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Wisconsin Depart ment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and 6Oilding Division
INSPECTION REPORT Sanitary Permit No:
140
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:
Broeren, Craig & Sunshine Star Prairie, Town of 038 - 1185 -10 -000
CST BM Elev: Insp. BM Elev: BM Descrjption: Sectionrrown /Range /Map No:
r
u / 13.31.18.932
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic / , Benchmark
�C
Dosing ' //" Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK IN ON
TANK TO P/L WELL r BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Y / Dt Bottom
Dosing / Header /Man.
Aeration Dist. Pipe
Holding Bott. Sy;�., > r�.�x�f
Final Grade
C''� `''�
PUMP /SIPHON INFORMATION 3� .-�'��c��' X �```� � ��� S ��
Manufacturer c" !cl 'jli .y, :�' Demand St Cover
GPM
Model Number
CIPJ
TDH Lift Friction Loss System Head TDH Ft �:,;� y` ` ,�L`; 4 4 1 L " 6'k—
Forcemain Length Dia. Dist. to Well (2 /
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length No Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELT LAKE /STREAM ACHING Ma ct f
qe
IN Type Of System: A LINER O ' S'�`E� -C 1 �1
t >
Model Number:
DISTRIBUTION SYSTEM Ct
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 7 c j t 4 Y ' �y a
Depth Over Depth Over xx Depth of xx Seeded /Sodded Mulched
Bed/Trench Center Bed[Trench Edges Topsoil xx
Yes 0 No E] Yes 0 No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 1396 211th Avenue New Richmo d, WI 54017 (SE 1/4 SE 1/4 13 T31 R1 8W) Prairie Flats Add ition Lot 1 Parcel No: 13.31.18.932
P
1.) Alt BM Description 'VZ_ - L' (,'-L
2. ) Bldg ewer length - )} G' 1
9 9 r_ L Y, cJit ,ti4 Y �4b, Zi
- amount of cover , =
[(k '� �c' U i SGt :u,< ,..�
Pl p te vi sinn Required? 0 Yes No
Use other side for additional information. �� A
Date - Insepcto gnature Ceyo
SBD -6710 (R.3/97)� (_ y,, `^�
05/26/09 TUE 10:33 FAX 715 386 4686 ST CRX CO ZONING 0 001
O� County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN
In accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT Personal information you provide may be used for second psea _ S . CROIX
COUNTY GOVERNMENT CENTER
[Privacy Law. S. 15.04(1)(m)) i 2 2 1101 Carmichael Road
( 715)386-4680 W Fax (715)386-4686
Attach compl plans for the system on paper not less than 8 -1/2 x 11 inches in size.
County Sanitary Permit 4 0A/D 0 Check if revision to previous application
1. App lication Inf=tlon - Please Print all Intormatio ocauon:
Property Owner / Name
� Q�- S 1/4 �1A, Sec 1
C f_1 1 C 1J �C � f� ,� J N, / R f g1 or W
Property Owner's Mailing Address at Number Block Number
f3q rRo ix Gott+n
ity, State Zip Code Pholilkjl�1NkIG & ubdivision Name or CSM Number
yp u M (check one) �Ity ❑Village wn of
t or 2 Family Dwelling - No. of Bedrooms: n ,
❑ Public /Commercial (describe use): -s" 1� J 1�
❑ State -owned Nearest Road r7 �L
11 411.� P epair e of e : (Check only one box on line A. Check box on line B if applicable) G 11 T
Parcel Tax Number(s)
❑ Reconnection ❑Non- plumbing . ❑ Rejuvenation Nf
Sanitation o3& —' I - I 0 — 6
B) Permitmber r , Date Iss d
State Sanitary Permit was previously issued(�'� /—
IV 7N,n-pressurized of POWT System: (Check all that apply) 5i aim / �Af�_? — kT _C /TV �H41 - e Arn 6
In- ground p Mound Z 24 in. suitable soil ❑ Mound 24 In. suitable soil ❑ Mound A +0
D Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line
❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass 0 Other
❑ At - grade E3 Aerobic Treatm n Unit ❑ Recirculating
V. Dis sat/Treatment Area Info rmation:
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed (Gals. /day/ .it (Min.lnc /� Elevation i
Goa (n 2 0 0 q�,8� y,g 19Y.
