HomeMy WebLinkAbout040-1243-10-000 Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y
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)], 344686
Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.:
Town of Troy ` ter
CST BM E ev -:- Insp. BM Elev. iBM Description: sa,� 6, % Parcel Tax No.:
TANK INFO MATION LEVATION DATA j, z8. 1 9, /z 9f
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 1 Benchmark 3 Z j
Dosing Alt. BM b
Aeration Bldg. Sewer 4 - 2 T3 7 0
Holding St /Ht Inlet S? 93, 07
TANK SETBACK INFORMATION St/ Ht Outlet 535
3 ` ol. 1 7
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inle
Air Intake
Septic 5� r q t --- NA D
Dosing NA Header/ Man. j S 31 6q
Aeration NA Dist. Pipe gq ?o . L(- q
Holding Bot. System `6,2 �'�, (op
PUMP/ SIPHON INFORMATION Final Grade
Manufa er De d St cover ` fb 94. t(o
Model Number GPM
TDH Lift Fricti S TDH Ft
Force Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED Width r Length t 0.0 PIT No, Of Pits Inside Dia. Liquid Depth
IMEN I N 3� DIMENSION
SYSTEM TO P 1 L BLDG WELL LAKE / STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type O } - 2, t �� Jl ) OR UNIT Model Number:
System: v. 2_ Z
DISTRIBUTION SYSTEM
Header/Manifold Y Distribution Pipe(s) i t x Hole Size x Hole Spacing Vent To Air Intake
Length__ Dia. Length � Dia. Spacing 3 � l
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: / / Inspection #2: I /
Location: 506 Trillium Lane, Hudson, WI (NW1 /4, SE1 /4, Section 3 T28N -R19W) - 3.28.19.1240
AA
ski. W � �%Cb
Plan revision required? NJ Yes ❑ No
Use other side for additional information.
Y SBD -6710 (R.3/97) Date Inspector's Signature Cert. No
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y
Count /�
Safety and Buildings Division INSPECTION REPORT T- . O 1 x
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No
Personal information you provice may be used for secondary purposes [Privacy Law, S.15k4 (1)(m)].
Permit Holder's Name: El City E] Village Town of: State Plan ID No.:
Dsb an - Tr
CST BM Elev. :- Insp. BM Elev.: BM Description: Parcel Tax No.:
6
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark 3 2_ 9 r
Dosing
Aeration Bldg. Sewer S� -�
Holding St /Ht Inlet &T-
TANK r
TANK SETBACK INFORMATION St/ Ht Outlet 35 .4=--
TANK TO P/ L WELL BLDG. Air Intake ROAD D
Air
Septic '5'Q' NA Dt`Bvtt
Dosing NA Header/Man. `f
Aeration NA Dist. Pipe ��T `Ff�, Y
Holdin _ Bot. System
PUMP / SIPHON INFORMATION Final Grade
Manu cturer Demand y, / b R ` ((i
Model Number GPM
TDH Lift Lriction S stem TDH Ft
Forcemain Length Dia. Dist. To Well
S °;ABSORPTION SYSTEM (,,
ED fi'I!'#I Width Len No. Of Trenches PIT No. Of Pits Inside Dia. Liqui Depth
DIMENSIONS DIMENSION
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer. j
INFORMATION TypeOf CHAMBER Model Number: /
System: , 4 4 2 3Z >1_5 OR UNIT
DISTRIBUTION SYSTEM
Header / ani f old ut Distribution Pipe( J U / x Hole ze x Spacing Vent To Air ntake
I Leng Dia Length Dia. T Spacing Si—
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 E] Yes E] No E] Yes El No
COMMENTS: (Include code discrepancies, persons present, etc.)
