BAra OF W[ACL/i -;IN µr:•..n-in f ••anl V.:'.
FORM _JO. 2 — 1