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038-1061-10-000
? 0 CD 0 & o o § 2 } 0 2 = $ 2 W 2 r /$]/ CL CD D # E X 27 0 . ` CD \ f X008 a\§/ \ \ / ¥� \ c z_f�_ §] c z_ 2 �f�� 2_ c /� / 3 � � ( $ 3 \ ) m§Eee E < «_ « � � ' � � � � m z z' 2 � � 0 � \ j } c w z . c 0 z :t 0z § ) df c z e / E / { § \ Cl) m N k \ 5f CD US CL ® -� i � e / / 2 { \ z co z z\ z 0 § G % �\ t c I ts 2 ~ % 2 § � � a i % ® � C e c • z ■ k k§ ) k 0 / 2) )/ 2 k z « }j �} k � Cc CN E = E m } - § a a a t a a a E ' j \ ) 7 \ z �) k § ƒ co § ® �) k § a a \ :� a =_ = o �� 2= o E / f � § ) D 2 ® § o 2 0 < 2 $ :o 2 # z n < z m , � § o \ �\ � � �\ 4 » k § k 2 E � 4) o ) § / '� \ 0 0 � ° f (D 2 \ a R B o G ) a r z to /± c \ k % a IL ; 8 § .; \ 2 2 E Cl) ■ { 2 $ f f . - 6 % / = E E e � ] .6 c g §§ w o z$ // �G m o z_ z R 2\ . 9 .. = i $ E zf L a » � �) k a § ■ ® v § & j a o& U o k Parcel #: 038 - 1061 -10 -000 05/09/2006 07:54 AM PAGE 1 OF 1 Alt. Parcel #: 15.31.18.264E 038 - TOWN OF STAR PRAIRIE Current EX I ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner DANIEL K & STACY M CAMPEAU O - CAMPEAU, DANIEL K & STACY M 2178 GOOSE LAKE RD NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description * 2178 GOOSE LAKE RD SC 3962 NEW RICHMOND SP 1700 WITC Legal Description: Acres: 4.152 Plat: N/A -NOT AVAILABLE SEC 15 T31 N R1 8W 4.152 AC NE NW LOT 4 OF Block/Condo Bldg: CSM 5/1290 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 15-31N-18W Notes: Parcel History: Date Doc # Vol /Page Type 10/0312001 658170 rib 1220_ WD 07/23/1997 851 /20 07/23/1997 0 2006 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/13/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 4.152 42,800 285,200 328,000 NO Totals for 2006: General Property 4.152 42,800 285,200 328,000 Woodland 0.000 0 0 Totals for 2005: General Property 4.152 42,800 285,200 328,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date Batch #: 594 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 I Visconsilpartment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 399536 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: Campeau, Dan Star Prairie Township 038 - 1061 -10 -000 CST BM Elev: Insp. BM Elev: I BM ascription: d dI l TANK INFORMATION ELEVATION DATA dAerafion MANUFACTURER CAPACITY STATION BS HI FS ELEV. Benchmark Z c ZcO 2 Z Alt. BM - -_, -- Bldg. Sewer - - - e "5�` `° S t Inlet Ht Outlet TANK SETBACK INFORMATION e I( TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet / Septic > � � r , Dt Bottom c � � psr xr 11 (Oo �C7 Dosing > l v � � � 3 Z � � Header /Man. Aeration _ -- — Dist. Pipe 4 .1r s - /L c rti ir H Bot. System 93. Final Grade PUMP /SIPHON INFORMATION ufacturer Demand St Cover PM Model Number TDH Friction Loss stem Head TDH Ft Forcemain Length Dia. Dist. SOIL ABSORPTION SYSTEM 3 S BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS T ZS / SETBACK SYSTEM TO P/L JBLDG WELL LAKE/STREAM L Ma fa r INFORMATION Bfl AM litQ B f F�t OR Type Of System: -7 � .'—� r $fir T Model Number: r i DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake tr Pipe( / .) j3 pacing Length / Dia '1 Length `� � s Dia S SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over IDepth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil /❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: If /_LL Inspection #2: Location: 2178 Goose Lake Road New Richmond, WI 54017 (NE 1/4 NW 11415 T31N R18W) NA Lot Parcel No: 15.31.18.264E 1.) Alt BM Description = 7 `" l 6 1 2.) Bldg sewer length = �D �PS� Sor�s . 4(2 W�v.f ova - amount of cover = Q1CiS� Plan revision Required? [] Yes No r Use other side for additional informati n. SBD -6710 (R.3/97) Date Insepctor's Si ature Cert. No. C 0 b 3 ' Ler V, r \ Q Cdhti �' GT( ►vim � k l i ior H— n-eL'✓ sy6 {,... i R s �sr - A )) 36b Sanitary Permit Application SafRy & Buildings Division In accord with Comm 83.2 1, Wis. Adm. Code 201 W. Washington Ave. See reverse side for instructions for completing this application PO Box 7302 iseonsin Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302 Department of Commerce n [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not _ state owned.) Attach complete plans (to the county copy only) for the sy%etfi, on paper not Iftajhan 8 -1/2 x 11 inches in size. County 7 State anit Permit Number ❑ Check ' revision to previous applic n State Pl I. D. Number '.r r<� 9 l S3 f I. Application Information - Please Print all Information r E Location: Property Owner Name .. ,Property Location , , /l� 1/4if -�14, S / 5 - T, , 3 N, R E o! w' Property Owner's Mailing Address $I G Lot Number Block Number City, State Zip Code P m' be Subdivision Name or CSM Number 6 II. Type of Building: (check one) — ❑ City 1 or 2 Family Dwelling - No. of Bedrooms: ❑ Village • Public /Commercial (describe use):_ v' ty , Town of • to -Owned f f Nearest Road ccs x �2e X/ � C Parcel Tax Number(s) III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) 5 1; ( A) 1. ❑ New 2. Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to System System Tank Only Existing System � $) 11 Permit Number Date Issued A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) Non- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. DispersaVrreatment Area kifor mation: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade �^ Required Proposed Rate (Gals. /day /sq. ft.) (Min. /inch) Tr -- / %� ,� s� Elevation `l,,5- VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks. Con- Con- glass New Existing crete strutted Tanks Tanks Jir ❑ ❑ ❑ ❑ �' ❑ ❑ ❑ ❑ VIII. Responsibility Statement I, the undersigne assume respo nsibility for installation of the POWTS shown on the attached plans. Plumber's Name (print) Plumber's 'gnature (no stamps): MP/MPRS No. Business Phone Number Plumbefs Address (Street, City, State, Zip Codg IX. County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issu* g Agent Signature (No stamps) A roved ❑ Owner Given Initial Adverse Surch ge Fee) ap pp Determination �• `� � / 0 5" 1 X. Conditions of Approval !Reasons for D approval•• n � • n• n _ � /�� �/ V, I'�" � $�e. � - � `�.7��.ip� -�0� ts.� L C'C.o.�'�R -- K "- n - � ,(� !i @��*.�+tr , a'r`.►�,+�,��- �lfL lG�� � C�-V' t S C�.0�4�/ Wl r`�`."eD Loop PLPJ "i =1 teowe L� SBD -6398 (R. 07/00) PLOT PLAN PROJECT Dan Camneau ADDRESS 2178 GooseLake Rd NewRichnond Wi. 54017 NE 1/4 NW 1/4S 15 /T 31 N/R 18 W TOWN StarPriarie COUNTY ST. CROIX 10 - - BEDROOM 4 MPRS Byron Bird Jr. 2205 DATE CONVENTIONAL XXX -Grade CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1200& 260gal LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE a LOAD RATE .9 ABSORPTION AREA 666 # of chambers 39 BENCHMARK V.R.P top of foundation ASSUME ELEVATION 100' ❑ BOREHOLE (DWELL .H.R.P. same as BM AT' nt SYSTEM ELEVATION T- 1= 93.48T- 2= 93.58T -3 =93.68 T -4 =93.78 Sidewinder High Capacity Leaching Chamber with 17.2 o Alt BM top of well 102 per chamber Long 34„ Elevation aks Rd 50' B2 was done in a low area r- this boreingdoes not match the other twoboreings needed to do another test to tie a third one in B3 ' ex drainfie d o 0' Ob pipe 4 G seLake Rd 12' 0 '►� 98' ( ��� v f� u.� B1 or 25' 3 ex septic 1 12' 99' 12' o pQ 4 bed house Garage Driveway u . PLOT PLAN PROJECT Dan Campeau ADDRESS 2178 GooseLake Rd NewRichnond Wi. 54017 NE 1/4 NW 1/4S 15 /T 31 N/A 18 W TOWN StarPriarie COUNTY ST. CROIX MFRS Byron Bird Jr. 220521` DATE 10 - 25 - 01 BEDROOM 4 CONVENTIONAL XXX -Grade CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1200& 260gal LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .9 ABSORPTION AREA 666 # of chambers 39 BENCHMARK V.R.P. top of foundation ASSUME ELEVATION 100' ❑ BOREHOLE O WELL *H,R.p. same as BM Vent SYSTEM ELEVATION T- 1 =93.48T- 2= 93.58T -3 =93.68 T -4 =93.78 >12" Sidewinder High C Capacity Leaching Cove Chamber with 17.2 o Alt BM top of well 6" t ^2 per chamber Grade qt Syst= Long 34" Elevation > 50' B2 was done in a low area r- : this boreingdoes not match the other twoboreings needed to do another test to tie a third one in ' 50' B3 ' 0' Ob pipe ex drai�e d ° p p 4 Ga seLake Rd 1 0 98' B1 25' 3 ex septic 1 12' 99' 12' 4 bed house Garage Driveway 1484 Wisconsin Department of Commerce SOIL EVALUATION REPORT page 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Sal & Site Evaluations Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must Cou St. Croix include, but not limited to: vertical and horizontal reference pant (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. 038- 1061- 10 -000, ID# 15.31.18.264E Please print all information. Personal By D Personal information you provide may he used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Ia ds- Property Owner Property Location Dan & Stacey Campeau Govt. Lot NE 1/4 NW 1/4 S 15 T 31 N R 18 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 2178 Goose Lake Rd. 4 CSM Vol. 5, Pg. 1290 City State Zip Code Phone Number ° —_ Town Nearest Road New Richmond WI 54017 715 - 2 -7772 `.,. Star Goose Lake Road R 0 New Construction Use: 0 Residential / Number of bedr 4 derived design flow rate 600 GPD Replacement Public or commercial - Descn ,' Xr - t' Parent material Glacial outwash _ _ r ,F _ "plain elevation, if applicable nor General comments' and recommendations: Install bull run valve to allow future use fi raulicall I tr ystem. Existing system elev. = 94.07'. Install high capacity infiltrators at 93.25' Boring # .J Boring � } 1R `� V1 Pit Ground Surface elev. 98.48 ft. Del4�to iirnking facto > 102 in. Sal Applications Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIft' *Eff#1 *Eff#2 1 0_16 10yr3/3 none sl 2fs mvfr c w 2f 0.5 0.9 2 16 -30 10yr4 /4 none sl 1 msbk mvfr gw 1 f 0.4 0.6 3 30 -54 10yr4/4 none sl 2msbk mfr cw - 0.5 0.9 4 54-64 7.5yr4/6 none gr.Is 1msbk mvfr aw - 0.7 1.2 5 64 -102 10yr5/6 none strat. s 0 sg ml - - 0.7 1.2 Boring # J Boring 0" Pit Ground Surface elev. 96.75 ft. Depth to limiting factor > in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft *Eff#1 *Eff#2 1 0 -9 10yr3 /3 n sl 2fs mvfr cw 2f 0.5 0.9 2 9 -17 10yr5/4 none sil 2fsbk mvfr gw 1f 0. 