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HomeMy WebLinkAbout026-1131-09-000 wsoonsin Department of Commerce PRIVATE SEWAGE SYSTEM ou Safes' and suitdrngs omsion J INSPECTION REPORT V. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: be used for seconds X383900 Personal information provice may N purposes (Privacy Law s.15.0a (1)(m)l. Y� n f : Stale Plan ID No.: City Vi Cage Tow o . er it er s Name: y �ocl, 'I �ichmon Tawnshfp CST 8M Elev.:• tnsp. BM Elev. 026- 1131 -09 -000 : BM Description: Parcel Tax No.: � (0 S TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark `igD y 1 1 In d It. BM fe _';T on Bldg_ Sewer 3 2 _ q7.5 Holding AbHt Inlet Y, QS. TANK SETBACK INFORMATION Al Ht Outlet q� TANKTO P/L W L BLDG. Ventto ROAD Air Intake Septic NA NA Header / Man. Aera NA Dist. Pipe 3 . Holding Bot. System z b 0 PUMP/ SIPHON INFORMATION Final Grade k over WLength Demand M S tem TDH Ft Dist. To well SOIL ABSORPTION SYSTEM 5— SED 1 width Len nth No. f Trenches PIT No. Of Pits inside Dia. Liquid Depth � t�(' D IMEN SIONS G Manu d Ere SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM L HM A M Num INFORMATION Typeaf q System: `rJ UNIT r DISTRIBUTION SYSTEM VLeng r / Manifold !� Oistri ution Pipes / x Ho a Size x Hole Spacing Vent To Air Intake Dia. Length Dia. Spacing ' ' s� SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Deptfi Over Oepth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center BedlTrenchEdges Topsoil ❑ Yes [I No ❑ Yes C] No / COMMENTS: (Include code discrepancies, persons present, ectlon #1: /Z 7Ja Inspection #2: 1 Location: 1023 159th Avenue, New Richmond, WI 54017 (NW 1/4 NE 1/41 T30N R1 8W) - 1 7301891# - Lot 9 j� � �wKll;ac�� Y��� lcxtf' h�s. It 1.) Alt BM Description= i" v f I rD l U"t . 2.) Bldg sewer length= 30 - amount of cover a �Strua> l a1 !� i� - 5`tt��d�t ih`� 4� ta Plan revision Vuired? ❑ Yes ® No ve, Use other side for additional informs ion. ZZ Dat Ins o Signature " ert No. SSO -6710 (8.3/97) L • Q �-� � �� '' — r _b �� _� "T �� Sanitary Permit App I eation Safety & Buildings Division In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. See reverse side for instructions for completing this application PO Box 7302 Wisconsin Personal information ma p rovide rov ou be used for second p urposes Madison, WI 53707 -7302 Department of Commerce y p y p [Privacy Law, s. 15.04(1 )(m)] (Submit completed form to county if not state owned.) Attach complete plans (to the county copy only) fort e , bn apex ndt than 8 -1/2 x 11 inches in size. County �) r State Sanitary Permit Number ❑ C ,rr Vkion to previous apoipation State Plan I. D. Number ✓t�1 3S� O� \s I. Application Information - Please Print all Information Location: Property Owner Name ; Property Location l Y A C_ ) & �IIJA I VA, S T,? `',N, R "E ( W Property Owner's Mailing Address Lot Number Block Number 'vllh y"� City State Zip Code P out Number Subdivision Nam or CSM Numbe II. Type of Building: (check one) ❑ City 1 or 2 Family Dwelling - No. of Bedrooms: Village Q Public /Commercial (describe use):_ L� �1 * Town of (SCC p f Q t4t �1 �j'ld - tG ❑ State -Owned F/d �►► tJ� �t`lG d (.