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HomeMy WebLinkAbout026-1122-15-000 Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar�7PWB3No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: []City ❑ Village ❑ Ttrwn of: State Plan ID No.: Stock, William Richmond Township CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: j U r Z u 026 - 1122 -15 -000 J TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic W ee S > Benchmark d( GC7 Do Ong— Alt. BM l� C t o S7 O Aeration ''' Bldg. Sewer G- �(�O. a Holding /Ht Inlet TANK SETBACK INFORMATION ( 9t Ht Outlet 3 lG TANK TO P/ L WELL BLDG. Vent to Air Intake ROAD Septic NA 1 Do -- - - - - NA Header I Man. 6 TP go Aerate NA Dist. Pipe olding Bot. System }. P PUMP/ SIPHON INFORMATION Final Grade facturer Demand St cover Model Number M TDH Friction stem TDH Ft [F - 0 - rcemain Length Dia_ Dist. To wen SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Tr the No. Of Pits Inside Di Liquid Depth DIMENSIONS �S er DIMEN SYSTEM TO P / L BLDG WELL LAKE / STREAM CHI Manu a SETBACK CHAMBER Mod INFORMATION Type O System: -2-`I r OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Z r Dia. y rt Length L Dia. Spacing Z� 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/Tr nch Center Bed / Trench Edges Topsoil I ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancie ,persons resent etc. Inspection #1 /� /off inspection I# Location: 1112 174th Avenue, New Richmond, 1 5401"1 N 1/4 SW 1/4 4 T30N R18W) - 04. 30.18.75 1 west Side Winding Trail Estates - Lot 15 fvk I ( rr 1.) Alt BM Description = LA., or St`d,',,9 A CS« �� ((v) _c) 0 c wa.0 �1/►'1 w� r� eS�m 7��/ 2.) Bldg sewer length= 13' i - J IK- _ e y (dX 4e / / �Y V - amount of cover = -7 1 P /' 3 •� do w � l � a� �`� Plan revision required? ❑ Yes No Use other side for additional inform ti on L SBD -6710 (R.3/97) Date Inspect or's S ture Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: E g S z a 3 m t { } F I � 41 I t Safety and Buildings Division SAN ERMI 201 W. Washington Avenue isconsin �,� P o Box 7162 Department of Commerce In accord with Comm 5�11llis. A m. 0&1 Madison, WI 53707 -7162 • Attach complete plans (to the county copy only) for the in, on paper not less ou ty than 81/2 x 11 inches in size. • See reverse side for instructions for completing this appl ration Stat Sanitary Permit Number 7 � . 37a2s3 Personal information you provide may be used for secondary purposes aN(;t�r:�tt:E heck if revision to previous application [Privacy Law, s. 15.04 (1) (m)). Z C'� to Plan Review Transaction Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL IN RMATI Property Owner Name cation ay e L w1/4 Iv 1/4, S T -3O , N, R �� E (or� Property Owner's Mailing Address 7� Lot Number Block Number CiState _/ Zip Code Phone Number Subdivision Name or CSM be A II. TYPE OF BUILDING: (check one) ❑ State Owned E] C it y :�;; rearest Road illage Public 1 or 2 Family Dwelling - No. of bedrooms wn OF 111 BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) � n O.r _7,5 1 1 ❑ Apartment/ Condo b ' 2(O 2 [] Assembly Hall 6 C] 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 1V. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. KVew 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an /_ S stem - 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 Dis ibution Pressurized Distribution Experimental Other 11,Seepage Bed Oc" r. 21 ❑ Mound 30 ❑ Specify Tyne 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (GaWday /sq. ft.) (Min. /inch) / Elevation . 