�• 7 ` - 1240 7 N vi I S61 60 ( "Fri II(LL l u►t� — �waa 1� t 8�
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No
Vi sconsin Safety and B uildings Division
SANITARY PERMIT APPL 2 01 W. Washington Avenue
1 i ; ,� P O Box 7302
Department of Commerce In accord with Comm 83.05, WI �/ ��., Madison, WI 53707 -7302
� `_�
• Attach complete plans (to the county copy only) for the syste�,�1, bcx'pap Colrvsty
than 8 1/2 x 11 inches in size. t t" �- , s �x
( State San tar Permit Number
• See reverse side for instructions for completing this application � n _ �g
V } j
19 Personal information you provide may be used for secondary purposes ST CROIX El C�k revision to previ(ius application
(Privacy Law, s. 15.04 (1) (m)]. COUNTY St n I.D. Number
ZON1 FFICE
I. APPLICATION INFOR MATION -PLEASE PRINT ALL INPQkMATI
Property wrier Name 1
-^I4 1 T N R orW
ProperTy Owner's Mailing Address Lot Number Block Number
7 71 S r ?A
City, State Zip Code Phone Number Subdivision Name or CSM Number
e frTh t YQ > __47_ Lou ,vT L�c�r S'� -�� -,--d d
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ it Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms V ow a n OF
I II. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s
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 RNew 2. ❑ Replacement 3_ ❑ Replacement of 4. I] 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
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 RSeepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPT 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) �Qr 70 Elevation
4;,6110 l00 U l-d Old r ee /vim- Feet I ;p Feet
VII. TANK Capacity
in gallons Total # of Prefab. Site Fiber- plastic Exper.
INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete strutted Steel glass App.
Tanks Tanks
Septic Tank or Holding Tank r7 : egt o J e v ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ I ❑ ❑ I ❑ I ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature,; (No Stamps) PRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Z' Code):
/d 76/ �'C d / 15
IX. COUNTY/ DEPARTMENT USE ONLY i
❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate Issued I llssw ng Agent Signature (No Stamps)
Approved []Owner Given Initial Y urcharge Fee) p
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -6398 (R. 4199) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
ST CROIX COUNTY
I
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer e L IL M,
�
Mailing Address j
t
Property Address 5 CP 7
(Verification required from Planning Department for new construction) I' O
City /State Parcel Identification Number
LEGAL DESCRIPTION
Property Location & V4, - '/., Sec. T2EN -R__�$ W, Town of % f
Subdivision Cdji-A/ftk 41 . Lot # 21
Certified Survey Map # . Volume . Page #
Warranty Deed # Volume /'i�5�° . Page #
Spec house ❑ yes �] no Lot lines identifiable ET 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 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the three year expiration date. c�
StGNATUI; 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 owners) of
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
y
SIGGNA OV 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 �
� a Qsb t j rAl cvl ::5,f wti' l md e ar fY�+
,
I
° 0
Q �
� CZ
�J \
�1 �L
` 4 • D
l
i
l
i r
1 �
�' 1
w
- Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page of
Bureau of Integrated Services in accordance with s. ILHR 83.09, 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 �YUt
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION - 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
I �) � Govt. Lot 1/4 1 /4,S T rZg ,N,R I Q(or) W
Property Owner's Mailing Address }} Lot # Block# I S ubd. Name or CSM#
City State Zip Code Phone Number
❑ City E Village N Nearest Road
W)r4h LQ r 5L1C)1 (p I ( 3&t 2_ V ` 4V-6 T+'t tVcAn Ln
New Construction Use: Residential / Number of bedrooms 3 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow �^ gpd Recommended design loading rate a bed, gpolfi _ trench, gpd /ft
Absorption area required 6 �� bed, ft _ trench, ft 2 S bed d /ft a trench, gpd /ft
./J Maximum design loading rate , a gp 6
Recommended infiltration surface elevations) E 17 P 7 () ic%/ r i►7u r� It (as referred to site plan ben
Additional design /site considerations b �D' . �d i / laC Z I �y / / • s 1 /5 4 - M {�1Gr
Parent material n(-) (i} (4 s Flood plain elevation, if applicable /y /'T It
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system ® S ❑ U ®S ❑ U NS ❑ U Ia S❑ U ❑ S [RU EIS 5a U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
i
0 14 r 312 L Q If' Z 3
z 2 i Z -IS 10 VC 4 IMF L nr) b r - )f Ivy .
Ground _) i mz 10 r �j tp i 2 - Q 1� t C
elev. f
L-i f � -70 r o r - y . l -- s rr l 1C -
Depth to 5 l L3 -9tfl 1 S C.s Ccs
limiting
factor
m in.
Remarks:
Boring #
I 0-�o to r 3(Z -- �- I wa 04r c
2 fu- i b r y 1 I k n&1 c s - F
3 I -46 1 A 14 r 9 16 Z C S , 5
Ground `� qo
elev.
`l z, e ft.
