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ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
Owner
/��` /'d'lv /?jF Ye�f -- -7 s y 1 • 7/ 7 f� ���
Propert Address / 3 2 '
p Sr CRaxlg
City/State tJ yL J'a 4> /-s . 2O NyVn f
Legal Description: 33 G y L V p/ 2
Lot / Block � Subdivision/CSM #
S '/4 SGJ /4, Sec. , T N -R Town of ST To t'E'"P 4. PIN # °3D - 2- 3 Z - T' d
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
M /.7- 3 ,/ y 6 - V
Tank manufacturer 7 Size ST/AC / Setback from: House Well P/L
Pump manufacturer Model
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM - 7,i E•04
Type of system: / ' - --" Width 3 Length 75 Number of Trenches
Setback from: House �U Well? P/L Vent to fresh air intake >
T61
>30 '
T `I'S� � o�
ELEVATIONS 0 CS T'S y /s(/G
i" S
Description of benchmarkO /Qaar.ST Elevation
p� ,PG� 5�
I
Description of alternate benchmark 9 TWI % J a� S ` Elevation 7
Building Sewer y3'�3 ST/HT inlet 93. ST Outlet � a 5 PC Inlet
[NLET TO PkOp /3 a jc
PC Bottom -�� Header/Manifold f2.3 Top of ST/PC Manhole Cover
DistPbution Lines ( ) 972 • ( ) V. d s ( )
Bottom of System () / a • -7 3 () � 3 d ( )
Final Grade
0, �yyti 3�1yG3ly N / -
plan numb er
Date of installation / / Permit number p
Plumber's signature License number Date � / /
Inspector KX,y(.v
X Complete plot plan �
I
NOTICE Please provide the following:
• A plan view sketch showing everything within 100 feet of the system.
• Two horizontal reference points to center of septic tank manhole cover.
• Show alternate benchmark, if applicable.
PLAN VIEW
ALL NON CONFORMING
TREATMENT TANKS SHALL
BE ABANDONED PROPERLY
FOR ILHR 83.03(2).
arr�
4A7 AA-
INDICATE NORTH ARROW
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• W con$in Department of Commerce PRIVATE SEWAGE SYSTEM County:
Safety and,Buildings Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Ix
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 344636
Per t I dds� Y
Name: E] City p Villa e Town of: State Plan ID No.:
r Vdit $ S, KEITH ST. O$ VH
CST BM Elev.; Insp. BM Elev.: Tt'.1; Description: Parcel Tax No.:
Hr, 1Z �L "&a �/ " c, 030 - 203,?,- -80 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic (� Benchmark -S �S `jS, `1 P,
Dosing fT •et 8}
Aeratio Bldg. Sewer , �a g7, r-�'
Holding St /Ht Inlet Cta *I at
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Air I to ntake ROAD
Air
Septic 7��j ]�Qp ?J`F� NA [A Bs4WFm
Dosing NA Header/ Man. ( '72 - 20
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade --) 3 p
Manufacturer Demand
Model umber GPM3h Ipp.lZ R PA
DH Li Friction S stem TDH Ft
Forcemain Length Dia. Dist. To Well
SOIL RPTION SYSTEM
TRENCH Width 3 1 1 Len th No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIME �- I I DIMENSION
SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHING Man a ur
SETBACK CHAMBER '`
INFORMATION Type Of UD t 1 M el Number:
System: 6mkO • .�$ > OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold w Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length —1-4! Dia. Length Dia. Spacing 7
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 Yes LN, ::J — .