1 Tank Information Capaicty in Gallons Tota # of Manufacturer Prefab Site Con - Steel Fiber- Plastic
New Existing Gallons Tanks Concrete structed glass
Tanks Tanks
Drn/�`3T /p so D ❑ ❑ D
r� ❑ ❑ ❑ ❑ ❑
VII. Responsibility Statement
I, the undersigned, assume responsibility for repair/ reconnenction /rejuvenationlnstallation of non - plumbing for the POWTS shown on the attached plans. A
license is not required for terralift repair or the instptialion of non-pluffibing sanitation system.
Plumber's Name (print) i natur no sta s� (_ PRS No. Business Phone Number
in P�
K W" 7 - 7/ S -y 7yv
Plumber's Address (Street, City, State, p Cod)
Ill. County Use Onl
D Sanitary Permit Fee D e Is ued Issuin ant Sig tur o
1 15 roved Owner Given to erse 2ZS D J1C�
lC Conditions of Approval /Reasons for Disapproval:
STEM OWNER: L S V ( ( �4���c
Y �� P �� Vj
Septic tank, effluent filter and
dispersal cell must all be serviced / maintained
as per management plan provided by plumber. iD /Y 1 _ 1 � � V %_0 Yr� . All setback requirements must be maintained / rk1O 4b as per applicable codelordinances.
1. `,,�„ aq,
:Ez evev T 4,1 1*1 ;:5 'k )
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner /Buyer
Mailing Address
Property Address �� 2 �� /V GW l� 1Ci�m a N / L) ( Szf1 ✓l
(Verification required from Planning & Zoning Department for new construction.)
City /State Parcel Identification Number
13-2 LEGAL DESCRIPTION Property Location /4, Sec. _3, T 3 N R I X W, Town of S P
Subdivision Plat: j �� �L , Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # / a d (before 2007)Volume �2 -3 , Page #
Spec house yes bo Lot lines identifiable yes no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
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. Owner maintenance
responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & 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 Planning &
Zoning Department within 30 days of the three year expiration date.
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 virtues of a warranty deed recorded in Register of Deeds Office.
Number of bedrooms J
SIGNATURE OF APPLICANT(S) DATE
** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * **
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 08/05)
05/26/09 TUE 10:34 FAX 715 386 4686 ST CRX CO ZONING CJ002
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner /Buyer
Mailing Address r�
Property Address �� 2 (`
(Verification required from Planning & Zoning Department for new construction.)
City/State Parcel Identification Number
LEGAL DESCRIPTION
Property Location S6 1 4 , S� 1 4 , Sec. _3, T 3 N R /d W, Town of
Subdivision Plat: 1 L , Lot #
Certified Survey Map # -7 , Volume , Page #
Warranty Deed # a (� �� I (before 2007)Volume 12 - 2 - 3 6 , Page # 00
Spec house 11 yes Lot lines identifiable yes.' no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
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. Owner maintenance
responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & 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 Planning &
Zoning Department within 30 days of the three year expiration date.
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.
Number of bedrooms
SIGNATURE OF APPLICANT(S) DATE
** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * **
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 08105)
COMBINATION SEPTIC/DOSE CHAMBER TANK & PUMP SPECIFICATIONS
PER COMM 84.25 CODE CHANGES 2/1/2004
Access Opening, not top d cover, Access Opening, not top of cover,
must a lend to a point no greater must eidend at least
than 6" Below Finished Grade 4" Above Finished / Gf ade .
510
Covervuith tdI ATH ' Y hITi "• 1'L'ssU� --
Locking Device IU &J60
(typical) Finished Grade /ZaMiN�rnvm
56we t Min. 23"
>30 F . Access Opening
IM5U LA* 6 Min. 23" Access Opening „
PIS I 2 ^6itC'�/hl��/�
Oulet Effluent Filter
�1 Union A-. r -?Y& - P ?iPE 3 Pf
� p/V`Ta .SOS -�D SO /L
Inlet Baffle i iem
i
Pump
,• I �n urndtr with eeh- {er " locuer' � , ah ed es
3 �'nd ar rav�
Two Compartment Septic/Pump Tank C 4a kev ale � q� o n o��de
SPECIFICATIONS .
TANK MFR: DOSES PER DAY:
TANK SIZE: SEPTIC GAL. DOSE VOLUME: GAL.
DOSE GAL. (INCLUDES FLOWBACK & <20% OF DWF)
ALARM MFR: CAPACITIES: A = INCHES = GAL.