Depth to
limiting
fatiin Remarks:
CST Name (Please Print) Sign ure Telephone No.
r
Address Date CST Number
0 QaC& So e s.2'ozS' " x`99 mss'
PROPERTYOWNER SOIL DESCRIPTION REPORT
Page Z of
I
PARCEL I.D.#
I
Boring Horizon Depth Dominant Color Mottles Structure 2
g Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
3 ( 6 -10 10 - 31) Si l I ma rnf
1 y I `L ry-�ub - S
Ground ZF K) 5) I q voC C.. - !5 '.(0
elev.
q�`o ft. 10 3 S J DSq Cri
Li
Depth to
limiting
factor
I
Remarks:
Boring #
0 -I0 (0 3 L 4 5
LA Z g 1()., yj — L s C f)
ig -DSO to 'LaA b mS cynia t l CS - `l
Ground
elev.
Depth to
limiting
factor
'0 in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Boring # ( )0 r 312 — SL I mo ` S
rj 2 I y$ I q LS c
b m5 n<C4 VYI c 5 $
Ground
elev.
'/ 30 t.
Depth to
limiting
factor
$ . - ' n • Remarks:
Boring #
0 - I ) r3fZ SL Irr, ItjK mfr C t 4 '.
l Z (()-28 C� e r `) (`I t_ F S I rn S rn l C 5
I
3 2g - �tD 10 '/ L S 1 15 - -1
Ground Q L I 1p mS cb LS D
elev.
I
Depth to
limiting
factor
in.
Remarks:
SBD -8330 (R. 07/96)
Gf I P uy �,'pe
pr',�Afy So J l -�D Z
a vn Z y,od t � puc P�'Pe
S
ax e loo ' 5e e 3
In S s
8
w Q 1 Z o oo ,) f tNUvc-
i
l -v
x�
/ J
J
L
63 � �Z • i3r.L
! 1 3 0 0
8
— TRIEbristn Department of Commerce SOIL AND 61TE EVALUATION
Zivisim of"SAW ar d Wddinos Page L 61
Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 6 112 x 11 inches in size. Plan must Count
include, but not limited to: vertical and horizontal reference point (BM), direction and t
. �.t(Vt '
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION - Please print all information Reviewed by Date
Personal intormatlal you Provide may be used for secondary purposes (Privacy Law, s. 15.o4 (1) (m)).
Property Owner Property Location
) 0* Govt. Lot N 1/4 �,E 1 /4,S T 'LS ,N,R �� E� (or) W
Property Owners Mailing Address `` ,, 11 Loot # Block# / S ; ubd. Name or CSM#
t� t . N 42 l.. ut) C ' _Vj,
City State Zip Code Phone Number
❑ City ❑Village gr Nearest Road
W& A 5H (31 (_16) M- 4ry r t ;
R New Construction Use_ 9 Residential / Number of bedrooms 3_ Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
code derived daily flow 1 7'50 gpd Recommended design loading rate r S bed, gpd/ft s (o trench, gpd/ft
Absorption area required bed, 1`12 it 2 Maximum design loading rate , bed, gpd/ft , 6 trench, gpd/ft
Recommended infiltration surface elevation(s) , 7/ 1 r ft (as referred to site plan benchmar L6AA_A0CC7'1
Additional designlsite considerations �' 4S . 70 ►,` / f, A, /Wa' z � �L � - � � S�sr1 `
Parent material _ (�U 4 - f c.c. S 1c� Flood plain elevation, if applicable _'�(M it
S = Suitable for system Convenfional Mound [ In-Ground Pressure AT -Grade System in Fill Holding Tank
U = - Unsuitable for system ® S❑ u ® S Cl u ® S u 1 5a s❑ U L os IR u ❑ s R u
SOIL DESCRIPTION REPORT
Boring # Horizon Deem Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD 1ft2
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
C.� i�' Z
Ground
elev.
U ,
7 °` ft. `! $ - 10 i r 41 1P L 5 1 c
Depth t0 -9(0
limiting
factor
4(c in.
Remarks:
Boring #
1 0-%6 312 cy r C. S Z
Jp 14C 410 ! zecAu mri CS
Ground L! 0 ( 5 1 a l l 6 — 1
elev.
Depth to
l '
2 - in. Remarks:
CST Name (Please Print) Si re Telephone No.
