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Wisconsin Department of Commerce Count y PRIVATE SEWAGE SYSTEM
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)]. 353284
Permit Holder's Name: ❑ City ❑ Village ❑ Tlawn of: State Plan ID No.:
Dalton Donald Richmond Township --
CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.:
CD _6 1 � C5 wt, . 544--e— ending
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic w s 12_0D Benchmark 01).0+
Dosing Alt. BM 3, 3D s'
Aeration Bldg. Sewer
Holding St /Ht Inlet ,5,(Z o3.6
TANK SETBACK INFORMATION St/ Ht Outlet /0 3.2I
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic -+ 22- + �5 Z 9 NA Dt Bottom
Dosing NA Header/ Man. f /02.6 S
Aeration NA Dist. Pipe S 7 7 0Z,
I Z to /
Holding Bot. System q• ) 4 Z-- /0 /• 33
PUMP / SIPHON INFORMATION Final Grade
Manufacture nd St cover 3-7 1 19y , 5
Model Number GPM
TDH Lift L Ion tem TDH Ft
For main I Length Dia. Dist. To we
SOIL ABSORPTION SYSTEM
BED / TRENCH Width / I LenZ N Of PIT No. Of Pits Inside Dia. Liquid Depth
DIME I N 8 0 3 1d9=7 DIMEN I N
SETBACK
SYSTEM TO P/L I BLDG WELL LAKE /STREAM LEACHING Man acturer: INFORMATION Type O + / CHAMBER Num e .
System: 2 ( d 93 —a3 OR UNIT
DISTRIBUTION SYSTEM >` r _IA
Header/Manifold v Distribution Pipe(s) v I x Hole Size x Hole Spacing Vent To Air Intake
Length 2 N Dia. Length lJ L Dia. Spacing b > (0 O +
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over t; M Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center �D '� Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS (Include code discrepancies, persons present, etc.) Inspection #1: 4 / (3 /C1b I ec � n#2:
Location: 1113 174th Avenue, New Richmond, WI 54017 (NW 1/4 SW 1/4 4 R18W) - 4 0.1�. _ _ _ West Side
Winding Trail Estates -Lot 9 �
1.) Alt BM Description = x " °
2.) Bldg sewer length = 3 0 Z
- amount of cover =
Plan revision required? [ No `
Use other side for additional information. 6 1 I g o Z I S Z
SBD -6710 (R.3197) Date Inspector's Signature Cert. No
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
� z E
E e f E
3 i �M� E 1 RRR
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I
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Safety and Buildings Division
Visconsi SANITARY PERMIT APPLICATION 2 1 Box Washington Avenue
Department of Commerce In accord with Comm 83.0 is,A4m. o)ie., Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the stem; on pier Less county
than 8 1/2 x 11 inches in size.
• See reverse side for instructions for completing this a pN�ation ` ? e tats Sanitary Permit Num er
Personal information ff «
you provide may be used for secondary purpose ; ,, �] Check if revision to previous application
[ Privacy Law, s. 15. 4 1 m
'�T Cy
Ci1X
Plan late a I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT LL IN
Property Owner Name / / Property Locati n
6- //p i w ,, /a a, S T 7 j d , N, Rl E (o
Property Owner's Marling Address C Lot Num Block Number
CMstte Zip Code Phone Number Subdivision Nape or FS Number r
re
P I DING: (c eck one) ❑ State Owned V E] Cit Ne st Road
Villa
El
� 9
Public 1 or 2 Family Dwelling - No. of bedrooms T w e OF lJ
o n
III. BUILDING USE (If building type is public, check all that apply)
Parcel Tax Number(s)
1 ❑ Apartment/ Condo Y Y
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Out oor Recreatio al Facility
3 [] Campground 7 E] Merchandise: Sales/ Repairs 11 C] Restaurant/ Bar / Ining
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. i New 2. ❑ Replacement 3. ❑ Replacement of 4 ❑ Reconnection of 5. ❑ Repair of an
System ________ System_____________ TankOnly _____ ____ __ExistingSystem _ 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 , Weepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit r i 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons P� y 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
gyp Required (sq. ft.) Proposed (sq. ft.) (Gals/day/ q. ft.) (Min. /inch) Elevation
- 3pe 1, ' Feet Feet
VII. TANK in g allon s s
g Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existin strutted
T nks Tanks
Septic Tank or Holding Tank 1e ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plum is Name: (Prl I Plumb Signature: (No amps) MP /MPRSW No.: Business Phone Number:
Plu er's Address (Street, City, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sa Z� s. itary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
surcharge Fee)
J Q Approved []Owner Given Initial -
Adverse Determination
o
X. CONDITIONS OF APPROVAL / R S �
ORS F DISAPPROVAL- Ls
SBD -6398 (R. 4/99) 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 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 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 maintained. The 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 Buildings Division, 608- 266- 3151.
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 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 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 or with complete dimensions, location of 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 the county; E) soil test data on a 115 form; and F) all sizing information.
----------------------------------------------------------------------------------------------------
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.
