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r i AS BUILT SANITARY SYSTEM REPORT
OWNER ?/� TOWNSHIP , jf4 7�z� SEC T?�N -RL;�'W
ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
SHOW EVERYTHI G WITHIN 100 FEET OF Y,.TEM
"
r
i
I di at N r h rr w
BENCHMARK: (Permanent reference Point) Describe:
Elevation of v p
vertical reference oint : f , ( Slope at site:
SEPTIC TANK: Manufacturer :
Liquid Capacity
TLS !. e' ��i�<��• 9 ,�' — � — ,� �rt�
Number of rings on cover Tank manhole cover elevation:
Tank Inlet Elevation: �� 'Tank Oulet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set for a cycle gallons; Total capacity of
r, distribution lines gallon: size of pump head;
.' gallon per minute ; horsepower ;brand name of pump
and model number
Type of warning device
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover
Type of warning device
SEEPAGE PIT SIZE; Number of pits feet diameter
feet liquid depth seepage pit inlet pipe - elevation
bottom of seepage pit elevation feet.
SEEPAGE BED SIZE: number of lines_ width ?' length)� tile deptl
, ,
' SEEPAGE TRENCH: width length
AREA REQUIRED
AREA AS BUILT
PERCOLATION RATE
�; .. >, sic: / Q s .
INSPECTOR_
DATED PLUMBER ON JOB �'y. �• ��, ;r< ..
LICENSE NUMBER
� I
DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADI� N, WI 53707
®CONVENTIONAL El ALTERNATIVE State Plan I.D. Number:
❑ Holding Tank El In-Ground Pressure El Mound (lf assigned)
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
James Brockpahler 53 S. Montana, New Richmond, WI 1-11t3 jJ ¢
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF, PT. ELEV..
SEk SW'34, Section 33, T31N -R17W, Town of Stanton
Name of Plumber: MP /MPRSW No County: Sanitary Permit Number:
Cal Powers 1563 St. Croix 43719
SEPTIC TANK /BOLDING TANK:
MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV TANK OUTLET E V. WARNING LABEL LOCKI CO ER
t -` PR VI D: PROV ED'.
r ES ❑ rp S ❑NO
BEDDING: V NT O NT MATL: HIGH WATE NUMBER O F ROAD: PROPERTY W BUILDING: VENT TO FRESH
ALARM: FEET FROM LIN ../ AIR INLET:
❑YES NO ❑YE ' O NEAREST /
DOSING C AM ER:
MANUFACTU ER: BEDDING: LIQUID CAPACITY PUMP MODEL. J PUMP/SIPHON MANU TU ER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
OYES ONO DYES ONO OYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS ATI AL OF PROPERTY WELL BUILDING IVENTTOFRESH
(DIFFERENCE BETWEEN ET O
RM LI "E' AIR I NLET:
PUMP ON AND OFF) ❑YE NO NEA EST'
SOIL ABSORPTION SYSTEM. Check the soil moisture at the deptf o plow) LENG DIAMETER MATERIAL AND MARKING
or excavation. (if soil can be rolled into a wire, construction sh II ease u Il f�RCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
' ° :WIDTH: LENGTH. NO. OF DISTR. PIPE SPACING. COVE J INSIDE CIA. #PITS. LIQUID
TREN IAL: PIT
NS
GRAVEL DEPTH FILL DEPT DISTR. PIPE DISTR. PIPE IDISTFE PIPE MATER L . DIS NUMBER OF PROPE TV WELL: BUILDING: VENT TO FRESH
BELOW PIPES. A OVE COVER: ELE 1 L� ELEV. D5. 4 PIPES FEET FROM LI AIR INLET.
ri/ NEAREST
MOUND STEM:
Mound site plowed perpendicular to slope Check the texture of the fill material f PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound system $ o make certain th i ON REVERSE SIDE. SHOW ELEVA-
meets the criter) edium sand. TIONS MEASURED.