COMMENTS: (Include code discrepancies, persons present, etc.) Z(� �4�� ( �i ,' s r`n( - -616"
�LOC�AT O ST JO EPH j 3 30,0. 56B, , E�SW� RIB E,
7 3if L4
g�- Zo — � RfI -- �—
Plan revision required? E] Yes (M No s 1 2 — 0 Use other side for additional information. ( 1 9 Ov
SBD 6710 (R.3/97) Date Inspector's Signature Cert. No.
f •
' 1
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Vi sciilnsi� Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 B Washington Avenue
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County -T aeney,
than 8 1/2 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
3 *y(o3(O
Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Propert Owner Name mm Pro
pert Location
/ /• /C"f LyE�} $rE 1/4 Lt1 1/4, S 2S T3 , N, R 2O E (oro
Property Owner's ailin Address Lot Number Block Number
13 W . E
Qty, State ip Code Phone Number S I i Name or S SM Number
pvL Idiv vds u • l Tytl.& l4 /'l 3 qty Z 1 • .3 f Xh
11. TYPE Or (check one). ❑ Stat2 Owned o it �• Nearest Road
Public or 2 Family Dwelling - No. of bedrooms V
OF s�• ` �`�� • E
111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) � T
1 ❑ Apartment/ Condo �� a 3� o. —60 2° • - PSb g
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 RMIT (Check only one box on line A. Check box on line B, if applicable)
A) 1. Lp l.ew 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 Number Date Issued e
V. TYPE OF SYSTEM: (Check only one) Z Si'��ly /;vj �. I/ AvGaA,P, 1 '1
Non- Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 [:]Holding Tank
12 eepage Trench / , Irk- ro nd Prue 3/, ,fQ.-{- f . J 0- 42 ❑Pit Privy
13 E] Seepage Pit Y S &F I' — 43 ❑ Vault Privy
14 E] System-In-Fill 7 r- D�..,C" 743.2— X f- � /
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. R 6. System Elev. 7. Final Grade
& Required (sq. ft.) Proposed (sq. ft.) (Gals/d /sq. ft.) (Min ch) pl,.Q Elevation
0 7�/ 3 Q ! Feet Feet
Capacit
VII. INFORMATION in gallo Total # of Manufacturer's Name Prefab. Con- steel Fiber- Plastic Exper.
New Existin Gallons Tanks concrete structed glass App.
Tanksl Tanks
e ticTa or Ig an 12. /O' ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber s r ❑ ❑ ❑ 1 ❑ 1 ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No Stamps) 10tP /MPRSW No.: Business Phone Numb r:
1RU ' UL-Ok i c. ITT zz 037 S 7 /,S• 3�0 •���5
Plumber's Address (Street, City, State, Zip Code):
Co S 6 � �u�2� G R-0 • 17 f� �
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit F (Includes Groundwater D ate I ssued Iss A nt Si nature (No Stamps)
Surcharge Fee)
C�pproved []Owner Given Initial
Adverse Determination
X. CONDITIONS OF APPROV L / REASONS FOR DISAPP O ! ��'
per, �wd ico 6 �. C.e•Q�2. aj - �__N � .;
— d
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, one copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitarypermit=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. 4f 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 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 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
manufacturet's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is,to fill in name, license number with. appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 81/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment 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; pu m p, 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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wise"oribin Department of Industry SOIL AND SITE EVALUATION
Labor and Human Relations Page / of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis.
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County 4e---Y-
Include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
030-2-032, - �o
APPLICANT INFORMATION - Please print all Information. Review Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
k 74�, Govt. Lot SC 1/4 S w1 /4,S T 3 ,N,R 2 E (or)o
Property Owner's Maiiin Address � Lot Bioc� Subd. Nam�r CS � /• Z �� ' 1
/ 39 Y
City ? State Zip Code Phone Number Nears t Road
�L / 0 � ��. � 7/,5 S • f'171 El city ❑ Village wn • 41
V —9-0 3z _$O
❑ New Construction Use: Residential / Number of bedrooms Addition to existing building
1A Fleplacement /f ❑ Public or commercial - Describe: p
Code derive daily flow W" gpd Recommended design loading rate—.7—bed, gpd/ft 4 trench, gpd /11
Absorption area required�_bed, ft 7�o trench, ft Maximum design loading rate . bed, gpd /fl gpd/ft
Recommended Infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material Flood plain elevation, if applicable ft
S = Suitable for system �Conv tional Mound / In-Ground Pressure AT -Grade ystem in Fill Tank
U = Unsuitable for system L�J 5 ❑ U ❑ S l9'U [r] -�5"o U ❑ S U ❑ S [•�'U ❑ S
SOIL DESCRIPTION REPORT
Boring # Horizon
�/' Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/112
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Z •/ o sG 4 � �// S CS Ground /0 L Cf / n
(� elev.
