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Wisconsin Department of Commerce
Safety an'd 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)). 353291
Permit Holder's Name: ❑ City ❑ Village ❑ Totwn of: State Plan ID No.:
Buttke Frederick St. Josep Township
CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.:
ts0 a 1 do • 0 oi4-- N C- 6--2- 030- 2021 -95 -000
TANK INFORMATION ELEVATION DATA !� L�. Zv h
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic S GM Benchmark I ' /o/. 2 6 / o v . o
Dosing Alt. BM
Aeration Bldg. Sewer
Holding St/ Ht Inlet qy r
TANK SETBACK INFORMATION St/ Ht Outlet ( .2 76.- ,, v 6
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet ---- --
Air Intake
Septic > IU D r r NA Dt Bottom
g� r
Dosing NA Header/ Man. 83.
Aeration NA Dist. Pipe S gz
Holding Bot. System 10 z6
q' /. V 0
PUMP/ SIPHON INFORMATION Final Grade 15. OD +
Manufacturer and St cover , Sz %.: -o
Model Number GPM
TDH Lift Friction TDH Ft
Forcemain I L Dia. Dist. To well
SOIL ABSORPTION SYSTEM S sl s
1MQT TREN!CW Width ( Leg No. f enches PIT No. Of Pits Inside Dia. Liquid Depth
DI N 3 ` DIMENSION
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manu a ct u er:
SETBACK
INFORMATION Type Of , , Mo a Num er:
System: �I t70 CHAMBER
`f " 9f� '�� OR UNIT
2
DISTRIBUTION SYSTEM s b
Header / Manifold u Distribution Pipe(s) Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length " Dia. Spacing 7 q57'
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over ,I „ Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed/Tr nch Center 2q -f Bed/ Trench Edges �— Topsoil I ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS (Include code discrepancies, persons present, etc.) Inspection #1: 3 / ,2$ /m Inspection #2:
Location: 1146 Highway 35 Hudson, WI 54016 (NW 1/4 SE1 /4 1 T29N R20W) - 1.29.20.430A
1.) Alt BM Description= � /A / — M / Z- c
2.) Bldg sewer length= — 3 0
- amount of cover = 1 + 9
�) 5, jWaiii;; L,&s .tOA:a-j
Plan revision required? ❑ Yes ;ff No H4+ I
0 2 8 rro
Use other side for additional Information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
i
Safety and Buildings Division
Vi SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue
P O Box 7302
Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
3s3aII
Personal information you provide may be used for secondary purposes Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Pr rty Owner Nam Property Location
�J1/4 S 't 1/4, S T a g , N, R .40 E (oro
Property Owner's Mailing Add res Lot Number Block N 4gr
City, Code T ne Number Subdivision Name or CSM Number f
)3 -
11. TYPE OF BUILDING: (check one) ❑ State Owned It e Neares Road
❑ V -�-
Public 1 or 2 Family Dwelling il lag - No. of bedrooms Town OF S4 X70
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
Q t
1 [] Apartment / Condo O® ._a
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 jNr Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
______ System - _____ 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 Distribution Pressurized Distribution Experimental Other
11 []Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12"RSeepage Trench 22 ❑ In- Ground Pressure 3 ' x c ' 42 E] Pit Privy
13 [] Seepage Pit a • 43 ❑ Vault Privy
14 ❑ System -In -Fill :rW4 WW
VI. ABSORPTION S EM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade
y o Required sq. ft.) Pro osed (sq. ft.) (Gal ay /sq. ft.) (Min 'nch) Elevation
S `J ( F 3 T Q .0 0 Feet 14. V d Feet
VII. TANK in Capacit gallo Total # of r Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existin structed
Tanks Tanks
Septic Tank or Holding Tank -P, QU U e `
ber ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Cham ❑ ❑ I ❑ I ❑ 1 ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Na . Print) Plumber's Sig ture: (No Sta s) MP /MPRSW No.: Business Phone Number:
7/,T- 38 -- 6
Plumber's Address (S eet, City, State, Zip Code):
76)
IX. COUNTY / D PARTMENT USE ONLY
❑Disapproved Sa taryPermit Fee (Includes Groundwater ate Issued Issuin gentSignatur No Stamps)
g Approved E] Owner Given Initial Surcharge Fee) ,p
Adverse Determination — �°
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: =�
SBD -6398 (R. 4/99) 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 septic tank(s) must be pumped by a ricensed 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:
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.
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; 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.
