HomeMy WebLinkAbout026-1122-10-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
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. (1)( m)]. 363885
Permit Holder's Name: ❑ City ❑ Village ❑ jown of: State Plan ID No.:
Richmond Townshi
CST B Elev.: Insp. BM Elev.: BM Description: rcel Tax No.:
`t 9. ? y 0 Pa 26- 1122 -10 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
SepticS �w0 nchmark 3 Z� ( I
Dosing Alt. BM ��lo 1 ?41 7
Aeration Bldg. Sewer ` S !S D
o ding ( �91 Ht Inlet T I 7 J`
TANK SETBACK INFORMATION / Ht Outlet q y
TANKTO P/L WELL BLDG. Ventto ROAD
A+4Make
Septic 1 Ql (2r �Z' NA
NA Header / Man.
Aeration N Dist. Pipe ? /�' - . 3 �� D z
Hol Bot, System 3 Z f3 -I
y
PUMP / SIPHON INFORMATION Final Grade , 3 ? -7 .
anufacturer Demand St cover
Mo umber PM
TDH Lift Friction m TDH
L oss ea 1 4
Forcemain Length Dia. Dist.T n
SO ABSORPTION SYSTEM
19 ED /)TRENCH Width i Len th No. Of Tr es PIT No. Of Pits Inside Dia. i uid Depth
N I N rr DIMEN 1
SETBACK
SYSTEM TO P/L BLDG WELL LAKE /STREAM LEAC Manufacturer:
INFORMATION Type O r MBER Model Number:
System: 4 Z 2 2 OR UNIT
DISTRIBUTION SYSTEM
Header /Manifold Distribution Pipe(s) r x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length &U Dia Spacing lz� }Z - Z -� Z 7 -.q 5 - 1
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 E] Yes E] No E] es ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: 7 / 1 1 /0 O nspection #2:
Location: 1109 174th Avenue, New Richmond, WI 54017 (NW 1/4 SW 1/4 4 T30N R18W) - 04.30.18.746 West Side
Winding Trail Estates - Lot 10
1.) Alt BM Description = VOP � � (u t (k btJ 4
2.) Bldg sewer length= I ?- /
- amount of cover= 7 '
3) s y s �a,. w� 0— % 1A4 1, e0( 1 &we�,
b ti .. h t /�`w, f•4 N e IO / 7��s f
Plan revision required? ] Yes o _
Use other side for additional information. 17Z.
U (�
SBD -6710 (R.3/97) Dat Inspector's ture Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: -
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Safety and Buildings Division
Visconsin SANITARY PERMIT APPLICATION 201 s W ashin g ton 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 157K /
than 81/2 x 11 inches in size.
• See reverse side for instructions for completing this application State sanitary Permit Numb r
3 (a 3 g'
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. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Property Owner Name 1 Pro ert L ocation
Loca
4 1/4,S T ,N,?lj5' (cKW7
Property Owners Mailing Address / q Lot Number ,,r) Block Number
City, t to
W I F L" �/ Zip Code Phone Number Subdivision Name or CSM Number
�Ccv�t�/ '�sdl 4 1( S, /NQ / Imo`
II. TYPE OF BUILDING: (check one) ❑ State Owned [:] ity age � J Barest Road
L.r " //921 j e
Public or 2 Family Dwelling VII
- No. of bedrooms own of / 7 /
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) Ou, 5 0. I f), -7,4 (p
1 ❑ Apartment/ Condo p� f /ate /O
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. [New 2_ ❑ Replacement 3. ❑ Replacement of 4 ❑ Reconnection of 5, ❑ Repair of an
- ___'_" _ -------- 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
1 1 eepage Bed 21 ❑ Mound 30 [:]Specify Type 41 []Holding Tank
epage Trench 22 E] In- Ground Pressure 42 E] Pit Privy
3 ❑Seepage Pit r r 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SY STEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Require ftElevation
Ll c ,�
Required (sq. ft Proposed (sq. .) (Gals/da /sq. ft.) (Min. /inch) �J Ele
.7 (� s �— f `7 ` / Feet 4 r. 7 - Feet
Capacit
VII TANK in Ca gallo s Total # of Prefab. Site Fiberxper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks
Septic Tank or Holding Tank ,� ❑ ❑ ❑ ❑ El
lift Pump Tank /Siphon Chamber 11 El El 1:1 ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plum 's Name: (Print) Plumb s ignature: (No St ps [ MP/MPRSW No.: Business Phone Number:
r
PF6i .is (S reet, City, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved nitary Permit Fee (Includes Groundwater ate ssue Issuing A ent Signature (No Stamps)
Approved ❑ Surcharge Fee) Owner Given Initial _ (M 1k, R' Adverse Determination%
X. CONDITIONS OF APPROVA / REASONS F DISAPPROVAL:
�` +c.Q Cow✓ ce�ce— w
y s- ,�,�, �
BD -6398 (R. 4/99) DISTRIBUTION: Original to County, a copy To: Safety & Buildin ivision, 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 -3161. -
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, et6 )
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 8 112 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; frictiortloss 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.