MODEL #
Switch type: B = — 2 — INCHES = GAL.
PUMP MFR: C = INCHES = GAL.
MODEL M
SWITCH TYPE: D = INCHES = GAL.
REQUIRED DISCHARGE RATE GPM PUMP & ALARM WIRING PER COMM 83.43(8)(e)
VERTICAL DIFFERENCE BETWEEN PUMP OFF & DISTRIBUTION PIPE (LIFT) = FT.
MINIMUM NETWORK SUPPLY PRESSURE (DISTAL & NETWORK PRESSURE) _ + FT.
FT. OF FORCEMAIN x FT. /100 FT. FRICTION FACTOR ...... _ + FT.
TOTAL DYNAMIC HEAD (TDH) = FT.
INTERNAL TANK DIMENSIONS: LENGTH ; WIDTH ; LIQUID DEPTH
MP/MPRS SIGNATURE: LICENSE NUMBER:
County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN
Gp In accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT
Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER
G ♦� [Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road
$� Hudson, WI 54016 -7710
(715)386 -4680 Fax(715)386 -4686
Attach complete plans for the system on paper not less than 8 -1/2 x 11 inches in size.
County Sanitary Permit # ❑ Check if revision to previous application
I. Application Information - Please Print all Information Location:
Property Owner
�tName 5t 1/4 5 1/4, Sec / 3
3 1 N, f R g1 (or) W
Property Owner's Mailing Address Lot Number Block Number
/39 2/ �12 -
City, State Zip Code Phone Numer Subdivision Name or CSM Number
emu/ I Cf- ml 1I) Oil P-r ticrS
ll Type f Building: (check one) amity ❑ Village Prwnof
1 or 2 Family Dwelling - No. of Bedrooms:
❑ Public /Commercial (describe use):
❑ State - owned Nearest Road � / v e
II. Type of Per it: (Check only one box on line A. Check box on line B if applicable) :
" " `�
Parcel Tax Number(s)
A) 1. epair 2. ❑ Reconnection 3. ❑Non - plumbing 4. ❑ Rejuvenation `� i — _1(
l )�
Sanitation 03$ — I I X S v "
B) Permit Number Date Iss ed
UP State Sanitary Permit was previously issued - ('� �
IV. Type of POWT System: (Check all that apply) H/ �
Non- pressurized In- ground ❑ Mound z 24 in. suitable soil ❑ Mound 5 24 in. suitable soil ❑ Mound A +0
❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line
❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Other
❑ At -grade ❑ Aerobic Treatm n Unit ❑ Recirculating
Dispersal/Treatment Area Information:
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade l/
Required Proposed (Gals. /day /s .ft.) (Min.finc) p Elevation
VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete structed glass
Tanks Tanks
/ bWL- - 37 - /bl9 3D ❑ ❑ ❑ 1 ❑
It to ❑ ❑ ❑ ❑ ❑
VII. Responsibility Statement
I, the undersigned, assume responsibility for repair / reconnenction /rejuvenation/installation of non - plumbing for the POWTS shown on the attached plans. A
license is not required for terralift repair or the installation of non - plumbing sanitation system.
Plumber's Name (print) Plumber's Signature (no stamps): MP /MPRS No. Business Phone Number
Plumber's Address (Street, City, State, Zip Code)
VIII. County Use Onl
Disapproved Sanitary Permit Fee Date Issued Issuing Agent Signature (No stamps)
❑ Approved Owner Given Initial Adverse
Determination
IX. Conditions of Approval /Reasons for Disapproval: Z _ /�
L � 6 ��� ,. 1 M14 /A 7U�/ .._�(A�C �
YSTEM OWNER: �GUtiJ� n CTA
Septic tank, effluent filter and �C t1`��"1�D/tJ���T
dispersal cell must all be serviced / maintained
as per management plan provided by plumber.
All setback requirements must be maintained
as per applicable code /ordinances.
J 2236 P 100 - 7;R Q!11
STATE BAR OF WISCONSIN FORM 2 - 2000 KATHLEEN H. WALSH REGISTER OF DEEDS
Document Number WARRANTY DEED ST. CROIX CO., MI
This Deed, made between Scott J. Counter, a married person and RECEIVED FOR RECORD
Ronald D. Johnston and Diana L. Johnston, husband and wife, 05/09/2003 139:30AM
th OTC 7e 070 1,f n c u p f
WARRANTY DEED
EXEMPT #
Grantor, and Craig G. Broeren and Sunshine J. Broeren, husband and
wife, as survivorship marital property, REC FEE: 0
.
