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HomeMy WebLinkAbout026-1122-16-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count y Safety and Buildings Division St. Croix INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar c Personal information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: ❑ City ❑ Village ❑ TrWn of: State Plan ID No.: Stock, William Richmond Township CST BM Elev.; Insp. BM Elev.: BM Description: Parcel Tax No.: /00 6 '�L r ' v u c✓ 026 - 1122 -16 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic lJ � r (Z jv Benchmark /00 D Alt. BM - 2 /0 0 �! Aera ' n Bldg. Sewer + y d , L olding � TS/Ht Inlet TANK SETBACK INFORMATION / Ht Outlet �. � . 3 d Vento TANK TO P/ L WELL BLDG. Ai Intake ROAD Septic )�� �� NA Dosin NA Header/ Man.. a Aeration Dist. Pipe . - 9z - / 1P, 6 Hol g Bot. System �3 PUMP/ SIPHON INFORMATION Final Grade 6 3 facturer Demand St cover Model Number - G TDH Friction stem TDH Ft orcemain Length Dia. well SOIL ABSORPTION SYSTEM 3� B /TRENCH Width Len th No. Of Trenches PIT No. Of Pits Insi Depth 1 N 1 N �S �— DI SYSTEM TO P / L BLDG WELL LAKE/STREAM LE Manufacturer: SETBACK C MBER INFORMATION Type O Moe r: e System: C 2_� 2- �RUNIT DISTRIBUTION SYSTEM 3' Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length _L� r Dia. / Length t Z Dia. � Spacing Z Z Z 7 5� 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 E] No E] Yes E] No COMMENTS: (include code discrepancie , pers n r t e C�-�,`, ns ectlon z ns ecthon Location: 1114 174th Avenue, New Richmond, � 54 t (NW 1/4 SW 1/4 4 T30N R18W) - 04.30.18.752 West Side Winding Trail Estates -Lot 16 9�Or1 I, �V� S wC f-e de< l✓ ( 1.) Alt BM Description = .fob a S /q! ,�9 u`wer ? / 2.) Bldg sewer length = 13' CS - amount of cover / = >36r' 3) c .4 We l ( 4f �(-+ Plan revision required? ❑ Yes PJ No Use other side for additional information. SBD -6710 (R.3/97) Dat Inspector's nature Cert. No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ®— w . a _._ e .r� 0 tl SCALE - 1, t e E ; , e� 4 ' a v fl � 3 � °�. �� .�� Safety and Buildings Division A sconsin SANITARY PERMIT AP CATION 201 W. Washington Avenue P O Box 7162 Department of Commerce In accord with Comm►t�rr]! Madison, WI 53707 -7162 .' • Attach complete plans (to the county copy only) fort em, pyn pier n` g County 1 than 8 v2 x 11 inches in size. NItIVED -' j / �'�0/ X • See reverse side for instructions for completing this a 'licat� n- State Sanitary Permit Number U4 0 5 Personal information you provide may be used for secondary purpos s`, ���� ❑ Check if revision to previous application - [Privacy Law, s. 15.04 (1) (m)]. State Plan Review Transaction Number I. APPLICATION INFORMATION - PLEA E PRIN I N Property Owner Name open o tion 8} A, 1/4,S T , N, R/ (otgN Property Owners Mailing Address r Block ber Cit tate Zip Code Phone Number Subdivision Name o S4 Nu mber � r `l1� B ( 'r l/� c r w r n. TYPE OF BU ILDING: - (check one) ❑ State Owned Cit crest Road Village �J ' Public 1 or 2 Family Dwelling - No. of bedrooms own OF P�11 III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Numbers) // OL�. 3 0 $ 75 1 [] Apartment / Condo & oz6 / w �°? - 6 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 _ S ystem ystem System Tank Only 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 [VI-eepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 t Seepage Trench 22 ❑ In- Ground Pressure , I n 42 ❑ Pit Privy c� k � ( Ike 13 ❑Seepage Pit 43 ❑Vault Privy 14 ❑ System -In -Fill = l SI 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/ q. ft.) (Min. /inch) �? Elevation / /in Feet C�pe_ j,Feet Cap acit y VII. TANK in Ca gallo Total # of Prefab. Site Fiber- Exper. INFORMATION M anufacturer ' s Name Con Gallons Tanks Concrete Steel glass App. Tanks Tank New Existin structed s Septic Tank or Holding Tank � t El 1 P ❑ 1:1 1:1 1:1 Lift Pump Tank /Siphon Chamber ❑ 11 El 11 11 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plum is Name: (Print) ` Plumber' ature: (No Stamp ` MP /MPRSW No.: Business Phone Number: Plu er's Address (Street, City, Stat Zip C e): "b� /I'y L r /• �8 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate I ssued Issuing Agent Signature (No Stamps) � Approved [I Owner Given Initial Adverse Determinati Surcharge Fee) on r p� X. CONDITIONS OF APPROVAL / REAS NS 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. 