Depth to
limiting
factor
Remarks:
Boring # d• /0 Y)? 4 " vT G �� PP N
13 / 1
o X
Ground
��. Qev
ft.
(
Depth to
limiting
factor
7 /o(0L_in. Remarks:
CST Name (Please Print) Signature Telephone No.
er u �L3 R i f�,T � � 711 • 3 ( •
Address � � � Date � CST Number
• 1 .
22-ee3'7 S
rc
p Sewage Consultants
655 O'Neil Rd.
t}ludsort, wis. 54016
ORIGINAL ,
7
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PROPERTY OWNER Q E— SOIL DESCRIPTION REPORT Page o L 3 '
f
PARCEL I.01 (� •ZD .3 Z `
Boring # Horizon Depth Dominant Color Mottles Structure 2
Texture Consistence Boundary Roots
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ; Trench
'around
:Aev.
7Depth tto(/ II
! imiting
factor
Remarks:
Boring #
Ground
elev.
ft. '
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/
In. Munsell Qu. Sz. Cont. Color Gr. Sz. 'Sh. Bed , Trench
Boring #
Ground
elev.
Depth to ;
limiting
factor
In ' Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
In ' Remarks:
SBDW -8330 (R. 08/95)
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
��,,// OWNERSHIP CERTIFICATION FORM
Owner /Buyer h ReG yz
Mailing Address
Property Address
(Verification required from Planning Department for new construction)
City /State Parcel Identification Number O ZD 3 L ~ 8 d
LEGAL DESCRIPTION
Property Location SE '/,, ' /q, Sec. 2- , T 3o N -R W, Town o TD ' s E P
Subdivision , Lot # J
Certified Survey Map # J 3 d Z— , Volume , Page # y Ye
Warranty Deed # 5 "2 - 5 33 / , Volume 0 7 , Page # 3 to .
Spec house O yes (�o Lot lines identifiable yC7 es O 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 wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
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 the three ye jxpi,tion date.
S ,
IGNATURE OF APPLIC T DATE
OWNER CERTIFICATION
gIGNA (we) certif hat all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
TUE
per escri ab e, by virtue of a warranty deed recorded in Register of Deeds Office.
R OF APPLI A T DATE
* * * * ** Any information at 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
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DOCUMENT, NO. WARRANTY DEED T"IS SPACa MRSERVCD POO ftC0*WN4 DATA
-152 1 Mal. STATE BAR OF WISCONSIN * FORM 2 --1982
19
VOL .
ST. MW � W1
Rpf Alry. J for Pacord
................................................. ........ ................................... ...... JAN 2 0 1995
......... I ............. ....................... ........................ ...... . I .... - ........ .......
......... I ......................................... ....................... ..... .... .................. 11:15 A
conveys and warrants to
. .................... ........... ........
..................................... I PA04JW of Dft&
.......... ...... ------ * -------- ..... ..
.................. ...... ............. ..... ................ ................. I .........................
.. . ..............................................................................................
......... .... .... I ........... .................... I ................................ .................
. ......... ......... ..... I .......... .......... ......... ... ........... .................................. .
the following described real estate in .............. $A . --- -- ... County,
State of Wisecu
Part of the Southeast Quarter of the Southwest Quarter Taz Parcel No: .... .........................