❑YES ❑NO
SOIL COVER I TEXTURE PER ARKERS: OBSERVATION WELLS
❑ ES NO ❑YES L1 NO
DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTH OF TOP OI SODDED SEEDED. MULCHED.
CENTER EDGES.
P' YES [ NO ❑YES ONO I 1:1 Y ES El NO
PRESSURIZED DISTRIBUTION SYSTEM: j
: LENGTH. NO. OF T RAL SPgCIN GR EL DEPTH BEL PIPE FILL DEPTH ABOVE COVER:
WIDTH
' hi "_ ° TRENCHES
lIIVI�tNS
MANIFOLD PUMP MANIFOLD DISTR. PIPE ANIFO LD MATERIAL. O. DISTR, DISTR, PIPE DISTRIBUTION PIPE MATERIAL & MARKING.
ELEV.: ELEV.: CIA_. ELEV, IPES. DA:
FyMyl,la+tie °HOLE SIZE HOLE SPACING. DRILLED CORRECTLY COVER M ERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED
%J PLANS.
DYES ❑NO ❑YES E NO
COMMENTS: ® PERMANENT MARKERS: OBSERVATION WELLS: PROPERTY WELL: BUILDING:
FER LINE:
4 11
❑ YES 1:1 NO 1:1 YES El No NEAESt"
��
Q4`
9 41 L
Sketch System on Retain j c fi
Reverse Side.
I,GRr TUR E: TITLE: ,r
DILHR SBD 6710 (R. 01/82) * r s` f
� wlsconsln APPLICATION FOR SANITARY PERMIT
�DILHR
(PLB 67) OUNTY
in0US VU UNIFORM SA I AR / PERMIT #
InOUSTRV,LRBOR6MUTRnRELRT10n5 A - � /y 9
— Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8' /zx 11 inches in size.
—See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
PROPERTY LOCATION C TY:
1 , 7 VILLAGE: <�
1/ 1/4, S �? , Tf; , N, R (Ort.. TOWN OF
LOT NU�BER BLOCK N MBER SUBDIVISI N NAME NEAREST ROAD, L KE QR,)_/� $DMARK STATE PLAN I.D. NUMBER
� J " ''11
TYPE OF BUILDING OR USE SERVED
Dq 1 or 2 Family Number of Bedrooms: Public (Specify):
THIS PERMIT IS FOR A:
New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
System -In -Fill ❑ In- Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued
❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump Tank /Siphon Chamber
Holding Tank capacity
Manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In- Ground Pressure
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump /Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
i
„ � a � Private ED Joint ❑Public
I, the undersigned, hereby assume responsibility for installation a private sewage system shown on the attached plans.
Na,7of Plumber (Print): Sign e: MP /MPRSW No.: Phone Number:
Plumb s Address: 4 Namtnof Designer:
J
COUNTY /DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Datee: / p .�( roved ❑ Disapproved
El •� /` `�f�'4� J A Owner Given Initial
AI
pp Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR -SBD -6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.);
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
Form - S T C 100
Owner of Property
Location of Propert 41 Section ,T 31 N R_Z_,7W
Township __
Mailing Address J�
Subdivision Name
Lot Number
Previous Owner of Property
Total Size of Parcel
Date Parcel Was Created
4 Are all corners identifiable? _ Yes No
Include with this application one of the following
Certified Survey Map
.Deed
.Land Contract, or
.Other Legal Document which describes the property
L
PROPERTY OWNER CERTIFICATION
I (We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the roperty described in this
information form, by virtue of a warranty d recorded ( he Office of the
County Register of Deeds as Document N and that I (we)
presently own the proposed site for the se tem (or I (we) have
obtained an easement, to run with the above de a property, for the
construction of said system, and the same has been duly recorded in the Office
of the County Register of Deeds, as Document No. ).
5 NATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
�I
DATE SIGNED DATE SIGNED
• I
CERTIFIED SURVEY MAP
LOCATED IN THE SW1 /4 OF THE SW1 /4 OF SECTION 33, T31N, R17W, TOWN OF STANTON,
ST. CROIX COUNTY.