1 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. 11. 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; Q 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. FLU I PLAN /7 �/ PR JECT L,�� � G � ADDRESS i�f/n� G ✓`"YO17 X1 /Ovrdon 1/4/S /T D N/R W TOWN L� �� COUNTY MPRS Bird Jf. X318 DATE BEDROOM CLASS PERC CONVENTIONAL IN - GROU D PRESSURE CONVENTI OVAL LIFT_ MOUND HOLDING G T ANK SEPTIC TANK SIZE ��� LIFT TANK SIZE DOSE TANK SIZE T HOLDING TANK SIZE ABSORPTION AREA PERC RATE BED SIZE b► Benchmark V.R.P. Assume Elevation 100' Location of Benchmark - a C7 Borehole Q Well Scale = Feet — O Perc Hole System Elevation Uent 1 2" Grndp IF TYPAR COVERING 2" aOG 12" 3' 4 6 0 3 3' O 3 y Sewer Rock 12 18 v Wisconsin Department of Commerce SOIL AND SITE EVALUATION 'Division of Safety and Buildings Page of Bureau of Intbgrated Services in accordance with Comm 83.09, Wi 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 all ' r►t W00 Reviewed by Date Personal information you provide may be used for secondary pu s �rcy Law, s. 15.04 (1) (m)). Property Owner r r : l,� ro Property Location Govt. Lot 1/4 �, ' /4,S T ,N,R E (o Property Owner's Mailing Address Lot # Bipck# Subd. Name or CS M# C ate . Zip Code e N u'r `° Nearest Road x - , Uri I] Citi"' � village To r � New Construction Use: tirgesidential / Number o p 1 i T�[Q� ins. -- Addition to existing building Replacement LJ Public or commercial - Describe: Code derived daily flow � gpd Recommended design loading rate _bed, gpd/ft S trench, gpd/ft Absorption area required �,-50T� bed, ft , /a% trench, ft Maximum design loading rate =bed, gpd /ft trench, gpd/ft Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design /site considerations a 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 S ❑ U 1 ,9S El U 2 s ❑ U 2�6 ❑ U ❑ S [RU [:Is „5� 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 g n 0 143/ Z ::..:..:.:: f Ground elev. Depth to limiting factor 3 -Z_ Remarks: Boring # / a Zooc e z .. :: o. Ground elev. Depth to limiting factor 7 in. Remarks: CST Name Please Print) Signature .� Telephone No. 4 who Address _ Date CST Number �' � 14C�i SOIL DESCRIPTION REPORT - PROPERTY OWNER— Page of PARCEL I.D.# Boring Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Groundz elev. / Depth to limiting fac o Oct �in. a Remarks: Boring # o iw Ground elev. Depth to limiting factor 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 # � ''� ' ' r? O;/f� i xomw Ground elev. Depth to t • Z limiting facto in. Remarks: Boring # I 1 Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R.9/98) Soil Test Plot Plan Project Name `����� sfoG/ Byron Bird Jr. Address CS oZoZ v S,, Lot �L'_ Subdivision Date A 1 /46 �© N /R� T o wnshi p ,nom Boring O Well PL Property Line County :n/-_ Z5��v���� BM or VRP Assume Elevation 100 ft o�� /� 0,0 0 , �j I c c 01 oo , System Elevation *HRP T dew �M — 7 ga 9 r • !q 7 Alf 0 t oo 37 fob Scale 1/4" = 10 Ft. When Dimensions aren't stated ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWN RSHIP CERTIFICATION FORM Owner /Buyer Mailing Address /Q ie07 M - Property Address / � �C' (� (V e ri(i / ation required from Planning Department for new construction) X612 X �. City /State TJ WOAJ 1.L� Parcel Idewification Number LF; GAL DESCRIPTION Pro crt Location k(� 'A, D N -R (D W, Town of A44" P Y �� 'A, Sec. 4 T t Subdivision W < < ' 7�eo-c , Lot # . Certified Survey Map # , Volume , Page # Warranty Deed # JL0_gef( , Volume 7v'�� , Page # Spec