HomeMy WebLinkAbout026-1122-13-000 Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM County
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)l. 370252
Permit Holder's Name: ❑ City ❑ Village ❑ T8Vvn of: State Plan ID No.:
Stock, William Richmond Township
CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.:
a0. UD ,0 r P L COO& C CT- 8viiix *1 026 - 1122 -13 -000
TANK INFORMATION ELEVATION DATA `(`30,(8.1g9
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark I OT; 40 t 00.0
Dosing Alt. BM 2,0 6 1 0Z .5 r
Aeration Bldg. Sewer ,p 8, -y
Holdin St/ Ht Inlet
TANK SETBACK INFORMATION St /Ht Outlet �,�0 Q�•$D
TANK TO P/ L WELL BLDG. Air i to ntake ROAD Dt Inlet .- --
Ar
Septic 36 f 3 NA Dt Bottom
S•(Z r
Dosing L'i A Header /Man. ' S .Z$
Aeration NA Dist. Pipe S 8,9z I? v R� -ot7
r
Holding Bot. System 7 , 35 -- 9 6 .D
PUMP / SIPHON INFORMATION Final Grade S; v / a.0 ,
Manufac Demand St cover �, , ao ,oZ'
Model Number GPM
TDH Lift
I Lriction Sys TDH Ft
F main Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
r WENSIONS RENCH Width r Len th N Of s PIT Pits Inside Dia. Liquid D
'8 3 t S DIMENSION
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING anu act
SETBACK <HAAMBE
INFORMATION Type Of I Moe Num
System: '1. ( 3( O T
DISTRIBUTION SYSTEM,
Header/Manifold c L u Distributio i es �� ` r x Hole Size x Hole Spacing Vent To Air Intake
Length ti Dia. �L ength Dia. - spacing b ` X00
a
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 discrepancie , persgqn resent etc. Ins- ection # : O o ala I nspection #_:
Location: 1108 174th Avenue, New Ric tmond, V,l 5401'7 (N� 1/4 SW 1/4 4 T30N R1 8W) - 04.30.18.749 West Side
Winding Trail Estates - Lot 13� _ p � S . AA
1.) Alt BM Description = s wirl
2.) Bldg sewer length = RF.o'
- amount of cover = 16 " 4- .
Plan revision required. ❑Yes X No ,
Use other side for additional information. oZ 1 13 o
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
201 W. Washin Avenue
SANITARY PERMIT APPLIC g
Visconsin P O Box 7302
Department of Commerce In accord with Comm 83.05, Wis. .\fc 0�_ _/ � f Madison, WI 53707 -7302
• Attach complete plans to the count co only) for the s ste ri ape o�ess ount C
p p ( Y copy Y) Y ��,. p i
ti
than 8 112 x 11 inches in size. /
• See reverse side for instructions for completing this applicati State._ nary Permit Number
liE
Personal information you provide may be used for secondary purposes ST U C revi
h sion to previous plic
[Privacy Law, s. 15.04 (1) (m)].
'AUNTY Sta"_,!la I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL IN W :
Property Owner Npmq erty Locatieri'
v j o 4? T3C r N, Re.AX `C(oif P
Property wner's Mailing Address ` Lot Nu Block NI m`b�r
City, ate nG / Zip Code ( hone Number / Subdivisi m ,fir CSM Number I �
11. TYPE OF BUILDING: (check one) ❑ State Owned ity age 4. �
p / Near Road / _,(
G /!/!?B % 7,
Public 1 or 2 Family VII Dwelling- No. of bedrooms own OF f
Ill. BUILDING USE: (If building type is public, check all that apply) arcel Tax Number(s) I) /13 4 q
1 ❑ Apartment/ Condo
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 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 Oseepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure / 42 E] Pit Privy
13 E] Seepage Pit eq 43 ❑ Vault Privy
14 ❑ System -In -Fill (SlZ
VI. ABSORPTION SYSTEM 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 / ft.) T (Min. /inch) Elevation
Feet Feet
Capacity -
VII. FORMATION in a llo n Total # of Manufacturer's Name Prefab. Con Steel Fiber Plastic Exper.
New Existin Gallons Tanks Concrete glass App.
