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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count y:
Safety and Buildings Division
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 370206
Permit Holder's Name: ❑ City ❑ Village ❑ jown of: State Plan ID No.:
enman Kimberl Troy Townshi
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
0 U L a� 6 040- 1242 -50 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Ple Q,9 O Benchmark /1) d (7v
Dosing 6S1) Alt. BM Z . P
Bldg. Sewer ?, SS . ps
ng QY Ht Inlet g' / 0
TANK SETBACK INFORMATION
TANK TO P/ L WELL BLDG. Ventto ROAD e
Air i�ke
Septic ' 3 z� 7-1 QP
NA Dt Bottom Z� q
Dosing y2S 3 3p� �Q' NA +4ead-ef -1 Man. hi
Pi `� */ , 34i
Aer A Dist. Pi
p Ce) -rz .35 ioo.aS'
ru - 6 L
Bot. System Ce�7z �i 3
PUMP / SIPHON INFORMATION Final Grade k lU
Manufacturer G Demand St cover
Model Number ,/) i s GPM
TDH Lift ? Friction Syestem TDH Ft
oss Forcemain Lengthy 2, Dia. H Z" Dist. To well
SOIL ABSORPTION SYSTEM q ry 5
BED / EN H Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN 3 3G. ?_- DIMENSION
SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACH Manufacture:
SETBACK
INFORMATION Type of r R Model Number:
System: && 3 Z 2 61
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
r /
Length A_ L Dia. Length SG • ZS Dia. At! Spacing (9 A/ 7 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 ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: / 11/00 inspection #2: / /
Location: 532 Trillium Lane, Hudson, WI 54016 (SE 1/4 SE 1/4 3 T28N R19W) - 03.28.19.1234 Countrywood Addn. II -
Lot 76 / /
1.) Alt BM Description= �' a.�;�►. a�iou� 4 � ic w «' �� ck4rnb Iva- a- wded / h ted/ /
2.) Bldg sewer length = 2 - 1 ' P. Care cice( s(`11
-amount of of cover = -750 z P R" k - s c cfr'oh
3) OX wet, � Ckru�
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 1
SANITARY PERMIT NUMBER:
1
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Safety and Buildings Division
201 SANITARY PERMIT APPLICATION W Avenue
Washington Av
��isconsin P O Box 7162
Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7162
• Attach complete plans (to the county copy only) for the system, on paper not less County -t- ,
than 8 1/2 x 11 inches in size. / < rA
• See reverse side for instructions for completing this applicataL \.r °- State Sanitary Permit Number
20(0
Personal information you provide may be used for secondary purposes ,` "v'F hec if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. Plan Review Transaction Number
F;
I. APPLICATION INFORMATION - PLEASE PRINT -INEIMMAILON
PropertyOwp NamePro rty. ion
,. /4, T a g r N, R/ k(o W
Property Owner's Mailin Address d !�`, r `� Block Number
/T�. S, c
City, Sta Zip Code F7� Num ber ivision r M Nub J
� 44 : t_ O
T YPE F BUILDING: (check one) ❑ State Owned ❑ vil a ° e r Nearest Roa r
9
Public 1 or 2 Family Dwelling- No. of bedrooms Town OF r r
III BUILDING USE If building type is public, check all that apply) Parcel Tax Number(s) ( 9 YP P PP Y)
1 ❑ Apartment/ Condo ovo - cl
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, u(New 2 E] Replacement 3_ E] Replacement of 4 E] Reconnection of 5_ ❑ Repair of an
______System ________System _____________ Tank Onl�r-------------- ExistingSyst -- ________ Ex - S rstem
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 /� �O 21 ❑ Mound 30 ❑ Specify Type 41 E] Holding Tank
12 [if Seepage Trench 6; .¢ 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 E] System -In -Fill c � p2J( - 3/ — S 7 2.