5 0.8 3 17 -37 10yr4/4 none sl 2msbk mfr cw - 0.5 0.9 4 37 -51 10yr4/6 none Is 1 msbk mvfr aw - 0.7 1.2 5 51 -96 10yr5/6 none strat.s /Is 0 sg ml - - 0.5 0.7 H#5 consists of strafiffW Osg s, 1 msbk Is and band 10yr Is. Loading rate adjusted to reflect reduced permeability of horizon associated with s on and banding. * Effluent #1= BOD > 30 < 220 mg/L and TSS > < 150 mg1L * Efftuent,#`Z = BOD < 30 mglL and TSS < 30 mglt CST Name (Plea a Print) Signal .. ( CST Number Jame K. Thompson 3 _ Address A.C.E. Sal & Site Evaluations Date E luation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 10/16/01 715- 248 -7767 • property owner Dan & Stacey Campeau parcel ID # 03 - 1061 -10 -000, ID# Page 2 of 3 F # 3 ] Boring A Boring sm Pit Ground Surface elev. 98.45 ft. Depth to limiting factor > 100" _ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP *Eff#1 *Eff#2 1 0 -12 10yr5 /6 none Is fill na na di 2f na na 2 12 -21 10yr3/3 none sl 2fsbk mvfr as 1f 0.5 0.9 3 21 -30 10yr4/3 none sl 2%bk mfr gs - 0.5 0.9 4 30-40 10yr4 /4 none sl 2 m s bk mfr aw - 0.5 0.9 5 40-45 10yr4/6 none Is 0 sg ml cw - 0.7 1.2 6 45 -100 10yr5/4 none s o sg ml - - 0.7 1.2 F—I Boring # A Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *Eff#1 *Eff#2 F-I Boring # -i Boring Pit Ground Surface elegy. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz *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. AL /o -ara L d r, � �b�.d�m (>t,• Ig. Top o��cl /Cr�S. 0 �radQ lEaf ol^bu. ;ldl SewLr = 9G, B3 v fnla� <d vlaJ a-� s. ro ctf ¢D g ✓Q�uafc e-kiSt n� Sep c s4�., Sys6e„e, ara✓t I be d 06 tei Qf 38' - lew B ,-Q. de. 'Slx 0, /ACS aF'S4.�n a cf�'1u�n-1.o6�n ✓e.d;n 70 ' d,-,t ge ld . � u 93 99.0' ■ 47.o' Contowr t 'n �oo ee 6cu:4 PT. 3 r3 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must County .� include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 3 106 to Please print all information Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location u `eC477 , -A4-,_ Govt. Lot 1/4 Ag14 S / T ,�J N R / E (o W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# City / St to Zip Code Phone Numb r ❑ City 1 ❑ Village Town Nearest Road ❑ New Construction Use; Residential I Number of bedrooms _` Code derived design flow rate GPD Weplacement ❑ Public or com - Describe: Parent material �tl� C r �4 / e Flood Plain elevation if applicable ft. General comments and recommendations: 1 Boring # [] Boring R Pit Ground surface elev. ft. Depth to limiting fact (r Off': 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 I f9` oZ I - r .-� /a,• � - S cif' , S" .s _ Boring ❑ 9 Boring F 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 — 7 — " Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L CST Name (Please Print) Signature CST Number Address Date Evaluation Conducted Telephone Number 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 /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 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 /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 F-1 Boring # E] Boring El 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 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 /00) Soil Test Plot Plan Project Name Dan Campeau Byror Bird Jr. Address 2178 Goosel-ake Rd New Wi. 54017 c W r m #220527 Lot Subdivision csm Date 10 /2512001 County CROIX NE 1/4 NW 1/45 T 31 N /F W Townshi Star Prairie Boring Q Well PL Property Line# Alt. BM ,BM or VRP Assume Elevation 100 ft top of foundation System Elv. T -1 =93.48 T -2 =58 H.R.P. T -3 =93.68 T -4 =93.78 Same as BM 50' B2 was done in a low area �- this s borein does not match the other twoborein g g needed to do another test to tie a third one in 50' ex drainfi d 0' B4 12' 0 0-- G oseLake Rd 98' 30' B1 2' ex septic 12' 12' 99' 12' 4 bed house Garage Driveway Z � v , 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 4orl (f 4c e- residence located at: Section , T,,? N, R W, Town of 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: .Did flow back occur from'absorption system? �. Yes No (If no, skip next line) Approximate volume or length of time: gallons /o minutes Capacity: Construction: Prefab Concrete Steel Other Manufacturer: (I$ known) : Zxj,2c /T5 Age of Tank (If known) j y r f (Signs re) (Name) Please print (Title) (License Number).< 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 for inspection opening over outlet baffle). Name 1'� S ignature ir/ >,� MP /MPRS C' e> ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer �� h �� �• e �c Mailing Address v? / 74 Property Address _ ���� .