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ST. CROIX COUNTY ZONING DEPAR A. }
AS BUILT SANITARY REPORT r�
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Owner
Property Address d
City /State
Legal D cri tion:
Lott Bock Subdivision/CSM #
/a, Sec. 4F T N -R - W, Town of #
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer 4 Size ST/PC
f Setback from: House Well P/L
Pum p manufacturer Model
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of system: / ; all Width -� Length Number of Trenches °Z
Setback from: House 4JM Well r- V PAL Vent to fresh air intake
xl�- � �
ELEVATIONS
Description of benchmark ��- z°"'`T'
Elevation
Description of alternate benchmark D,�� ��l'l'G ZA la rrw Elevation
Building Sewer ST/HT Inlet z ?l , � ST Outlet = PC Inlet
PC Bottom Header/Manifold Top of ST/PC Manhole Cover
Distribution Lines Q ) �l✓�' ��� () ( )
Bottom of System
Final Grade O O ( )
S/
Date of installation D / Permit number ./ '� 25� State plan number
Plumber's signature License number Date
Inspector 7i077
Complete plot plan
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.
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P AN VIEW
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INDICATE NORTH ARROW
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.
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P AN VIEW
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INDICATE NORTH ARROW ��
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Wisconsin Department of Commerce Count
PRIVATE SEWAGE SYSTEM
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)]• 3 3 8+M A
Permit Holder's Name: ❑ City ❑ Village 5 Town of: State Plan ID No.:
BAKER, NEIL STAR PRAIRIE
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
Lc� '� ,� 038 - 1185 -40 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV.
Se ti �,J Bench r 6•3k lCy_•3,T /oc'>
Dosing 14 q. 6 Y L
Aeration Bldg. Sewer p� 6•�f�- ��j. ��
Holding C Inlet Dw 3 7 • O
TANK SETBACK INFORMATION Outlet
TANK TO P / L WELL BLDG. Air i to ntake ROAD Dt Inlet
ir
Septic y � 12— t ?,`. ( NA Dt Bottom
Dosing NA Header / Man. p� '? .7
Aera ' n NA Dist. Pipe �Ob �� 7i9 s g
4.'71
H ldin Bot. System 9,
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer D mand
Model Number GPM
TDH Lift Friction System TDH Ft ead
Forcemain L gth Di I ( Dist. To Well
SOIL ABSORPTION SYSTEM
BE TR €IdCH Width Length No. Of Trenches PIT No, Of Pits Inside Dia. Liquid Depth
DtM 3 DIMENSION
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING IK -:
INFORMATION Type O C HAMB ER Model Nu er:
Syste `[ 6 (9 ko OR UNIT
DISTRIBUTION SYSTEM
Header /Manifold h Distribution Pipe(s) � x Hole Size x Hole Spacing Vent To Air Intake
Dia.
Length tO Dia. Length �/oZ 7 Spacing 40� :T
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over pt Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges To [] Yes ❑ ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRAIRIE 13.31.18,SW,SE 1386 211TH AVENUE 0 19 f C�6 V&
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,PiU�tts�- �� g. 77
ros �
11':17 � Id! es
Pla revlslo�n f uir E] Yes [�lo j �7j
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspectors Signature Cert No
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ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
IT 201 W. Washington Avenue
I SAN ARY PERMIT APPLICATION P O Box 7302 g
In acco with ILHR 83.05, Wis. Adm Code
DepartmentAf Commerce Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8112 x 11 inches in size.
• See reverse side for instructions for completing this application State sanitary Permit Number
33`i��s r 2<
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 INFORMATI N
Property Owner Name Prop Location
/4 ert tf - T /4, S T , N, V'/ E (o
Property Owner's Mailing Address Lot Number Block Number
n C. o 4Z: 1
City, State Zip Cofje Phone Number Subdivision Name or CSM Nu r ,
I. TYPE OF BUILDING: (check one) ❑ State Owned ° v � e / TN earest R d
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF /��'X
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
d � � //Vs ^Oc �{®
1 ❑Apartment/ Condo
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 0New 2 [] Replacement 3_ E] Replacement of 4 E] Reconnection of 5 E] Repair of an
System________System___ __ Tank Only______________ Existing System ________ Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 Seepage Bed 21 E] Mound 30 E] Specify Type 41 E3 Holding Tank
12 Seepage Trench 22 ❑ In- Ground Pressure rte,. 42 E] Pit Privy
13 []Seepage Pit - k C 43 ❑ Vault Privy
14 ❑ System -In -Fill
V ABSORPTI SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5, Perc. Rate 6. 5 "ev- 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
gall /W. _ Feet
Vll. TANK Ca aut in allo Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing strutted
T nks Tanks
Septic Tank -� ❑ 1:1 1:1 1:1 11
Lift Pump Tank /Siphon Chamber ❑ C1 C3 El 11 11
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's me: (Print) � Plumb e ' I nature: (No Stamps) MP /MPRSW No Business Phone Number:
Plum e ' ess (Street, City,, Staatt Zip C de): _
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (InduciesGroundwater ate ssue Issuing A ture (No Stamps)
Approved E] Owner Given Initial r �s �hargefee)
Adverse Determination (�
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: Original to county, One copy To: Safety & Buildings Division, Owner, Plumber
k LU I ELAN
PROJECT �� /IA ADDRESS
.�; 1/4 ,�5�i /4 /S / AE6 N /R/ W -, 'TOWN_
'MPRS Byron Bird Jr. DATE
BEDROOM CLAS - CONVENT[ 0 AL,ZIN -GROUN RESSURE
CONVENTIONAL LIFT MOUND_ HOLDING TANK ,
SEPTIC TANK SIZE LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA PERC RATE BED SIZE
► Benchmark V.R.P. Assume Elevation 100'
Location of Benchmark
C] Borehole Q Well Scale = Feet
0 Perc Hole System Elevation
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wiscort�n Department of Commerce SOIL AND SITE EVALUATION Page 1 of
Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
Dille Trucking & Excavating, Inc.
Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal refere t (BM), direction and St. Croix _
percent slope, scale or dimensions, north ar; ii �rint443 1 1 f� is n tance to nearest road, parcel I.D.#
APPLICANT INFORMATION - P i n n, - -- - - - - - -- -- -
Personal information you provide may be used or ndary e (Privacy s. 15.04 (1) (m)). Revj�W d y �_ �� irn
Property Owner U y Location
Cas Da n _ ` - ;� SW im S E 1/4 ,S 13 T 31 N,R 18 Pro Owner's Mailin Address r perry g �� 1 Block # Subd. Name
or CSM#
323 Sawmill Lane -'� " ''' D Ci Prairie Flats
'' City State ipbdez'^ tAlfil� ❑Village Town Nearest Road
New Richmond WI 5 (n 715 -24Star Prairie Hwy 65
Z New Construction Use: Z Resl 1 edrooms 3 ❑Addition to existing building
EJ Replacement n Public or commercial describe
Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/fts .8 trench, gpd/ft
Absorption area required 643 bed, ft 562 trench, ft Maximum design loading rate .7 bed, gpdM .8 tr ench, gpd /ft
Recommended infiltration surface elevation(s) r l �, ,�" ft (as referred to site plan benchmark)
Additional design I site considerations
Parent material out-wash Flood plain elevation, if applicable -- ft
S= Suitable for system Conventional Mound In Ground Pressure AT - Grade System in Fill Holding Tank
U= Unsuitable for system S 0 U z S❑ U z S U ❑ S M U ❑ S M U ❑ S N U
SOIL DESCRIPTION REPORT
Horizon Depth Dominant Color Mottles Texture Structure onsistenc Bounda Roots GPD/ft2
Boring# in, Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. rY Bed Trench
1 0 -8 7.5YR2.5/1 -- - - - - -- SIL 1FA BK MVFR AW 1VF .2 .3
2 8 -22 7.5YR4/6 - - - - - -- CL I FA MVFR AS I VF .2 .3
Ground 3 22 -96 7.5YR5/3 ---- - - - - -- S O -GR ML - - -- - -- 7 8
ele- -- — -- - - -- - - -- — - --
v 0047 -
Depth to
limiting - — -
factor
96 in.
3S c1f - - -- -- — — --
Remarks:
2 — 1 0 -10 7.5 YR2.5/ 1 — - - -- SIL 1FABK MVFR AW 1VF .2 ` 3
2 10 -24 75YR4/6 --- - --- -- CL 1 MVFR AS 1VF .2 .3
Ground 3 24 -96 7.5Y R5/3 ---- - - - - -- S O -G ML - - -- - -- .7 .8
ele — — —
Depth to -- -- -- -- - -- - - - -- - - - -t -- -- i -
limiting — — - -- — —— --
factor
96 in. — -- --
Remarks:
CST Name (Please Print) gnature'. Telephone No.
_D GIL _ .. �— - - /S =ZL�'° �C 3 ;> Addre — f� � t CST Number Ref #
Z 0 S i .,,� &/� ao / 9�f6/97 J Yo 9 106
PROPERTY OWNER: Casey Dan SOIL DESCRIPTION REPORT Page 2 of
_ g
RARCEL 1.D. # -_ Csille Trucking & Excavating, Inc.
Depth Dominant Color Mottles Structure GPD/ft
H'orizOn in. Mansell Qu. Sz. Cont Color Texture Gr. Sz. Sh.