TRANS FEE: 651 651.00
COPY FEE:
CC FEE:
Grantee.
PAGES: 1
Grantor, for a valuable consideration, conveys and warrants to
Grantee the following described real estate in St. Croix
County, State of Wisconsin (if more space is needed, please attach addendum:)
Lot 1, Prairie Flats Addition in the Town of Star Prairie, St. Croix Recording Area
County, Wisconsin. Name alftflUTIONAL BANK
109E 2nd St
PO Box 89
Richmond, 0 54017
038 - 1185 -10 -000
Parcel Identification Number (PIN)
This is not homestead property.
(is) (is not)
Exceptions to warranties:
Easements, restrictions, and rights -of -way of record, if any.
n�
Dated this o a ' , 2003
* J. Counter * Ronald D. Johnston
* * Diana L. Johnston
AUTHENTICATION ACKNOWLEDGMENT
Signatures) STATE OF WISCONSIN )
) ss.
County ) A
authenticated this da of Personally came before me this 0 ? 1 day of
�Dne M. 6arron " al & q 2003 the above named
Notary Public Scott J. Coun er, a married person, and Ronald D. Johnston and
* Diana Johnston, husband and wife,
TITLE: MEMBER STATE BAR OF WISCONSIN
dimArrre 4, c arol ya Cou,
(If not, to me ]mown to be the person(s) who executed the foregoing
authorized by § 706.06, Wis. Stats.)
instrument and acknowledged the same.
THIS INSTRUMENT WAS DRAFTED BY * ,
Brent R. Johnson - Lommen, Nelson, Cole & Stageberg, P.A. Notary Public, State of WISCONSIN
400 S. 2nd St. - Suite 210 - Hudson, Wisconsin 54016 My Commission is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not necessary.)
• Names of persons signing in any capacity must be typed or printed below their signature.
STATE BAR OF WISCONSIN
WARRANTY DEED FORM No. 2 - 2000 INFO -PRO (800)655-2D21 www.infoproforms.com
[qGOULDS PUMPS Submersible
Effluent Pump
MODEL 3871
EPO4 & EP05
Series
APP
LICATIONS
Fully submerged in high ■ EP05 Impeller: Thermo- ■Bearings: Upper and lower
Specifically designed for the grade turbine oil for plastic enclosed design for heavy duty ball bearing con -
following uses: lubrication and efficient improved performance. struction.
• Effluent systems heat transfer. ■ Casing and Base: Rugged
• Homes Available for automatic and thermoplastic design provides AGENCY LISTING
• Farms superior strength and corrosion
• Heavy duty sump manual operation. Automatic resistance. Canadian Standards
• Water transfer models include Mechanical ■ Motor Housing: Cast iron for c os As sociation
e # LR38549
• Dewatering Float Switch assembled and g�
preset at the factory. efficient heat transfer, strength,
and durability. Goulds Pumps is ISO 9001 Registered.
SPECIFICATIONS FEATURES ■ Motor Cover: Thermoplastic
• Solids handling capability: cover with integral handle and
■ EPO4 Impeller: Thermo -
3 /d' maximum. Capacities: u to 60 GPM. plastic semi -open design with float switch attachment points.
• Ca
p p pump out vanes for mechanical ■ Power Cable: Severe duty
• Total heads: up to 31 feet. rated oil and water resistant.
• Discharge size: 1'/2° NPT. seal protection.
• Mechanical seal: carbon -
rotary /ceramic- stationary,
BUNA -N elastomers.
• Temperature: METERS FEET _
104° F (40° C) continuous 10
140° F (60° C) intermittent.
• Fasteners: 300 series 9 30i -
_L —► 5 I
stainless steel.
• Capable of running s 2.5 Fr
dry without damage to 251 - - -
components. °a 7
6 20 _
Motor " _
• EPO4 Single phase: 0.4 HP Z 5
115 or 230 V, 60 Hz, 1550
RPM, built in overload with a 4-
EPOS
automatic reset. o
• EP05 Single phase: 0.5 HP ~ 3 10 EPO_ - --
115 V or 230V, 60 Hz, 1550
RPM, built In overload with 2
automatic reset. 5
• Power cord: 10 foot 1
standard S1TW with three prong ° �i01._ 20 30 40 so GPM
grounding plug. Optional 20
foot length, 16/3 S1TW with o 2 4 6 a 10 12 m3 /h
three prong grounding plug CAPACITY
(standard on EP05).
