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HomeMy WebLinkAbout026-1122-14-000 n CA O $ m n con d V� 7 A 3 � N 0 (D D n D # C ^ (D 3 0 CD CD m 0 o r (n �? A N C • S 9D < < � O O (� (D W O.. << r O as N N N < O. 00 N ^t p $3 C C O 3 0 O w N C T7 O O � y O V D CD co q C:, W CD N O Z N O v g N N CD 0 N CAD O O H y C c O O + a D ID h. r -3 y N N CD cr v v v W (D L, m 0) m � CD 'fir o Z m o m _ a a 3 N z c o a l p D O a =3 o ' I m CD m N h • N CD N N C fD CCD I � a m (6 A Z n c A A Z O a O Z --1 A W -D 0 CL Z !�! Z A (D A I� O N N D p Q CD l < o: N ? C CD Z N N CD CJ D d CD Z N O (D O d S CD � o y 3 oo cn L y. p d A N c ~ a CD �_ A (D n CD 'O O O CD O O 0 N _ O O C CL 4 Nj C w 00 E!3 O N O V O (D �: a Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary PermitNo.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)], 370251 Permit Holder's Name: []City ❑ Village ❑ T n of: State Plan ID No.: Stock, William Richmond Township CST BM Elev.:. Insp. BM Elev.: BM Description: Parcel Tax No.: 026- 1122 -14 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic S r 2617 Benchmark I D Dosing Aft. ,3M I04 Aeration Bldg. Sewer (p, ZZ_ 19 If r Holding St/ Ht Inlet ( �-fv Cj3.( TANK SETBACK INFORMATION St /Ht Outlet ?.Oz 61q.3 TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet ir Septic f 1 S / NA Dt Bottom Dosing NA Header / Man. 5 ( O 9/P . :7- -To Aeration NA Dist. Pipe � 9.6(0 Holding z $ r Bot. System 6.5 S PUMP/ SIPHON INFORMATION Final Grade M cturer Demand St cover S 3 8 IZ Model Numbe GPM TDH Friction S stem TDH Ft Forcemain I Length Dia. Dist .To 591L ABSORPTION SYSTEM B'E Width ( Len r' 1 No. Of T ench s PIT No. Pits Inside Dia. uid Depth M N 9 DIM SYSTEM TO P/ L BLD EL M LEACHING cturer: SETBACK CHA INFORMATION Sys e O 0 Moe Number: System: 3 6 UNIT DISTRIBUTION SYSTEM Header / M nifold N Distribution Pipe(sk k < < x Hole Size x Hole Spacing Vent To Air Intake Length Dia Length ?Z Dia. � Spacing SOIL C E x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed/Tr nch Center Bed /Trench Edges Topsoil I ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, peison�spresent etc.} Inspection #l: I o/03/� Inspection # Location: 1110 174th Avenue, New Richmond, W1 5401'1 (NW 1/4 SW 1/4 4 T30N R18W) - 04.30.18.750 West Sidle o Winding Trail Estates -Lot 14 --� 1.) Alt BM Description _ie f _ Y 0 2.) Bldg sewer length = 21 a °" r - amount of cover= L8 r e s k " C_ Ft�ly� ter Lf'lq;.." ov.., at T - 1 4e S4 oxa2_ Plan revision required? ❑ Yes No Use other side for additional inform ti n. S ' - b SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ---------- � mm m .. l7 t l ot- g S p a � 3 99 E I I E � k �� �� Safety and Buildings Division Visconsin SANITARY PERMIT APPIMCAU.Q 201 W. Washington Avenue P O Box 7162 Department of Commerce In accord with Comm 83,05, A�Irh. Code j Madison, WI 53707 -7162 • Attach complete plans (to the county copy only) forth sy n r m y than 8 vi x 11 inches in size. N .11 G /^p • See reverse side for instructions for completing this app/ tl n © �® a anitary Permit Number Personal information you provide may be used for secondary purposes QIX S� C � k it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. �(�( to Ian Review Transaction Number I. APPLICATION INFORMATION -PLEASE PRINT ALL Property Owner Nam _ _ f ©� & 1 , T Q, N, R E 7^4 Property Owndrs Mailing Address Lot Block Number /j _ Z!!5� /q [ St r Zi Code Phone Number Subdivis on Name o SM{V ber O ( / G ' t / 1 2 IL F B NG: (check one) ❑ State Owned E] C it y Nearest R ad LJ Public or 2 Family Dwelling - No. of bedrooms ! ow 9 o �` G_� �27'5i� III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) Y. 3 0- / S. �O 1 ❑ Apartment/ Condo o 7 J ul � CJ --&OO 2 Q 