C ?- 17a6
Address Date CST Number
D So c S'56 - 5 7 - 7 -9Q As
_ _ _ __ ■
f S M S
�, w• .fie 4O��.N
:ham T n SOIL
7Y - DESCRIPTION REPORT T - -
/ EH OWNEi Page _� of •
AR CEL LD.#
Boring # Horizon Depth Dominant Color Mottles 2
Structure .
in. Munself Qu. Sz. Cont. Color Texture Consistence Boundary Roots
Gr. Sz. Sh.
. to f 3 � 1 Bed ,Trench
2 Si 1
Ground
1 - U 10 - r 2 r ub r -
elev.
93�o_rt. -10 r 3
5
Depth to `� 1 Li { to M1 C S '.
factor
-M in.
Remarks:
Boring #
o -IU 3I L SL I mU bk fy, r
q S
C5
L i
r r un t.i I to _ MS I CS
_ `1
Ground
elev.
Depth to ,
limiting
factor '
in.
Remarks:
Horizon Depth Dominant Color Mottles Structure
In. Munseli Qu. Sz. Cont. Color Texture Consistence Boundary Roots PD
Gr. Sz. Sh. Bata
Boring # Trench
( 6 - 1to Ip ' r (Z SL
5 2 -y8 y US
M5 5_ 1 $ Jf) 4 r Ito
Ground
elev.
Depth to
limning
factor
Remarks:
Boring #
.
m mfr C. . �
to 2 1) , r �J 11 ! IFS irn
Ground
elev.
Depth to
6rroting
factor
U1 ' Remarks:
SBD -8330 (R. 07/96)
4ngj
/; C3nr Z qq.ocS f J pt c_ p,
s Cole t /oGN
, o
i U r
V.
I
� f J
S ♦13 R3 e pre and r
q�e 3 Z
Q
r't - •
am 1
ad7Z •
.1456PAG[ 103
6.10260
STATE BAR OF WISCONSIN FORM 2 - 1998 KATHLEEN H. WALSH
UI
Document Number WARRANTY DEED ST. CROIX
This Deed, made between Douglas G. Olson and Marjorie C. Olson, RECEIVED FOR RECORD
husband and wife 09 -13 -1999 11:00 AM
Grantor, conveys WARRANTY DEED
and warrants to Allan C. Osburn and Joan M. Osburn, husband and wife EXEMPT #
CERT COPY FEE:
COPY FEE:
TRANSFER FEE: 156.00
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
(The "Property Recording Area
Name and Return Address
Citizens State Bank
1602 North Broadway
Menomonie, WI 54751
ATTN: SUE
�tarc 3 -10
dentifi cation Number (PIN)
This is not homestead property.
Lot 82, Country Wood Second Addition in the Town of Troy, St. Croix County, Wisconsin.
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this day of September, 1999.
* glas Olson
�i
* *
MarjolQC. Olson
ACKNOWLEDGMENT
AUTHENTICATION
STATE OF WISCONSIN )
Signature(s) Douglas G. Olson and Marjorie C. Olson, ) ss.
husband and wife County )
i
authenticated Personally came before me this day of
this L day of September, 1999. September , 1999, the above named
to me �
known to be the person(s) who executed the foregoing instrument
* Krishna Og nd and acknowledge the same.
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, Notary Public, State of Wisconsin
authorized by § 706.06, Wis. Stats.) My Commission is permanent. (If not, state expiration date:
THIS INSTRUMENT WAS DRAFTED BY )
Attorney Kristin Ogland
Hudson, WI 54016
(Signatures may be authenticated or acknowledged. Both are not
necessary.)
,a•
*Names of persons signing in any capacity should be typed or printed below their signatures
WARRANTY DEED STATE BAR OF WISCONSIN
FORM No. 2 -1998 -
INFORMATION PROFESSIONALS COMPANY FOND DU LAC, WI 960655 -202'
� � 0
s � w
o � �
o `
v `
9
N
CD
C
a' 33 , 33,
S A
CA
t
C� to
_ _ _269.59 _ - - --
STATE BAR OF WISCONSIN FORM 2 - 1998 * *This is a true and certified
Document Number WARRANTY DEED copy of the original. The original
This Deed, made between Douglas G. Olson and Marjorie C. Olson, has been sent in for recording.
husband and wife
Grantor, conveys
and warrants to Allan C. Osburn and Joan M. Osburn, husband and wife U /'
ark C ,
Citizens State B nk
Grantee.