SCALE IN FEET
UNP L - ATTED -LANDS 01 100' 200'
Xr
NI 194.17' 135.82' N V)
41
ZI East 330.09' w
= ZI
¢ ~
L ¢
JI 0 JI
LOT 1 --r
0 130,714 S.F., Being c
w � 0 3.00 Acres including N
Highway right -of -way w wI
F-' Cn 104,306 S.F., Being
M co co
1 p 2. 39 Acres excluding o E
ASSUMED ¢I � Highway right -of -way � W
BEARING J I � M M O ¢
N LU J I
Bo _Z
("
ZI ° ® o J I
ZI
D Ln OI
z Northerly right -of -way Line ¢
West 330.09' LU
N N p L - ------
O pp
987.76' 00 °00 o c
East West 330.09' 'n West
w M COUNTY TRUNK HIGHWAY z, "K" o Ln
rl- Z 0 CD ca --------- - - - - -- W M
O — - - - - -- -------------- - - - - -� Z Z'
UI"Z W0�
� W M POINT OF SOUTH LINE OF THE SW1 /4 1-
V) � I' BEGINNING U z
W M
U N P L A T T E D L A N D S V)~
LEGEND
COUNTY SECTION CORNER MONUMENT.
O 1 "x24" IRON PIPE SET, WEIGHING 1.68# /LINEAL FOOT.
m EXISTING WELL.
This instrument drafted by James T. Swanson.
DESCRIPTION
A parcel of land located in the SWl /4 of the SW1 /4 of Section 33, T31N,
R17W, Town of Stanton, St. Croix County, Wisconsin described as follows:
Commencing at the SW corner of said Section 33; thence East (Assumed
Bearing referenced to the South line of said'SW1 /4) 987.76' to the point
of beginning; thence N1 °18'24 "W 396.10'; thence East 330.09 thence
S1 0 18'24 "E 396.10' along the East line of said SW1 /4 of the SW1/4; thence
West 330.09' along the South line of said SW1 /4 to the point of beginning.
Subject to existing County Trunk Highway "K" right -of -way.
Also, Subject to all other easements of record.
This parcel contains 3.00 Acres, being 130,714 Square Feet, more or less,
including County Trunk Highway right -of -way and 2.39 Acres, being 104,306
Square Feet more or less
q excluding County Trunk Highway right-of-way.
Y
I certify that the above description and map are correct and that I have
fully complied with the provisions of Section 5.4.B of the St. Croix
County Zoning Ordinance and Section 236.34 of the Wisconsin Statutes.
Date: October 24, 1983. Ax' '-'- -,//. oY
James T. Swanson S -1482 Job No. 83 -1450
Ogden Engineering Co.
123 E. Elm Street
s lists it River Falls, Wisconsin 54022
�� G 01V, �
FRIVER ES T. OWNERS
SON RICHARD F, BETH ULRI CH
Sa82 .. STEVE & NANCY ULRI CH
i
S LLS, i NEW RICHMOND, WISCONSIN 54017
d " y SURVEYED FOR
/VC) �Sa � JAMES J. BROCKPAHLER
2S3 MONTANA AVENUE
NEW RICIMOND, WISCONSIN 54017
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 53707
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION: OWNSHIP /MUNICi IU PA07Y: LOT O.: BILK. .: SUBDIVI. ION NAME:
'/4 J31 H/R (p(
COUNTY: O N R'S BUY R'5 NA E: MAILING ADDRESS: 1
Aydt- / _ �� 7
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION] IPROF[L DES RIPTIONS: FI O ATION TESTS:
`Residence New El Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN- GROUND - PRESSURE: SYSTEM -IN- ILLHOLDING TANK: RECOMMEN ED SYST�M:(option 1
❑UZS DU GAS ❑U DS :��U OS ®U >
If Percolation Tests are NOT re uire DESIGN RATE:
Q If any portion of the tested area is in the
under s.H63.09(51(b), indicate: a F indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING1 TOTAL DEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER jDEPTHtN. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- /
B- ZO
9 ( ZZ `
1 �
B- -� p .�
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL -MIN. PERIOD 1 PER 2 PERIOD 3 PER INCH
P 4 1- 3y1
Amalzi
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all rings and,thg direction and percent
of land slope. m
SYSTEM ELEVATION
E
I •___ - ______ .__.{
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3
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAMF,(print : / TESTS WERE COMPLETED ON:
NAM
AD ESS: CERTIFICATION NUMBER: PHONE NUM,BER(optional):
r
C �SIG(1SA URE:: h.
