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Form- STC_ 10
AS BUILT SANITARY SYSTEM REPORT
OWNER &/10A TOWNSHIP S/, SEC. 3 Z T 3 PN-R~W
6 G'
ADDRESS Xi ///nj ~c / /ST. CROIX COUNTY, WISCONSIN
SUBDIVISION V61 3 756 LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of IILHR,83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
; ~k" X13
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OZ l~~-C.tc~res .'~X !oo
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vel-l
INDICAT NORTH ARROW
%I\i,/
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: 160 Proposed slope at site: /'M
SEPTIC TANK: Manufacturer: Ideeks c ow Liquid Capacity: /0~00 .-Q
01
Number of rings used: / Tank manhole cover elevation:
Tank Inlet_Elevation: Tank Outlet Elevation:
Number of feet from nearest Road.: Front 10 Side
10 Rear, O feet
From nearest property line - Front 10 Side,O Rear, O feet
Number of feet from: well 1zbuilding;: a
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: S Length: old Number of Lines: Z Area Built: zyo
Fill depth to top of pipe: .3011
Number of feet from nearest property line: Front, O Side, O Rear,O Pt./a
Number of feet from well:
Number of feet from building: 7,1,
(Include distances on plot plan).
SEEPAGE PIT
Size: /y Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box 0 or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: Plumber on job: lol
License Number : ~yl145
3/84:mj
LOCATION: ST. JOSEPH 32.30.19.342D,SW,NE,3I,ROLLING HILLS TRAIL, LOT4
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT
Safety ar* Buildings Division
sanitary ermitNo.:
It i (ATTACH TO PERMIT)
GENERAL INFORMATION
Permit Holder's Name: ❑ City E] Village f(] Town o : State Plan I o.:
PERRON, DAVID E ST. JOSEPH
CST BM Elev.: Insp. BM Elev.: 7121/ Description: Parcel Tax No.:
V
TANK INFORMATION ELEVATION DATA A9200112
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark pa,d$ I~~ Ug 160.0
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet 3~ ~ ! 0
TANK SETBACK INFORMATION St/ Ht Outlet 3o 60
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic 7 ~ NA Dt Bottom
13,61 RS.u I
Dosing NA Header / Man. Io ,q a ^oi, _ _
13.B9 1:3 S• a'
Aeration NA Dist. Pipe 11,04
I o , u
IS.S(. (,•Sv
Holding Bot. System a " gq;g7
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width , Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS (eo Z DIMENSIONS
LEACHING Manu acturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM
INFORMATION Type O CHAMBER Mode Number:
System: 7~°° OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
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 ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) L
1
Plan revision required? ❑ Yes ❑ No q a
Use other side for additional information. q
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL' COMMENTS AND SKETCH r
SANITARY PERMIT NUMBER: ~
z
DILHR SANITARY PERMIT APPLICATION COUNTY
In accord with ILHR 83.05, Wis. Adm. Code
a STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than
8% x 11 inches in size. ❑ Check if revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
Std Y4 tv& Y4, s 3 2- T 3 d, N, R L ~f (or)
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK
jy d AX 14/4_0 k 4/ A/
CITY, STATE ZIP CODE PHONE NUMBER OR CSM NUMBER
II. TYPE OF BUILDING: (Check one) 1:1 State Owned VILLAGE NE EST ROAD
.7a ~tl,
❑Public U 1 or 2 Fam. Dwelling-# of bedrooms,-3- PA L xN B ( n
III. BUILDING USE: (If building type is public, check all that apply) 036 - /oq 3 Z S-
1 ❑ Apt/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 in line A. Check line B if applicable)
A) 1. A New 2.E] Replacement 3.E] Replacement of 4.E] Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit # - 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 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSJEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) T/ 5'y ELEVATION
T. Sweet /D 3. Feet
41 6cr>
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank 1l~v LJ~ C f
Lift Pump Tank/Si hon Chamber
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No S ps) MP/MPRSW No.: Business Phone Number:
'~~.w 322 713 7-7 2.. 'z`/
Plumber' Address (Street, City, State, Zip Code):
23 Zgfk e 0 ~5do Z,J4~e-d Z.
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater a s ssue issuing A m signature (No Sts s
Surcharge Fee)
Approved ❑ OwnerGiven Initial OIZ15- 7/~3119Z
Adverse Determination ^r 7`e
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: ,
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety Ili Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years., y
2. Your sanitary permit may be renewed before the expiration date, and at the 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 (S13D 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 &-Buildings Division, 608-266-3815.
To be complete and accuratg.tt;his 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.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in 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 in ##1-7.
VII. Tank information. Fill in the capacity of every new and/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 131/2 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 tankks; 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, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
O~U- GD~~- SS
3z;-3a 15)
APPLICATION FOR SANITARY PERMIT
STC - 100
This application form is to be completed in full and signed by the owner(s) of the
property being developed. Any inadequacies will only result in delays of the permit
issuance. Should this development be intended for resale by owner/contractor, ("spec
house"), then a second form should be retained and completed when the property is
sold and submitted to this office with the appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
f'~.C./✓dY!