Grantor, for a valuable consideration, conveys and warrants to Grantee
the following described real estate in St. Croix County, State of Wisconsin
(The "Property Recording Area _
Name and Return Address
040- 1243 -10
Parcel Identification Number (PIN)
This is not homestead property.
Lot 82, Country Wood Second Addition in the Town of Troy, St. Croix County, Wisconsin.
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this day of September, 1999.
* ugl�601
• �i
* *
MarjolVC. Olson
ACKNOWLEDGMENT
AUTHENTICATION
STATE OF WISCONSIN )
Signature(s) Douglas G. Olson and Marjorie C. Olson, ) ss.
husband and wife County )
authenticated Personally came before me this day of
this 1 day of September, 1999. September , 1999, the above named
to me
known to be the person(s) who executed the foregoing instrument
* Kristina Og nd and acknowledge the same.
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, Notary Public, State of Wisconsin
authorized by § 706.06, Wis. Stats.) My Commission is permanent. (If not, state expiration date:
THIS INSTRUMENT WAS DRAFTED BY )
Attorney Kristina Ogland
Hudson, WI 54016
(Signatures may be authenticated or acknowledged. Both are not
necessary.)
*Names of persons signing in any capacity should be typed or printed below t.- signatures
WARRANTY DEED STATE BAR OF WISCONSIN
FORM No. 2 - 1998
INFORMATION PROFESSIONALS COMPANY FOND DU LAC, WI 800555 -2021
. Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM ' y (� I
Safety and Buildings Division Count '
INSPECTION REPORT VP+.
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)]. 3114 q (0 V l�
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
osbu.rn A lan I
CST BM Elev. Insp. BM Elev.: BM Description: Parcel Tax No.:
4 L — 12L+"6 —1 v -006
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P / L WELL BLDG. AirI to ntake ROAD Dt Inlet
Air I
Septic NA Dt Bottom
Dosing NA Header/ Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH I Lift Friction System TDH Ft
oss H ead
[ Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSION
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type O Mo el Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
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.)
'�r�l� �i• 28.1 • 12q-0 , N vi 1 6 506 - Tr I I l i L.rn Lan e- — wa o d lio t 8
L
Plan revision required? ❑ Yes ❑ No I F__ I I _H
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No
Safety and Buildings Division
Visconsi SANITARY PERMIT APPL � 201 W. Washington Avenue
''� 13 .l P O Box 7302
Department of Commerce In accord with Comm 83.05, WI Madison, WI 53707 - 7302
• Attach complete plans (to the county copy only) for the syste bMpapRgto c y
than 8 v2 x 11 inches in size. itt''�f3` ► ►LLUU
• See reverse side for instructions for completing this applicat 0,n Stato U tar Permit Number
n Q 9 1999
Personal information you provide may be used for secondary purposes ST CRUX p k revision to previous application
[Privacy Law, s. 15.04 (1) (m)). Ccx INTY
ZONI FICE St n I.Q. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL 1 fit
4 ' TI N
Property wner Name I < I
a t T 2 , N, R Q ®(or) W
ProperTy Owner's Mailing Address Lot Number Block Number
7 S ! ,a ?02
City, State Zip Code Phone Number Subdivision Name or CSM Number i)
e )r7k t • yd ) -AQ?3 CelwA,T ld dodl S a -vaQ ' Gr
1. TYPE OF BUILDING: (check one) ❑ State Owned ❑ It Nearest Road
❑ village
Public &L 1 or 2 Family Dwelling - No. of bedrooms own OF
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Numbers '
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, g 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 Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 RSeepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 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) Elevation
Feet Feet
VII. TANK in city Total # Of Prefab. Site Fiber- Exper.
INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete strutted Steel glass Plastic App
Tanksl Tanks
Septic Tank or Holding Tank Q `dl.J e s N ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ I ❑ 10 ❑ ❑ I ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signatur (No Stamps) PRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Z Code):
l j 7d 77`
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date I ssued l lsswng Agent Signature (No Stamps)
Approved []Owner Given Initial Q urchargeFee)
Adverse Determination
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
I
DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer h - le, i1 - 1 /` a >
Mailing Address �'� 7
Property Address Q 6; 7 - ; ,- / %
(Verification required from Planning Department for new construction)
City /State Parcel Identification Number
LEGAL DESCRIPTION
Property Location o %4, ,!�� '/4, Sec. _ 2 T_2,LN -R_L�LW, Town of r,,
Subdivision _ Cd Alt IV 4 , Lot # .t .