I D
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR -SBD -6395 (R. 02/82) — OVER —
INSTRUCTIONS FOR COMPLETING FORM 115 - S - 6395
Tc be a co replete anti accurate sail test, your report must include:
1, Curnplete legal description;
2. Tho use section rnrrst Clearly indicate whether this is a residence or commercial project;
3, MAXIMUM number of bedrooms or commercial use planned;
4. Is this a nevv or replacernent system;
S. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLUING TANK ONLY IF ALL
O SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
0, PLEASE use the abbreviations shown here for'vriting profile descriptions and completing the plot plan;
?. MAKE A LEGIBLE diagram accurately locating Your test locations. Drawing to scale is preferred, A
separate sheet may tae used if desired;
E. Male sure t okir benchinark and Volti al ele € , iation t efeirance paint rare clearly shown, and trt( plot manent;
p. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exernp
,ion, if appropriate;
10, if the information kuch a flood plain, elevation) doss not apply, plate N,P, in the appropi late box;
11 . Sign the form and 16CO ycaur current address and your certi'fieati0n nurnkrer;
12_ tiklal<e legible copies and distribute as required- ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUtHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
s t _ O"i"r {ar (ovper 10 BR -- Bedvock
coax Col taht (3 - 10 ") SS - a IIdstnne
gr - Gravel {under 3 "j LS - Lianestone
X s -- Starld HGW - High Gi orfoOvvater
€;s .._ C: Kai:lii Sa„d peic - P� . ="ralatior� I1aie
s; r f
rn {�ad s ._ Ira{ rra. `°,z,r,J lv
fs B!dt,
Is Loamy sand G eeau{ r l h at
st .:.;;iiaffy Lr;ar°t L €.�s
€ -- Loam Bn — B r o vv!
'`-
s - rlt L acts " =t BI Im1as—
r i - Sill t3y art {y
sci &I nd l y C:l,iy Lo am R Rc,d
sicl Silty Clay Loam mot N'lnIties
sc - `l <indy �
Clay 0i 01tkl3
.s_ -_ siltr, Cl[ -, v faa '- TE R', tIC €g;, lair "1 }
c _.... 07Y (,i; °` i; oi`atmor9,
.. t,f. ..... r1i:T1 ._. kvl E ;y. naf dECt,' ",
fii ___ ,' "uirk: c1 — dist
HkVL High
` Ix z;r } {? €'<al soil (extnr {'s ski fucu 3
for lirtrli a vvastr di-jowl BM Bcnelh Mai
iiRP -- ` eilicai f f:r €:ric i',ir;t
TIME () NER:
r �.i.., .; +�), } .;? r £:. =,�rS ¢: E's 3lli� kIt "SC i €' J ail st,t,..,i "jmj a sanitcary pE'Cn } €'i. T C:r3 tU 3Y - E:y or "=l"i!'. L14: {)r3YCi1'1 t; " §f rYlay 3'f'tt
L9 e=;T
s ihc '! Li ,)7 ".[a €" 9, €3 ta:'¢I'(Ir,
s i _ +aids. A ccamr)k to ai of floes fm the piiv;;tf
if) orde r
fuisl ,3 S €aj rr� t spa t.. =Y,` ,iltpl E)�1� "r a, =t t;al £P�tt:hnli!v rde to
a '.'.�i t i - i! t- -rte alifI rici r to :'Ee s(,lrt o ; a iiv Pon) ,$:ructl£3rt.