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/da /sq. ft.) (Min. /inch) ( Elevation
';7.0 r
0 6 Z 5 s . / �S Feet O Feet
Capacity
VII TANK in Ca allons Total # Of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank 16 O O ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ 1 ❑ 1 ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plum is (Print) Plumber' ignature (No St mp /MPRSW No.: Business Phone Number:
Plumber's ATl�ress (Street, City, State, Zip Code):
r s_
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved janitary Permit Fee (Includes Groundwater D ate Issued Issu'ng Agent Sig ature (No Stamps)
Approved []Owner Given Initial Surcharge Fee)
Adverse Determination -),
X. CONDITIONS OF APPROVAL / REAS0f4S FOR DISAPPROVAL:
M o�
SBD -6398 (R.12199) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS '
1 . A s a nitary permit is valid for two (2) years_
2. Your sanitary permit .maybe renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a 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 legal 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.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber into fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County / Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location I 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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Wisconsin Department of Industry SOIL AND SITE E V A L U AT I O N, R E PORT Page 1 of 3
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05 W& Adm. Code COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in sizo. Rlan mustl+tli;tt�de,-btw x
not limited to vertical and horizontal reference point (BM), direction ands% of slope, scale'or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. 040- 1242 -50 -000
APPLICANT INFORMATION— PLEASE PRINT ALL INFORMATION,
{ VVIEWED BY DATE
PROPERTY OWNER: PRO , - JQN
Richard Stout GOVT. LOT SE f/4 S�." /4,S 3 T 28 N,R 19 Ekor) W
PROPERTY OWNERS MAILING ADDRESS 10T 4 BLACK# ,Sl, 6 NAME OR CSM #
1353 Awatukee Trl. 76 -.ha Country Wood Second Addn.
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE 99OWN NEAREST ROAD
Hudson, WI. 54016 (715)549 -6731 A Troy I Trillium Ln.
k] New Construction Use [x] Residential / Number of bedrooms 4 [ ] Addition to existing building
I ] Replacement [ ] Public or commercial describe
Code derived daily flow 600 gpd Recommended design loading rate • 7 bed, gpd /ft2 - 8 trench, gpd /ft
Absorption area required 858 bed, ft 750 trench, ft Maximum design loading rate • 7 bed, gpd /ft .8 trench, gpd /ft
Recommended infiltration surface elevation(s) 98.65 ft (as referred to site plan benchmark)
Additional design / site considerations na
Parent material outwash Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem - 0 S El ®S ❑U I ®S ❑U CAS El CAS ❑U ❑S 91U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bartdary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Twich
1 0 -10 10yr4 /3 none 1 2msbk mfr gw 2f .5 .6
........ "':'' 2 10 -19 10yr4/4 none is Osg mvfr yw if .7 .8
Ground 3 19-120 7.5yr4/6 none co s Osg ml na na .7 .8
elev.
10 ft.
Depth to
limiting
factor
+
Remarks:
Boring # 1 0 -9 10yr3 /3 none 1 2msbk mfr gw 2f .5 .6
<< 2 '< 2 9 -120 7.5yr4/6 none cos Osg ml na na .7 .8
Ground
elev.
1
Depth to
limiting
factor
+ 120"
Remarks:
CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200
Address: 1554 200th. Ave. , Richmond WIB4017
Signature: Date: 4 -12 -2000 CST Number: m02298 ce A
i
1
PROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Page 2 v of 3
PARCEL I.D. # 040 - 1242 -50 -000
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends
1 0 -13 10yr3 /3 none 1 2msbk mfr gw 2f .5 .6
2 13-120 7.5yr4/6 none co s Osg ml na na .7 .8
Ground
elev.
1 03 . 2 ft.
Depth to
limiting
factor 9 g,6S —
Remarks:
Boring #
1 0 -9 10yr4 /3 none 1 2msbk mfr gw 2f .5 .6
4 2 9 -18 7.5yr4/4 none lfs Osg mvfr gw if .5 .6
3 18-120 7.5yr4/6 none co s Osg ml na na .7 .8
Ground
elev.