Goulds Pu mps
02005 ITT Water Technology, Inc. ITT Industries
Effective January, 2005 w
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y
Safety and Buildings Division C ounty- Croix
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) SanitarXP-ellq� po.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 3 /UULL
Permit Holder's Name: ❑ Cit [I Villa a Tow State Plan ID No.:
Counter, Scott y Star l�raine ownship
CST BM Elev.:- Insp. BM Elev.: B Description: Parcel Tax No
b o 0 038- 1185 - 10 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic s f dv Benchmark Z�
Dosing 5 Alt. BM 9 �,
- -- Bldg. Sewer D -5
Holding
6 "t Inlet d 9a.
TANK SETBACK INFORMATION e
TANKTO P/L WELL BLDG. Air I ntake ROAD
Air
Septic NA Dt Bottom I Q 9 Z
Dosing 4 Z NA Header/ Man.
Aeration NA Dist. Pipe
ding Bot. System
11 4(.1 L�) 6 3
PUMP/ SIPHON INFORMATION Final Grade x 3 for
Manufacturer Demand St cover
Model Number ea
GPM
D Cove►— �? 2
TDH Lift i Friction /, System I TDH oss Forcemain Length / Dia. Dist. To well
SOIL A ORPTION►SYSTEM
BED TRENCH Width / Len t No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
IM N I N �S DIMENSI
SETBACK SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEAC Ma of ctu..' w, INFORMATION Type of � � � / -7 SOU _ IT HAMBE Model umber:
System: 6, dj Lj A
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length /y � � Dia - Length &4E75' Spacing A �✓� . > S�
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 S ❑ Yes ❑ No
CO (( 4 1 ddee c disc a 'e , ers e tt t i nspect ion : tI ( J#a spec ion
Location: 139i�1�1th Avenue, r New 1ci �4�'1'7 �S 1/4 SE 1/4 13 T31N R18W) - 13.31.18.932 Prairie Flats -Lot
1
1.) Alt BM Description= IV o
2.) Bldg sewer length S)P G�+r.,r��� ✓G/, nttC� e aK r
- amount of cover = > S ' W R A w
3 � r G ,`or ��pe5 y s(,t�� O` Corrrcfc�l d`F� Coln
w, I'd n l t our1.p k- SCe-i;.,,.
G C lY l70» Off ^ /'qw�r' GKrtJe
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
Vi scons i n SANITARY PERM 2 01 W Washington Avenue
P O Box 7162
Department of Commerce In accord with Com 3. Is x dn*oode `, Madison, WI 53707 -7162
• Attach complete plans (to the county copy only) fort ^ tem, less county
than 8 112 x 11 inches in size. '' ii p q�1 trb i
• See reverse side for instructions for completing this a i atiOnu N 0 7 2000 S, ate Sanitary Permit Numb_
ST C *X
Personal information you provide may be used for secondary purposes 0000'Y / ,�' Check if revision to previous application
(Privacy Law S. 15.04 (1) (m)]. ZOMIVE�C)F!dC
6' ' State Plan Review Transaction Number
I. APPLICATION INFORMATION -PLEASE PRINT AL F'ORWTION '
Property Owner Name ' / Prbp, ocation
- 114, S T , N, R F E (or) 19
Property Owner' ng Addres Lot Number Block Number
City, State Zip Code Phone Number Subdivision Name or CSM Number
II. TYPE 6F BUILDING: (check one) ❑ State Owned it Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms_ voan of i�` C_
III BUILDING USE (if building type is public, check all that apply) Parcel Tax Number(s) I q� 3 i � , q3a
T
1 ❑ Apartment/ Condo 11 6 3 g- 11 5 — - 6v d
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. g[New 2. I] Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an
-- __ Syrstem ........ 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 jSeepage Trench ( ((Roc K) 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit (2-) x C�o 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION: (,co
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min. /inch) c� Elevation"
2 ,$"' r ,.[�1� /•S�r •2- Feet a Feet
Ca acit
VII. TANK in allo s Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name concrete con steel glass Plastic App
New Existin structed
Tanks Tanks
eptic Tank � ❑ r 13 ❑ 13
Lift Pump Tank /Siphon Chamber ❑ 1 ❑ I ❑ 1 ❑ 1 ❑ 1 ❑
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: o tamps) MP PRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Co e):
Q d
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate I ssued Issuing Signature (No Stamps)
Surcharge Fee)
[5Approved [] Owner Given Initial i_ (z` - f
Adverse Determination I`Ta
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -6398 (R.12I99) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, plumber Aj
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 permif 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 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 and Buildings Division, 608 - 266 -3151.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the l,gal description and parcel tax number(s) of where the
system is to oe installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
111. 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 isto 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 8 112 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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wiscAsm Department of Commerce SOIL AND SITE EVALUATION Page 1 of
Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
Grille Trucking & Excavating, Inc.
