HomeMy WebLinkAbout026-1122-08-000 / lisconsirl Department of Commerce SYSTEM Count y PRIVATE SEWAGE SYS
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)1. 353300
Permit Holder's Name: ❑ City ❑ Village ❑ Aown of: State Plan ID No.:
tock William I Richmond Township
CST BM Elev.: , Insp. BM Elev.: , BM Description: Parcel Tax No.:
I L-212 • O ep . O ST 13 r10� :L - - � o'� S (a. _ pending
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 2 d0 Benchmark 3 1 OV D '
Dosing Alt. BM 3. S",Z
Aeration Bldg. Sewer 5 32- o . 99
Holding St /Ht Inlet $75,e 101•IfS'
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Air I to ntake ROAD Dt Inlet - ---- --
Air
Septic 3 NA Dt Bottom —
Dosing NA Header / Man.
Aeration NA Dist. Pipe z 9�•s$
Holding Bot. System
t o- 1 1 t 11. 00' a B' 96
PUMP/ SIPHON INFORMATION Final Grade �• �Y 99.6D
Manufacturer Demand St cover
Model Number GPM
TDH Lift Fri * n S stem TDH Ft
ss ad
Forcemain Length Dia. To well
SOIL ABSORPTION SYSTEM
TRENCH Width Len th f No Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIME N�' $D ' DIMEN 1 N
SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
SETBACK • (•4v� - S1&&o 1
INFORMATION TypeO CHAMBER Model Number:
System: W.v ( / �- OR UNIT p C
DISTRIBUTION SYSTEM q0' + G '-t l0 38
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
u r
Length Dia- �_ Length — Dia. Spacing
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_/15/00 Inspection #2:
Location: 1117 1117 174th Avenue, New Richmond, . W W I 54017 (NW 1/4 SW 1/4 4 T30N R18W) - 4.30.18. ----West Side cl Winding Trail Estates - Lot 8 �� GV°`'�^F�w'
� I' - t h reG� �
1.) Alt BM Description = 5� ''�1 - 4AA--�
2.) Bldg sewer length
- amount of cover =
1z K
00 L-ea
Plan revision required? ❑ Yes CR No A f k 1 2-
Use other side for additional information. O O oi r
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No
ADDITIONAL COMMENTS AND SKETCH `
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 W. Washington Avenue
Visconsin P O Box 7302
Department of Commerce In accord with Comm 83.05, ' .� '' f .� Madison, WI 53707 -7302
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Attach complete plans (to the county copy only) for the st;ptrr, on p per not less County
than 8 1/2 x 11 inches in size. .
• See reverse side for instructions for completing this a p`bcation JJ state sanitary Permit Number
Personal information ou provide may be used for ... 3
y p y second purposes - E °� �r � �`�ji't} Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. ?<
ate Plan I.D. Number
I. AP LI TI N INFORMATION - PLEASE PRINT NF
Prope 1071 erName Prope" y Locat
t/a 1 , S T , N, Rlg E (orb
Property Owner's Mailing Address Lot Nu[nbel\ - Block Number
y,
C 4 it, Cit , tate Zip Co a Phone Number Sub ivision Name or CS Number
YP F BUILDING: (check one) ❑State Owned ❑ !t� Nearest Road
E] VII age
Public 1 or 2 Family Dwelling - No. of bedrooms
Town OF
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Numbers)
1 [] Apartment/ Condo &
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 104 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. CR 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 ® Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System -In -Fill g
VI. ABSORPTION SYSTE IN ORMATION:
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 (s ft.) (Gals/day /sq. ft.) (Min./ nch) Elevation
Feet Feet
VII. TANK Capacity gallons Total # of r Prefab. Site Fiber- Exper.
INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete st noted Steel glass Pla App
Tanks Tanks
Septic Tank or Holding Tank 1A .2 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ I ❑ 1 ❑ 1 ❑ 1 ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the ndersigned, assume responsibility for iW of th nsite sewage system shown on the attached plans.
Plum r' am Pr Plum ign r i p MP /MPRSW No.: Business Phone Number:
3
Plumber's Address (Stre, City tate, Zip fie):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuina Agent Signature (No Stamps)
A roved Surcharge Fee)
pp ❑Owner Given Initial ,,��ff
" 1
Adverse Determination a�.� . &M
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
i
$BD -6398 (R. 4199) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit maybe 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 ownership 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 nfaihfained.' She septic tank(s) must be pumped by a licensed 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- Buildipg6 Divisiori., -608- 266 - 51-51. -
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.
II. 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 isto 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 Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale o'r with complete'dimer'sions, locatron'6f holding tank(s), septic_
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 th 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) fora 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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Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page of
Bureau of Integrated Services in accordance with Comm 83.09, Wi 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 �T
rG✓'p/
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. #
APPLICANT INFORMATION - Please print all i Reviewed by Date
Personal information you provide maybe used for secondary pu nkticy =Laws 15.04 (1) (m)).
Property Owner Propei� Location J
' Govt. Lot �1/4S/4, T E (a®
Property Owner's Mailing Address !/r ° ` Lot # Block# Subd. Name or CSM#
�7
I.,` k�cau
Ci t State Zip Code I`*e . A t �i� ❑ village
Town Barest Road
�ew Construction Use: Residential / Nu oi'bia 'ropl ' S Addition to existing building
tJ Replacement ❑ Public or commercial -
Code derived daily flow � gpd Recommended design loading rate _ bed, gpd/ft • trench, gpdhI
Absorption area required . lo e_:j_ bed, ft f t rench, ft Maximum design loading rate bed, gpd /ft ._J -- french, gpd/ft
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design /site considerations 7 --
Parent material G Flood plain elevation, if applicable
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = unsuitable for system E,;163 ❑ u 5's ❑ U 2-8 ❑ U I L(� ❑ U ❑ S -au ❑ S -R�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
YXV
Ground Av
elev.