17- Y Feet Feet Capacit VII. TANK in Ca allo Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Exist in structed Tank Tanks ptic Ta ,® ❑ 1 ❑ ❑ 1 ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 1:1 El El 1:1 1:1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plum Name: (Print) / Plum be ' 1 ature: (NOS ps) MP /MPRSW No.: Business Phone Number: r0 i7 ird Plum is Ad ress (Street, City, State, Zip Code): Ape IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved ' Sanitary Permit Fee (Includes Groundwater ate sue ss Agent Signature (No Stamps) � A roved Surcharge Fee) pp ❑Owner Given Initial D � � Adverse Determination X. CONDITIONS OF APPROVAL / REASONS F011 DISAPPROVAL: fix' Kas 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 maybe 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. e r PLU_I FLAN sf PROJECT A/Caw, �. `� ©l? ADDRESS r 1 /4 1/4/S , /T N/R , W yGV � 3Q l TOWN COUNTY PRS B�fton Bird J . 3318 DA BEDROOM � CLASS PE RC CONVENTIONAL, IN-GROU NlrPRESSURE CONVENTIONAL LIFT MOUND HOLDING TANK SEPTIC TANK SIZE y /, = �2� LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE / ABSORPTION AREA /SAD PERC RATE BED SIZE ,ma Benchmark V.R.P. Assume Elevation 100' f Location of Benchmark o o * H. R. P. CI Borehole Q Well Sc e = Feet O Perc Hole System Elevation y� Uent 12" Grarlp TYPAR COVERING 6T6 _- 12" 31 O 3' 3' 0 3' I s " Sewer Rock 12' 18' /,J� 1`— l�ofi WJ( is {e, w.� ft tZ 6P'% � `r�VJ. alt. g ro vv.�iKs 1 �►� ell' �v G ��` . 0-1 v LIP WiAconsin Department of Commerce Division of Safety and Buildings SOIL AND SITE EVALUATION 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 t , percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please prin vrntatibn: Rev' we by Dat Personal information you provide may be used for seconda rp ses ° (Privy la s. 15.04 (1) (m)). ( (L Property Owner Property Location Govt. Lot &/41/4,S N,R E ( W Property Owners Mailing Address (�� Lot # Block# Subd. Name or CS M# 4 1 o_ a t r ;4 City S to Zip Code Phone Nearest Road ty Village � To ew Construction Use: CgResidential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow _4L6'_ gpd Recommended design loading rate o bed, gpd /fi • ✓ trench, gpd/ft Absorption area required bed, ft -o`D trench, ft2 Maximum design loading rate . T bed, gpd /ft • .5_ trench, gpd/ft Recommended infiltration surface elevation(s) 4 9,7. It (as referred to site plan benchmark) Additional design /site considerations 4 Parent material �g� f +° K l/c^ Flood plain elevation, if applicable It S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system fi�rs ❑ U 0 ❑ U ,&S ❑ U JR:S ❑ U ❑ S 0-U EIS .g 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 Vr D, d Ground X elev. loe Depth to limiting' ,t ; ITr fat i , - Remarks: Boring # Al Ground elev Depth to limiting facto in. Remarks: CST Name lease Print) Signature Telephone No. Address y� r Date CST Number PROPERTY OWNER �!r° SOIL DESCRIPTION REPORT Page of , v PARCEL I.D.# Boring Horizon Depth Dominant Color Mottles Structure 2 g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench Ground / elev. Depth to limiting 3 facto in. ' 1 . � Remarks: Boring # # . Ground f elev. Depth to limiting factor in. _ Remarks: a - � Horizon Depth Dominant Color Mottles Structure GPD /ft Boring # in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trench r ✓� i� Ground elev. 3 D /th to limiting factor ' Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R.9/98) F + Soil Test Plot Plan Project Name / /z " - Byron Bird Jr. Address /,V`x 11AIVI � CS M oz02 0 Lot �,�. Subdivision Date j1 /4 1 /4S T N /R ,�Y W ` Township Boring O Well PL Property Line County •��_ G�"a�i� �j BNI