Attach complete site plan on paper not less than 8% x t 1 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference pant (BM), direction and
St. Croix
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. p I. .#
Pa rce l D
APPLICANT INFORMATION fx; - P/ prin. trt Law io 1 d By — - -- Da te 4/
Personal information you provide may used r dary pur e6 (PH y Law, s. 15.04 (1) (m)). o0
a
Property Owner Property Location
Case , Dan I;m'� Govt. Lot SW 1/4 SE 1/4,S 13 T 31 N,R 18 ��
Property Owners Mailing Address Lot # Block # � Subd. Name or CSM#
323 Sawmill Lane — S�� - 2 i. - 1� Prairie Flats
City St tom, Zip CodT um r City ❑ Village ZTown Nearest Road
New Richmond WI 4017 CoB4 46 -44 Star Prairie Hwy 65
New Construction Use: t'ttv��� �rooms d 3 ❑Addition to existing building
[� Replacement o c scribe
Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpdfffz .8 trench, gpdit
Absorption area required 643 bed, ft 562 trench, ft? Maximum design loading rate -7 bed, gpd1W 8 tr ench, gpd/ft
Recommended infiltration surface elevabon(s) ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material OUT -WASH Flood plain elevation, if applicable ----- ft
S= Suitable for system Conventional Mound In Ground Pressure — AT - Grade System in ' 11 bl&kg Tank
U= Unsuitable for system S U S❑ U j�5 ® U ❑$ u ❑ U (❑ S U
SOIL DESCRIPTION REPOR --
Depth Dominant Color Mottles Structure GPDlftz
Boring# Horizon in Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. onsistenc Boundary Roots Bed Trench
1 1 0 -12 7.5YR2.5/1 - - - - -- SIL IFABK MVFR AW 1VF .2. .3
2 12 -28 T5YR4 - - - - -- CL IFABK MVFR AS 1VF .2 .3
Ground 3 28 -96 7.5YR5/3 - - - - -- S O -GR ML - - -- - - -- .7 .8
ele - - - -- - -- -
v 9��'
Depth to
limiting
factor _
96in. f
Remarks:
2 1 0 -11 7.5YR2.5/1 - - - - -- SIL IF MVFR AW 1VF .2. .3
2 11 -29 7.5YR4/6 - - - - -- CL IFABK M VFR AS 1VF .2 3
Ground 3 29 -99 7.5YR5/3 - - - - -- S O- ML - - -- - - -- 7 .8
ele
fig$= y .� vwaufiw
Depth to
limiting -
factor
99in. - -- —
Remarks: -- - -- - - -- -- - -- — -------
- -- - -- ------ - - - - --
CST Name (Please Print) Sign re: Telephone No.
DEN GILLE Via.... /5' ZG r- C 6 3 7
Address t,( t CST Number P,
A PROP&Y OW Casey Dan SOIL DESCRIPTION REPORT Page 2 of
PARCEL LD.# Gille Trucking & Excavating, Inc.
Depth Dominant Color Mottles Structure GPD/I`tz
Horizon in Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. onsistence Boundary Roots
Bed Trench
1 0 -12 7.5YR2.5/1 SIL 1FABK MVFR AW 1VF .2. 3
2 12 -26 7.5YR4/6 - - - - -- CL 1FABK MVFR AS 1VF .2 .3
Ground
3 26 -96 7.5YR5/3 - - - - -- S O -GR ML - - -- - - -- .7 .8
elev -____— ___ --
C M
Depth to l
limiting —
factor
96 in. -- - — -
Remarks: -
4 1 0 -12 7.5YR2.511 - - - - -- SEL 1FABK MVFR AW 1VF .2. .3
2 12 -26 7.5YR4/6 - - - - -- CL 1FABK MVFR AS 1VF .2 3
Ground '
ro 3 26 -98 7.5YR5/3 - - - - -- S O -GR ML - - -- - - -- 7 8
ele - -- - -
Depth to
limiting — — -- - - -- - --
factor
98 in.
