Loading...
HomeMy WebLinkAbout026-1122-12-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division Counk Croix INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanit111 rrp,itNo -: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)1. 1 7VVLJJ44 Permit Holder's Name: ❑ City ❑ Village ❑ own of: State Plan ID No.: tock, William Richmond Township CST BM Elev. : - Insp. BM Elev.: BM Description: Parce I a (00 t 6 � o er /, v Ul� ��22 -12 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic s 1 � p p Benchmark b Q Alt. BM 3. 3 t i Aerat' Bldg. Sewer sZ olding Ht Inlet fp TANK SETBACK INFORMATION (2�JY Ht Outlet 6 y fl- -5 TANK TO P/ L WELL BLDG. Airi to ntake ROAD irl Septic [r P6 / NA D NA Header / Man. �! Aer ' n Dist. Pipe l'• C v Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade P a er errand St cover S�',Z �' Model Nu GP T Lift Friction tem TDH Ft Forcemain Length Dia. Dist. To SOIL ABSORPTION SYSTEM a TRENCH Width / Lengt p r No. Of Trenches IT No. Of Pits Inside Dia. Liquid Depth I I DIMENSIONS Q D SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LE anu acturer: INFORMATION Type Of �/ CHAM umber: System: Z'] •--�5 IR U IT DISTRIBUTION SYSTEM Header / Manifold �� Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake y ' / Length Dia. � Length � 4 Dia. / Spacing _IC l d 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. Ins ection - e D nspec ion : Location: 1106 174th Avenue, New Richmond, Wl 54 1/4 SW 1/4 4 T30N R18W) - 04.30.18.748 West Side Winding Trail Estates -Lot 12 (r �, 5(\, f W4`�g 10{ 1, we 1.) Alt BM Description =ice 2.) Bldg sewer length = Z S - amount of cover = Plan revision required? ❑ Yes 0 No Use other side for additional information. 7, �j 6 SBD -6710 (R.3/97) Dat nspector's Sign ture Cert. No. x a � ADDITIONAL COMMENTS AND SKETCH < SANITARY PERMIT NUMBER: .._. m € t �4 �. � r € i € z WW my a e e E s� y : e m e,e..z ass ... m� ..T>, k i_a i p gg £ £ m fl q S . _ ., t B a � € € t � E � F . e e 1 t £ :......,« SaW m� ...,...M _ ,.. a ,...., sm� sae r le.,.m_.d F f 3 F ,.i. € m ,p., �..,.�.,... b a £ ...�., �,., . ... _ ,. ,.�. ..... .n.A..,... „a P _ m . a ....... } .� .. .......» a b 3 9 € 1 t t t � � 1 R A S £ t ¢ € ..ww 1 1, 171 Safety and Buildings Division Vi sc 6p s i n IT 201 W. Washington Avenue P O Box 7302 Department of Commerce In accord with Comm 83.05, Wis. A ode, i Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the systeny, on paper nit less , E. ty than 81/2 x 11 inches in size. ` • See reverse side for instructions for completing this applica tii,' Stat�S itary Permit Number , � 37ozs Personal information you provide may be used for secondary purposes .� u t y p C I revision to previou�pplication [Privacy Law, s. 15.04 (1) (m)]. y r t_ j ". Staf I n I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL I r M Property Owner Nam perty Location f � �csTy, ECG 1 /4 1 /4,.S T J7 , N, R E (o Property Owner's Mailing Address L Block Number City, Stat �""�� Zip Code Phone Number Subdivision Nam �r CSM ber r rJlo &/( d ( � �/ _._. / II. TYPE F B IL ING: (check one) ❑ V State Owned It(/ i Nearest Roe �, / Public 1 or 2 Family Dwelling - No. of bedrooms To il l age wn OF 4 4t III BUILDING USE (if building type is public, check all that apply) Parcel Tax Numbers) 1 ❑ Apartment/ Condo P Grt�t ® ©� / 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. gNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an Sysstem ........ 