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HomeMy WebLinkAbout026-1122-17-000 �/* Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y 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)). 370263 Permit Holder's Name: ❑ City ❑ Village ❑ T6wn of: State Plan ID No.: Stock, William Richmond Township CST BM Elev -:- Insp. BM Elev.: BM Description: Parcel Tax No.: csl9.O c70. 0 ` 5T_ g t,) I e#cut ar rag 026-1122-17-000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic � Benchmark A LO I,� $'o D6)•� Dosing Alt. BM Aeration Bldg. Sewer S , 3 $ • 1 ' Holding St/ Ht Inlet 90 g. 1r), TANK SETBACK INFORMATION St/ Ht Outlet G- 01-f gg• L(L' TANK TO P/ L WELL BLDG. Air i to ntake ROAD Dt Inlet .� Air Septic -- NA Dt Bottom 77 Dosing NA Header /Man. `S t -ZB 43 -ZZ Aeration NA Dist. Pipe S 7 - Holding Bot. System 8 --yo cif (p' PUMP/ SIPHON INFORMATION Final Grade q6 ` Ma urer De St cover ST 96 ` Model Number GPM TDH Lift Friction S stem TDH Ft Force Length Dia. Dist. 11 SO L ABSORPTION SYSTEM / Width Len r o. f T rich PIT No. Of Pits Inside Dia. epth EN I N D� DIM EN I N SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING acturer: SETBACK CHA INFORMATION T pe0 Mo a Num y e . ► �� It System: ytt/, O NIT 0t DISTRIBUTION SYSTEM ea r/ anifold u Distribution Pipe(s) r r I x Hole Size x Hole Spacing Vent To Air Intake r Lengtk Dia. Length � Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over D th Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center 1 0 1 Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present etc. Inspection #1: l�Ld(1 oZ #2: Location: 1120 174th Avenue, New Richmond, Wl 5401`7 (N 1/4 SW 1/4 4 T30N R18W) - 04.30.18.75 3 West Side Winding Trail Estates -Lot 17 1.) Alt BM Description= 2.) Bldg sewer length = 4 rn �- f /� - amount of over = 4 ��E, G t'''° -� iot62 1 y Plan revision required? ❑ Yes N No Use other side for additional information_ ) 2- (3 d Z w SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: �. ®e . m m. d.. . . ... � _ � ( f k E E L® E � I ss T SCALE ll 2e� f Safety and Buildings Division Visconsin SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue P O Box 7162 Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7162 • Attach complete plans (to the county copy only) fort stf 7 nr not less County than 81/2 x 11 inches in size. , • See reverse side for instructions for completing ` t ik lic • State Sanitary Permit Number Personal information you provide may be used for secondary p rip s ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan Review Transaction Number I. APPLI ATION INF RMATION - PLEASE T ALL ION Property Owner Name _ Property cation y 4 1/4,5 tl T p,N,R , Ig E(o Property Owner's ftlin6 Address ` Lot Number: Block Number IQ Stat Zip Code Phone Numb ision N ie or CSM Nu mber II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Ity arest Road Village Public X1 or 2 Family Dwelling - No. of bedrooms wn o 111 BUILDING USE: (If building type is public, check all thatapply) Parcel Tax Number(s) �L53 Ba�6 ✓ 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. New 2. ❑ Replacement 3, ❑ Replacement of 4 E] Reconnection of 5. ❑ Repair of an stem ________System _____________Tank Only______________ Existing System ________ ExlstingSystem 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,�j Seepage Bed 21 [3 Mound 30 E] Specify Type 41 E] Holding Tank 1 ❑ Seepage Trench 22 [] In- Ground Pressure �x�7 ' 42 E] Pit Privy 13 ❑ Seepage Pit {, 7 43 ❑ Vault Privy 14 ❑ System -In -Fill rs(Z N BsGe� 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) �j / Elevation Feet Feet Capacit VII TANK in Ca allons Total # of Prefab. Site Fiber- Exper. INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete strutted Steel glass Plastic App Tanksl