Tanks Tank strutted
Septic Tank or Holding Tank e ] ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ I ❑ 1 ❑ ❑ 1 ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber' Name: (Print) Plumbe ' gnature: (No Stamps) MP /MPRSW No.: Business Phone Number:
Plum bepK Address (Street, City, State, Zi Code):
Y r G #-
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved S Surcharge Fee)
itary Permit Fee (Includes Groundwater ate ssue Issuing Agent Signa re (No Stamps)
(Approved El Owner Given Initial �
Adverse Determinations Z_ 4t��
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
6h S
SBD -6398 (R. 4/99) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
r
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, Safetyand Buildings Division, 608 - 266 -3151. - - -
To be complete and accufote 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 sc5re 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 a 115 form; and F) all sizing information.
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GROUNDWATER SURCHARGE
1983'Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
NLUI KLAN � 11,;7_1x PROJECT ,�(1► r �u Eyc/� ADDRESS J ? � , ` o
l X1/4 iV 1/4/S e{/T / oN /R W TOWN COUNTY
MPRS Byron Bird Jr. 3318 DATE
BEDROOM CLASS PERC CONVENTION V, IN -GR ND PRESSOR
CONVENTIO AL LIFT_ MOUND_ HOLDING TANK
SEPTIC TANK SIZE /- LIFT TANK SIZE
DOSE TANK SIZE HOLDING TA& SIZE
ABSORPTION AREA era PER RATE _ BED SIZE
Benchmark V.R.P. Assu a i n 100' /f %.n IL
Location of Benchmark 1?4 ;9pe,1
* H.R.P. —
O Borehole Q well Scale = Feet
0 Perc Hole System Elevation /_
Uent
12"
TYPAR COVERING
2"
12' 3' 4 ` 6' 0 3' 3' O 3'
1
6' Sewer Rock
12' 18'
�
6 A
�
�b
Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page of
Bureau of Integrated Services in accordance with s. ILHR 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
t
percent slope, scale or dimensions, north arrow, and loca ' n to e nearest road.
�f I Parcel I.D. #
f ;' i
APPLICANT INFORMATION - Please iq 11 info"at,(qn. R viewed by Date
�,
Personal information you provide may be used for seco u osas Priv�ti .k�dl s 5.04 1 m .
rP c )> 'g"�
Property Owner <� Propert y Location
r ky'1 R Govt. LOt 1/4 /4,S /4,S T N,R E (or
Property ner's ailing Address �. Lot # Block# Subd. Name or CS #
�? 4w /ash ._
Ci / State Zip Code o Number City Villag Town Nearest Road
11 I le O� �� ���� �� ...I � , s' oZ
FXT New Construction Use: 54Residential / Number of bedrooms Addition to existing building
❑ Replacement �tv� El Public or commercial - Describe:
Code derived daily flow � !L/ gpd Recommended design loading rate at 4 1 bed, gpd/ft trench, gpd/ft
Absorption area required f 0 =bed, ft _ :renc ft Maximum design loading rate bed, gpd /f1 115 trench, 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 w 4i e ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system ] S ❑ U 5? S ❑ U jkS ❑ U [ S ❑ U ❑ S �2 U EIS le 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
�t �J .--
.�
Ground
Depth to
limiting
factor ai
S in. 3b f Z
Remarks:
Boring # 3
zwevio-
Ground
e ev.
D% do
D pthRo
limiting
factor
���in. Remarks:
CST Na (Please Print) Signature Telephone No.
Addrever Date CST Number
��'�� �-- �.�• -` / ,mil o.S�i?
4 e �
SOIL DESCRIPTION REPORT
PROPERTY OWNER � � ,Page of.
PARCEL I.D.#
Boring Horizon Depth Dominant Color Mottles Structure 2
g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed ,Trench
Ground 5 1
elev",
Depth to
limitin Rb • fi�
f ctor -
Remarks:
Boring #
Q-2 Ar
JR/ AN
A J
Ground
elev.
l
Depth to
limiting
factor
y6 in.
Remarks:
-.
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Boring #
Ground
elev.
/
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
Depth to
limiting
factor
in.
Remarks:
SBD -8330 (R. 07/96)
Soil Test Plot Plan
Project Name' 4'� /. J�o� Byron Bird Jr.
Address �7VI /4o /,f 57` 3n �1�1
/L y , c �, ,Ow 4 TM OZOZ v .5',
Lot I Subdivision Date / _
1 /4_1 /4 ST N/R W -.— Township '/��---
Boring O Well PL Property Line County - ��t�
BM or VRP Assume Elevation 100 ft.
t
System Elevation *HR
P
co
31 h�
gO � Scale 1/4" = 10 Ft. When Dimensions aren't stated
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION
FORM
Owner/Buyer LV � 11 CA � xg
Mailing Address 7 /- // S' e'Lp 7 /e-'j le!" .
