HomeMy WebLinkAbout026-1137-14-000 Safety and Buildings Division County !
Alf 201 W. Washington Ave., P.O. Box 7162 t C f )
Y Madison, WI 53707 - 7162 Site Address
Department of commerce
Sanitary Permit Number
Sanitary Permit Application �d �/
in accord with Comm 83.21, Wis. Adm. Code, personal information you provide 11 Check if Revision
may be used for purposes Privacy sl5. 1 m
I. Application Information - Please Print All Information R E C EIVE D State Ptah I.D. Number _ /
Property Owner's N Parcel Number * - !!
JUN 1 2 2002
pe A s Property Location M
Pro rty Owne . CROIX COUNTY r ' I
�/ OFFICE ✓ If T N, E
City, State Zip Code Phone Number Lot Block Number
Subdivis'on N CSM Number
II. of Building (check all that apply) Z ❑City
or 2 Family Dwelling - Number of Bedrooms �T ❑Village
❑ Public/Commercial - Describe Use ownship
❑ State Owned 4 3�X �� f /�/ Neare it Ro ,
!M r � t3aalr�s«.
III. Type of ermit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applica e)
A. For Coutaty use
ew 2 ❑ ERep1a=c-m:ent:System 3 ❑ Replacement of 6 ❑ Addition to
ste I Tank Only I Existing stem
B. El Check if Sanitary Permit Previously Issued
Permit Number Date Issued
IV. of Permit: (Check all that apply)(numbering scheme is for internal us ZZ
4-� - Pressurized In- Ground 2111 Mound 47 ❑ Sand Filter 50 11 Constructed Wetland
22 ❑ pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line
45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other
V. D' tme Area Information:
Design Flow (gpd)� / Dispersal Area Dispersal Area Soil Application Percolation Rate s em levgtion Final Grade s•��
V Required Proposed Rate( Gals ./Days /Sq.Ft.) (Min./Inch) / eva on
VI. Tank Info Capa*in Total Number Manufacturer Prefab Site Steel Fiber Plastic
GaGallons of Tanks /� Concrete Constructed Glass
New Tanks Septic or Holding Tank
Dosing Chamber
VII. Responsibility Statement - I, the undersign , responsibility for installation of the POWTS shown on the attached plans.
Pitrmber' Name (Print) Plumber's MP/MPRS Number Business Phone N ber
J ~ " I ,/
Plumber's Address (Street, City, State, e) �� /����
( �// r S
oust /De artment Use 6 nly
Sanitary Permit Fee (includes Groundwater Date Issued Is em Signature (No Stamps)
Approved ❑ Disapproved Surcharge Fee)
❑ Owner Given Initial Adverse `4 -? 2,, r
Determination !�
EK. Conditions Approval/Reasons for Disappr9val - L�6La.0'y+v►'�r -t
A-hl� � >ti - fl w. e. 95 6.9 ' 2s /"I� ` /�zel�lack -ate Y3 41-3
)lam EOW &12-- - N.s 4 u F! I & 7?- AW JZWAI " I "'Aj'
Attach —OWe plans (to the County only) for the system on papa' not less than 31a x 11 Inches in sae
SBD -6398 (R. 05101)
PLOT PLAN
PR OJECT Jeff Pa rtridae ADDRESS 1367 Omaha Ave Stillwater Mn 55082
$E 1/4 NE 1/4S 20 /T 30 N/ 18 W TOWN Richmond COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE /12/02 BEDROOM 3
CONVENTIONAL XXX IN-GROva PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chambers 22
BENCHMARK V.R.P. '� ASSUME ELEVATION 100 Filter Zabel A -100
❑ BOREHOLE O WELL *H Same as Benchmark
SYSTEM ELEVATION
V ent
>6" Standard Infiltrator
of Cover Leaching Chamber Plans Designed Using
with 31.1 ft2 of Area Conventional Powts
6 Long 12„ Manual Version 2.0
34
Grade at System Elevation 0 ) "
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. CPOIX
Safety and Building Division
INSPECTION REPORT sanitary Permit No: 405169 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: city Village X Township Parcel Tax No: 1137-^4
Partridge, Jeff I Richmond Township 026 - 166&40 --M0
CST BM Elev: Insp. BM Elev: BM Description:
y... 2�
J 4
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark t 4 %, C) A , p /Do'
Dosing Alt. BM T:
Aeration Bldg. Sewer I " / • ��
Holding St/Ht Inlet / y V j �� �p� s
St/Ht Outlet (O Mill
TANK SETBACK INFORMATION . (�(� 77- 3
TANK TO P/L WELL - BLD� Vent to Air Intake ROAD Dt Inlet �-
Septic t / Dt Bottom /
1\ v
Dosing Header /Man. / - / 71) e, 7
Aeration Dist. Pipe o
Holding Bot. System
Final Grade ,t- Ol�tr Ahr �Of' -I/'*— PUMP /SIPHON INFORMATION _ Z
Manufacturer — Demand St Cover r /Z
' M 1 •� D .
