HomeMy WebLinkAbout026-1122-07-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count y
Safety and Buildings Division
INSPECTION REPORT St. Croix
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)]. 353288
Permit Holder's Name: ❑ City []Village ❑ Tgwn of: State Plan ID No.:
Wi lliam Richmond Township ` -`—
CST BM Elev -: Insp. BM Elev.: BM Description: Parcel Tax No.: —
• O I ts0 • r) i w�� 1 - - 0+ S4.t c_ - �- : cQ pending
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic S �� Benchmark o 4,gg • 0
Dosing Alt. BM s• 12
Aeration Bldg. Sewer , 35 q�, 53 r
Holding St/Ht Inlet $O CY7 .0 $
TANK SETBACK INFORMATION St/ Ht Outlet ,d , ( ?3
TANK TO P / L WELL BLDG. Air i to ntake ROAD Dt Inlet
Air
Septic >4 ^'36 — NA Dt Bottom
Dosing NA Header / Man. -
Aeration NA Dist_ Pipe `N6.06
Holding Bot. System & qcr
PUMP/ SIPHON INFORMATION Final Grade 9 o `
Manufacturer mand St cover �Or 3� g• �9 r
Model Number GPM
TDH Lift Frict' Sit m TDH Ft ea
Forcemain I Lefi Dia. H Dist' e
SOIL ABSORPTION SYSTEM
BWKTBEN Width Length N f Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DI MENSION S 8� 93 DIMEN I N
SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manuacturer:
SETBACK CHAMBER A (4—:6- - C. t&` '`'`-
INFORMATION Type O ( �^ Moe Number:
System: Cowv. 3 4 3 �� OR UNIT a.0
DISTRIBUTION SYSTEM
Header/Manifold a Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing } (W r
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 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: 3 /IS /O° Inspection #2: - i l
Location: 1121 174th Avenue, New Richmond, WI 54017 G4W 1/4 SW 1/4 4 T�qN R18W) - 4 30.,8. _ _ _ _West Side
Winding Trail Estates -Lot 7 C o �S' l�- �.csg•�,..
1.) Alt BM Description = Si « u'°� k " 1 Q ,t � MS
2.) Bldg sewer length= S
- amount of cover = L/
Plan revision required? ❑ Yes ;9(No
Use other side for additional information. (9 d t+- — M] �0
SBD -6710 (R.3197) Date Inspector's Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Vi sconsin Safety and Buildings Division
SANITARY PERMIT APPLICATION 2 1 B W shington Avenue
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
than 8 112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
35 zv
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. APPLI ATION INFORMATION - PLEASE PRINT ALL INF RMATI N
Prop y ner Name Property Location(Or67
Pr
1/4 1/4, 5 T , N, R
operty Owner's Mailing Address Lot Number ~ Block Number
Lit State Zip Code Phone Number S di ision Name or CSM N ber
� / ( ) �, ,
II. TYPE F LDING: (check one) ❑ State Owned 2 ❑ it� Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms y E3 Town OF '
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑Apartment/ Condo - - , � o, i •���
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
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. ;g New 2 ❑ Replacement 3 ❑ Replacement of 4_ ❑ Reconnection of 5 ❑ Repair of an
______System ____ -_ -_ System _- Tank Only_ __ ______ _ __ __ Existing System ____ -_ -- 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 D§ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit -� n� _�((�� 43 C] Vault Privy
14 E] System -In -Fill , r�R aZ�
VI. ABSORPTIONS STEM 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) Elevation
G Feet Feet
VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name concrete Lon Steel glass Plastic App
Tanks Tanks
New Existing structed
Septic Tank or Holding Tank a 0 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ 1 ❑ I ❑ I ❑ I ❑ ❑
Vlll. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for inst Ilation of the onsite sewage system shown on the attached plans.