Certified Survey Map # . Volume , Page #
Warranty Deed # l �� O , Volume . /5� Page #
Spec house ❑ yes no Lot lines identifiable Er 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, restrietedplumber or a li cense d 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 of the three year expiration date.
l
SidNATOCE 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.
SIGNA O 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
Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labcv and Human Relations
Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size PlAn but St. Croix
not limited to vertical and horizontal reference point (BM), direction and %As{dpe, scale br RCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road.'a * p endin ci
APPLICANT INFORMATION PLEASE PRINT ALL INFORMATI REAEWED BY DATE
PROPERTY OWNER: • f ROPERTY,LOCATION r
Richard Stout ', • :GOVT. LOT'S. 1/4 SE ,S 3 T g N,R 19 { (or) W
PROPERTY OWNER':S MAILING ADDRESS ' 0T"# 1 BLOOM* ` =SU E OR GSM #
c
CITY, STATE ZIP CODE PHONE NUMBER []671 ILLAGE% OWN NEAREST ROAD
Hudson, WI. 54016 (715) 549 -6731 Tr ,
o ...._,,.. w... Tower Rd.
n New Construction Use [ Residential / Number of bedrooms 3 [ J 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/ft
Absorption area required 643 bed, ft 563 trench, ft Maximum design loading rate .7 bed, gpd /ft .8 trench, gpd/ 2
Recommended infiltration surface elevation(s) 97.25 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 for s stem [a 11 U ZI S ❑ U a s ❑ U ®S ❑ u R7 S ❑ t) O S ® u
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BoulxW Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 0 -4 10 r3 3 none sil 2csbk mfr cs 1f .5 .6
1
2 4 -20 10yr4/6 none lfs lfsbk mfr gw if .4 .5
Ground 3 20 -35 7.5 r4/4 none sl 2m r mvfr QW na .5 .6
elev.
10 4 35 -84 7.5 r4 6 none cos osq mvfr na na .7 �.8
Depth to
limiting
factor
+84"
Remarks:
Boring #
1 0 -14 10 r3 3 none 1 f' -- -- --
2 2 14 -36 10 r4 4 none sil 1
Ground 3 36 -84
elev.
10 1.15 ft.
Depth to
limiting f +84"
Remarks:
CST Name:— Please Print Phone:
Gary L. Steel 715- 246 - 6200
A ddress: 554 200th. Ave. New Richmond WI. 54017 m02298
Signature: Date: CST Number:
8 -7 -96
PROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT �Iage 9 - of
PARCEL IA # pending Lot #82
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
Boring # Horizon in Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
<: 3
-- cs if
1 0 -12 10 r -- --
.. °.....:. °.... 2 12 -26 10 r4 6 none lfs lfsbk mvfr qw na .4 .5
Ground 3 26 -38 7.5 r4/6 none sl 2m r mvfr 9w na .5 .6
elev.
10 ft. 4 38 -84 7.5 r4 6 none cos OSQ mvfr na na .7 .8
Depth to
limiting
factor
+84"
Remarks:
Boring #
<:;<:;:`: <:::• 1 1 0-17 10y r2/2 none 1 fill -- cs if -- --
;rti
2 17 -36 10 r4 4 none sicl lfsbk mfr w if .2 .3
Ground 3 1 36-84, 7.5 r4 4 none is osq mvfr na na .7 .8
elev.
101 ft.
Depth to
limiting
factor
+84"
Remarks:
Boring #
.:•::;:: >.::<:: >.:::::;:: 1 10-12 10 r2 2 none 1 fill -- cs if -- --
,..:.; ;
2 1 12-30 10 r4 6 none sl lm^ r mvfr qw na .4 .5
3 1 30-82 7.5 r4/6 none cos osg mvfr na na .7 : .8
Ground
elev.
10
Depth to
limiting
factor
+82"
Remarks:
Boring #
.................
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(R.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel 1554 200th Ave.
Richard Stout New Richmond WI 54017
MPRSW 3254 NW4SE4 S3- T28N -R19W
town of Troy t 715 ) 246 -6200
lot #82- Country Wood Second Addn.
N
1x40'
BM.= top of SW lot stake @ el. 100'
A
to` P.,•
4 3`
Gary L. Steel
8 -7 -96