/ PROJECT PLU I PLAN /*
/I / r
ADDRESS �� � S
Az) 1/4/S rT N/R oC W TOWN
M
!i
PRS Byron Bird Jr. 3318 DATE ,5 l c COUNTY A_oi�
BEDROOM CLASS PERC _,G2Z- CONVENTIONAL_ IN GROUND PRESSURE
CONVEN ONAL LIFT_ MOUND HO ING TANK
SEPTIC TANK SIZE LIFT TANK SIZE
DOSE TANK SIZE HOLDING T7 /1'- SIZE
ABSORPTION AREA PERC RATE - BED SIZE 1'--
16 Benchmark V.R.P. Ass e Elevation 100'
Location of Benchmark
* H.R.P. -
M Borehole Q Well Scale = Feet
0 Perc Hole System Elevation qzl,
Uent
12" Grnffp
IF TYPAR COVERING
12" 3' 4 6' 0 3' 3' 0 3'
1
6 . Sewer Rock
12' is, f117
X
i lk
po
V
�
7
��- 1 20
w' sin Department of Commerce SOIL AND SITE EVALUATION
Divis n 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
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. #
APPLICANT INFORMATION - Please print l�,hgrmation. Reviewed by Date
Personal information you provide may be used for secondary os (Priva w 15.04 (1). (ynj . S_ _
Property Owner Property_L cation
Govt Lot ; f /4 e /4,S T e,N,R E (o
�l n
Property Owner's Mailing Address j t # ,' lock# Subd. Name or CSM#
Al
City ate Zip Code Ph ne tub /
er ` CE
O ( - i ❑ Nearest Road
Villager n
)II
ZZ
Construction Use: Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow A: :�V gpd Recommended design loading rate Ybed, gpditl trench, gpd/ft
Absorption area required bed, ft z!�2_ trench, ft
M imur si to ding rate bed, d /ft2�, trench, gpd/ft
Recommended infiltration surface elevation(s) `T'o G � (as to sit pan benchmark)
Additional design /site considerations 1
Parent material a lc Flo d plain elevation, if applicable ft
S = Suitable for system Conventional I Mound In- Ground Pressure I AT -Grade System in Fill Holding Tank
U = Unsuitable for system }WS ❑ U .5 ❑ U - 2 S ❑ U LR S ❑ U ❑ S 2� ❑ S 49 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
Ground = "-
��
f
Depth to
limitin g to r
yy,
factor ,
�in. 3o GG
Remarks:
Boring #
ems_
r
Ground
elev.
y Dept
limiting
f rAddre tor
in. Remarks:
Name Please Print) , Signature � j Telephone No. /
Date CST Number
�G �' dS�
� SOIL DESCRIPTION REPORT t
PROPERTY OWNER T,, —,..4 g G � Page of
PARCEL I.D.#
Boris # Horizon Depth Dominant Color Mottles Structure 2
Boring Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Ground �-a'—� ' �! • J
elev.
Depth to
limiting 9�
factor
Remarks:
Boring #
O
LV
Ground
�
Depth to �
limiting
factor_
in.
Remarks:
a7
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # �l r r ��' • z ' - I—
wL r F
, - AMC •
Ground
elev.
a ft.
6epth to `
limiting
factor
in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in ' Remarks:
SBD -8330 (R.9/98)
Soil Test Plot Plan
Project Name / Byron Bird Jr.
,
Address /7 //;z ' A j
CSfM W 0
Lot — Subdivision Date _
1 /4_� /4S�T , SL N /R2ZW -,– Township o z
I3oring 0 Well PL Property Line County
BM or VRP Assume Elevation 00 ft.
System Elevation *HRP
Am
G
t
l
D � l
fit/ fir;
o a?�r
a
Scale 1/4" = 10 Ft. Wilen Dimensions aren't stated
• ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
f f
Owner/Buyer
Mailing Address / 7
��
Property Address /16' 7 --'
(Verification required from Planning Department for new construction)
City /State / /� Parcel Identification Number
LE GAL DESCRIPTION /�
Property Location /4, S 'f4, Sec. , / y{ , T -R �� W, Town of /C'
T
Subdivision �� %C.� e, lv' ^ �L �� , Lot #
Certified Survey Map # , Volume , Page #_
Warranty Deed # �/& �f , Volume 7 2- , Page # S
Spec house yes O no Lot lines identifiable.Q_yes 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.
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
days of the threeyear expiration. date.
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 d scribed abov , y virtue of a warranty deed recorded in Register of Deeds Office.