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
28
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:
Bernd, Stephen I Stanton Township 036- 1086 -30 -000
CST BM Elev: Insp. BM Elev: BM Description:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing Header /Man.
Aeration Dist. Pipe
Holding Bot. System
Final Grade
PUMP /SIPHON INFORMATION
Manufacturer Demand St Cover
GPM
Model Number
TDH Lift Friction Loss System Head TDH Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: UNIT Model Number:
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
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
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 1654 County Road K New Richmond, WI 54017 (SW 1/4 SW 1/4 33 T31N R17W) NA Lot 1 Parcel No: 33.31.17.523B
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Plan revision Required? LEI Yes ®No
Use other side for additional information.
SBD - 6710 (R.3/97) Date Insepctor's Signature Cart. No.
I
County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN
: In accord with 15.04 St. Croix County Sanitary Ordinance ZONING OFFICE
Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER
[Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road
Hudson, WI 54016 -7710
(715)386 -4680 Fax(715)386 -4686
Attach complete plans for the system on paper no �WS$4 2.4 4 in es in size.
County Sanitary Permit # ❑ Check if revisioA 0 ous a1plication
1. Application Information - Please Print all Information V LocatJ :
Property Owne Name l o �r /y� ` �� '" 1 /4S 1/4, Se
�l'7 - 1rV� l d ' S it T N, R E (or)
Property Owner's Mailing Address Z°~" u I�er Block Number
� \ I
City, State Zip Code Phone Numer Subdivision Name or CSM Number
/���� - L y6 _ 137
11 Type of Building: (check one) (amity F1 Village own of
1 or 2 Family Dwelling - No. of Bedrooms:_
Public/Commercial (describe use): ��an
❑ State -owned Nearest Road
MEN j 11. Type of Permit: (Check only one box on line A. Check box on line bter
Parcel Tax Number(s)
A)
1 1.[] Repair 1 2. ❑ Reconnection 3. ❑Non - plumbi 4. Rejuvenation 33
Sanitation 0,3
Permit Number Date Issued
B) � A
State Sanitary Permit was previously issued 3
IV. Type of POWT System: (Check all that apply)
Non - pressurized In- ground (� ❑ Mound ❑ Sand Filter [I Constructed Wetland
El Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
11 At-grade El Aerobic Treatment Unit ❑ Recirculating ❑ Other
V . Dispersal/Treatment Area Information: `S �t °�
1. Design Flow (gpd) 2. Dispersal Area 3. rsa Area 4. Soil Application Rate 5. Percolation Rate 6. System Elev ion 7. Final Grade
Required Proposed (GalsJday /sq.ft.) (Min.Anch) Elevation
L-1 d a� Z 111
I. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel r Fiber- Plastic
d
New Existing Gallons Tanks Concrete structed glass
Tanks Tanks
5 .1.7r-N ❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
VII. Responsibility Statement
I, the undersigned, assume responsibility for repair/ reconnenction /rejuvenationfinstallation of non - plumbing for the POWTS shown on the attached plans. A
li nse is not required for terralift repai or the installation of non - plumbing sanitation system.
ame (print) S' ature (no stamps): MR&APIROrNo. Business Phone Number
5
" mo- -
Address ( treet, City, State, Zip t
VIII. County Use Only
Disapproved Sanitary Permit Fee Date Issued Issuing Agent Signature (No stamps)
Approved Owner Given Initial Adverse
Determination 7- DU �D
IX. Conditions of Approval /Reasons for Disapproval:
1. The probe must be inserted no deeper that one foot below the elevation of the infiltrative surface of the distribution/dispersal cell.
2. The probe must be inserted outside of the distribution/dispersal cell and no closer than one and one -half feet from that edge of the
distribution/dispersal cell.