102.6ft. —
Depth to
limiting �� 3
factor
+1
Remarks:
Boring #
1 0 -9 10yr4 /3 none 1 2msbk mfr gw 2f .5 .6
5 2 9 -20 10yr4 /4 none ms Osg ml yw if .7 .8
3 20 -100 7.5yr4/6 none co s Osg ml na na .7 .8
Ground
elev.
10 ft.
Depth to
limiting 36 Z
factor
Remarks:
Boring #
.................
Ground
elev. j
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
I -
.
1 .
STEEL'S SOIL SERVICE
Gary L. Steel Richard Stout 1554 200th Ave.
CSTM2298 SE4SE4 S3- T28N -R19W New Richmond, WI 54017
MPRSW -3254 town of Troy (715) 246 -6200
lot #76- CountryWood Second Addn.
v " =40'
✓iM.= top of SW lot stake C el. 100.00
-Alt. BM.= top of tel. ped. C el. 101.05'
1�
2 �►
s
40- _5
Gary L. Steel
4 -12 -2000
i
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer �r,�S 4-0 0"-ri >4. &,( zt 4-4: a ha or 1 : . �em I" ej ja
Mailing Address Z Alle. S ea r el ,
Property Address ��02 �•
(Verification required from Planning Department for new construction) f_ --
City/State 4Au41Sd)0*- W I Parcel Identification Number O
LEGAL DESCRIPTION
Property Location S C r /,, 5 C r /4, Sec. _.3 T g N -R_ _W, Town of I r
Subdivision Covnfru tan _SQ -"j AAA Lot h # 7
Certified Survey Map # , Volume , Page #
Warranty Deed # Volume /spa , Page # 6 _7___
Spec house ❑ yes ET"no Lot lines identifiable 0 ❑ 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.
! C
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
ism proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
da of the three ear expiration date,
�._ LD
DATE
SIGNA O PLICAN A
OWNER CERTIFICATION
I (we) certify that all statements on (iris form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the roperty described above, by virtue of a warranty deed recorded in Register of Deeds Office.
c
SI N XfLjAB bF)0K,!1CM4T 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 co of the certified survey ma if reference is made in the warranty deed
PY tY
Y P
VOL 16
STATE BAR OF WISCONSIN FORM 2 - 1998 6234 ?4
WARRANTY DEED KATHLEEN H. WALSH
REGISTER OF DEEDS
Document Number ST. CROIX CO., WI
RECEIVED FOR RECORD
This Deed, made between 05 -23 -2000 9:15 AM
RICHARD O STOUT
WARRANTY DEED
Grantor, EXEMPT #
CERT COPY FEE:
and CHRISTOPHER A PT ()VHaRT any KIMBERLY J COPY FEE:
PENMAN TRANSFER FEE: 171.00
RECORDING FEE: 10.00
PAGES: 1
Grantee.
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate in St _ Croix County, State of Wisconsin:
Recording Area
Lot 76, Plat of Country Wood Second Addition, Name and Return Address
Town of Troy, St. Croix County, Wisconsin.
,void
040- 1242 -50 -000
Parcel Identification Number (PIN)
This i G no homestead property.
(is) (is not)
Exceptions to warranties: easements, restrictions, rights -of -way and covenants
of record.
Dated this 22nd day of May 2000
Q A,iC" \ �) . S� (SEAL) (SEAL)
* Richards Strut
(SEAL) (SEAL)
* *
AUTHENTICATION ACKNOWLEDGMENT
Signature (s)
State of Wisconsin,
ss.
St. Croix
County.
authenticated this day of Personally came before me this 22nd day of
May 2 0 0 0 the above named
$i chlard O Stout
* NOTAHY TITLE: MEMBER STATE BAR OF WISCONSIN ��++��I�� 'AI to
(If not, me kno o r �Wtad�,%Wed t foregoing
authorized by §706.06, Wis. Stats.) i ument an suLB
THIS INSTRUMENT WAS DRAFTED BY
Janet P. Stout
1353 Awa - Fukep Tr
Hudson, WI 54016 Nota6 Public, State of Wisconsin
My Comm* ton is perman t. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not
necessary.)