house es O no Lot lines identifiabloyes O no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper mat consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into th 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 t master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposa is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of I /we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the s set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Cert stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office w days of the three year expiration date. �/3! cD SIGNATURE. Or 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 owr the properly described above, by virtue of a warranty decd 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 OCCr N,3 WARRANTY DEED t "`+ + ++�[ w[ +.wr[o row acowo.Ne o•.. STATE BAR OF WISCONSIN PORN B 4a� s11 rot i t PILE 25 . Dennis W. Schultz and Rachel Schultz ` "x Wis. and wife as joint tenants " "` - " -- ' �' husband ;;•'t 30th _ ...... Sept. s.. 1. i _ Wi Iliam Stock aihd Roxariiie.D�•• B:34Ar ti comra anJ wananta to . ' Stock, husband and w Ee ".as_, ". Join t..•tenants....... .. _ ......... ........ ......... ........ .............. __. . .......... .. - - Northwest Federal SQL the tYllawinK desu,bed real eataq in . St....CroiX . . P.O. Bolt 160. New Richmcnd, WI ......................County, `;4017 State of Wucot.sin: Tax Parcel No: .............................. Part of the *mrthwest Quarter of the Southwest Quarter (Mrs. of Shy), Section pour (4), lbwnship Thirty (30) North, Range Eighteen (18) nest, described as follows: CCINencing at the hest quarter corner of said Section pour (4); thence South 89 58' 56" East along the East -hest quarter Section line of said Section, 660.38 feet; thence South 01 07 40" East, 330 feet; thence South 89 58 56" East 660 feet; thence South Ole 07 40" Fast, 634,57 feet; thence North 890 58 56" West, 330 feet; thence South 01 07 40" East, 33 feet; thence North 89 59t 56" West to the 41est line of said Section Four (4); thence ?kirth along said West line to the Wiest quarter corner of said Section Four (4) and the Point of Beginning, !� 3•.Yt Ttil, is not ........ homestead property. cis) im not) xeeptv,n to warranties: 20th day of September .19 85. � r \ r ` y 1rt:.l�" (SE:tLI ._ � _: ,� : � .... . L �'J<:. -%:.. � (:EALr Dennis .4. Schultz Rachel Schultz 'SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Siltn+ture(s) .... ", , STATE OF WISCONSIN .... ............... .. ......... - ... . .......... ............ .._ -.. -. St Croix -_.... � as. ...... ..................County. authenticmed this ...... da; of ............. 19 ...... 20th came before trK this .. 2 0th.. 1 of September "" " h 1985.... the above named " " ".. Dennis tv. Scultz and Rachel Schultz -. .... ...... ...... ... . ... ..... ......._ _.._ ...... .... .. TIT LE: MEMBER STATE BAR OF WISCONSIV 1 If ant. .. .. ... ..... authorized by $ 104,06, Wis. Stata.) .. .. .. _ .. ..- .- to me known to be the person _.. WI-o executed the forevintt instrument and aeknowledK ,Iba,a mw Ni "RUWNr N[e DRAPy ED aT Reir,stra, Van Dyk 6 Needham, S.C. r. / ` Y- — :,..��� °�' � : ' l Zttora•�s at L<iw . ._ _ _ Linda J. CoclEr <1 �. �.... c)'•. ed aicrt::.und, Agiscunsin 549 17- 0 12 7 N•,ta -y Pnh17e q� Ct{mty" ia: iixnaty rrs may he authenticated or arkn•,w•led;;rd. P•,th Ny CommkMon is p rman St. (I `Q- " �at�exp�wtifoR .re not neerasary.I { ({ v7 T date: 11- 15-•87 a��0 ti t Q ;!!♦ r .f •�•mw f r, n,m. • rn.nr .n , ..•e «tr •r- r •. •, i...t r eYd ti..r.•. 'n .r •rr•,.n•. �•4 • • ff L4 � /'� • 5 1I't i b ! � i r r i D r / t � ; .4POTi?1Y14�1'm14' +tom` ►Uas'�►a�i�.6r� .+ww;d+ 1 A ka l 1 I'a -� D ✓ t \ � "'1 . It a`:.-� �- .'� �' T-+ I I Ap l a p l F4 r x �c a - i iii" OL I -----------'----- -- -- -- __- ._------ Yom_______ __ ___ ______ __ _. -__� K -- 1 - ____-� �. :+I - Nd 3d i4 �Q dP 4S F - - - - - - - r s-