3. The elevation of the system's infiltrative surface must be above the estimated highest groundwater elevation or bedrock by the
distance prescribed in Table Comm 83.44 -3, Wis. Adm. Code.
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page — L — of�
Division of Safety and Buildings
in accordance with Gofrim 85 Wis. Mm. Code
County
Attach complete site plan on paper not less than 8 1/2,* i 1 trlches in size. Pta[r t
include, but not limited to: vertical and horizontal refer2rCe`,p8int BM), irecfion,and • Parcel I.D. percent slope, scale or dimensions, north arrow, an4ldstion an e to nearest,
ad. [� 40 _. pp
Please print all infg1tionIV� Reviewed by Date
Personal information you provide may be used for seco da" urposes (Priv y %W1
W s 15.04 (1) (mj
Property Owner - - ropry %Loc tion
�� �e. r � C, b t. Lot •;� W 1/45 E 1/4 S 33 T N R E (o
Property O ner's Ma ing Address `,, Lod 431ock # Subd. Name or CS M#
-
City State Zip Code Phone Number'-�_ City ❑ Village [gTown Nearest Road
❑ New Construction Use: ® Residential / Number of bedrooms _�� Code derived design flow rate y5 Q GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material 10 C 5 b0 C V AV l W 94 Flood Plain elevation if applicable ft.
General comments _ n
and recommendations: �°�^ ' — S f o �^ G Fo P e S s. l d t fe j u rev► a°} ; a r , S y.54w" .
alcva.'1-�a►.. S�- a.$ 9y.17 e3.Z' / in Zr .4) , alY It3uiSL ; n Q:�a 3 S y5fer•.
►g yrs bf� Ta.,1t.. l 1q- -+ S o e.r-. Gl Surne N- !Q * X - W d
F-/ I Boring # a Boring /,� c Sir 5 Gt SrcJC y
g
❑ Pit Ground surface elev. ft. Depth to limiting factor • s a in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
3 r tti r` o��
❑ Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 " Eff#2
* Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 _< 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L
C T Name (Please Print) Signature CST Number
5 +, -v k a
Address a Do-t a obi'* Date Evaluation Conducted Telephone Number
-1 y -o/ �5 Y8 -358 8
SBD -8330 (R07 /00)
Property Owner Parcel ID # Page of
F-1 Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
F1 Boring # Boring
❑ -T
❑pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
❑ Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 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.
SBD -8330 (R.07 100)
S5e-rt 331 -�'3
/ • 7 A
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NV
ST CROIX COUNTY
SEPTIC
TANK MAINTENANCE AGRE
AND
OWNBRSHIP CERTIFICATION FORM
I 'I DwnerBuyer
Mailing Address / J
Property Address
(Verification required from Planning Department for new construction)
City/State ,
Parcel Identification Number = ,112 - Q0
LEGAL DES CRIPTION
Property Location y4, 5cs2 . ' /•, Sec. T_N-R1)—W, Town of s�
Lot # __._�•
Subdivision
Cer[if' Y Ma n # S 3 0 , Volume � , .Page #
red S urve P
Warranty Deed # V36 201 _ , Volume 2ro . Page # Sa O
Spec house ❑ yes ❑ no Lot lines identifiable ❑ yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenanceof 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,
mr, signed by the owner and by a
The property owner agrees to submit to St. Croix Zoning Department a certification fo
masterplumber, journeymanplumber, restrictedplumber or a licensed pumper verifying that (1) the on-site wastewaterdisposal 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.
I/we, 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 and returned to the St. Croix County Zoning Office within 30
'a maintained must be completed
days of the three year expiration date.
DATE
SIGNA dF
OWNER CERTIFICATION
I (we) certify that all statements on this foam are tru e 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.