RLU l� KLAN
PROJECT o ADDRESS
/�'�( '
,�- E
/ /T�9 N /Fj/. W TOWN - ��-, -o COUNT
MPRS Byron Bird r. 3318 D E
BEDROOM �CLASS PERC_0 VENTIONAL_ IN - J ND PRESSURE
CONVENTIOTVAL LIFT . _ MOUND _
HOLDING TANK
SEPTIC TANK SIZE / LIFT TANK SIZE
DOSE TANK SIZE w HOLDING TANK SIZE
ABSORPTION AREA ! PERC RATE R BED SIZEg
�► Benchmark V.R.P. Assume Elevation 100' — T - - �A i
Location of Benchmark
*
H. R. P.
0 Borehole Q Well Scale = Feet
0 Perc Hole System Elevation
Vent
12•
Grndp
TYPAR COVERING
2" _
12" 3' 4. 6' 0 3' 3' O 3'
I
6" Sewer Rock
12' 18'
D
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rte
v
Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of SafAty and Buildings R 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 r
include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
026 -lo /s —
APPLICANT INFORMATION - Please print all i Reviewed by Date
Personal information you provide may be used for secondary pu s s r p 1, w(si (1) (m)). —
Property Owner , . Prop Location
f ,^" _ Govt. Lbt1 /4I /4,S T er ,N,R �E (o
Property Owner's ailing Address F ,� £ ? Lot # Block# Sub . Name or CS M#
City State Zip Code 1?tinne Nu ` eI w, g ,� Ton Nearest Road
,- _ �. �Ca, ❑ Ci Village /
5kN ew Construction Use: gResidential / Nu e- b�cfooltis Addition to existing building
Replacement El Public or commercial -
Code derived daily flow gpd Recommended design loading rate bed, gpd /ft trench, gpd /ft
Absorption area required Z;qV bed, ft A trench, ft 2 Maximum design loading rate gi bed, gpd /ft r .- trench, gpd/ft
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material 4 z !- d Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system S ❑ U S ❑ U �S ❑ U _ 9s ❑ U ❑ S �U El S .�'U
SOIL DESCRIPTION REPORT
Boris # Horizon Depth Dominant Color Mottles Structure GPD /ft
Boring Texture Consistence Boundary Roots
^VtM in. Munsell Qu. Sz. Cont. Color Gr. S�z. Sh. Bed , Trench
0 Z- 0.
Ground
elev. All
Depth to
limiting
factor
' Remarks:
Boring # �, z o.s
Jq %-
Ground
elev. 3 �p ,
DeptKto I
limiting - ki- s
factor
in. Remarks:
CST Name lease Print) Signature Telephone No.
Address Date CST Number
�� SOIL DESCRIPTION REPORT
PROPERTY OWNER /' / Page � of
PARCEL I.D.#
Boris # Horizon Depth Dominant Color Mottles Structure 2
9 Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
0 .
Of
Ground
elev. , ol
�a�ft. '
Depth to
limiting 3° (e4
factor
a ->
Remarks:
Boring #
44 . s
r
Ground
elev.
Depth to
limiting
factor
/ Remarks:
J Horizon Depth Dominant Color Mottles Structure GPD /ft
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed ,Trench
Boring # o• 2 - ' °•
Or
Ground
el
a.s ;
Depth to
limiting
facto
' "' Remarks:
Boring #
[3
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R.9/98)
Soil Test Plot Plan
Project Name �f �� j f Byron Bird Jr,
Address
/ 7 y$ / /0 7'�4 5
,j c� ��,�a CS M p� 0 S
Lot Subdivision Date
& 1 /4 � 1 /4S I T, N /Rd W -.— Township s
Boring Q Well PL Property Line County � f ��,o�Ile,
BM or VRP Assume Elevation 100 ft "��
System Elevation / � *HRP
f
P a
Scale 1/4" = 10 Ft. When Dimensions aren't stated
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address 4 1 /��' S � �✓ ����J ? C' �� " - -> `
Property Address �w-
(Verification required from Planning Department for new construction)
City /State Parcel Identification Number ,�2
LEGAL DESCRIPTION
Property Location '/ <, Sec. �-, TN -R Town of j c�
�JJ /
Subdivision Q5 �� d� Gft hc� ih IZ- Lot # . .
Certified Survey Map # , Volume . Page # /L/
Warranty Deed # IV/,/6 3 , Volume Page # D
Spec house 0-yes 11 no Lot lines identifiable Kyes O 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 (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 expiration date.
G
SIGNATURE OF AP ICANT 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 above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNATURE O 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
r
/ V
Vill..1481 440 616373
STATE BAR OF WISCONSIN FORM 2 - 1998 KATHLEEN H. WALSH
REGISTER D Numbe WARRANTY DEED ST. CROIXOCO., WI
This Deed, made between William B. Stock and Roxanne D. Stock, RECEIVED FOR RECORD
husband and wife, Grantor, and Donald J. Dalton and Belinda J. Dalton, 01 -03 -2000 10:00 AM
husband and wife, as survivorship marital property, Grantee.