Plumb am : (P Plum r'sS at o s) MP /MPRSW No.: Business Phone Number:
!t / -
Plu ber's Address (St� t, ity State, Zi ode):
a �
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate issued Issuing Agent Signature (No Stamps)
\
X Approved E:] Owner Given Initial Surcharge Fee)
Adverse Determination 1 / _
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -6398 (R. 4/99) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
l
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 owne'Fship 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 licen6ed 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 Divia + on, 266-3.151•.. -
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.' `
Il. 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 OrilY_ Y f
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 112 x 11 inches must be submitted to the county. The plans must
include the following:' A) plot pran','drawn to scale oe with complete dirriensions, location of holding tank(s), septie
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.
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GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated.practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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AL 5�417
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Wi scon*in Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page of
Bureau of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and :5�41 4!::e
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
02.1• - /o/ 3 - 10 -1
APPLICANT INFORMATION - Please print fo_"t '•', Reviewed by Date
Personal information you provide may be used for seconda Privacy La s. 1 .04 (1) (hl)).
—&
Property Owner ! . `' ; �', , .� -,-, Prope , Location
/�GlUdol O f Govt, fiat 1/4 �( /4,S T Q ,N,R/ � E (r�
Property Owner's J M aa i ll iing ' Address � T ter Lot # ' - - - - Block# + I Subd.NameorC S M# ,_ (a� � Q &j aq;L
Ci S to Zip Code P hone J"Y j Ne st Road
d � � � •, ��,✓i Village Town
S � . i�� l
LS-N ew Construction Use: Fiesidential / Number of e ' ms Addition to existing building
LJ Replacement ❑ Public or commercial - Describe:
Code derived daily flow gpd Recommended design loading rate bed, gpd/ft • ' trench, gpd/ft
Absorption area required bed, ft 2 _ZeN0-.& trench, ft Maximum design loading rate . c bed, gpd /ft :5 trench, gpd /ft
Recommended infiltration surface elevation(s) fT S - ,.a ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material ! a Flood plain elevation, if applicable Je ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system I A�s ❑ U 5;s El U ;9s El ,� E] U S U El S 2ru ❑ S U
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD /ft
g Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
y O •L
,A
0.7—
Ground - �' •� - Z/
e �� lev. //
Depth to
limiting
factor
3 Y Remarks:
Boring # p
01 o p
'r
Ground
elev.
Depth to
limiting
factor
> in. Remarks:
CST Name f Please Print) Signature Telephone No.
Address Date CST Number
,f 1
PROPERTY OWNER "�/ /�,f c SOIL DESCRIPTION REPORT Page of
PARCEL I.D.#
Boring Horizon Depth Dominant Color Mottles Structure 2
9 Texture Consistence Boundary Roots
in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Jam ► *5t
Ground �y,►/��-' , l� ��j
elev.�
Depth to
limiting
factor
Remarks:
Boring #
Ground
ellevv
�' O tt•
Depth to
limiting
faptor
in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Boring #
�
d _
ppo
U ;
Ground
elev.
�ft.
O 5
Depth to
limiting
factor
� Remarks:
Boring #
I
! ,
Ground
elev.
ft. '
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R.9/98)
Soil Test Plot Plan
Project Name /j �� Byron Bird Jr.
Address 4�&=
STM X0 S �
0 �
Lot Subdivision Da'te
�1 /4 Z1 /4S 2T ' 70 N /RYW -,- Township �,
Boring Q Well PL Property Line County
BM or VRP Assume Elevation 100 ft "'
System Elevation *HRP
b l , h
i
V A 3�
®�
P-,
i - s- q9 t+ ,Q�Q f �
C W- `5 �`� - cJ WV, "
AA4& ",441's t �, JAW
Ao
�O X 52.
Scale 1/4" = 10 Ft. When Dimensions aren't stated
i
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
l OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address �:"A'23 J.4 7:Z�/ Z
Properly Address Z 1
(Verification required from Planning Department for new construction)
City /State Parcel Identification Number
LEGAL DESCRIPTION
Property Locatio y
JJJ V4, ,$mil V4, Sec. , T
A N -R W, Town of
Subdivision - -� - Lot # 7
Certified Survey Map # . Volume . Page #
Warranty Deed # , Volume . Page #
Spec house 0 yes ❑ no Lot lines identifiable [a yes ❑ 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.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
masterplumber, joumeymanplumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system
ism proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Uwe, 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 Zoning Office within 30
days of the three year expira . n date.