�' f 'o t l/�- /L���` Nearest Road Number( s) V ` Y � 1 III. Type of it: (Check only one box on line A. Check box on line B if applicable) (" 3 Q — O 0 A) 1 ew 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to Syste System Tank Only 3 C . T1 Existing System B) Permit Number Date Issued Cl A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) 'Non- pressurized In ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. Dispersal/Treatment Area Information: a 3¢" x O C — r-, 1. Design Flow (gpd) 2. Dispersal Area 3. DispersaTArea 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed 5 c/ Z Rate s. /daylsq. ft J (Min. /inch) T _- C Elevation VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks 1 t � Zj.rZ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ VIII. Responsibility Statement I, the undersign assume responsibility for installation of the POWTS shown on the attached plans. Plu Is Name (print) , Plumber' gnature (nos s): MPlMPRS No. Business Phone Number Pl er's AddresslStreet, City, State, Zip Code) IX. C ty/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date lssue IssuineAllent ig ture (No stamps) Approved ❑ Owner Given Initial Adverse Surcharge Fee) Determination X. Conditions of Approval /Reasons for Disapproval: P"444AW?rwk _ 6" e'd 4 vqt ' ( 4 - 0 �� SBD -6398 (R 07/00) t3e- elk- 41 Iv �1 r y� t I PLOT PLAN PROJECT r JE // o ADDRESS 1/41�/� 1 /4S 7 /T 0 N/R W TOWN �C � d � OUNTY 5�Q G �x MFRS Byron Bird Jr. 2 DATE S — ° -2 y :E9 / BEDROOM CONVENTIONAL XXX At -Grade CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE �90-e-1 IFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE O LOAD RATE ABSORPTION AREA # of chambers ,► BENCHMARK V.R.P. ASSUME ELEVATION 100 1 ❑ BOREHOLE 'O WELL *H.R.Pi �[ ��/ IV L6 : SYSTEM ELEVATION >12" dewinder High Of .._ Cov hamber with 17 2 ` f 2 per chamber 34 Grade at System Long Elevation 9� f� S r � o � � N w �, lip K, Maintenance and Contingency Plan for a Septic System Maintenance Plan 1. Septic Tank is to be pumped once every 3 years. 2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in order to extend the maintenance interval of the filter. 3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of the cells. 4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system. 5. The owner agrees to save this plan. 6. Do not plant trees nor park nor drive over system. Contingency Plan 1. If system fails, determine cause of failure, use aftematetea and install new system or install system at a lower elevation. 2. Replace any other failing components as needed. 3 4s- • Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of dMsion of Safety and Buildings In accordance with Conan 85, Wis. Adm. Code Attach complete site plan on paper not less than 8112 x 111nches in sits. Plan must �� Include, but not limited to vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all lnformadon. e D � ate Personal information You provide may be wed for aeoondery pwpom fruit+ Loo a 15.04 (1) (m)) J 1,x-)1v Property Owner ` y Property Location D C 1 Govt. Lot jW 1141V4 Sa T Property Owners Mailing Address Lot # Block # Subd. Name or 9SM# Z: city S tale zjp Code Phone N ncftv 0 Village Gown Nearest Road New Construction Use43-Residential 1 Number of bedrooms Code derived design flow rate B "110 GPD 0 Replacement P Public or I - Describe: Parent material �� C-Gf of 1 1 0 A Flood Plain elevation if applicable ft. General comments f� and recommendations: A/,_ x Sy 5/ ! v • �- 0 ..r F—/] Bori # pit Ground surface elev. �� -�' ft. Depth to limiting factor In. Sofl Application Rate Horizon Depth Dominant Color Redox Description Texture Structure . Consistence Boundary Roots GPDW tn. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 Boring # Ong Pit Ground surface Slay. /'S' - ft. Depth 10 Wwdng factor in. SoH Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDMF In. Munsefl Qu. SL Cont. Color Gr. Sz. Sh. •Eff#1 •042 m �.; OUO top TY � f • Effluent #1 = BOD > 30 < 220 mg& and TSS >30 -c 150 myl • Effluent 02 ■ SOD, <30 CS ame (Please P t) umber _ �^ mess Data Evaluation Conducted Telephone Number I ' Property Owner ` Parcel ID # Page of Boring # ❑ Boring Pit Ground surface elev. ft.. Depth to limiting factor ;7 1 � 0 .. in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD1ft In. Munsell Qu. Sz. Cont Coldt Gr. Sz. Sh. I 'Eff #1 'Etf#2 zp e ❑ Boring # Boring C/ Q Pit Ground surface elev.— / fL Depth to limiting factor 7 in. UW ication flats Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary f loo's f?PWftz In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. r 'f1 •Ef1#2 J - / --� ❑ © Boring # Boring surface elev. �, fL Depth toAmitinj facto in. Pit Soil Application Rate Horizon Depth Dominant Color _ ' Description,_.:... - Texture Structure Consistence Boundary Roo:. GPD/ft In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 0 tit r fit¢... Ile Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 1.150 mg/L • Effluent #2 : BOD, < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity. service provider and employer. If you need assistance-to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608- 264 -8777. SBD4330 (3L6W) f . • Soil Test Plot Plan Project Name Bill Stock Byron Bi d Jr. Address 1478 112th St. New Richm Wi. 5 4 0 01 CSTM 4 20527 Lot 9 Subdivision Rolling Acres Date 11/4/ NW 1/4 NW 1/4 S 1 7 T 30 N /F W Township Richmond .— F� Boring d Well PL Property Line County ST. CROIX ,BM or VRP Assume Elevation 100 ft top of PL wood stake System Elevation 92.5 H.R.P. same as BM # Alt. BM assume 102.3' top of white stake -' B 1 q1•> B 120 12 ' c Pri A. > 4 7 133 ep A. rV� 275' L ment Rd B 0(l B 7' 10' 15' 15' 10' 335' PL L B.M. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CE RTIFICATION FORM Owner/Buyer < / d �- /I Mailing Address 7 /o? ��z f/ _Property Address ®0 ,L�j�! 7`h� (Verification required from Planning Department for new construction) C City /State zLe t) "e" �?Ll n 1 Pa rce l ldcnti(ication Number ILF GAL DFSCRIPTION Property Location l�' /4, eL6! ' /,, Sec. 17 , T - b W, Town of Subdivision O A K �G/'-� , Lot # �. 7 Certified Survey Map # ° ° , Volume , Page # � r Warranty Deed # ° , Volume Page # Spec housevyes 0 no Lot lines identifiable [ `yes 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 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 master plumber, journeyman plumber, restricted plumber or a licensed purnper 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 113 full of lrwe, the undersigned have read the above requirements and agree to maintain (lie 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. SIGNATURE. Or 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 owr the property described above, by virtue wf a ti+airanty deed recorded in Register of Deeds Office. lot /Z� ��� / 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 . yon_ 1539eA6464 62'� 143 STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH Document Number WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., WI This Deed , Y made between John C. Van D and Eileen K. RECEIVED FOR RECORD Van Dyk, husband and wife, 08 -31 -2000 2:30 PM WARRANTY DEED EXEMPT # Grantor, and William B. Stock and Ro Stock, husband and CERT COPY FEE: wife, COPY FEE: TRANSFER FEE: 186.00 RECORDING FEE: 10.00 PAGES: i Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Recording Area Lot 2 and 3 of Certified Survey Map filed July 28, 2000, in Vol. 14, Page Name and Retupp Addre