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 (k New 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 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 C] Holding Tank 12 Seepage Trench 22 ❑ In- Ground Pressure 8 rx �7 i 42 ❑ Pit Privy 13 E] Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fi l l (sl Z 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/day /sq. ft.) (Min. /inch) Elevation Feet tt $ Feet Capacit VII. I NFORMATION in gallo Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. New Existing Gallons Tanks Concrete strutted glass App. Tanks Tanks Septic Tank or Holding Tank e 11 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumb 'Name: (Pr�, Plum Signature: (No St mp) MP /MPRSW No.: Business Phone Number: Plum is Address (Street, City, State, Z IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sa Itary Permit Fee (Includes Groundwater D ate I ssued Issuing Agent Signature (No Stamps) Surcharge Fee) � pproved ❑ Owner Given Initial Adverse DeterminationS X. CONDITIONS OF APPROVAL_/ REASONS FOR DISAPPROVAL: SBD -6398 (R.12/99) 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 oe 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 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. NLU I KLAN PROJECT - '� ADDRESS col 1 /4 /S f /T o N/ W TOWN MPRS Byron Bird Jr. 38E CO NTY . BEDROOM CLASS PER C ONVENTIONAL,�C IN -GROUN PRESSURE CONVENTI NAL LIFT_ MOUN _ HOLDING TANK SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA 2v `/ PERC RATE - - BED SIZE �� r b Benchmark V.R.P. Assume Elevation 100 Location of Benchmark 'z ( M Borehole Q Well Scale = Feet O Perc Hole System Elevation Uent 12" Grndp TYPAR COVERING 2" 12" 31 4` 6' 3' 3' 0 3' I 6' Sewer Rock i 12' 18' al ! Y Q v. \X ✓� /o a `6 Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division 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 t road. Parcel I. D. # T APPLICANT INFORMATION - Please rint a ��: ` r P � R viewed by Date Personal information you provide may be used for secondary pu `Orivacy w, s.04 (1) (m)). ; ; 0 ( W J Property Owner ° a =' , operty Location `Govt. Lot 114J� 1/4,S T ,N,R E (o Property Owners Mailing Address ` \ Lot # Block # Subd. Name or CS M# City { Slate Zip Code Phb� Nearest Road o L ti City .' ❑Village [� Town rte` )` fQ New Construction Use: [Residential / Number of bedrooms Addition to existing building Replacement El Public or commercial - Describe: Code derived daily flow ,,sr ,�,, ,�..,, gpd Recommended design loading rate e bed, gpd/ft - -J trench, gpd/ft Absorption area required JDD bed, ft 2 –,&2V0 trench, ft Maximum design loading rate 1 bed, gpd /ft - 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 ft S = Suitable for system Conventional Mound in- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system 2S ❑ U ®S ❑ U Z S ❑ U JZ s ❑ U ❑ S au ❑ S Z U SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /ft g in. Munsell / Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trench Ground rS` elev. /ft- Depth to limiting factor in. 0 Remarks: Boring # Ground elev — , Depth to limiting factor in. Remarks: fAddre Date T Nam (Please Print) Signature Telephone No. CST Number E' $% r s SOIL DESCRIPTION REPORT PROPERTY OWNER �, ��� Page of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsel Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench ........._............J e Ground ;. f - t elev./ Depth to limiting li F 98.3 U factor ' 3 ° .1; Remarks: Boring # Set s -- Ground elev. Depth to Z limiting factor lI Remarks: 3 Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # ,. f� z ' Ile Ground elev._ Depth to C( 7 limiting factor Remarks: Boring # I ....................... . Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R.9/98) Soil Test Plot Plan Project Name ��� / , y � jf� Byron Bird Jr. Address loz 'irl , M ova 0 -57,21 � Lot Subdivision Date > ^/_ ' 1 /4 x,1 1 /4S q j 0 N/R W -,- �'� Township � ��m�� Boring Q Well PL Property Line County JVo X r— 4, t4 BM or VRP Assume Elevation 100 ft. /ap o �-��. ��� __---- 7o�o��J�.� System Elevation �'�� 3 *HRP o2 7 7 lee NO ; Scale 1/4" = 10 Ft. When Dimensions aren't stated ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERS�HI_P / CERTIFICATION FORM Owner/Buyer Mailing Address Property Address � � 7�, 14 o E (Verification required from Planning Department for new construction) Sf '�- City/State t et_L) r6"C U tAi o Parcel Identification Number LE DESCRIPTION DESCRIP ION D Property Location < '/4, '/4, Sec. /�, T N -R ZS' W, Town of /� `� l v� Subdivision 0-p— (-'-) i N ("M I& , Lot # . Certified Survey Map # , Volume , Page # Warranty Deed # , Volume Page # as1 Spec house yes ❑ no Lot lines identifiable yes ❑ 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 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 expiration date. G 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. 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 MCUMENT f40 WARRANTY DEED •ew STATE BAR OF WISCONSIN PORN 2 —low �assii •.t:t �� ?P��E�5 t::ptict Dennis W. Schultz and Rachel Schultz husband X Wis. and wife as' point fenants ••- , 30th - ............. ... ............. _ .... ............................... Sept. _ 1 William Stock 'aricT itozarine "D. � -r coneres and „arraota to .... q .............. ...... ......... . Stock husband and wi fe .as j .... oin ...•tenants... -•.- .... _ AMUtf K I ......... .... - ..... . Northwest Federal S&L the fullo P.O. Ball 160, New Richmond, WI r•inY dexnbed real estate in .. St.....Cl;pj.�.._ ... ............... .County. `4017 State of Wlscol.ain: Tax Parcel No: .............................. Part of the !k)rthwest Quarter of the Southwest Quarter (Nkh of SF's), Section Four (4), 'township Thirty (30) North, Range Eighteen (18) toast, described as follows: Camencing the EasW�s e quarte rcorner of said Section Four (4); thence South 89e 58 56" East along 40" East, 330 feet thence South 6 South age Sol 56"" East 660eet;thence South 001 " Fast, 634.57 feet; thence North 89e 58 56" West, 330 feet; thence South 01 07r 40" East, 33 feet; thence North 89 59 56" West to the Vilest line of said Section Four (4); thence North along said West line to the West quarter corner of said Section Four (4) and the Point of Beginning. 3• -q is not This __....... .homestead property. l is) to not) 'r:vreptiin tv warranties: I.,•.•,i d:,.; 20th day of September . 19 85. yy {{ r• ` 1.L'_�cL.:,t� IseAL, ...�_.••�:'.... :�` �•_' (SEAt., Dennis tv. Schultz Rachel Schultz nSEAL) (SEALf AUTHENTICATION ACENOW LEDONIENT Six"ture(a) _ ...... STATE OF WISCONSIN as. _ . .............. County. a •his ...... da; of....... .... .. ..... 19...... Personally came before me this .. 20.th dad of ...SePtembe 1985 -. -- the above named -.... Dennis t3. Schultz and Rachel Schultz TITLE; MEMBER STATE BAR OF WISCONSIY - -.._ ........ ..... ............... I If not. -- _..... ..... authorized b y ,j :Mi06, Wis. Stata.) to me known to be the person -_ wPo executed the /oteltnintt instrument and acknotr N is-U-47 Nw4 DRAFTED BY • �r rL Reir.stra, Van Dyk b Needham, S.C. _L` %— :,.. ,G1'•' T�Ey �'�` Attorrevs at' Law'.. Linda J. Cod Er /f �•�. <1 C - -.. V '•f P ..ixw Rich;:.und..lvisconsin 54917 70 1 2 7 N.da•Y PnAtir naG,re \fy t'nmmi +sion in :.ii ft +may he authenticated or arkn.,wled,t,nl. prrmancet.(I(, 11af�espi;w n ,re not —e—+ arY 1 date: 11 -15 -87 A' •�•mw . f p.n..n• . [nm[ ,n r •b,r .n... 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