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Vyisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3
- Division of Safety and Buildings in accord with Comm 83.05, W is. Adm. Code
A.C.E. Soil &Site Evaluations
Attach complete site plan on paper not less than 8 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix
percent slope, scale or dimensions, north t�w,*a ; nd distance to nearest road. parcel I.D.#
�' i �
APPLICANT INFORMATION,W `!*ase print ail411 ► ation. 030 - 2021 -95 -000
Personal information u provide may eviewed By Date
Yo P Y,I��!s8d for secory pu es ( .• Law, s. 95.04 (1) (m)). ` T
.r
Property Owner Property Location
Frederick E. Buttke Govt. Lot NW 1/4 SE 1/4 S 1 T 29 N,R 20 W
Property Owner's Mailing Addre Lot # Block # Subd. Name or CSM#
542 6th Street NA NA
City State Ziq �,rumhdt. City E] Village ❑Town Nearest Road
Hudson WI . 540 y 71 -3 ,48 St.Joseph Hwy. 35
❑ New Construction ❑ $esidetltiafj N er of bedrooms 3 ❑Addition to existing building
Use:
Replacement ❑ Public or commercial describe
Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd /ft •8 trench, gpd/ft
Absorption area required 643 bed, ft 562 trench, ft Maximum design loading rate .7 bed, gpolf? .8 trench, gpd/ft
Recommended infiltration surface elevations) 90.001— ft (as referred to site plan benchmark)
Additional design / site considerations Jnstall trenches using high capacity infiltrators.
Parent material Glacial outwash Flood plain elevation, if applica ble NA ft
S= Suitable for system Conventional Mound In Ground Pressure AT - Grade System in Fill Holding Tank
U= Unsuitable for system MS ❑ U ® S❑ U M S❑ u S❑ U ®S ❑ u ❑ S® U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD/ft
Borin Horizon Texture Consistence Boundary Roofs
g# in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 1 0 -8 10yr3 /2 None sl 2fcr mvfr cs 2f 0.5 0.6
S 0.
2 8 -21 1Oyr4 /2 None A 2fsbk mvfr cs if
Ground 3 21 - 36 10yr3/3 None sl 2msbk mfr cW if &m 0.5 0.6
elev
94.44' ft 4 36 -43 7.5yr4/6 None Is Osg ml cW - 0.7 0.8
Depth to 5 43 -112 10yr5 /6 None s Osg ml - - 0.7 0.8
limiting '
factor `tom 2ft 9.2� 2�/3q
>112'
Remarks:
Z 1 0 -8 10yr3 /2 None A 2fcr mvfr cs 2f 0.5 0.6
2 8 -15 1Oyr4 /2 None sl lthinpl mvfr cs if 0.4 0.5
Ground 3 15 -35 10yr3/3 None sl 2fsbk mfr cW if &m 0.5 0.6
elev
94.49' ft 4 35 -43 7.5yr4/6 None is Osg ml cW - 0.7 0.8
Depth to 5 43 -115 10yr5/6 None s Osg ml - - 0.7 0.8
limiting
factor s X7.88
>115'
Remarks:
CST Name (Please Print) Signature. Telephone No.
James K. Thompson _ Z-- 715- 248 -7767
Address A.C.E. Soil & Site Evaluations Date CST Number Ref #
340 Paulson Lake Lane, Osceola, 54020 12/16/99 3602 1141
PROPERTY OYMER: Frederick E. Buttke SOIL DESCRIPTION REPORT t ta, Page 2 of _
PARCEL I.D.# 030 - 2 021 -95 000 A.C.E. Soil & Site Evaluations
Depth Dominant Color Mottles Texture Structure nsistence Boundary Roots GPD/ftz
Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
3 1 0 -10 10 yr3 /2_ None sl 2fcr mvfr cs 2f 0.5 0.6
O.6
2 10 -1 1 /2 None sl 2fs - mvfr cs if $3-
Ground
elev 3 15 -24 10 None sl 2fsbk mfr cw if &m 0.5 0.6
95_80' ft 4 2 -31 7.5yr4/6 Non is Osg_ dl cw _ 0.7 0.8
Depth to 5 31 -60 7.5yr4/6 None s O s g dl gs - 0.7 0.8
limiting
factor 6 60 -116 10yr5 /6 None s Osg dl - - 0.7 0.8
-
Remarks:
Ground
elev
Depth to
limiting
factor
Remarks: –
Ground
elev
Depth to
limiting -- - -- — - — —
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Remarks: — - - -- — -
Ground
elev
Depth to
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Remarks:
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
� , OWNERSHIP CERTIFICATION FORM
Owner/Buyer l'P C,� e!` ��/�u��
Mailing Address .5 �� /� 1-ye IJ all = f "0
Property Addres
(Verification required f om Planning Department for new construction)
City /State /.lr�Sn/�J �jr Parcel Identification Number
LEGAL DESCRIPTION
Property Location %4, %,, Sec. -,Z—, T��N -R _W, Town of
Subdivision 111,4 , Lot # Ah�
Certified Survey Map # , Volume , Page #
Warranty Deed # 4 1 Volume , Page # JY
Spec house ❑ yes Co no Lot lines identifiable ❑ yes ❑ 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.