✓� Flo (Verification required from Planning Department for new construction) City/State Parcel Identification Number LEGAL DESCRIPTION Property Locations + /a, Sec. ly , T_N -R �W , Town of Subdivision G5 �° �� �d �'� . Lot # Certified Survey Map # _-7 -5 �� . Volume 5 , Page # Warranty Deed # � , Volume _ / 3/ , Page # / 5 Spec house ❑ yesZ no Lot lines identifiable E 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 frill 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 ee year expiration date. /' s SIG TURF CekPPJdtANT DATE OWNER CERTIFICATION I (w 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 prop escribed Bove, by virtue of a warranty deed recorded in Register of Deeds Office. O /.0�% 0 / SI ATURE OF APP CANT 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 POWTS OWNER'S MANUAL ez MANAGEMEN PLAN �ra of FILE INFORMATION, SysTEM SPECIFICATIONS d al ❑ Owner �� G , � G � Septic Tank Capacity NA Permit # Septic Tank Manufacturer & E3 . Effluent Filter Manufacturer w 6h 13 NA DESIGN PARAMETERS ❑ NA Number of Bedrooms C3 NA. Effluent Filter Model ❑ NA Pump Tank Capacity gai 13 NA Number of Commercial Units ❑ NA Estimated now (average) gal /day Pump Tank Manufacturer Estimated x 1.5) gal /day Pump Manufacturer ❑ NA Design flow (peak), Soli Application Rate gal /day /ft Pump Model ❑ NA Pretreatment Unit ❑ NA Influent/Effluent Quality Monthly average* ❑ Sand/Gravel Filter ❑Peat Filter Fats, Oil at Grease (FOG) 530 mg/L ❑ Mechanical Aeration ❑ Wedand Biochemical Oxygen Demand (BODs) 5220 mg /L ❑ Disinfection ❑ Other: Total Suspended Solids (TSS) 5150 mg /L Manufacturer Pretreated Effluent Quality , ❑ NA Monthly average* * Dispersal Cell(s) Biochemical Oxygen Demand (BODs) 530 mg/L Oln- ground (gravity) ❑ In- ground (pressurized) ❑ Mound Total Suspended Solids (TSS) 530 mg/L ❑ At -grade El Other: Fecal Coliform (geometric mean) 510 cfu /IOOmI ❑ Drip -line Maximum Effluent Particle Size -A inch diameter * Values typical for domestic (non - commercial) wastewater and septic tank effluent. * * Values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Frequency Service Event ❑ months - �gyear(s) (Maxima rs.) Inspect condition of tank(() once At least every Pump out contents of tank(() When combined sludge and scum equals one -third (Ys) of tank volume Inspect dispersal cell(() At least once every ❑ months E2 year(s) (Maximum Yrs.) Clean effluent filter At least once every ❑ mo nth( >Y ears) IF Inspect pump, pump controls ez:alarm At least once every ❑ months ❑ year(() ❑ NA Flush laterals a pressure ressure test At least once every ❑ months ❑ year(s) ❑ NA Outer: At least once every ❑ months ❑ year(s) ❑ NA Other: At least once every ❑ months ❑ year(s) ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an inodi POWWTS carry aintained Septage Servicing Operator. inspection Plumber, Master Plumber Restricted Sewer; POWTS Inspect , must include a visual inspection of the tank(s) to Identify any missing or of effiuent the ground surfaceeaTh ) e dispersal volume of combined sludge and scum and to check for any back up or p ondin g cell(() shad be visually inspected to check the effluent levels it g ob Indicate a t condition and requires the immediate n the ound surface. The ponding of effluent on the ground surface may notification of the local regulatory authority. the entire When the combined accumulation of sludge and scum In an y Operator d dispi e vo o ed of in accordan ewith ch.NR 113, Wiscon! contents of the tank shall be removed by a p a ge Administrative Code. and The servicing of effluent filters, mechanical or pressurized POWTS erformed by a certified POWTS Main�tainer.ny °then maintenance or monitoring at intervals of 12 months or less shat be p A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. START UP AND OPERATION • For new construction, prior to use of the POWTS check treatment tank(() for hit pain products or are detected have ti the con ter that may impede the treatment process and/or damage the dispersal ceil(s). I g Af rr,. rardrrftl rnmoved a senwe servicing opera prior to use. i O �g u04 ! u �twafly. ze awrK AirdoR1nV Avolvi1 oix IV301 1l1d1411d) bO1Y113d0 ONINA113S 37VIAS 7 L w 9 buoy L -- oyd. d ba stut� �D 7 7 awe» 1NIVINlvm LAO& V311VISNI SLMOd S1N3W140:) 1YR0111aad A 1a1»Vds`41 2!O 11n�lddlG 3s kyK XNdl d 101!0!1131141 3lil 1+1 011! 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He )o slualuoo a4y •paleas s3ulusdo slid pwoputgr a4l Put pa»auuo>slp sq lleys nld put shun o1 auldid lib' :*M sAllennulwpy ulsuOAM '£><•£g wwoa •y.7 y11M aNtlldw) ul pauopurge A16)ts put Alsadoad si W,)WT jit111ey1 6snsul 01 ualle3 aq f1rys sdals SUIIAOlto) alp a_-lASas)o lno ualr1 /1 2uaur tuiad sl ro /pur sl!t1 S.LMOd 041 U • LN3 W3 Pt0(1 NVHV •wpq iwayos la1vM put !tuoawn =11aeu Ai n!ues :sapixlsaa twilposa xupuiea rl!o .sunarorpaw ItdrlM !raw t»pplq,ay tasew taugosra (ssulload slgna3m put 1l" :aaleM (dwnd awns) uirsp uo!lepuno) fie) tsluws)ulsip lsasdgp . leluap !siaseaaaap tsgeMs t1 nw 'swopuo) islinq MJrSla tsadlM Agtq tsopolgllur :SIMOd atp )o a) *to lool01d put awtu land all! OAOJ Atw wt J611MIStM atp WO.y 3 UIMO110) 041 JO U011eulw 10 u011D -pan uopd tosgr go$ spe,as•lr jo punotu Aue )o adols ut op 1aa) S I ulyliM rase a41 115edtum so 4 ntip W1mV11 s0'san0 K.ied so &App IOU Od •sllao Iessadslp Put s11ue1 JaAO s1113114aA 1lsed JO anilp 1ou od •jut1 dwnd a p ul4l1.M sianai IetsUOU as0lt6s o1 closluo) dwnd stp auptado stllenuew ul t slss e 01 saulrlURW S1MOd JO aagwrMd a I.)eluo .io dwnd luanll)a a41 01 a6Atod auls(lsa.a of :lolld• joitladp aupWaS 6stldaS t Aq pinOUW lltatl dwnd atp )o slualuW og1 aney uopenlls s!y1 plonr. o f IuanWo 1 aasryaslp ot pns .lo dn*tq" ul 11nm Arw put ($)Il W JUIptOlsano 'atop asstl auo Ul (s)II» )esiaOSlp a4l 01 paasePslp A4 li!M saleMalsrM tM" atp pumai s1 jaMod uagM 312A21 .21eM4314 Ittwou 6Aoge Ilu Attu quel dwnd soltlno samod Sulsn(l •auyans anpe.nlllul No It uatoa) oit suolllpuo Ilos uayM m»o 1ou 1leys do vets walsAS �:. 