SI� F VP LICAN . DATE
* * * * ** Any information that is mis represented may result in the sanitary permit being revoked by the Zoning Department.
s *ssss
** 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
VOL 1714PAGE360 KATHLEEN H. WALSH
REGISTER OF DEEDS
ST. CROIX CO., WI
Document Number Document Title RECEIVED FOR RECORD
St. Croix County 09- 05-001 10:00 AM
AF=IDAI)IT
Affidavit of System Rejuvenation CERT FEE
COPY FEE: 2.00
kECGRDING FEE: 11.00
1
Name — (Owner) Typed or printed
being duly sworn , states, under oath, that:
1. He /she is the owner /part owner of the following parcel of land located in St.
Croix County, Wisconsin, recorded in Volume !�O Page O Document
Numbe St. Croix County Register of Deeds Office: Recordincy Area
Name and Ret Address
A parcel of land located in the,��1' /. of theme' of Section _ , �/t cy, f ^ c�
T 31 N - R 1— W, Town of <'raiff h , St. Croix I ( Co ' }
County, Wisconsin, being duly described as follows (include lot no. and ,UGC I'-1 ��� 0
subdivision/CSM or detailed legal description): A
Lot I C5 w) vvi ,,r„ c ,� i3�i C�3� - oY,` - 3�6
Parcel Identification Number (PIN)
t�oc # 3193ad
As owner of the above described property, I acknowledge that the septic system serving this residence (is/is not) undersized by current code
standards. 1 understand that the issuance of a sanitary permit to allow the attempted rejuvenation of the septic system does not imply that the
system meets current code sizing requirements, nor does it imply that the proposed procedure will be successful. 1 also ac l I will
make this information available to any future parties interested in pruchasing this property. SCHMfT
NOj pR�
Dated this day of d+ O
� OF W�`'
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
)ss.
authenicated this day of St. Croix County. )
Personally came before me this day of
/ the above named
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the person(s) who executed the foregoing
authorized by § 706.06, Wis. Stats.) instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
NN'grj'Public, State of Wisconsin
(Signatures ma be authenticated or acknowledged. Both are not My Commis ' is ge anent. If not, state expiration date:
necessary.) Date: _ _, �f 5-
"THIS PAGE IS PART OF THIS LEGAL DOCUMENT - DO NOT REMOVE"
This information must be completed by submitter. document title. name 8 return address. and PIN (if required). Other information such as the
granting clauses, leagal description, etc. may be placed on this first page of the document or may be placed on additional pages of the
document. Note: Use of this cover page adds one page to vour document and $2.00 to the recordina fee. Wisconsin Statutes. 59.517.
i
f
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently serving
the �,py�P residence located at: /,, %,
Sec . J 3 T N, R _ W, Town of St . Croix
County, Wisconsin. Upon inspection, I certify that I have found the tank and
baffles to be in good condition, and it appears to be functioning properly.
Last time serviced QG'TU�e F ' ;O0 d
Did flow back occur from absorption system? Yes No (if no, skip next
line.
Approximate volume or length of time: d 00 gallons minutes
Capacity: 1000
Construction: Prefab Concrete Steel Other
Manufacturer (if known) :
Age of Tank (if known):
(_L/� / Z 4,0e— .�� ' 1< /-, 03.2A (Signature) (Name) Please "Print
C -Pty 4-c C! /
(Title) (License umber)
2S - 2 C - 0
(Date)
Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or
licensed disposer (NR 113 Wisconsin Administrative Code)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
- -
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank condition, I
certify that the tank, to the best of my knowledge, will conform to the
requirements of ILHR 83, Wis. Adm. Code (except f inspection opening over
outlet baffle) .
Name / >�?�S �cT Signature
MP /MPRS
STATE BAR OF WISCONSIN FORM 3-1982
QUIT CLAIM DEED
REGISTER'S OFFICE
W. CROIX Col, W1
the following described real estate in ------- S:�. Croix
�Warren W. Wood, Ltd.