Owner of Property La tie
Location of Property S 14-f 1t h_It, Section 2 , T -37) N-R / W
Township S'A CSdA
Mailing Address '!5~f" 4&,-e
fAJ 11C Ala 6~5 )1
Address of Site
Subdivision dame 1~0-P .~~`'09• gsw
Lot Number L!
Previous Owner of Property
Total Size of Parcel
Date Parcel was Created 7
Are all corners and lot lines identifiable? i~ Yes No
Is this property being developed for resale (spec house) ? Yes /K No
Volume 6al 2-'
and Page Number J? as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A Warranty Deed which includes a Document number, volume and page number, and the
Seal of the Register of Deeds. In addition, a certified survey, if available, would be
helpful so as to avoid delays of the reviewing process. If the deed description refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
1 (We) ceh ti.6 y that aCt statements on thus ohm ahe th.ue to the but 06 my (oun )
hnowtedge; that I (we) am (cvicel the ownen(,s) 06 the pnopehty de~sch,i.bed in .thiA
.in6o"atLon 6o4m, by viAtue 06 a waAAanty deed n con ed in the 066.ice 06 the
County RegiAteh. o6 Veed~s ah Document No. i ` ; and that I (We) pn"ent,ty
awn ph.opoded date bon the Aewage di~spos eye em (on I (we) have obtained an
eaeement, to nun with the above deAcAi.bed ph.opehty, bon the eonath.ucti.on o6 said
eya•tem, and the dame hae been dut necohded to the 066tce o6 the County Reg.i,6ten. o6
V da, as Docume 67
I .
SIGNATURE OP OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
d / L1 1j
DATE SIGNED DATE SIGNED
71 at
~ ~ h. .
' X45'75 I 4
This Deed, made betv►een
Rica fcw
r.
Grantor
'I MAkIC,
M.: Parrrtn,,.1~9~ LO Tw - ~'Owd 4rMw;I iter i valttaill+ ctaa~derat3 r sx+r7,~s a
amt ral"cble/. .C0,t16 _ t
is fla lrf ~ t
-
aewm+ to g"xetes Ow foGo+winst dkACrowd Vogl estate
R ° "qty, Blau of Wimij dn: _ . _
Tax KeY NO.....
!J'OOPK~ONO 2,
4 of Cert4i?i+>lA Svrw►eY as r i~t Vo1a~:.3* Pam 856a:
a
eas~ts restrictions and re#t"Wom sf record. if aror. ~a
C! MW
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gas k - _ y. =a..
homestead property.*
01i) "vs urtenanees thereunto beWnBi~ Y _
VIO all M*,sitlpWr tht Mreditamenta and aPp }
tnlefPasible ir► fee simple and fra ;and ch:ar of cnegatby"ces e3u* I
r s ~Ml`t'aa''i t1Ulf _ tom. tilt ~ i~~ -
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and +4W,,W,,wt and defend the "Ante.
clay ofc
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f
Ednard T,.:
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ACKNQ~WLXDOWowk
AUTHENTICATION
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7`une .1 Sri! to fore meme, ibis
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FORM NO. 985•A
CERTIFIED SURVEY MAP
LEGEND
COUNTY SECTION CORNER MONUMENT, FOUND.
SCALE IN FEET
• I" IRON PIPE, FOUND.
--x- EXISTING FENCE LINE. 300' 200' 100'...0' 300'
o I"x24" IRON PIPE WEIGHING 1.68#/LINEAL FOOT, SET.
N 1/4 CORNER
SECTION 32
T 30N , RI9W bad
2 LANDS 0•~
NPLA TED
stiff
Aso U
-
.r
e1 N OUNTY TRUNK HIGHWAY
0
3/,, OLD C _ ,f'~..._
' N
_ - - - 8 57 4 E 5'15.12 N 8811 20' S2" E 615.97'
T o 5 !
r- - 01= _WA -rf
r^^v1~~T OCCUr ;E^ 46 1 N 8x°20' +2"E 2 O.C70~' tt FtIGHT~ o _
By CONCRETE tvt
PAVED DITCH
MN 0m
oin o m .106
ON 2 m
z CD N 0 O ~
111' ! 33'0 8.00 ACRES z v a +c~I
12.66 ACRES a e j
41 Q I
- 316.87' 519.92- W It W S 88° III-02" W m
z 736.79' o EXISTING W W
SE -NWT a SW-NEO. o HOUSE
7 r1
on U. 6.53 ACRES 0 h • Q
' s 88°11'0$"W s a, I
W I Z! ® v 688.61' 600.00' z 1
-8634 218.52' 247.87' I 3. :3 I
1'" I J I oc 601.67'
S-88011'02"W 1288.61' 71-
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4 0
ASSUMED Z off. ~OSD
. 8.84 ACRES
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BEARING
0
0 5 8 8 11'02" W 1280.58*
z
z 378.48' Y 502.66 399,448
16 SOUTH LINE OF THE SW 1/4 OF THE NE 1/~
POINT 0 =UNPLATTED LANDS
BEGINNII'G_~
Z
.