' Names of persons signing in any capacity must be typed or printed below their signature.
STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc.
WARRANTY DEED FORM No. 2 - 1998 Milwaukee. Wis.
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Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page i of - 3—
Lalr:r and Human Relations
` Civr^ jn if Safety & Buildings in accord with ILHR 83.05, Wis de
1 Q COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in 041ope,S& ust include`bW
not limited to vertical and horizontal reference point (BM), direction a, '" ; - PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road���� �pending
APPLICANT INFORMATION- PLEASE PRINT ALL INFORM +'� �EVIEWEDBY DATE
PROPERTY OWNER: PROPE 94TION
Richard Stout GOVT. I Tyr 1/4 , -E 1/4,S 3 T 28 N,R 19 )&or) W
PROPERTY OWNERS MAILING ADDRESS TWY "CK'#` ,.$ NAME OR CSM #
1353 Awatukee Trl . `. C ` t Wood Second addn.
CITY, STATE ZIP CODE PHONE NUMBER ILLAGE OWN NEAREST ROAD
Hudson, WI. 54016 (115) 549 -6731 Troy Tower Rd.
[ :4 New Construction Use [ t, Residential / Number of bedrooms 3 [ ] Addition to existing building
I ] Replacement [ ] Public or commercial describe
Code derived daily flow 450 g pd Recommended design loading rate -7 bed, gpd/ft - 8 trench, gpd/9
Absorption area required 643 bed, ft 563 trench, ft Maximum design loading rate .7 bed, gpd/ft .8 trench, gpd/
Recommended infiltration surface elevation(s) 95.95 ft (as referred to site plan benchmark)
Additional design / site considerations a1t . areas stem el . =95 , 5'
Parent material outwash Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE 7ATY SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem ®S ❑ U ®S ❑ U ® S ❑ U S ❑ U ®S ❑ U ❑ S CCU
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Botxtdary Roots GPD /ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Ttertdt
1... 1 0 -12 1
2 12 -82 7.5 rd 6 none MS na na -7
Ground
elev.
99. ft.
Depth to
limiting
factor
Remarks:
Boring #
_ 2c 1 mfr cs 1f no .2
Ground
99ele45 ft.
Depth to
limiting
fact
Remarks:
CST Name:—Please Print Phone:
Gary L. Step
Ad dress:
a 200th. Aye. Mew gir W 54017 m02298
Signature: Date: CST Number:
8 -6 -96
PROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Page 2- .3
PARCEL I.D. # nding
Lot #76
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
.3 _ i 2col mfr cs if n .2
na cild na n .2
Ground 3 27 -82 7.5 r4 6 none ms os ml na na .7 .8
elev.
99 ft.
Depth to
limiting
f +921,
Remarks:
Boring #
-*X : v
..,;... 2 18 -82 1 Q r7/6 none cos os - ml na na .7 ? .8
Ground
elev.
97 ft.
Depth to
limiting
factor
+82
Remarks:
Boring #
1 10-12__ 1 2 /2 none 2c 1 mfr cs if n o .2
._,
S 12 -?6 7.5 r4 4 none is os mvfr w na .7 .8
Ground 16 .7 .8
elev.
98 ft.
Depth to
limiting
factor
+80"
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(R.05/92)
I
STEEL'S SOIL SERVICE
Gary L. Steel Richard Stout 1554 200th Ave.
CSTM2298 SE4SE4 S3 T28N - R19W New Richmond, WI 54017
MPRSW 3254 town of Troy (715) 246 -6200
lot #76- Country Wood Seocnd Addn.
1 " =40'
BM.= top of SW lot stake C el. 100'
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Y
X31 k �,
Ar
Gary L. Steel
8 -6 -96
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