173 1Fa;,� STATE BAR OF WISCONSIN FORM 2 • 1999 6581 70 KATHLEEN H. WALSH WARRANTY DEED Document Number REGISTER OF DEEDS ST. CROIX Co., WI This Deed, made between Kelly J. Erickson and Annette R. Page, RECEIVED FOR RECORD hus band a wife, 10 -03 -2001 9:10 AM -- - - -- _ YARRANTY DEED Grantor, and Daniel K C ampeau and Stacy M. Campeau husband EXEMPT A and wife, — CERI COPY FEE: _._ COPY FEE: TRANSFER FEE: 792.00 RECORDING FEE: 11.00 Grantee. PAGES: 1 Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix _ County, State of Wisconsin (if more space is needed, please attach addendum): Recording Area Lot of Certified Survey Map recorded in Volume Son pa e I as c 384946 being a part of the N east Quarter of the Name and fit tblfts TO: TITLE ONE Northwest Quarter (NE 114 of NW [A), Section 15, Township 31 North, 706 19TH STREET SOUTH Range 18 West, Town of Star Prairie, St. Croix County, Wisconsin. HUDSON, WI 54016 038- 1061.10 -000 _ Parcel Identification Number (PIN) This is _ homestead property. Exceptions to warranties: Easements, restrictions and rights-of-way of record, if any. (13) ArXOO Dated this 2* day of September 2001 - -- __ —_ *11. ickson y Annette R. Page 6 AUTHENTICATION ACKNOWLEDGMENT Signature(s) Kelly J. Ericks and Annette R. Page, husband STATE OF WISCONSIN ) and wi ) ss. County ) authenticated this day of September 2001 Personally came before me this _ day of the above named .Kr 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. Slats.) ^� instrument and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY + -- Attorney Kr Og Notary Public, State of Wisconsin Hudso W13 4016 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. Inl- 1— Profess —aia C"Pany. Fed dw Lac, wi STATE BAR OF WISCONSIN e0osss -2021 WARRANTY DEED FORM No. 2. 1999 `'%gape ST. CROIX COUNTY CERTIFIED SURVEY MAP LOCATED IN THE NE 1 /4 -NW 1/4, SEC 15, T 31 N, R 18 W, 4TH P. M. LEGEND THE NORTH LINE OF THE NW-1 /4 OF SEC. 15 IS Q I" X 24" IRON PIPE SET ASSUMED TO BEAR WEIGHING 1.68 LBS. /UN. FT SCALE: I" =200' S. 89 38' 57" W. I" IRON PIPE FOUND IOU 50' 0 IOU 200' CURVE DATA: CURVE LOT RADIUS CHORD CURVE NQ NQ LENGTH LENGTH CHORD BEARING CENTRAL ANGLE LENGTH 1 -2 4 162.17' 205.7C1 N_ 50° 48' 26 "E. 78 43' 03" 222.81' '3 4 3 -6 1542.86' 690.72' N. 24 23'00" E. 25 52' 12" 696.63' aR c , y �► s N 3-4 3 " 225.93' N. 15 38' 50" E. 8 23' 52" 226.14' "► MA leI L C 0 4 -5 2 128.84' N. 22 14' 20"E. 4 47' 09 %W. " 128.87 2CON V 5 -6 I 340.92' N. 30 58' 30" E. 12 41' 11" 34134' ll � M &*Ode NE(� � 6 UNf _LANDS _ OWNED _ BY _ _OWNER SECTION LINE VW SEC. COR. N. 89 38' 57" W. 829.41' N. 89° 38' 57" W. 502.84 N -I/4 COR. 57 "W N. 89 38' .� `0 .990S /' 8 788.10' N. 3701 ' LOT / 53oO1'ST .6 03 /�3� o 1.31' DETAIL. 60 192 92 56 06 2 g�, 19, 4 3' 3.836 ACRES•.INC. 'R /W % O S'' 18' (0o1, 3.505 ACRES EXC. R /W, 33, CURVE 11- 12:R= 1509.86,L= 337.00; JI v 43 y9 , 6A Q q ! Gq A=12 C =N 30°55' 27" E, 336.30' LOT 2 so' 0 �:F� s' • w 3.594 ACRES INC. R/W X02 = z U .c� F Q , 1- a 3.503 ACRES EXC. R/W 0 0 N = w a / / OP I- 0 N I U 7 01- URVE 10 -11: R= 1509.86',L =111.51', ° V Z U- 5 =4 °13'53 ",C =N 22°24'52'E1111.48- w G 20' N N. 90 00 00 E. 549.18 ® 10 , O c = O _ M 514.05' 3 5.13' ! 0A W a H - - - - --T LOT 3 ° ° Z CURVE 9-10;R=1509-86',L=233.22'. cr OJ N 4.008 ACRES INC. R /W ° !'� 0 =8°51'01 C= N 15 °52'24" E, 232.99' a o a s 3.736 ACRES EXC. R/W �p ! M 0 Q N Z M / Q3 p/ Z� a00Z N w 3 N. ll 0 �' 1,34 w CURVE 9 -12* R= 1 L =681.73, 0 O� 3 -; N. 90 OCl 00 E. 460.79 a : A= 25 52' 12 ", C= N 24° 23' 00" E, 675.95' w 21.5' ti - 427.68' co • ` rn ' 33.11 v: �p N f.� LOT 4 M 6- r<i vj 4.512 ACRES INC. R/W rMn o: p� ' J w 3.938 ACRES EXC. R/W W M (p ��� APPROVED ALLEN G. 0 I , a c\1 P� MMAGEN v _ : J? S•140T cu'i . _ z: 1W 4 1980 MOSON, Q \p, rn & 2g„ 2 Z R/ W LINES WIS. cn 0 1a, N . 8 SL C;(O:X W cO 8 , COMPIICHEN5IV IRKS /LANNW($ wBI��� SU %4 Z� , � S. 89 50 03 " E / AND ZONING COMMIT HE g 61'� 22' 203 43 1 i 203.45' •� �,, �' S. 89 50`03"E 7 SIGNED a��^^ DATE d o'S 33.07' CURVE 7 -8� R= 195.17, L =LvB.Iri', ALLEN C. NYHAG RLS 1407 p= 78° 43' 03 ", C= N50 E, 247.55' Volume 5 Page :1290 ...,. ._��� .., ..,�...., - Ina non stn -_:a A. 10/22/01 MON 10:04 FA% 716 986 4686 ST CRY CO ZONING 0001 D F PARTMENT OF INDUSTRY, -INSPECTION REPORT FOR SAFETY BI BUILRINGS P .O. BOX 9 REL A TIONS PRIVATE SEWAGE SYSTEMS DIVISION .O. BO 7969 BUREAU OF PLUMBING MAO 9t1N wt 3747 NE�1vctNec.15,T31-RI,$W El CONVENTIONAL ❑ALTERNATIVE S Town of Star Prairio H .Lai,ei ❑ Holding Tank 12 In-Ground Pr6ssure Mound Goose Lake Rd, HAMS OF PERMIT HOLDER. ADDRESS AN IT HOLDER: INSPGCTiQN OA Annette Page 497 Marshall Rd., New Richmond, WI 54017 BENCH MARK f emhn t DESCRIBE IF VII•Fe.RENT FROM PLAN RiF. PT, [LEV.: F T H6F. PT. E LEV N.