o APPROVED
~ 3M see°u;
adi 33,00
W ;n 3.13 , Q03.71' AU G 15 IM
z N POINT OF
° BEGINNING S1. CiOIX COUNTY
v' COMPREHENSIVE PAW PIANWN6
z ' AND ZONNO Q'OMMITTEE
S 1/4 CORNER
SECTION 32
T 30N I R 19W DETAIL APPROVAL Ot MINC►k SUnDtVtS,G
This instrument drafted by James T. Swanson. DOES NOT MEAN BUILDING SITE OR A!'PROVA! Fp
R,fut To Z.~► Senc sYS>r ,
ri
ro,
fi
STC - 105 0
SEPTIC TANK MAINTENANCE AGREEMENT w
St. Croix County
OWNER/ BUYER ~~L Je f e r~~n H•
o
ROUTE/ BOX NUMBER 7 a~i ~O/fi 44 l~ Fire Number
tv
CITY/ STATE !-j~ "S ZIP ro
PROPERTY LOCATION: -.50 k, VUF ' , Section 3'Z T 2(p N, R -)q W,
Town of vh St. Croix County,
t
Subdivision 496 Lot number.
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed .se tic tank pumper. What you put into
the system can a .ect t fiction off' the-septic tank as a treat-
ment-stage in the waste disposal system.
St. Croix County residents may be eligible to recieve a grant for
a maximum of 60% of the cost.of replacement of a failing system,
whit was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all'new systems agree to keep their system properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a mater plumber,
journeyman plumber, restricted plumber or.a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and .(2).after inspection and pumping (if nec-
essary), the septic-.tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration.
H
I/WE, the undersigned have read the above requirements and agree
to maintain the private sewage disposal system in accordance with W
the standards set forth, herein, as set by the Wisconsin Depart-
FA.
went of Natural Resources. Certification form must be completed
and returned to the St. Croix Count Zoning Office ithin 34 days
of the three year expiration date.
SIGNED
DATE ~2 - 1y 9Z
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
Safesy b Buiiurngs Division
Wisconsin (apartment of Industry, SOIL DES(.KIPTION REPORT P.O. Box 7969
Labor and Human Relations Madison, WI 53707
(Attach Soil Profile Location Map - To Scale - On A Separate, Signed Sheet) - Page / of
52-23
Parent Nlatena s
ustsfiner Na me i va cation it urrent Lan Use or Vegetative over S
5411E ,aEiPRoN 9 8 - f/ P17-7EA-3 ot„~
noun ater i P am E evatron
W Estimated Shallowest
ustom r resa %T 157r-A G,-. r,
~So N
Per q. Ft. Per
ax arts No. C.S~ System Loading flare in a ons
County
S T ~jz o ~'X r Y p~tioa ~ Fo,P T,PE,v~eS -
ystem eometry an Dept ope an Aspect
Lot Legal Descnption A WS Torva OF SEE ,(D£,y~►/fs~$ S eIo 6-157-t'-Rfy Ir ~q, 80 SW itJ~~ S?c• 32-T3U•J f21y4> ST. ToSEPtI
Horizon Depth Dominant Color Mottles Structure Remarks: clayskins Loading
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-y^ - /o.,<,~ 5h< ~-F2 Luf cw . s-
3 30 S.y 3, n~~ sbK -F 1, 3nt~ e' w .44 / -Ico / 2, Ike ~v - a
YA 4/¢
.IYv' 6` 116 .J
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ter, rt~'l
HOMESITE SEPTIC PLUMBING CO.
855 O'NEIL RD., HUDSON, WIS. 54016
ROBERT ULBRIGHT 0 s r /~'Z
' ' 1 D :11S. MASTER PWMBER LIC. NO. 3307 M.P,A S.
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REPT131 ST. JOSEPH ST. CROIX COUNTY ZONING PAGE 1
609/11/92 10:19 REQUESTS FOR INSPECTION WORK SHEETS FOR: 9/14/92 AREA: MJ
Activity: A9200112 9/14/92 Type: CONVSEPT Status: PENDING Constr:
Address: ST. JOSEPH 32.30.19.342D,SW,NE,3I,ROLLING HILLS TRAIL, LOT4
r Parcel: 030-1093-95-000 Occ: Use:
Description: 149266
Applicant: PERRON, DAVID E Phone:
Owner: PERRON, DAVID E Phone:
Contractor: TIMM, ROGER Phone: 772-3214
Inspection Request Information.....
Requestor: TIMM, ROGER Phone:
Req Time: 09:09 Comments:
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION
Inspection History.....
Item: 00012 FINAL INSPECTION