Property Address Z�0 S �1 7Z t
(Verification required from Planning Department for new construction) syYL C
City /State M g" A't9 Parcel Identification Number
LE GAL DESCRIPTION
Property Location /U�/ '/4, SO `/4, Sec. T N -R —W, Town of 0C ql' 0
_� Subdivision S r Lot # 0
Certified Survey Map # , Volume , Page #
Warranty Deed # , Volume 7� ,�_, Page #
Spec house W ❑ no Lot lines identifiable Xyes ❑ 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 licensedpumper verifying that (1) the on -site wastewaterdisposal 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 a p ation 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 described above, by virtue of a warranty deed recorded in Register of Deeds Office.
1, --4W- / 3 / 00
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
4 Oc%c mLtir ho WA RRANTY DEED rwu nsca wuawreo .oR rricow.Ra o..•
STATE BAR OF WISCONSIN FORM 2 —IM
4 a s si i .22 5 t
Dennis W. Schultz and Rachel Schultz W;.%. its husband •
and wife as joint' Eenar " "' " . ....... • ..... x y :: , 30th
_ ................ ............................... Sept.
_. _ 8:3Q A .► :.t
eonce y s anti warrants w William 5 - tock 'and'R:oxanne D
Stock, hus " " " " " "' �
.... ............... ................ ..... ,
band and wife .as, joint.. enants...
— laertar of
......, _ ......... ................... ....... .... . .............
.....
. ..............
Northwest Federal S&L
.. _ a ._ " P.O. 80x 160, New Richmatd, WI
. .. ........................ .
the following descnbed real estate in ..St....C1;OiX ........................County, ,;4017
State of W
Tax Pared Not ..............................
Part of the " nrthwest Cuazter of the South test Quarter W- of SF';) , Section Four (4) ,
Tbwltship Thirty (30) North, Range Eighteen (18) West, described as follows. CcmTencing
at the hest quarter corner of said Section Four (4); thence South 89° 58' 56" Fast along
the East-Rest gtku ter Section line of said Section, 660.38 feet; theme South 01° 07'
40" East, 330 feet; thence South 89 58' 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"
Fast, 33 feet; thence North 89° 59' 56" West to the Vlest line of said Section Four (4);
thence North along said West line to the West quarter corner of staid Section Fair (4)
and the Point of Beginning.
�i3••�t
is not
This ........ . homestead property.
,is) (,A not)
FN vpt,en to warranties:
t):.., 20th .Jay of September 19 85.
V • r•
'H C..�N.:.t I.l•• �� (SEAL) ....�C _t •:. i �.... f.. : �- � (SEAL) Den, is W . Schultz Rachel Schultz
(SEAL) 1SEAI.r
AUTHENTICATION ACKNOWLEDGMENT
Siar.+ture(s) ...... STATE OF WISCONSIN
>e.
_ .................. ........................ ....... St. Croix
COU nty.
authenticated this ...... da; of .............. ..... 19...... Personally came before me this . 20th day of
__- SePtember .11- )BBS.... the :,bove named
z an
Dennis Sv. Schult l Rache Schultz
.......
_. _.__ ..... ._ ....... ........_............... ..
TITLE; ?1F.NBER STATE BAR OF WISCONSIY
, °not.
... .. ...
authorized b .. ..... .. .. ........
, . .. _.g ... -
y j ;OB.J6, Wis. itnU.) to me known to be the person ve^o executed the
futexoinK instrument and acknowledlr ,this ma
IN i:RVMNr N.1 ORsFr(0 By - r` �� • �•,,y'
Reir.stra, Van Dyk b Needham, S.C. ` �— :L� ,G p is �%t>.
. • ri} Y
Attorneys' at LaW' Linda ,t. dorifr c I I. a, «f,
Rica :.und- Alisconsin 54)17 -0127
Notary Puhlir St. C1 *. Q -. I i (:;i"ty'' s:
, i;Rnatvre4 may he authenticated or ackn..wle,1ged. P,�th Ny CommkAon is
rr permnne�t�l� th, �Ia�exPirRt�frt
.re not neesary,l :
date: 11 -15- 87 } o � y �: 1 4 ce
'S•mq / Nn•.n, .+n.na' to Y '••6u'•ty .U... , �. •yp .. rued ,n.L.r 'A • w�••* "
S
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