SIGNATURE OF APPLI ANT 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 above, by virtue of a warranty deed recorded in Register of Deeds Office.
l l Od
NATURE 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
�^ DOCUMENT NU, W DEED THIS SPACE RESERVED FOR RECORDING DATA
' STATE BAR \ O r F MMf1 W Il I II' S 11 CONSINFORM 2-1982
4'7551.9 viii 921PAGE 593_ REGISTER'S OFFICE
ST. CROIX CO., WI
-- Vernon Marty, _a... single person Recd for Record
- -- ......... - ----- - - - - - --
- - -- - - - -- - --- - - - - -- -.................... A 0 81991
- ---- --- ------ - - - - -- - -- -------- - - - - -- ---------- - ------- - - - - -- - -- at 8 A. M
.....---. ..- - --- ------ ---- --- --- ---------------
conveys and warrants to __ Fr ed._. BU ttke --------- ---------------------------------------
---- --------------------- - Reglsterof0eeds
-- ------ - - - - -- ----------- --------------- .................. ._._-------------------------
------
- -- - -- - - - -- - - -`
-_ - -. .. ... .. . .. . .. . . .. .. . .. ---- RETURGxV & Wertheimer, S.C.
_____ __________ _________ ___ __ ___ __ _ -------------------- .. -•_. - __.__._._- ._._...----------------- '. ... .. -� �.
,i
the following described real estate in -_ St. CroiX ___.. County, — - - -
State of Wisconsin:
Tax Parcel No:
All that part of the West One -half of the Southeast Quarter (W� SEa)
of Section 1 Township 29 North, Range 20 West lying West of State
Trunk Highway "35" EXCEPT the South 66 feet of the Southwest Quarter
of the Southeast Quarter (SW4 SEk) of Section 1 Township 29 North,
Range 20 West.
This Warranty Deed is given in full satisfaction of a certain land
contract dated March 1, 1985 and recorded in Volume "707 ", page 05
as Document No. 400099 in the office of the Register of Deeds in
and for St. Croix County, Wisconsin.
This _- .iS --- not ---------- homestead property.
(is) (is not)
Exception to warranties: Subject to municipal and zoning ordinances and
,recorded easements and restrictions of record, if any, and any liens or
:encumbrances created or suffered to be created by the acts or.defaults
of bq e GQ rantee. �
a ed 1t11s ------------- -- - ------------------ . day of ---- - - - - -- _ (<'l?.Ce 4�. - 19.8.7.
-- -- -- -- --..(SEAL)
- - - - - -- - - - - -- - -- - - --- -- --- - - - - -- - - - - - -- - (SEAL) --- / 1. 4 - --- -- --
--------------------------------------------- - - - - -- ----- - - - - --
Vernon Mart
--- ------- -- --------- -- - --- (SEAL) -- - - -- _--------- ----------- - - - - -- - ------ ------ - - - - -- - - - --- -(SEAL)
ii
�I
AUTHENTICATION ACKNOWLEDGMENT
Signature (s STATE OF WISCONSIN
I , I -------------------------------------------------------------------------- - - - - -- POLK ss.
- --- --- -- - - -- •----- -- - ----- --County.
l authenticated this -------- day of______________________ _ ____ 19 ...... Personally came before me this __ -_23rd day of
_- _--- February_________ _ _ _ ___ 19 ... 8 :_ the above � x
A ed gi
- - -- ---------------------------------------------- - - - - -- -------------- - - - - -- Vernon Mart y a single P e r 0 - - -- - - -- - -
; .
w Q
- - - - - - --------- - - - - --
TITLE: MEMBER STATE BAR OF WISCONSIN
-----------------
s (If not- ---- - - - - -- --------- - - - - -- authorized by § 706.06, Wis. Stats.) to me known to be the person ------------ wh
e oing instrument and uklipyledge the sari A cc,c
THIS INSTRUMENT WAS DRAFTED BY ' 4-
'CWAYNA NOVITZKE BYRNES GUST WIL IAMS - -- - - - -- -- - -- - - - - -- - ------------ - - - - -- ----- - -- - --
.. - - -- t------------------ - - - - -- ---------- '--- -_ - - -- ' - - Daniel M. r es
!I& ERSPAMER, LTD., Box 18, Amery, WI 5400" L----------- - - - - -- -- s ------------------------------
Daniel A4:--- Byri-res -� -- Att- er- ney- - - - - -- Notary Public ---- -- ----- - - - --- - --------------- County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not state ex iration
are not necessary.) �.
date- ------ - -- - -- -- -•- - -- ........_............- - - - --. 19 .........
*Names of persons signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Thank Co. Inc.
FORM No. 2— 1982 Alilwnukee. Wis.
kh—