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 05eepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 5 Seepage Trench 22 ❑ In- Ground Pressure p p,l 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. AB SORPTION S YSTEM 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/da / q. ft.) (Min. /inch) `� Elevation S'Q , Feet /!Ve., VII. TANK Capacity In gallons Total # of Prefab. Site Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturer Name Concrete Con Steel glass App. New Existing structed T nks Tanks S ptic ank o *61U, ng Tank ��Q El ❑ ❑ 11 El Lift Pump Tank /Siphon Chamber ❑ I ❑ I ❑ I ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumb 's Name: (Print) Plum Signature: (No Stamp MP /MPRSW No.: Business Phone Number: Plum s Add ess (Street, City, State, Zip Code): Q� IX. COUNTY I DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Ag Issu ent Sig ature (No Stamps) Approved E] Owner Given Initial Surcharge Fee) - Adverse Determination "PS /to X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: -7o-i e L SBD -6398 (R. 4/99) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber °i "NSTRUMONS 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 most be properly maintained. - The septic tank(s) must be pumped by a licensed pumper 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 3 Wisconsin Safety and Buildings Division, 608- 266 -3151. - To be completeapd accurate,this sanitary permit application must include: I. Property owner's name and mailing address. Provide; the Iegal desc(rption 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 8 112 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to sca'le'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. PLU - 1 PLAN �7q - e PROJECT / /�G� ADDRESS AW1 /4J4 1/4/S 4 1 /T,-_�Q N/R TOWN rr COUNTY MPRS Byro Bird J r. 3318 - BEDROOM CLASS PERC -d L CONVENTIONAL IN -GRO ND PRESSURE CONVENTI NAL LIFT MOUND HOLDING TANK SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA _� PERC RATE _ BED SIZE _ <_ b► Benchmark V.R.P. Assume Elevation 100' Location of Benchmark 0 Borehole Q Well Scale = Feet O Perc Hole System Elevation Uent 1 1/ TYPAR COVERING yy`` // 12" 3 4. g O 3' 3 O 3' Lo t IZ I 6 " Sewer Rock i 12' 18' �h 10/ Nife = r ` v �"�� ,I'll 04;4. 'p � Iv . b. Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division otSafety 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 p rtn l, _ a�4Q/i Rev ed by Dat Personal information you provide may be used for seconds s (Privacy La s 15.04 (1} (m)). Property Owner Property Location 41/ �. Govt. Lqt :;�/114,S T e ,N,R E (o Property Owner's Mailing Address ' a Lot # Block# Subd. Name or C # kx) Cltv 42ate Zip Code PtaotDe v Village Town N crest Road .New Construction Use: residential / Number of a rooms "7 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow ) gpd Recommended design loading rate bed, gpd/ft * -S� trench, gpd/ft Absorption area required bed, ft2 4' �� rench, fyt2 Maximum design loading rate bed, gpd /ft gpd/ft Recommended infiltration surface elevation(s) % ft (as referred to site plan benchmark) Additional design /site considerations Parent material / ��� ` _ Flood plain elevation, if applicable ft S = Suitable for system Conventional rMoound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system [yes ❑ U X'5 ❑ U A!! S ❑ U ,®-s ❑ U ❑ S 2fu ❑ S A U SOIL DESCRIPTION REPORT Borin g # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color GS Sh. Bed , Trench X 22 Ground elev."`e.G� G / --- --------- Depth to 6 + limiting Din Remarks: Boring # _ ffig a � fh - -v _ G z d Ground elev. /' v Depth to S�pr 7 n Remarks: Name lease Print) , ,- - ;)Signature ,� Telephone No. Addre Date CST Number SOIL DESCRIPTION REPORT PROPERTY OWNER Page - - of PARCEL I.D.# Boring Horizon Depth Dominant Color Mottles Structure 2 g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color . Sz. Sh. Bed Trench Ground elev. Depth to limiting 7 factor 7 -in. 3� Remarks: Boring # 0 Ground elev. A ft. Depth to limiting factor n. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft o. in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # U Ground elev. Depth to limiting factor ' "' Remarks: od. Ir Boring # Ground elev. ft. ' Depth to limiting factor in. Remarks: SBD -8330 (R.9/98) Soil Test Plot Plan Project Name �� v ,�.