� O nsisten c Boundary Roots --�--
Bed Trench
I
3 1 0 -10 7.5 -- - - - - -- SIL 1FABK MVFR AW 1VF .2 3
I
2 10 -26 7.SYR4 /6 --- - - - - -- CL lFABK M AS 1VF 2 .3
Ground
elev 3 26 -96 7-I - -- -- S O - ML - - -- - -- .7 .8
Depth to
limiting -
,
factor
96 in. - --
Remarks: — — —
4 1 0 -11 7.5YR2.5/1 -- - - - - -- SIL 1FABK MVFR AW 1VF .2 .3
2 11 -26 7.5YR416 --- - - - - -- CL 1FABK MVFR AS 1VF .2 .3
Ground - - - - -- S O -GR ML - -- 7 .8
elev 3 26 -98 7.SYR5 /3 — - - --
Depth to
limiting — — — — —
factor
98 in,
i I
Remarks: — — — - -- - -- — - --
5 1 0 -10 7.5Y R2.5/1 -- - - - - -- SIL 1FABK M VFR AW 1 VF .2 3
2 10 -25 7.5YR4/6 --- - - - - -- CL 1FABK MVFR AS 1VF .2 .3
�
Ground
F - -
3 25 -98 7.5YR5/3 ---- - - - - -- S O -GR ML - - -- - -- 7 .8
elev— - - - -- — -- - -- -- — — -- -- - - - --
I
Depth to
limiting — — _—
I
factor
98 in.
Remarks: -- -- — - -- -- — - --
I
I
Ground
elev __—
,
- I
Depth to
limiting — — - -- - - -- -
I
factor
I
I
Remarks: —__ -- —_
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ST CROIX COUNTY
` SEPTIC TANK MAINTENANCE AGREEMENT
AND
O /WNEERSHISIP CERTIFICATION FORM
Owner/Buyer
Mailing Address
Property Address 3 9 (SP
(Verification required from Planning Department for new construction) W
City/State A L /r al'-z Parcel Identification Number
LEGAL DESCRIPTION
Property Location '/4, '/4, Sec. , T
? � — N -RZ! W, Town of
Subdivision �/'�r rr 'C / – Lot #
Certified Survey Map # , Volume , Page #
Warranty eed #
ty 5 :24 - ': 4 � ,Volume 11 411 _ Page # 3 gg ::n
Spec house }yes ❑ no Lot lines identifiable R 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 113 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 off the � t t hree y ear lives/ expiraation date.
�=�ir s 2 //e/ 7
SIGNATURE OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
z / 44A.1. 1 3 /gel y 9
SIGNATURE OF APPLICANT DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * **
Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
I
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STATE BAR OF WISCONSIN FORM 1 — 1982 Sr 995$2
WA T NTY�D �q �, KATHLEEN H. WALSH
V OL.1PAGE t} REGISTER OF DEEDS
DOCUMENT NO. ST, CROIX CO., WI
RECEIVED FOR RECORD
This Deed made between Daniel i Casey and Betty D. 03 -18 -1999 9:30 AM
C'asP3Z Husband and Wife as survivorship
WARRANTY DEED
Mate i a l P ropert y _ EXEMPT N
Grantor, CERT COPY FEE:
and Neal P.-Baker COPY FEE:
TRANSFER FEE: 56.70
R FEE: 10.00
li ,Grantee,
4
i
Witnesseth That the said Grantor, for a valuable consideratio l
I I II THIS SPACE RESERVED FOR RECORDING DATA
conveys to Grantee the following described real estate in S t . Croix _ __ ..: _...
County State of Wisconsin: NAME AND RETURN ADDRESS
r I
Lot 4 Prairie Flats Addition in the Town of I� Pf Q�t^ j e �Wl 5 a b
Star Prairie. St. Croix County Wisconsin _
I I PARCEL IDENTIFICATION NUMBER
ll i�
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I � This is not homestead property.
I (is) (is not)
1 i Together with all and singular the hereditaments and appurtenances thereunto belonging
And Daniel J Casey and Betty D. Casey j
i warrants that the title is g ood, indefeasible in fee simple and free and clear of encumbrances except
Recorded Casements rights of way and Covenants.
and will warrant and defend the same. f
I
{
Dated this 16th day of March ,19 99
(SEAL) ' (SEAL) '
Bett D. Casey Daniel J' asey li
1
(SEAL) (SEAL) 1
• I
AUTHENTICATION ACKNOWLEDGMENT
i
Signature(s) State of Wisconsin,
ss.
St- Croix _ _ County.
authenticated this day of , 19 Personally came before me this 16 day of
March 19 9 9 the above named
_ Rani 1 J . ,a G )
Betty D Casey
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
instru tan acknow dge the sam .
THIS INSTRUMENT WAS DRAFTED BY
Dan iel J. Casey `
k 1
Notary Pub c,
S� ��a County, Wi-
(Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiratin-
necessary.) / -I /�
- -- - - -- - _ -- _- _ - - - -_— -------- #i�Mk - :- -
• Names of persons signing in any capacity should by typed or printed below their signatures. p..� k cis of
r1iV11W►�� i�onsin Lega Blank
STATE BAR OF WISCONSIN l M i lwau twau ke
WARRANTY DEED Form No. 1 - 1982
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