(SEISWJ) of Section Twenty-Three (23), Township Thirty (30)
North, Range Twenty (20) West, described as follows: Lot One (1) of
Certified Survey Map recorded an Document No. 338642, in Vol. 2, Page
348, Certified Survey Maps, St. Croix County, Wiscorsin.
The above described parcel contains 7.76 acres.
Together with a 66-foot easement for access road and for installation of utility
lines, the Ust line of said 66-foot casement being the same as the West line of the
above-described parcel, and an extension of said 66-foot easement identical to the
66-foot easement for access road and for the installation of utility lines described
and granted in the Land Contract between Henry J. Lentz and Leo M. Germain and Marion
L. Germain dated October 13, 1980, and recorded December 30, 1980, in Vol. 623, Page
331. as Document No. 368664; said 66 foot easement extending to C.T.H. "E".
This dead in given in full and final satisfaction of that Land Contract between the
parties herein. dated October 8,1954. recorded October 23, 1984, at 11:45 A.M., in
Vol.698, on page 499. an Document No. 397242, in Office of Register of Deeds for St.
Croix County, W1.
This ......... Is-nor .... --- homestead property.
(in) (is 3100
Exception to warranties: Easements, restrictions, and rights -of -way of record, if any.
Dated this ......... ................ day of ............... .--January .................... ........... 19
-- ---- ---- --------------------
-------------- (SEAL) ....... . ............... ... .... ... I ...................... (SEAL)
.
. .......... ................ ... .... .............. ........... Henry Lents ...............
.................
(SEAL) ...
------------------- - -------- ........
PC#
............ ** ......... --- ..- ..._...•.- ..-• --- --.
... ........................... . . .............................. ....... .......
.............. ---------------- ------
A 9 T R J! M T I C A T 10.119 ACENOWLRD0004
---- — - - - -- - ------------- ------------- STATE OF WISCONSIN
— — ---- — — ------- — — — -------------------------- -------- all.
§T.CRDIX
authenticated U& —.---dsy o1__-- -- --- ._..___._._.. -• ------ -- -- -- ---- County
Personally came before me this Of
....... . ....... --- - --- - I-an"ry ----_----- - ---- 19.9.5 --- the above named
0 . . . . ..... .. &nxy_.J._.LAxLt,& .........................................
Tiiii:iikiaii1W --------- - ------ * ------- I— ---------------------------
(if not, .............. I ------- . ................................... .........
a u tborlsed --------------------- — — ---------------------- ---------------------------------------------
to me known to be the _ ......... who executed the
ti-rejuje Instrument atell s_&_-_ th same.
....... - ----- 0 ............ . .. ...... .
... .
A. Bas her, Attorney --- _U ....
THIs It"sTnum"T was on^mo *y
Leo ...
Rodli, Beska --------- 0 Virstivia R. Gartman
-------------- . ...........................................................
Notary Pu' ylic ............... -S%-Crro1X ....... County, Win.
(Signabar" may be ae%4anti or acknowledged Both MY Commission is Permanent. (if not, state expiration
not -OMM7.) date ...... . ............ F.ebzvary_..4
-Names of persons sWalag IN sal esPatity should be trP• or Printed below tbeir shrushLres.
WAW'ANT DZW BTATR 3&X (W WISCor#sM Wisrrisin U91pi Blank Co., Inc.
FORK V a— Im Milwau%ee, Wscznwn
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CO. MON.
SW COR!
SEC. 23 CERTIFIED SURVEY MAP
----SE 1/4 - SW 1/4- SEC. 23, T-30-N, R- 20 -W
66' PRIVATE
ROAD _EASEMENT
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APP ROVED
m MAR 1 1977
�1�y ST. CROIX COUNTY
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VOL. 2 PAGE __ 248 - (A SEE REVERSE SIDE FOR SURVEYOR'S &
CERTIFIED SURVEY MAPS a CO TOWN BOARD CERTIFICATES
CROIX COUNTY, WIS. w S 1%4 1
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