— of PN+m6.r. +VPIMPRGW 14. SIIIHNy ft—t nyll�lll�: LEIAle '17- Hudscin 6699 $ PTIC TANKIHOLDING TANK: !SA!yuE ACTV'iEi' .IUUi�CAPI I� [ANK INLET i4LLV. -- ANK OUT Lit iLGV . MIwRNiNlT LABLL LUCKIN(:QVvEIi 'U: MOW oil) BEDDING: t V NTMATL. fl! "IIWAT'LN E3 ❑NO ❑YES CINO .� 7M NUMBER pF RDAD. F NE: OPERTV wfLL ulLOlNa venrTDPReai PUFF FRDR; AIR INLET' nYES QNO ❑YES N NEAAEsT _ -- -- — -�� _ —_ -•, DOSING CHAMBER: MANUFACTURER P4DDINr,:: �L IOUID 1 fv I l`UIUIN:AUDEI PUMPIDII'HON IU. +EARNING LABEL LOCKING COVER PHOVIDEO PROVIDE O: AYES NQ_.I I CYEs nNn Myot r W Nki YCH VYU1_t:; 4UMP AMU COMf OPERATIONAL NUMBE OF vMUP(HT• V+il44 BUILDINIi V NT TO FRE RENCE BETWEEN FEET FROM LINE alA INLET rihNO OFF) DY ES 13 NO 14 6AR6 T SOIL ABSORPTION SYSTEM. Check the svii TTmisture at the depth of plowing .H I M A"t . RIAL ANO MA IK IN6 or exrovelion. III soil Can be rolled into a wire, construction shall onese until FORCE 14 soil is dry enough to Continue,) I MAIN I �',NTICNA,L iltrsl't: WKI'1/,hCC11Y"Y WI�f12 I.FIOET� 1i3T11" LIIS TR. PIPE SPACING COV INOUG DIA ■pl r5 LIOUIO �--_,. _.... ..._ 0IMEN81ON9 ''MA EEO %PTh LUEPTH t.115T1t wlpi `Ism PPe ._I I N u�s+H. NUMBrcR OF y '•O�ETiTY WLLL ler'ILOINri V NT *Q LUiiH ?FLOW 'IPCS AEUVe COWi. SLEV FNi. PIPGG — `LINE I AIR INLE7 I FEET FR O f ,.•,.�.� -- -�. I �' Iii i I 1 t MOUN SYSTE Mound site plowed perpendicular to slope Cheek the texture of 'the - till material for — PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope- mound systems to make certain that It ON REVERSE SIDESHOW ELEVA• DYES 0NQ meets the criteria for medium sand. TIONS MEASURED. _ S OIL TEKTVPE 1'I.HMAN' 11VA TION WELLS ❑ ❑NO D ii OVER TRENCNlern ULh lli i)VrN rli,n:l�i li I TU1'GOI St100 F.D YES YES ;�f GVI.0 V C'Np CGNTGR EO(TES ❑YES • ONO DYES ONO InYEs E: N PRESSURIZED DISTRIBUTION 9Y9TEM: WIDTH j LfiNi, . TH NO. OF _ATERALSACIKC` GPAv L UEFTH BELOW PiFP PIL: DE n AEUVE COVER TRENCHES; DIMemIdNIS MAN'F Pu M MANI POLO VI5T IMP IRE M I rvo F"I 11 11 DIM Pau rION PIPz MA I f Ti K ING ILEV ELEVATION A ELe V. DIA ELEV.' PIPES DIA. CI�1'RIB11T1ON '. tNFOPMAIrION IQLE SIZE HOLE SPArIN6 VK,LLFrJ VER UArER1AL WOOR'AL Or T CORRESPONDS To APPpUVEO PLANS DYE ❑Y ES ED No COMMENTS: ORSERVATION WELL,$; IW I L E rT aFROM R OF PROPERTY WELL BW1 41Ne. ❑YES , DNO AYES ONO NEARI<ST ,7 L /0 Sketch System on Retain in county file for audit. Reverse 3ltle. SIONATUFIC; TITLE 71 DILHR SBD 6710 (R 01/82) � � a q M � r u Z4, .e 12, A � tj fA l` T u L* t ►. a.1 � � � ♦� Fa � 1 a S � 1 q O �• N I u q � a CO bEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOP* HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BQX 7969 . BUREAU OF PLUMBING MADISON WI 53707 NE4N -R18W ❑CONVENTIONAL ❑ALTERNATIVE State Plan LD.Numbe Town of Star Prairie r IH assigned) ❑ Holding Tank ❑ In- Ground Pressure El Goose Lake Rd. 0 , q 112,11 NAME Of PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DA 7 Annette Page 497 Marshall Rd., New Richmond, WI 5401 BENCH MARK (Permanent reference pomil DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV. Name of Pl.-be, . J— MP /MPRSW N. County: Sanitary Permit Numb -, SEPTIC TA NK /HOLDING TANK: MANUFACTURER: LIOUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED F_1 YES ONO DYES ONO BEDDING: VENT DI: VENT MATL. 11111311 WATER NUMBER OF ROAD PROPERTY WELL BUILDING VENT TO FRESH A. ALARM FEET FROM LINE: lA1R INLET. O YES ❑ NO DYES ONO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING: 1IOUID CAPACITY PUMP MODE L. PUMP /SIPHON MANUF ACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ONO DYES ONO DYES ONO GALLONS PER CYCLE: PUMP AND CONTRD LSOPERATIONAL. NUMBER OF PROPERTY WELL BUILDING VENT LE FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) ❑YES ❑NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGi H uIAMETEH MATERIAL AND MARKING; or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: _ -. WIDTH LENGTH NO. OF UISTR. PIPE SPACING COVER — INSIDE DIA. -PITS LIQUID BED/TRENCH TRENCHES MATERIAL• TPIT DEPTH. DIMENSIONS GRAVEL D PTH FILL DEPTH UISTR PIPE DISTR PIPE, DISTR. PIPE MAT RIAL NO DISTR. NUMBER OF PROPE TY WELL. BUILDING VENT TO FRESH BELOW PIPES ABOVE COVER F.LEV INLET ELEV END PIPES FEET FROM LINE. AIR INLET. NEAREST------10- MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. OYES ONO _ SOIL COVER TEXTURE PL M RANENT MARKERS OBSERVATION WELLS O YES ONO OYES ONO DEPTH OVER TRENCH; BED DEPTH OVER TRENCH;BEU DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES ❑YES ONO ❑YES ONO ❑YES - ]NO PRESSURIZED DISTRIBUTION