Remarks: ----- - - - - -- - - --
5 1 0 -12 7.5YR2.5/1 - - - - -- — SIL 1FABK MVFR AW 1VF .2. 3
2 12 -30 7.5YR4/6 - - - - -- CL 1FABK MVFR AS 1VF .2 .3
Ground
elev 3 30 -100 7.5YR5/3 - - - - -- S O -GR ML - - -- - - -- .7 .8
Depth to _ - - -�
limiting -- - — — - - - --
factor
100 in —
Remarks:
Ground — — --- - - - - -- - -— - - - - - --
elev
Depth to
limiting — --
factor
Remarks:
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer 7 1, �0 u kc+'er z n p( '�Wb a X l� T oh h �Y �j o
Mailing Address
I `7 �3a to kAQVJ6 Ave Sc1 l �p 10SIV 910 * 04 4/ /S�i z
Property Address , 3 2�' U 7C �'� r `�¢ J l 7
(Verification required from Planning Department for new construee
City/State Parcel Identification Number l 5 8 / LES / 0 - C -L) CJ
LEGAL DESCRIPTION
Property Locations_ r /4, 5 C t /4, Sec. I . T - R W, Town of %TAl2 N 41 RK
Subdivision ' R -A A- . Lot #
Certified Survey Map # . Volume , Page #
Warranty Deed # ( 2- 23 �� , Volume (D , Page # _ 37 57
Spec house 0 yes ❑ no Lot lines identifiable 0 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
masterplumber, 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.
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 sy/StFm has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
da the ye p' ti
on date.
, 5 13( / o n
SI F APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that 0 statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of
the c 1 by virtue of a warranty deed recorded in Register of Deeds Office.
o
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siGNATUR bf 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
1.f� 10 375
, v. J PAGE
STATE BAR OF WISCONSIN FORM 2 -1999 E,�2
Documeat Number WARRANTY DEED KATHLEEN H. WALSH
REGISTER OF DEEDS
ST. CROIX CO., WI
This Deed, made between Scott J. Counter and Carolyn J.
Counter, husband and wife RECEIVED FOR RECORD
05 -15 -2000 9:30 AN
Grantor, and Scott J. C ounte r , a married man with 1/2 EXEMPT DEED
)iENPT
Interest and RoArdjd g, and D ina L CERT (OPT FEE:
cb and and wife with /2 Interest as COPY FEE:
_ TRANSFER FEE: 31.50
-- ^omman RECORDING FEE: 10.00
Grantee. Grantor, for a valuable consideration, conveys to Grantee the PAGES: I
following described real estate in St. Croix County,
State of Wisconsin (if more space is needed, please attach addendum):
Recording Area
Name and Return Address
Lot 1, Prairie Flats Addition in the Town of Star Prairie, St. Croix County, Fib Federal Savings Bank LaCrosse
Wisconsin. 201 So. Second Street
Hudson, WI 54016
035'- /4S i0-coo
Parcel Identification Number (PIN)
This �f5 i1nf hommteadpro".
(is) (is not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this day of May 1 2000 t
(
• • Scott . Counter
• arolyn . Co r
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
) ss.
St Croix County )
authenticated this day of Personally came before me this _L� day of
May 1 2M the above named
Scott J. Counter and Caro J. Counter, husband and wife
TITLE: MEMBER STATE BAR OF WISCONSW
"t: ;;.., to me known to be the persons who executed the foregoing
(Ifnot, : � Dom a djtcknowl edged / % A
authorized by § 706.06, Wis. Stats.);? °�Qx' �'W4�
THIS INSTRUMENT WAS DFiiAF BY • I/ A dl cC191:n t� ICJ
Attorney David J. Estmea MAUF2 r Notary Public, State of Wisconsin
Hudson, WI 54016 % My Commission is permanents. (If not. state expiration date:
(Signatures may be authenticated or aclonowled& are not nece )
• Names orpersoos signing in any capacity must be typed br�ted their signatum. gn °a•^ •s' ° °"P°"I F on tl ° t'o w
e du Lm ort
WARRANTY DEED STATE BAR OF WISCONSIN
FORM No. 2 -1999
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