Model Nu
TDH Lift rj oss System Head TD Ft
Force Length io Welf
_7
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of TrencWks PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS cuff U JL - /
SETBACK SYSTEM TO P /L:. BLDG WELL LAKE /STREAM LEACHING Manufacturer• S.J'T��1r'l
INFORMATION T e System: CHAMBER OR
YP C�Mva�n. _^ �J 0 1 j UNIT 1
DISTRIBUTION SYSTEM
Header /Manifold 1` IDistribution i !� I x Hole Size x Hole Spacing Vent to Air Intake
i e(s)
Length Dia Length Dia pacing
SOIL C VER 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 31 Bedrrrench Edges Topsoil
� "o # Yes U No Yes Iii No
COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1:1/ /Q>- Inspection #2:
Location: 1094 148th Ave New Richmo d, WI 54017 (SE 1/4 NE 1/4 20 T30N R1 8W) Golf View Acres Lot 14 Parcel No: 20.30.1188.�2�0h.
1.) Alt BM Description 4 / a
2.) Bldg sewer length r33 I �` y
� QYI ! 0u�
- amount of cover = �i I,.. /Vp l nor Aort y pamper li
Plan revision Required '! Yes _ No 4ins /', Use other side for additional information. Date or's nature Cert. No.
SBD -6710 (R.3/97)
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Wiscori5in Department of Commerce
SOIL EVALUATION REPORT Page t of 3
D•ivi &A of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County S � . . CrOt�
Attach complete site plan on paper not less than 81/2 x 11 inches in size. 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. O Z p. — O&O - /a
Piease print all information. by Date
Personal information you provide may be used secondary urposea (Privacy Law, s. 15.04 (1) (m)). '
Property Owner Property Location
Govt Lot _S 114MF 1/4 S Z T ?Via N R t g E (or) rtV�
Property owners Address Block # Subd. Name or CSM#
/O I /-I : * 4j c- -e s
City Ststre zip Code Phone Number ❑ Village [SaTown Nearest Road
61 (1 1'e' b yu--Clk M 1 S: --T / 16 1 ( I . 4 :�]
New Construction Use: [R Residential / Number of bedrooms X ' Code derived design flow sate ' 'rSa GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material _6C)
l c , ra -50,- Flood Plain elevation if applicable ft.
General comments 5 yS/e r^ Gowj r
and recommendations: 4v? 117. ao,
(T
l I;
F � Boring # n� Boring C�,yjTM
La Pit Ground surface elev. /o Z C ft. Depth to limi factor 11y Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Roots
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. *EM
i o -r t z I 2n-r b
2 /4 - tp 9/-/
O `fy" H
F B oring # E] Boring
5 Pit Ground surface elev. 1 0 2 ,1 0 it Depth to limiting factor in. soil Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. *EfM *Eff#2
6 -1 io 5 0 C.5 14 .5 .8
2 i S i l ' L5
Z-
41 7 6 14
Effluent #1 = BOD > 30 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) S' a re CST Number
253309
Address Date Evaluation Conducted Telephone Number
2 - E �-qo
Property Owner Nle I S6n Parcel ID # Page 2 of 3
L_! #
pi Ground surface elev. /O0.2 d ft Depth to limiting fecbor _ ! SLS.p_ in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 - Eff#2
Z 5iI c .5 . i'
13-3q - S I c5
LI l% '
Bwft
F—IBoring # ❑ . S
❑Pit Ground surface elev. ft. Depth to limiting factor in. al Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 •Etf#2
Boring # ❑ Boring
F
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Sal Application Rate
Horizon Depth Dominant Color Redox Description Texture Struc t ue Consistence Boundary Roots GPOW
in. Munsell Qu. Sz. Cont. color Gr. Sz. Sh. 'Eff#'1 'Eff#2
Effluent #1 = BW > 30 _< 220 mg& and M >30 <_ 150 mg& ' Effluent #2 = BOD g 30 mg& and TSS < 30 mglL
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 (R0l/00)
I
PAGE 3
NAME N LOT# 1 LEGAL DESCRIPTION, C' /4Aj SZaT3d ,N R ($ E (or)�
SCALE: I "= q(
BM I ELEVATION /00• d '
BM I DESCRIPTION 4c� p e (i 2G P'0 e
BM 2 ELEVATION 9 Y• 2
Sec.ZU
BM 2 DESCRIPTION o 1 r K o r. (J p e
SYSTEM ELEVATION & D TIF-5i L °w �r 98.