.New.Richmond, W1 54017
Part of the Southwest Quarter of the Southwest Quarter (SW of SW
Section Thirty-three (33), Township Thirty-one (31) North, Range
Seventeen (17) West, more particularly described as Lot One (1) of
Certified Survey Map filed in Volume "5" of Certified Survey Maps,
^-'- 1371
This deed is given in satisfaction of divorce judgment.
| EAbporx
�
�
�
This --�i.S------------ homestead property
(m) (wm�)
'���
nu�um�v-------���/^�.--�
day of ril ----------,Iu'88'
--------'-------- _(SEAL) *')xw�r,��� ----- SEAL)
~---------------------- ~--- 7a_me_s'J^_B.rp.ckgahle1r ...........
-
--.............. --------- -------- ---- ----- ... (moAL) -'--- --- .................. ............................. (mEAL)
^ ,
---------------------- ---........... --........... -----.........
AUTHENTICATION ACKNOWLEDGMENT
�g-J n������.���` ------------- nT zi
------'-----'-' -----------'---
...................................... County. i
----,oz.B8 p�o�u�xcame yem�um ................ day -- �� ��. �1,�-_ _-_----._-__-o�._-mw above named
--
° " --
------------------------------------------------------------------------------ .------_--- ------------- ......... --------------- ---------__-- ..................................
.....
TrrLo - mxmmooRuTATomAaoFn/mCnma/N
--------'---------'----------
(If not ----------.--------.
authorized wvg 706w6,vvis. otats.) --- '--'
u,me known xobw the person ------------ who executed mw
foregoing instrument and acknowledge the same
THIS INSTRUMENT WAS DRAFTED o.
�MAR RMI N^'. WgQP�^JtTD,-------'--- ------------ ------ ------ ---------- ......................
��e�..j�i ^'l�i�����i�_S4.0l7__.. -------------------------
� m�nxhu�d",��n^��d��. Both - ����'� permanent. Coun
( uv
are not ') date: _----'---- ` nm --
� -------.—. -_
�
QUIT cmomoonm STATF HAR OF WISCONSIN W I.- Ftlank v° Inc.
..~~ ~^^_^~. ~._~.~` ~..
V
38 9340 CERTIFIED SURVEY MAP
LOCATED IN THE SW1,14 OF THE SW1 /4 OF SECTION 33, T31N, R17W, TOWN OF STANTON,
ST. CROIX COUNTY. \�!
SCALE IN FEET
UNP LATTED —LANDS 01 100' 200'
I
�I 194.17' 135.82' 1 N �I
DI DI
ZI East 330.09' w
= ZI
Q I F-
I LL Q
JI O J�
LOT 1
130,714 S.F., Being
w l 0 3.00 Acres includin ° N of
Highway right -of -way w wl
F I 104,306 S.F., Being
c 2.39 Acres excluding o F (.-
ASSUMED Q G Highway right -of -way w LL
BEARING JI n M 0 ¢
a I N N W —I
0o z
Z I o -j z
�I I
z Northerly right -of -way Line N Q �I
West 330.09'
w
N N o� --
0
0 0
987.76' 00 00 c
East West 330.09' Ln West
w n COUNTY TRUNK HIGHWAY o " K " o
Z Ln `n
Z co to c n
& O W i --------- - - - - -- Z
O— - - - - -- -------------- - - - - -� Z'-
U I"" Z W 0 0�
U M POINT OF SOUTH LINE OF THE SW1 /4 O F- Z
cn cn F- BEGINNING w M
U N P L A T T E D L A N D S N�F-
----------- - - - - --
APPROVE-D
LEGEND
& COUNTY SECTION CORNER MONUMENT. NOV 1 198
p 1 "x24" IRON PIPE SET, WEIGHING 1 .68# /LINEAL FOOT. ST. CPOIX COUNTY
COMPkEHENSIVE PARKS PLANN NG
/1t+D 1ovN" COMMrrt E
® EXISTING WELL.
9
NO I[ ED This instrument drafted by James T. Swanson.
AaES 2 21983
U'cp
•r o,vivelu Volume 5 Page 1371
$ g