Tanks Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ 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. Plumber's Name: (Print) Plumber' 'gnature: (No Stamps) MP /MPRSW No.: Business Phone Number: s 6l Plumbd0ress (Street, City, State, Zip Code): 4Ar IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate I ssue ; d Issuing Agent Sig atu (No Stamps) Approved ❑Owner Given Initial Adverse Determinati Surcharge Fee) on a2s- X. CONDITION OF APPROVAL / REASONS FOR AL DISAPPR V � 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'sdotic 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 4nd accuraje this sanitary permit application must include: 1. 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. M. 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 into fill inbame, 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; Q soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1953 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 KLAN � - 6 PROJECT � /, , e 1 ADDRESS 1 14 1S /TO N /R,/,W TOWN COU Y MPRS Byron Bird Jr. 3318 DATE .777 4' — BEDROOM CLASS PERC - GRO ND PRESSURE CONVENTIO AL LIFT_ MOUND HOLDING TANK SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA _Z., z ? PERC RATE BED SIZE �► Benchmark V.R.P. Assume Elevation 100' Location of Benchmark �-I * H.R.P, ED BoiLnoie Q Well Scale = Feet 0 Per,; Hole System Elevation Vent 12" Grnde G / TYPAR COVERING7l 2" 12" 3' 4 6' 0 3' 3' 0 3' 6' Sewer Rock �► 12' 18, t � 3' � D � e J� v �U Wisconsin Department of Commerce SOIL AND SITE EVALUATION Divisioh 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 �j / lfd' 0 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. # APPLICANT INFORMATION - Please print aJ Reviewed by Date Personal information you provide may be used for secondary ^s Law, s. 15.04 Property Owner Property' Location ovt. Lot // 1/4 /4,S T ,N,R /- E (otr�? Property Owner's Mailing Address Lot # + Bloc # Subd. Name or CSM# t :•,. Ci State Zip Code khonb } ❑ y ❑ Village To Nearest Road z; tir , New Construction Use: P5Residential / Number of Addition to existing building ❑ Replacement // ❑ Public or commercial - Describe: Code derived daily flow 42!P� gpd Recommended design loading rate bed, gpd/ft S_ trench, gpd /ft Absorption area required �S bed, ft d` aWtrench, ft Maximum design loading rate f i bed, gpd$ trench, gpd/ft Recommended infiltration surface elevation(s) �- G ft (as referred to site plan benchmark) Additional design /site consideration Parent material Gr �CsT`�J� Flood plain elevation, if applicable ir�''� ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system S ❑ U ,® ❑ U J:96 ❑ U 1 06 ❑ U ❑ S ' §R _U ❑ S /E!I-U SOIL DESCRIPTION REPORT Borin g # Horizon Depth Dominant Color Mottles Texture Structure GPD /ft Consistence Boundary Roots .. in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Ground u - elev. Depth to limiting factor in. ° Remarks: Boring # Ground el qy. 3 --z- ' Depth to limiting fact in. Remarks: C T Name (Please Print) Signature Telephone No. Address Date CST Number �� ��,�� • fit ,' � 70� � dsa7 SOIL DESCRIPTION REPORT PROPERTY OWNER `� � o� Page � of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench � � s �i ; Ground 3 elev. s - ft. Depth limiting factor Remarks: oring # Ze Jv Ground _ el , ft. Depth to limiting factor in. Remarks: fi Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # loor LA r n Groun��. — Depth to limiting factor = �,' n ' Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R.9/98) Soil Test Plot Plan Project Name' /�ae� Byro ird Jr. Address cem 0 - 5�i L ot Subdivision Date . ,,� W1 /4�1 /4S(T N /RZll/ -,- Township F Borin Q Well PL Pro ert Line County ' � n y � Gro �,x i nn , BM or VRP Assume Elevation 100 ft �le<, System Elevation �l. z _ *HRP 4Z�� �, �;ee ) OZ- - .