�► O�� ft' '
Depth to y
limiting $� ;
factor
3- Remarks:
Boring # .2-
. CL
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Ground
j elev.
Depth to
limitin99��
factor 5
in. Remarks:
CST Name E e Print) Signature Telephone No.
Address. CST Number
/ SOIL DESCRIPTION REPORT
PROPERTY OWNER � ` "� � Page of •
PARCEL I.D.#
Boring Horizon Depth Dominant Color Mottles Structure 2
9 Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed . Trench
Ground
elev.
Depth to
limiting
factor
Remarks:
Bo Ing #
Ground
elev.
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Structure Consistence Boundary Roots GPD /ft2
Texture
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # O /l� ,t.� ��_� //f' /2 •
G Z , • 3�
m
Ground
elev.
Depth to
limiting
factor
in. Remarks:
Bo Ing #
Ground
elev.
ft.
Depth to
limiting
factor
' Remarks:
SBD -8330 (R.9/98)
S oil Test Plot Plan
Project Name /�W Byron ird Jr.
Address 7449
Lot Subdivision Date 7 r
& L 1 /4 /4 S T N /RZYW -.- Township
��
0 Boring O Well PL Property Line County
v
BM or VRP Assume Elevation 100 ft
System Elevation Z *HRP z -.�_�,
/1,
1
3
P r �'
4'
/1l Scale 1/4" = 10 Ft. When Dimensions aren't stated
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address '`
Property Address
(Verification requied from Planning Department for new construction) ,
City /State Parcel Identification Number
LE GAL DESCRIPTION
Property Location ,Ntti '/ 4, ,- , 57iJ ' /4, Sec. , _�Z N- R _,45_ W, Town of
Subdivision / 5 , Lot
Certified Survey Map # , Volume , Page #
W r my Deed # , Volume , Page #
P e i S ID ► i J�. �ZL pe 2
Spec house M yes O no Lot lines identifiable 0 yes 0 -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
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 (Z) 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 Zoning Office within 30
day o the three ye e7 t'
SIGNATURE OF APPLICANT 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 descri Z94�7 of a warranty deed recorded in Register of Deeds Office.
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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
I
0C•C( No WARRANTY DEED * "• ■•• <• " + +• ■o .o" es<o " ", o...
STATE BAR OF WISCONSIN FORA/ 2 —,.
,ct i '
1 �cACt ?5 �
Dennis W. Schultz and Rachel Schultz husband
and wife as joint tenants ." �" "`" -
r 30th
_ .......... ............. ...... Sept. , "
IT
William Stock nd Roxaiin& b—..' L ee and warrants to a _ -- ck, husband and wife .as �o>_nt tenants A t
_ _..... ..... I .. ............ ... ....... .................
...... ... ............... .. .. ....... .... "■TURR 10
. . . ....... _ ......._ .... _.. -. ... ... ...._.. Northwest Federal S &L
__...- ......
S t a following de real otate in .. �t. . ._CrAis P.O. Box 160, New Riahmand, WI
._ ......... ......Cout '4017
i Stata of R'ucorsin: ...... county,
Tax Parcel No: ..............................
Part of the * mrthwest Quarter of the Southwest Quarter (NW's, of SV , Section Four (4) ,
Township Thirty (30) North, Range Eighteen (18) West, described as follows: comtencing
at the West quarter corner of said Section Four (4) ; thence South 89 58' 56" Fast 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 01 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 58' 56" West to the P, line of said Section Fcur (4);
thence North along said West line to the West quarter corner of said Section Fete (4)
and the Point of Beginning.
!r 3• "q�
is not
This __... -._.. homestead proper:}•.
iis) ( not)
- xCrpU— to warranties:
20th _ day of September 19 85•
Ll.'_,,c (SEAL) - F.. _ : L � �� � (SEA1.r
Dennis W• Schultz Rachel Schultz
,SEAL) (SEAL.
AUTHENTICATION ACKNOWLEDGMENT
i
STATE OF WISCONSIN
_..
........ - - -- --- St. Croix
_.. ....... . . ..- County.
aathenLCated 'his ._ . da; aL........__. ._. 19...... Personally came before me this 20 th_.112Y of
Se temb
.- .P.... . w . .... 1985.... the above named
.......- -- - - -- De
— September nnis . Schultz and Rachel Schultz
_ ...... ......... .. ....._.................. .. .
TITLE: MEMBER STATE BAR OF WISCONSIN
_ ...
1 1.0 not,
._. .._. .__._ _.... ....
authorized by i 706.06, Wis. State) .._ 5
_.. ..
to me known to he the person who executed the
forerinK. instrument and acknowledKe th me.
.
INS 7 RI; IFNT N4$ OR>FT ED BY ��� • .r
L �.�E
3eir.stra, Van Dyk & Needham, S.C. - . - /.r., -.__ .::. -.( 01'�•'t ' 1 ,Y,I!j�f��
ttore•7 s at La Linda J. CodEr c� L:
� P. _.. c�'•,i v s�;
New aich::,onQ. _C[isconsin 54 , .,tary p nhlic St �.�tt x"
iSivnawre,t may he authenticated or acknowledged. Path Jlv Cnmmkmon is perm ane G �il� • at
.re not nerrssary.) �.
date: 11-15-87 ';0"
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