Y 1
SIGNATURE OF PLICANT DATE
OWNER CERTIFICATION
I (we) 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 abov virtue of a warranty deed recorded in Register of Deeds Office.
�� i
SIGNATURE OF APPLICANT 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 in the warranty deed
WARRANTY DEED T HIS %V4k;X R[9ERV[O 'OR R[COROINQ OATH
STATE BAR OF WISCONSIN FORM `l — IN2
- WISCONSIN
Dennis W. Schultz and Rachel Schultz, husband
:. s
and wife as joint tenants � � ..... " - - . - -.-• .. 3 0th
Sept.
conve }'s and Warrants to W illiam - Stock - a:id Roxanne D.
Stock, husband and wife a� „point tenants
- - -. RETURN TO
... .......... Northwest Federal S &L
_.... - eaI .__-.- _ P.O. Box 160, New Richmald, WI
4 (? 1
7
the following descr; bed zeal estate in .. St.....GXQ.�,y_...- ....._.County,
State of Wisconsin: ;
Tax Parcel No : ..............................
Part of the "k Quarter of the Southwest Quarter MW of SF a) , Section four (4) ,
Township Thirty (30) North, Range Eighteen (18) West, described as follows: Commencing
at the West quarter corner of said Section Four (4); thence South 89 58' 56” East along
the East-West quarter Section line of said Section, 660.38 feet; thence South 01° 07'
40" East, 330 feet; thence South 89 53' 56" East 660 feet; thence South Olo 07' 40"
Fast, 634.57 feet; thence North 89 58' 56" West, 330 feet; thence South 01° 07' 40"
East, 33 feet; thence North 89 59' 55" West to the West line of said Section Four (4);
thence North along said West line to the infest quarter corner of said Section Four (4)
and the Paint of Beginning.
This is -lot
.- ....homestead property.
(is) (IS not)
sceptioa to warranties: �
20th day of September is 85.
(SEAL)
(SEALi
Dennis :7. Schultz Rachel Schultz
(SEAL) _ _. (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Sigmature(s) _- .,,. -- STATE OF WISCONSIN
SS.
- -- -- - -- -- County.
authenticated this --- ._ -..da of. _.__.------ __ lg. ..... Personally came before me this __.2 -day of
Sep to mbe T _ 19 _ the above named
_.._. -.. -._ Dennis .�. S c hultz and Rachel Schultz.
-- -
TITLE: �NfE.l1i3ER STATE I3AR OF SISCONSI- N -- - - - - -- - - -
._..-__---- ._.- ._- _------ •----- -._ - - -.-, --
i If not,
authorized by .._.._._...- .. - - ---
Y 3 106.16, Wis. Stats.J to me known to be the S
person .- .__... -. who executed the
Fo�etniTrg instrument and acknowledge ths,NNru,
IN R:;`nFNT HAS OR.�FTED BY „f'� ."","*
,�, , Ey ,
Reins tra, flan Dyk & Needh m J.C. _/.. z t :.�
ttOrn2 f __
n a L:iw i nda J i od r ".
2ich ..,ond, .i'(i S.CS?ZlalTl. .. Sn 7,0 .. � . ,�
� Mary Puhlic St. �a'h X_ . - G —
i algnat -ores may he authenticated or acknowledge.d. Pnth Iiv Cnmmi =.von is nermaneSt. r t, b'tat expi�l
- ire not nec ,
sary.) � L • GG77
date: 11 t Z). 19
•gamy • +r^.rr.a aRa;n¢ :n y , •a::urry h. .i ; O Jvd !
„e :.. .. r;td •!n.a• cn•r =fr r.an:n< �,' >�. � •••�
.... .. .` STAr?, B:.R OF wjScOySI': •9 L -r ..
K _&&1 Cu..p.*y M FORM NO 2 SfrCk N O. 1 301