� e Scale 1/4" = 10 Ft. When Dimensions aren't stated ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner /Buyer kt Z? Mailing Address - Property Address (V ^ rcqui � rcd from Planning Department for new construction) City /State ,� Parcel Identification Number I T F; CAI, DESCRIPTION Z Property Location '1, '/4, Sec. , T3 N -R � W. Town of C LfLt'c7 Subdivision e .5 aiz t4_)'X_rjr (/2tA_c ? S , Lot # . Certified Survey Map # , Volume , Page # Warranty Deed # Jos lo/( , Volume Page # Spec house P D no Lot lines identifiablrri-IE;4es O no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper mai consists of pumping out the septic tank every three years ©r 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 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 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 days of th/Je, ►thhr c year x 'r ►on date. SIGNATURF. Or APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements our this form are true to the best of my (our) knowledge. I (we) am (are) the owr the property de cribed above by virtue of a warranty decd recorded in Register of Deeds Office. 6 13 / 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 Occu MENr No W ARRANTY DEED .. •.. •• "o o••• STATE BAR OF WISCONSIN FORM 2 - 19N Yassll ' +Lt � �( vaLE 75 Dennis W. Schultz and Rachel Schultz, husband `�X �`„ Wlti• and wife as joint tenants "' "'.. -.r 30th _ __. . .. .. .. . . . .. . ...... Sept. ,roncrys anJ %,- :,era to William Stock and Roxanne B:3Q_A..,/:•L _ q , Stock, husband and wife._a joi ... nt, tenants . ,tptaat it ! _... __ ...... Northwest Federal S &L __ . F.O. Scat 160, New Richmond, W1 the following descnbeJ real estate in .. St.•_. Cl; p.) ,X....._.........._.....County, ',4017 Mate of Wiscoe.sin: Tat Parcel No: .............................. Part of the Nlnrthwest Quarter of the SOuthueSt Quarter W- of SP-%) , Section Four (4) , Township Thirty (30) North, Range Eighteen (18) Test, described as follows: Calmencing at thP West quarter corner of said Section Four (4); thence South 89° 58' 56" East along the East-West quarter Section line of said Section, 660.38 feet; thence South Ole 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 Ole 07' 40" East, 33 feet; thence North 89 58' 56" West to the Viest line of said Section Four (4); thence North along said West line to the West quarter corner of said Section Fcar (4) and the Point of Beginning. is not - -... _... .homestead property. tis) (,s not) F:xcrpt n to warranties: Iar„i th;; 20th d ay of September 19 85 ty� , (SEAL) ._ � _: �_ � ,-- L � =)�-2. �' DEAL, Dennis !J. Schultz Rachel Schultz (SEAL) - tsEALt AUTHENTICATION ACKNOWLEDGMENT Sign3ture(s) _ STATE OF WISCONSIN . ........... . ss. St. Croix ... ... .. _C.ounty. authenticated this .... da, of ...... 19...... Personally came before me this 2O ,l of September 1985. the :,hove name) ........... Dennis w. Schultz and Rachel Schultz ...... _.. - TITLE: MEMBER STATE BAR OF WISCONSIN .._. . ... - ._.._ ....... . ...... _ .. ..__ _.. _....._....__.._. 1 t not. -. _ .. authorized by § 706.06. Wis. Stit.3.) _. .. _. ....... .... _. to me known to be the person S .. . ... WI-o executed the fote¢nirtg instrument and acknowledge,(hN IN iTRU —NT NAS ORAFTED BY _` Reinstra, Van Dyk S Needham, S.C. - �''y �L / Attorneys at. Law' ....._.._. _ Linda J. Co . :..0 . , Rich::.und, llisconsin $4017 -0127 Ngta o PnbLr $(;• (,`yf .. Q I .Cy/,nty s. �Signatv , r may he authenticate) nr ark nnWlyd;;ed. I!�th N >• ('nmmiesion is permanret l ,h, aRar�ex oirwt fn .re not ncr <s ary.l - G7 as date: L1 - 15 -87 I Iti •— ,i {[ s,0 . .. V: A16 *DMMM Up. om F 4 3r An ic C- 1z Z Z rn 0 >Zlc ---- - ---- lit Z 0 t rn lit I -Tr- -A I -- - ' ^ --- - - - --' ' 4 -------------- L-/ ---------------- — ----------- ----------------- ---- ----- ----------- 4i i