or VRP Assume Elevation 100 ft '7 System Elevation *HRP tl� o ON � 0 Scale 1/4" = 10 Ft. When Dimensions aren't stated ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM & ' / o om OOwner/Buyer uyer Mailing Address �� Property Address �� �� �y ��� ��� (� �` (V required from Planning Department for new construction) X1'1 C City /State /2J��'rC� wld Parcel Identification Number (0,-� LE GAL DESCRIPTION Property Location /4, -54.) /4, Sec., T�N R W, Town of 4VtX Subdivision GJ %AJ i'y 7A2c,c >°C , Lot # 45 . Certified Survey Map # , Volume , Page # Warranty Deed # yos(.P/( , Volume , Page # 9s7 Spec house)B ❑ no Lot lines identifiab4� ❑ 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. o�P / /UCH 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 ab ve, by virtue of a warranty deed recorded in Register of Deeds Office. 6n / - 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 OC'CUMLr)T NO WARRANTY OEEO Tw,e u.ct u.awrw •,rR uco,w.we "•r. STATE Bab OF WISCONSIN FORT! 2 -190 4a 5cm A CL (11 P&GE P- j i Dennis W. Schultz and Rachel Schultz husband and wif ...........:.. ...... .. • ._ ..., ._. _joint ten,ints' �•' `. , 30th e as .... ............. ...... I .......... ............ _ �.eas us .... : .. x anne . D �...... �_8:34_A.r:•w . rr }a ur Stocband anint_..t '� 1 4� . ..... .... ................... . ................. ............ ....... ............... Northwest Federal S" ... .................... P.O. Bat 160, New Richmond, NI tl;e fullawme desrnbed real .... estate in ., St.....CrOi.X ........................County, 'A 017 State of 1t',scot.sin: Tax Parcel No: .............................. Part of the "ctrthtaest darter of the Southwest Cuarter (Nwh of SP's), Section Four (4), Tbwnship Thirty (39) North, Range Eighteen (18) West, described as follows: Camtencing at the) hest quarter Corner of said Section Faun (4); thence South 89 58 56" East along t1:e East -hest quarter Section line of said Section, 660.38 feet; thence South 01 07 40" East, 330 feet; thence South 89 53t 56" Fast 660 feet; thence South 01 07 40" East, 634.57 feet; thence North 89 58. 56" West, 330 feet; thence South O1 07' 40" East, 33 feet; thence North 89 58' 56" West to the Vilest line of said Section Four (4); thence W along said West line to the West quarter corner of Raid Section Four (4) and the Point of Beginning, is not This ....... homestead Property. fill (,a not) 'x.•rpt+na to warranties: 20th day of September 19 85. �T L br.bN.t W _�C y (SEAL) ...� _: •: r L :J�. -�•c tSEALI Dennis ta, Schultz Rachel Schultz tSEALI (SEAL) AUTHENTICATION ACKNOWLEDGMENT SiKraturn(a) .STATE OF WISCONSI. ss. ..... .. I ........ ..........County. aithentinted 'his ....... da; ol ........... ......... 19...... Personally came before the this .. 20th.. ,lay of Sep ,- , 198 the above named Dennis w. Schultz and Rachel Schultz t ... ..............I._ .. ... .............. ........ . _..... _ . ..................... TITLE: )t F.NIdF.ft STATE BAR OF WISCONSIY . .. ... .. "` " " "" I if not. --- _ .............. authorized L .. .. ... .. y j 70RAR, Wis. Statn. .... ) to me known to be the Person wi•o executed the fofegnins instrument and acknowled ,tha,KIM IN is RUNENT Noe DR.f TE0 "y % _fir "L •I,,,y� Reir.stri, Van Dyk 6 Needham, S.C. - /•f':. _ ;�..�Gr`•t 1ttorr,eys at La(i Linda .t. Cod Er fZ :ew iticn:..unQ..iliscon�sin 59 -0127 „tarp• PIA lie St. CPta - }k Q iignaV+r «n may he authenticauvl nr ark n..wtedf;od. R•.th fly t•nmmi+.iion is fwrm+mf�t. !, jlat�es �;Lw -re not n,,c —ary.) G7 date: 11 - 15 - i�? 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