s 3914, as Document No. 627230, located in part of N W 1!4 of NW 1I4 of E j � Section 17, Township 30 North, Range 18 West, Town of Richmond, St. 4co5 Croix County, Wisconsin. �.5 t k LA) I'_ 4E5 Ot ( ##-* 26- 1049 -70 -100 Parcel Identification Number (PIN) This is not homestead property. (K) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this day of August 2000 * • Jo Van Dyk k + * Eileen K. Van Dyk AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) Is ss. . PHA EUF P���. County authenticated this T E eF WISCONSIN d TARY PUBLIC Personally came before me this day of August 1 2000 the above named John C. Van Dyk and Eileen K. Van Dyk, husband and wife, TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be the person(s) who executed the foregoing (If not, a instrument and acknowledged the same. authorized by § 706.Ob, Wis. Stats.) oe THIS INSTRUMENT WAS DRAFTED BY Attorney Kristina Ogland Notary Public, State of Wisc sin Hudson, W1 54016 My Commission is perman n . (1f not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) /0 3 ) Of # Names of persons signing in any capacity must be typed or printed below their signature. information Professionals company. Fond du Lac. WI STATE BAR OF WISCONSIN 800- 655-2021 WARRANTY DEED FORM No. 2 - 1999 Cow RONALD F. tr p .IOHNSON '3 AM is. ` 6 2000 3 WlS. � E l� Kt+SH 0%0 mm ,4�a S "� J �� E R T I F� %,% V E Y M Af Paa Locoled in port of the Northwest Ouorter n h OUnrlar of Section 17, Inwnship 30 North, Hnnga 18 We,t, town of 1601411ond, St. Croix Conn ircnnnin. Prepared for and of the request o(: OWNER: LEQ: John C. and Eileen Van Dyk Alb County Section Corner Monument 1591 1001h Street of Record New Richmond, 1M 54017 • Set i" x 24" Iron Pipe weighing Drafted by, Ty R. Dodge o minimum of 1.13 pounds per linear foot. • • • • • . Denotes Building Setback Line (�^o� 3 (100' From R -O -W) 4 om r- -x —ar- -X- Denotes Existing Fence Z UNPLATIED LANDS r c� t VI E.tlSAYG f£NGF, R'PI'G�� Izz SOD 52'46 "E 830.07'_ 4 EA.ST LINE OF 1NE NW 1/4 W O � OF 7N£ NW 114 r' CV u < ° , o < <5 U dE rz0 3 Al am 3 s { �v s 5 U y U O I+! Z L O T 3 Z w WW U O z p U C l! II U N� 1.. ,.2 O rr ' m; o° io l 2 p uW k 1 4. a ° '•a g N m E'a °a NI\I �F pY I 1 .:SI p,tVhQ W^'Y O a`L 2 N« �12t I r h I�N 4 N ` U 7 �< +�' M 51 c. o. < aI �M Wry $ �' m 4�VWInnf4 r j I zl �'. 0 0, Nb Z;w� N l 010 H 2 7(�Z N 2 m c 1 m ��'' q N00'37'29 'W 434.72' Q o ai ci N 2 I p p�p '}f 3 h� ^ Q ao yr � ?� u r1. S00 "37'29 "E W� 66.OQ \�� a L O T 4 : pp S00'37'29 "E 329.31' o- m \ 1 � I"�pO�tp� q I k L O T Z N x�a S.g .............. S :.. !.� °QNri Na no no 0: r .............. tr o - e U t 1 m.?o 0 P,, o o , o `H:Q- -500'J7'29 "E n m 6 M--830.03'---- - - - -- -n P 434.72' n y ---r- N17C137'29 W 17_9 329.31' _ _ 66 — — — _434.72' — -- — N00'37'29 "W 830.03' NO0 "W - - -- 2626.82' - - -- -- i 1007H 8rREE7 3 ° t I JOINT DRIVEWAY EASEMENT 6 �l UNPLATTED UV4DS RESTRICTION: LOT 2 MUST �i I 1 14£ST LOVE OF 7HE NW 114 ACCESS AT LEAST 200 FEET °o JOB { A00060 zlt I FROM THE CENTERLINE OF�'2+q �I 1 1OOTH STREET ON THE JOINT 7{ h Prepared by. �I 200 DRIVEWAY EASEMENT FOR £i A . & E POSSIBLE FUTURE TOWN ROAD � 2 LAND SURVEYING do CIVIL ENGINEERING ORAPHtC SCALE Cs Phone No. (715) 246 -4319 109 East Third Street, P.O. Box 325 SCALE IN FEET: 1 inch = 200 feet Rich New Richmond, W 54017 u�{ BEARINGS ARE REFERENCED TO THE WEST LINE OF THE E NW 1/4 OF SECTION 17, TOWNSHIP 30 N.. RANGE 18 W. Sheet 1 of 2 WHICH IS ASSUMED TO BEAR NOO'37'29 "W. 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