ALTERNATE ELEVATION jo q 7
•
CONTOUR ELEVATION 1do .ao T /OL• ° °
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/ -�� SIGNATURE DATE
1 q l�
STATE 13AR Ok9CON& FORM 6- J90 XAAT81�
l H A ,$H
WARRANTY DEED REGISTER OF DEEDS
Document Number ST. CROIX Co., MI
This Deed, made between Hillvale Development Limited, a RECEIVED FOR RECORD
Minnesota Limited Liability Partnership, 06 12 - 2W2 9 ;30 All
WARWK EXEM # DEED
Grantor, and Jeffery M. Partridge and Crissy . Ann S chtni eg REC FEE;
TRANS FEE: 85.59
COPY FEE:
CERT COPY FEE:
Grantee. PAGES: 1
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 14, olfview Acres, Town of Richmond, St. Croix County, Wisconsin. Name and Return Address
Estreen & 0gland
304 Locust Street
Hudson, W154016
Pt of 026 - 1060 -80 & 026- 1060 -10
Parcel Identification Number (PIN)
This is not homestead property.
CK) (is not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this 10 day of June 2002
Hillvale Development Limited
* * By: Richard S. Nels n ,
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
) ss.
St. Croix County )
authenticated this day of 0 day of
Personally came before me this _� y
J uge 1 2002 the above named
Hillvale Development Limited, a Minnesota Limited Liability
*
Partnership, by Richard S. Nelson
TITLE: MEMBER STATE BAR OF WISCONSIN —
(If not, to me known to be the person(s) who executed the foregoing
n n w
authorized by § 706.06, Wis. Stats.) instrument edged the same.
THIS INSTRUMENT WAS DRAFTED BY * ++�
Attorney Kristina Ogland Notary Public, State of Wisconsin
Hudson, WI 54016 My Commission is permanent. (If not, state expiration date:
(Signatures maybe authenticated or acknowledged. Both are not necessary.) •)
* Names of persons signing in any capacity must be typed or printed below their signature. Information Professionals company, Fond du Lac, WI
WARRANTY DEED STATE BAR OF WISCONSIN 800-655 -2021
FORM No. 2 - 1999
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Maintenance and Contingency Plan for a Septic System
Maintenance Plan once every 3 yew- /`�A`
1. Septic Tank is to be pumped
2 �fiiter is to be dean once a Please : a largerfiPoer is being inslAW in
order to extend the maintenance interval of the filter.
3. Once every 3 years, cab are to be inspected via the inspections pipes at the 'ands of
recalls.
4.Owner agrees to Imit greases, garbap, and water conditioner discharge into the system.
S. The owner agrees to saw this Plan.
6. Do not plant trees nor park nor drive over system.
7. Watershed is to be diverted away from system.
S. Discharge into system is not exceed those required as per Comm. 83
Contingency Plan
1. if system tails, determine cause of failure, use aifiernal3e area and install now system or
install system at a lamer elevation.
2. Replace any other failing components as needed.
Plumber. Shaun Bird 715- 246 -4516
2 u- j c,�,/
J am., 86
A �/
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Shaun Bird #226900
SEPTIC TANK mAiNTBNANCB AGREEMI3 T
AND
_ OWNERSIO CERTIFICATION FORM
OwnedBuyer V,,2k-t--'JU
Msn'ling Address
11, Address O 9
(Verification, required from Planning Department for now construction)
ciWIState Parcel Identification Number OZ(a
LEGAL DESCRIPTION
Propedy I.ocatton v., .,� ��, sec.
Zd Ta N -R W. Town of
• � O /' Lot/Z-.
CerMed Survey Map # . Volume . Page #
Wan an t3' Deed # f . Volume 1 71 . Page #
I
Spec house p y j Lot Imes identifiableyes 0 no
SY�MAIN'L�NANCE
hmqXeper use and mambenanoeof your septic system emdd result in its premature failure to hanift wastes. Propermaintenanoe
if needed b a licensed pumper. What Y'e'a put into the
the
tank three ey Y
ooaos�ts of pumping out septa every Y� or soar rjgftM
can affect the fiuction of the septic tank as a treatment stage in die waste disposal 8 Y 8 bML
IU property owner agrees to submit to St. Q oix Zouing Department a cartHicatkin fann, signed by the owner and by a
pinmbe4 jomwymanplumbe4 re Wctodphunber or a lieoosodpumpervedfJiu8 that (1) the on -site w water'dispocal system
is in proper operating condition and/or (2) after inspection and pumping (if Y), do septic tank is IM than M fall of sludge..
Uwe. ttra mod have read the above requirements and agree to maims dw private sewage disposal with do standards
set fortk herein, as set by the Department of Commerce and the Department of Natural Rte, State of Wisoo®shL motion
that your septic system
has ban maintained must be completed and returned to the St. Crom Cooney Zoning off= within 30
of tiu throe lion date. /
TURF C�,NT DATE
OWI�IER CERTII�'ICATION
I (we) certif Y that all stat�nts on this form are true to the best of m (our)lmowledge. I (we am (are) the owner of
property above, by virtue of a wanaaty deed recorded in Register of Deeds Office. Y4 Z�z
d# APPLICANT DATE
t be' revoked the « ««« ««
« « « « «« Any information that n mis- represented may result in the sanitary penni mg by Zoning Department
** Indude 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 wananly deed
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