- Byron Bird Jr. Address 444 // 7 �51 Lot -- Subdivision ----- - - - - -- Date - `& 1 /4;1 /4ST N /RW Township - � Boring ()Well PL Property Line County �f, ,�r„ X 1a , 76- 4 BM or VRP Assume Elevation 100 ft. �P System Elevation * H R P Sa as Benchmark 0 4 So 73 s { ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 1 ( ( 5 7� C /�_ Mailing Address Property Address Z 4 ( 7 (Verification required from Planning Department for new construction) J'& C City /State AktJ9(r–R A-Q—_ Parcel Identification Number Va�z( LFG DESCRIPTION Property Location ' /4, ' /4, Sec. 4, TAN -R I S W, Town of Subdivision ZA- w i Nj��24 �t2v~cS7� , Lot # /1-P . Certified Survey Map # , Volume , Page # Warranty Deed # �f �1/ , Volume , Page # 9-S7 Spec house yes ❑ no Lot lines identifiable,7FT ❑ no SYSTEM MAINTENANCE Improper use and maintenanceof 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 three year expiration date. _el� 61-3100 SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION 1 (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. L /"% 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 DGCtIMLNT NO WARRANTY DEED T "'a a•,ca enaerao .o" "acoeo."o o. STATE BAR OF WISCONSIN FORM 2 — Ion as�11 r ? PACE 75 Dennis W. Schultz and Rachel Schultz, husband ~'X 30th and wife as joint tenants ' °- .L t -- - _. _.... _ ..... ........ _ ..- .......� apt coni, and scarranta to Willi S am Stock aid Roxanne D. tock, husband a. wife_ joint tenants ..... )sYbae N i _ _. ...... __._. .._... _...... ... . ........... ...... .............. Ncrthwest Federal S &L St ate following described reel estate in .. St.....CroiX ..... P.O. Box 160, New Richtncnd, WI ..._ ........... State o[ R•iscor.ain: ...County, ';4017 Tiaz Parcel No: . ....... ..... ...... ........... Part of the *nrthwest Quarter of the Southwest Quarter W, Of SP's), Section Four (4) , Township Thirty (30) North, Range Eighteen (18) West, described as follows: Catmencing at the hest quarter corner of said Section Four (4); thence South 89e 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" Fast 660 feet; thence South 01° 07' 40" Fast, 634.57 feet; thence North 89° 58' 56" West, 330 feet; thence South Olo 07' 40" East, 33 feet; thence North 89" 58' 56" West to the West line of said Section Four (4); thence North along said West line to the West quarter corner of said Section Fcur (4) and the Point of Beginning. !� 3• -qt is not T his -... _... _ homestead peeper'.}•. I's) 0.4 not) r:A.rptiln to warranties: n..•,,; 0:,.; \ ( 20th day of September 19 85, (SE.AL1 _::_ ,' L '.�� �- (SEALt Dennis W. Schultz Rachel Schultz (SEAL) _ (SEAL) i AUTHENTICATION ACKNOWLEDGMENT STATE OF WISCONSIN ' s __.. ......_._._.._............_.._. 1 s. _....._ .............. .... St, ,- .Cro ix f .. ..__ ....._.County. n1thenticated •his ..... da; of.......___ _. 19. ..... 20th came before me this.. th., say of Septembe_ __. 1985., the above named ...................... Dennis W. Schultz and Rachel Schultz _ . ............ . .. _._.. ......_... __...__. .......__ ............. TITLE: SIF.)Ii:ER STATE BAR OF WISCONSIN -- I[f not. _... .. _.__. _ .. _. authorized b ... - ._._...__. .. _ ... .. y 3 70F.06, Wis. itati.) S to me knu to be the person _ . -Fo executed the fosegninp instrument and acknow th iN i'RI:NFNT N,S OR \FLED HV 3eicstra, Van Dyk s Needham, S.C. Y, <ttorr.ev, at Law Linda J. Cod fr I n t 0 -r. � Jed a1ci1.:.ur.Q..iiisconsin 5U 17- 0127N -, _ (ary Puhlir SL'. C/ . /.ry/mty iiignabtr.w may he authenticated or arkm.wled;;ed, Rath NIv ('nnunie.rion is perman,6t11(P jQ- 19, Q - ne It et�ex P;�•r,t t.t e not , re,;ary l date: 11 -15 -87 A% V C ' •N'.— -r assa r . ,n... i ..,..t .,t n,a.w s ,r r , .....,. '��'; �' • 5 ` * t4• t ,, � ' lbi JA N t /