SYSTEM: BED/ TRENCH: FMANIFOLD H. LENGTH: TR OF ENCHES LATER A LSPACING: GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER DIMENSIONS PUMP MANIFOLD DISTR, PIPE IMANIFOLDMATERIAL NO DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEVATION AID ELEV. DIA. ELE V.. PIVES DIADISTRIBUTION 512E HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED mFoft"TION PLANS OYES ONO OYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WE BUILDING. FEET FROM LINE ❑YES ONO DYES 1:1 NO NEAREST 41 Sketch System on Retain in county file for audit. Reverse Side. _71 SIGNATURE: TITLE. DI LHR SBD 6710 (R. 61/82) — "' SANITARY PERMIT APPLICATION COUNTY ©ILHR In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT PERMIT # –Attach complete plans (to the county copy only) for the system, on paper not less than ❑ lad f44 Q 8% X 11 inches in size. Check i revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFOR - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION e e Y. /,t %, S C� T2/ N, R if (Or) PROPERTY OWNER'S MAILIN ADD ESS 1 LOT # BLOCK # _// a,• s al ;e CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME SM NUMBER 11. TYPE OF BUILDIN : (Check one CITY �. NEAREST ROAD yy / { � t ) ❑State Owned ❑ VILLAGE 5,61 7.-a�i , �e 9oor2 X c 4 ,ICI Public ®1 or 2 Fam. Dwelling -# of bedrooms i— PARCE TAX NU BER( ) III. BUILDING USE: (If building type is public, check all that apply) 1 _ Il ly �- 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility S ❑ Campground 7 ❑ Merchandise: Saies /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.,Z New 2. ❑ 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 # — 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. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals /day /sq. ft.) (Min. /inch) Q r7 ELEVATION � g F 110 1 3 7 7' / Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exp INFORMATION New istin Gallons Tanks Manufacturer's Name C oncrete Con- Steel glass Plastic App Tanks strutted Tanks Se tic Tank or Holdin Tank / 2 7 -001 – O /ZOO 2 Lift Pump Tank/Siphon Chamber L f Fj VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) rP/MPRSW No.: Business Phone Number: -Dale Aoo�ol 71.5 L - 375 Plumber's Address (Street, City, State, Zip Co g Zo /Yl o.'>7 _5 l3al��v�i� IX. COUNTY /DEPARTMENT USE ONLY Lj Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Surcharge Fee) Approved ❑ Owner Given Initial , � O T7 L Adverse Determination X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: SBO -6398 (formerly Plb -67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber i INSTRUCTIONS j 1, A sanitary permit is valid for two (2) years. 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 (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 & Buildings Division, 608 -266 -3815. 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. 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. Vlll. 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% 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 erved; B horizontal and vertical elevation reference i 9 ) 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 (8.11/88) n Qj N p °o Y U t7 G M M 57 Rq A � c Qp- 0 J N O V1 41) N � o 0 �op ♦ L7 1 1 1 h .06 50� J n I 00 vi 3 tv O p o O `� Sj �1 w � N 0 kK C9 0 0 Al tee hope o �► a w cJ O n �d D � o � y b U DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINC ��INDUS�'RY, DIVISIC MA AND P.O. BOX 791 HUMAN PERCOLATION TESTS (115 MADISON WI 53T HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: OWN UNICIPALITY: L T N .: O.: U DI VISION NAME: ,oa / /T N /R/ c C OYT Y: MAILING ADDRESS: / •Gro - e. � dr / USE DATES OBSERVATIONS MADE 6 NO. BEDRMS.: COMMERCIAL DESCRIPTION: TES Residence /1 IgNew ❑Replace RATING: S- Site suitable for system U- Site unsuitable for system ONVENTIONAL: MOUND: IN- GROUND- PRESSURE: SY TEM -IN -FILL rE1S1ZV OLDING TANK: RECOMMENDED SYSTEM: (optional) ®Sau MSou c9Sau oSCAu If Percolation Tests are NOT required DESIGN RA If any portion of the tested area is in the under a. ILHR 83.09(5)Ibl, indicate: / Floodplain, indicate Floodplain elevation: /r PROFILE DESCRIPTIONS BORING TOTAL P H T R UNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTI NUMBER DEPTH IN. ELEVATION OBSERVED EST. WTHTS TO BEDROCK IF OBSERVED (SEE ABB .ON BACK.) B- ( 19 /a J - Iq " '✓'�� O n5,� O, 2 B -Z o /� G 9G s is B• 9 d o' � - s 70 B- PERCOLATION TESTS TEST PTH , WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER 1102111" AFTER SWELLING INTERVAL -MIN. PE RIOD t _ PERIO D2 PER INCH P. o 4f P- O R - 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 he zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and pera of land slope. SYSTEM ELEVATION � G I C4 C r , - - - - -` -- _ _ IW lit 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified i!thh Wi sco Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. LNAM:Eprint)- T xZ0 14o WERE COMPLETED ON: 01 DDR ESS t � / CERTIFICA 'NUMBER: PHONE NUMBER(op CST AT E- < i IBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. SBDb395 -JR. 10183) — OVER — H _ L H ' a ST C'- 105 r a � H SEPTIC TANK MAINTENANCE AGREEMENT Ho St. Croix County z d a OWNER /BUYER 1212e� l e F O L? ( T r C Sd� ROUTE /BOX NUMBER '�'971111),1.5x(�l�I, Fire Number CITY /STATE Ale-,Q2 e,,C "20/20, 7..IP PROPERTY LOCATION: Az_ �41 /V A , Section /_5 T 31 N, R Af W, Town of _5 /0,' St. Croix County, Subdivision //Xj . Lot number A/>9 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 septic tank pumper What you put into the system can affect the function of the septic tank as a treat- ' ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which 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 systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master 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. 0 I /WE, the undersigned, have read the above requirements and agree to maintain, the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart - 10 ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE_ _ 22_ �2 St. Croix County Zoning Office P.O. Box. 98- Hammond, WI 54015 715 -796 -2239 or 715- 425 -8363 Sign, date and return to above address. �_ 1 w 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. --------------------- Owner of property r`� l�- & Location of property /IL 1/4 /4, Section `� , T 3/ N -R 4 W Township Mailing address Z / a e0°. /k" -11 .5 / Address of site Subdivision name /U14 Lot number /W - Previous owner of property _y�� OfY' Total size of parcel Z 7 ( Z' 4C��S Date parcel was created Are all corners and lot lines identifiable? X Yes No Is this property being developed for resale (spec house)? Yes /k No Volume 1 and Page Number 20 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 references to a Certified Survey Map, the Certified Survey Map shall also be required. ' --------------------------------------------------------- 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 property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. 5�5/ i:f ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of a County Regis er Deeds, as Document No. ). ra d- 1— Signature of Owner Signature�k to-Owner (If Applicable) Date of Signature Date of Signature WARRANTY G S _ DEED 7'611PACE REuCRVED FOR RL'CORDING DATA ti ST:1TL BAR OF WISCONSIN FOItM 2-1882 451414 � vc. sa1eAcot 20 REGISTER OFFICE ST. CROIX CO., WI Recd for Record Jeffrey- B. -_ McRoberts and Bernardine C. McRobe.1~ts,. hu$band- _and .wife.. as point - , - SEP 11 1989 .... tenants- - - - -- at 10-15 A. M -- comc.ys and a�.irr:ult;; to Kelly. -J.- .Era_cks.gn_. and Annette.. R. - •- Page, as tenants. _. Regisrerof0ecds.` ................ - - --- • ........... I� RETURN TO .- .. -_.. .. .......... ........ .. .... ................. .._ .......... ........... the following described real estate in ._.__..:. St. Cro lX ...... . ..................••-------�-- .county, State of Wisconsin: !i Tax Parcel No: ................... ..... ...... Part of the NE 1/4 of the NW 1/4 of Section 15, Township 31 N, Range 18, more fully described as follows: Lot "4" of the Certified Survey Map filed in the Register of Deeds Office - St. Croix County on May 26, 1983 in Volume "5" of Certified Survey Map at page 1290. 1 I This . S .... 1 n111estead lmoperty. (is) (is not) Excel )Lion to warranties: municipal and zoning ordinances, easements and restrictions of record. j , hated this I - - -- day or _.. - - - -.- ._September gg .. ..... I9.. dl�G4 �. -- _.... ------ -- -- (SISAL) (SEAL) - -- B. f B McRoberts -_.. . ..._...---- • ....... .......... ....... . . . .. ..... ......................... ------- (SEAL) c - ..�/� ,>{!(/ i. - r .._ * . _Bern,ardine__ C. McRoberts -- - AU'!'IdENTICATION ACKNOWLEDGMENT Signature(s) •-_Je�frey - -• -- - B. McRoberts STATE OF WISCONSIN and Bernardine C. McRoberts • -- ---------------------------------------------- ss. • Si ...............County. authenticated this _ /_�„ b J ay of•__Sapt•(n `Y (' Personally came before me this ________________day of ---- -___ -- 19 ........ the above named --- -• r 1 Tu i + _ Rcmir. tO, - ----- -- -- - - -- --- •-•- --•-- -••••---•---•-•- TITLE: MEMBER STATE BAR OF WISCONSIN - -- -------- -- ------ --- -- - -- ' (If not, - --- -- _ -• -- -• •-- •- •----- •- --•- -• -•-- .......................... authorized by § 706.06, Wis. Scats.) to me known to be the person ____________ who executed the foregoing instrument and acknowledge the salve. THIS INSTRUMENT WAS DRAFTED BY REMINGTON LAW OFFICES Judit$ A . R min ton N-elrr -- Rzc zltQt?_ ., - -_W ... . .... 54017 -•- -• Notary Public •--"--•-----------•------- re no t necesstures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state a expiration re noary) date: - --- - -- ................ 19 --------- * Names of Persons signing in any capacity should be .yired o;• printed helmr heir aign:r4i rex, WAIInANTY Dj7r•-D STATE IIAit OF WISCON S11Y I +OHM TJO. ;r I , rti ., R'iarnn;:ur Lr•gnl ItlurJ: f1.. lug•. alil�:r�ukr wix.