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
0CCL,1ME -NT NO rR„ crAC[ ecc[,vc
WARRANTY DEED
STATE BAR OR WISCONSIN FORM 2 -19M
40ss11 CL PAGE 75
Dennis W. Schultz and Rachel Schultz, husband X 1Ytti•
and wife as t 30th
_.......
joint Tenants ''
ept.
avnveye and warrant, to William StOCk in 1toxaiir@6 D. .. 8.3U_A.r
Stock, husband and wife
..as', _joint tenan_ts_
_..... Ncrthwest Federal S &L
_......_......._ ..._.. P.O. Box 160, New Richmond, WI
01e following described real estate in .. St.....C);O1X ........................County, '4017
State of ILhcot.cin:
i
Tax Parcel No: ....
Part of the *mrthwest Quarter of the Southuiest Quarter (Nw ;, of SF'%), Section Four (4),
Township Thirty (30) North, Range Eighteen (18) ;Jest, described as follows: Camencing
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 Ole 07'
40" East, 330 feet; thence South 89 53' 56" Fast 660 feet; thence South 01 07' 40"
Fast, 634.57 feet; thence North 89' 58' 56" Wlest, 330 feet; thence South 01 07' 40"
Fast, 33 feet; thence North 89 58' 56" West to the Etest line of said Section Four (4);
thence North along said West line to the Wst quarter Corner of .
and the Point of said Section Four (4)
Beginning.
This is not
- -.... _._.. homestead property.
i's) (LS not)
•'Xceptrtn to warranties:
tr•r tl:,.s 20th ,l of September 19
85.
(SEAL)
Dennis W. Schultz Rachel Schultz
(SEAL) (SEAL.)
AUTHENTICATION ACKNOWLEDGMENT
I �
I Signature(s) _...- _ ..... ._ _._. .. .._ STATE OF WISCONSIN )
} ss.
St. Croix County.
authenticated this ..... da; oL...... 19...... Personally came before me this ... .. .... , {ay of
September , 1985 the above named
Dennis W. Schultz and Rachel Schultz
...........
TITLE: 31E1(BF,R .STATE BAR OF WISCONSIN - -
1 I f not.
......
_._
authorized 6 _. _...._........_ .. _._. _.. ....
y p 70fiAfi, Wia State.) S
to me known to he the person __ ... wFo executed the
fol:Kming instrument and acknowledge ,tha,Rme.
INiTRL;N.NT NAS DRAFTED By /\ _L ,,♦
3einstra, Van Dyk & Needham, S.C.
''• f EY •„
Attorneys at LA ....
Linda J. Co�lEr cy •. C v•. fig,
ew aicn:.unQ, — Wisconsin 5 -0127 t . 4 s
N,tar Pu hlir St. �. 1 Q. 1 .(�jmty " ��Nd s.
bL n•s may he authenticated or ark nowled;;rd. Rath Sty ('nrn
�iigna mi:.ainn ie pcnnancyt. (tlft, dRaf�exoitw [+n
,re not necessary.) date: 11- 15 — $7 �' v ae
tt� ;�:
• [mina •i..t, ,n.., � .. .c..r • . L..t n.d:w 'n n ' �
i
' 10 342.02
' UAL. EsMr. ` \
'
i
i� vi
i \ � � POND /NG AREA � I � �
HIGH WATER EL. = 1003.4 I \ LOT g
83483 SO. FT. �n N
2 \ 1.92 ACRES N ;
N
I a I \ Z
I �
C.S.M. 759 LO
LOT _5 1.74 I
LOT 13 N
o �� , VOL 11 PG 3204
0
� 115,742 54. FT. _.' �' -------- - - - - -- �
N i j "6 2.66 ACRES
O
I
I w kph �• O•
I � pA t
e p
LOT
86810 S4. FT �' �. \ • 1 ` O 1 �
W SSS. 1.99 ACRES ' • O <v
�9 �
U7, I � / ��`•
Gl
I ,
Z I I d
Q,
-�i N O C
I
` LOT #
I i 'n �
I 49980 SO. FT. PD
~Qi 1.15 ACRES a,
�' p G86• w �6F' �� h p
1
I �
LOT 9 ti" °
43686 SO. FT.
1.00 ACRES
rn 3
9 R D
OT AO °
A D �
6743o so. Fr z LOT 8
1.55 ACRES 65634 SO. FT.
1.51 ACRES LOT 7 =
I 46838 SO. FT l /
3 1.08 ACRES
1 /
I � /
r c(p / 9
�i u r p fO
l
170.21' z 165.83' 241.93'
N8,9 5622 "W 871.56'
R= N8958'56 "W
t UNPLATTED_LANDS
z
\\� SOUTHWEST CORNER
SEC. 4 -30 -18
ALUM1NUM MONUMENT
DRAINAGE E RESTRIC�
NO GRADING OR CONSTRUCTION PERMITTED WITHIN
THE DRAINAGE EASEMENTS SHOWN HEREON.
RFNCHMARK