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N a CL N O N l< a O C� N 3 ^ 3 (� ' O N a) � 4 CD < o v a D� o ° o w o c c� (D !0 EA O O O O D 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 E I s I �� /l!3 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 ' 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 9 UNPLATTED - LANDS "T r low Or nr sw 114 or U=M f -JO -lI N0104 09"W 998.14' 278.W 313.31' 1 a 313.40'y I ; = I I Nno 602 6'w ° I �vi� I F •�• iZ a _ S10 it �,' w %b , , , , rwn 01 �'OO I n � + � io i• F$ Qo + le o g • , Ot ' �'' — — 70p4 °' ? ►r0 22'5e'E 276.20 )0 . 7 O� 2 3 4. 37 +k! fat (' . NO %jig N > I 290,22' S.6 SOI07,38E 208.02 1 SO10738T 723 67' I I O 1 i0 A i0 I I< I i< r I +O +p p +r F z I ' 'r 1 n 1 i i I N b i 'r In I I +r � I I lr In l0 i' i i0 in % t i i0 i� I h iU l� I i 't M I l� i i + -� iN lit +G7 1 i + i' +G) KA iu + I I 1G) is i . I i + I I(A iN !CA !to NQ 0 I +� I IICID I IOD 10 P. 1p N@ WrN_ r arReff __ . �,fyj� w « 7cwt - -.._.. 07'17'£ -66.00'_.. _ now ---- 112 T dT - - Z� I 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 cc: file