Grantor, for a valuable consideration, conveys and warrants to Grantee WARRANTY DEED
the following described real estate in St. Croix County, State of Wisconsin (The EXEMPT #
" " CERT COPY FEE:
Property): Y ): COPY FEE:
TRANSFER FEE: 45.00
LOT 9, PLAT OF WEST SIDE WINDING TRAIL ESTATES IN THE TOWN RECORDING FEE: 10.00
OF RICHMOND, ST. CROIX COUNTY, WISCONSIN. PAGES: 1
Recording Area
Name and Return Address
Ronald L. Siler
VAN DYK, O'BOYLE & SILER, S.C.
Post Office Box 127
New Richmond, WI 54017
026 -1013- 70-140
Parcel Identification Number (PIN)
This is not homestead property.
Exceptions to warranties: Subject to all easements, restrictions and covenants of record.
Dated this _.Q�day of
L
*Wi ' B. Stock
� Z�r A �0
*Rotande D. Stock
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) W ' 0 i o w, V- s+oc k a-A STATE OF WISCONSIN )
R o)(a n h e n. —'%ce K ) ss.
County )
authenticated this 29 � day of Personally came before me this day of
the above named
pp �/ to me known to be the person(s) who executed the foregoing
* 110 1 q �� L • S i Q r instrument and acknowledge the same.
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by § 706.06, Wis. Stats.)
*
THIS INSTRUMENT WAS DRAFTED BY Notary Public, State of Wisconsin
Ronald L. Siler My Commission is permanent. (If not, state expiration date:
VAN DYK, O'BOYLE & SELER, S.C. )
Post Office Box 127
Ne w Richmond. WI 54017
(Signatures may be authenticated or acknowledged. Both are not
necessary.)
STATE BAR OF WISCONSIN FORM 2 -1998
N r WAIMANTY DEE
This Deed, made between William B. Stock and Roxanne D. Stock,
husband and wife, Grantor, and Donald J. Dalton and Belinda J. Dalton,
husband and wife, as survivorship marital property, Grantee.
Grantor, for a valuable consideration, conveys and warrants to Grantee
the following described real estate in St. Croix County, State of Wisconsin (The
"property'):
LOT 9, PLAT OF WEST SIDE WINDING TRAIL ESTATES IN THE TOWN
OF RICHMOND, ST. CROIX COUNTY, WISCONSIN.
Recordine Area
Name and Return Address
Ronald L. Siler
VAN DYK, O'BOYLE & SILER, S.C.
Post Office Box 127
New Richmond, WI 54017
026 -1013- 70-140
Parcel Identification Number (PIN)
This is not homestead property.
I
Exceptions to warranties: Subject to all easements, restrictions and covenants of record.
Dated this day of
L *
B. Stock
*Ro ande D. Stock
AUTHENTICATION ACKNOWLEDGMENT
Si�nat W A < i u " V S+ne a—A _ STATE OF WISCONSIN )
„ytP n_ 5ye ) ss.
4- County )
authenticated this 29 day of No ee..,b.. 199 9 . Personally came before me this day of
the above named
Q to me known to be the person(s) who executed the foregoing
* � oAq L • S o r instrument and acknowledge the same.
TITLE: MEMBER STATE BAR OF WISCONSIN
Of not,
authorized by § 706.06, Wis. Stats.)
*
THIS INSTRUMENT WAS DRAFTED BY Notary Public, State of Wisconsin
Ronald L. Siler My Commission is permanent. (If not, state expiration date:
VAN DYK, O'BOYLE & SILER, S.C. )
. Post Office Box 127
Ne w Richmond. WI 54017
(Signatures may be authenticated or acknowledged. Both are not
necessary.)
I
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P
1101 Carmichael Road
Hudson, WJ 54016
Phone: (715) 386-4680
Croix County
Fax: (715) 386 -4686 Zoning Department
Fm
To: Jo Hintz From: Shawna Moe
Fax: 247 -3622 Date: May 23, 2000
Phone: 247 -5900 Pages: 2
Re: Septic Report — D. Daulton CC:
❑ Urgent x For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle
-Comments:
ST. CROIX COUNTY
_ WISCONSIN
ZONING OFFICE
r�n_■���� - „�` ST. CROIX COUNTY GOVERNMENT CENTER
A
. lum - _ 1101 Carmichael Road
Hudson, WI 54016 -7710
- (715) 386 -4680 Fax (715) 386 -4686
May 22, 2000
REMAX Team 1 Realty
Attn: Jo
103 Main Street
Somerset, WI 54025
RE: Septic Inspection for Donald Dalton located at 1113 174t Avenue,
Lot 9 of West Side Winding Trail Estates, Town of Richmond,
St. Croix County, Wisconsin
Dear Jo:
A septic inspection of the above referenced property was conducted on April 13, 2000.
This property is located in the NW' /4 of the SW' /4 of Section 4, T30N -R1 8W, Lot 9 of West
Side Winding Trail Estates, Town of Richmond, St. Croix County, Wisconsin. At the time
of the inspection, this septic system was found to be code compliant for a four (4)
bedroom home.
If you have any questions regarding this, please contact our office at (715) 386 -4680.
Sincerely,
Kai C M��
Kevin Grabau
Zoning Technician
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