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ST. CROIX COUNTY ZONING DEPARTMENT!"
AS BUILT SANITARY REPORT
Owner S .
Address
City /State
U
?Cx v1Vi; �= HCE
Legal Description- \ ;,
Lot �_ Block � Subdivision/ < 1
'/, ' /,, Sec. �, T,N -R1SW, Town of PIN #
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer, Size ST/PQ, / Setback from: House_ Well ,4,- P/U
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
Type of system: Width Length ,7S' Number of Trenches
Setback from: House za Well �— P/L j l ,�Ie Vent to fresh air intake o
ELEVATIONS
Description of benchmark Elevation ,Ica.
Description of alternate benchmark Elevation ,�,,R, 8
Building Sewer ST/HT Inlet ST Outlet 7. zf PC Inlet
PC Bottom Header/Manifold Top of ST/PC Manhole Cover ,i4 7
Distribution Lines () 951,.E () ( )
Bottom of System O y 7
Final Grade O 4:1,, 7 O ( )
Date of installatio / / Pe mit numb r . State plan number
Plumber's signatu / License number Y Date
Inspector
Complete plot plan
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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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PLAN VIEW
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710. e��slZ C�9�Fit6�'
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gas
INDICATE NORTH ARROW
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Y
Safety and Buildings Division ST . CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary 07800 :
Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)).
Permit
SMITH, Y RT6 INIAD9 Town of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel
0 E
o.:
OlJ f' — 1022 -95 -000
TANK INFORMATION ELEVATION DATA A9800188 Z
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic �� Benchmark
D + 1 3 Z•
Aeration Bldg. Sewer ,/ /6 , SS
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD
Air e
n �e<
Septic 7� l 7 Z6, NA
osing NA Header /Man. 13, Z
Aeration NA Dist. Pipe ( 9
In 3 C)
Hol g Bot. System Z 4 Z„
PUMP / SIPHON INFORMATION Final Grade 446ve v,vU 16 1,
Manufacturer Demand S
Model Nu
T Lift Friction S stem TDH Ft
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
( BEDqRENCH Widt Len th N Of Tr nch s IT No. Of Pits Inside Dia.
IM ASION5
SETBACK
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHIN ufacturer:
CHAM
INFORMATION Type O � / Z�► � 0 i O IT Mo e
System: 7 7S
DISTRIBUTION SYSTEM
Header / Manifold �� Distribution Pipes) i f x Hole Size x Hole Spacing Vent To Air Intake
/
Length Dia. Length Dia. Spacing / � 3 7 (JU
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.)
LOCATION: RICHMOND 6. 30.18.85AtSW,SE 3 707 95 TH cTR -RE
4(I Ent - s, d wa /koj41 9S8 ?O r CfiV l.�-s`
2� b6il Sewer f "14 : Z &'
Plan revision required? ❑ Yes 5] No
Use other side for additional information. Z Z o
SBD -6710 (R.3/97) Dati Inspecto ignature Cert No.
SANITARY PERMIT APPLICATION 201eE.WashnlgtonAve Division
Wi scons in In P.O. Box 7969
Department of Commerce accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 81/2 x 11 inches in size. `
• See reverse side for instructions for completing this application State Sanitary Permit Number
� �7 �tCxb
The information you provide may be used by other government agency programs ❑ check it revision'.. previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N
Propert Owner Name Property Location
114 - 1/4, S T , N, R ACTT&
Property Owner's Mailing A es r 5 - g � , ) Lot Number Block Num r
f I'll City, to Zip Code f Phone Number Subdivision Name or CSM Number
(.TYPE 8 LDING: (check one) E] State Owned ili Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms _=2 town of tf/
III. 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 ® New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System -------- ________System _____________ Tank Only______________ Existing System Exlstinci 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 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 E] Pit Privy
13 E] Seepage Pit I X 7 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
Ca acct
' _ Feet Feet
VII. TANK in allons Total # of r Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- steel glass Plastic App
New Existin strutted
Tanks Tanks
E Ta p "-- � ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ E] E]
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for inst Ilation of the onsite sewage system shown on the attached plans.
Plumber' Nam (Pr ) ` Plumb 's �at S s) MP /MPRSW No.: Business Phone Number:
Plumber's Ac dress (Street, ity, Stat ip Cod
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater D ateAsueo Issui g Age t Si at re (No Stamps)
Appro Surcharge Fee)
pp []owner Given Initial Ov �.
Adverse Determination 4D ta�) 7
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -6398 (R 11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber'
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wsc;cu►sin Eye of Commerce IL AND SITE EVALUATION
Division of Safety and Buildings / 9 Page of
Bureau of Integrated Services �� with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper legs`than has inl i e. Plan must County
include, but not limited to: vertical a zontal point (BM), di 'on and
percent slope, scale or dimensions, arrow, and locatio and is
nt ta' me o nearest road.
J 1 ti Parcel I.D. #"
APPLICANT INFORMATION se p*Aform view by ` Date
Personal inforrnation you provide may be us f nj>(�jyld�dJ� s. 15.04 (1) (m)).
Property Owner , y Z Property Location /
E . Govt. Lot Cj 114 1 /4,S T :� ,N,R (or) W
Property Owner's Mailing Address Lot # Block# Subd. ame or CSM#
1 6,� _75 x/ 7 _4
C Sta Zip Code Phone Number E] city El village [A Town Nearest R
K �V /422 J New Construction Use: Residential /Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow and Recommended design loading rate ,L bed, gpd* < l __ trench, gpd/ftz
Absorption area required bed, ft ft Maximum design loading rate bed, gpd/ft trench.
Recommended infiltration surface elevation(s) X735 ft (as referred to site plan benchmark)
Additional design/site gonsiglerations
Parent material . :o - Flood plain elevation, if applicable ft
1-1 Lu = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in FU Holding Tank
= Unsuitable for system I ® S ❑ U ®S ❑ U D s ❑ U 2 S ❑ U EIS n U ❑ S Eq-u
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
13 in. Munsell Ou. Sz. C nt. Color Gr. Sz. Sh. Bed , Trench
Ground s
elev.
Depth to S ''
limiting
factor Y q
97 in.
Remarks:
Boring #
Ll as 5
S
L v
Ground A
elev
i g - -
Depth to
limiting
factor
;t�in. R arks:
CST Name !(P ase P ' t) Signature Telephone No.
s
Address � Date CST Number
l
PROPERTY OWNER SOIL DESCRIPTION REPORT Page �z of
PARCEL I.D.#
Boris # Horizon Depth Dominant Color Mottles Structure 2
g Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
r s
Ground _
elev.
/ 105 SJAq s ^
It
Depth to „
limiting
factor
in. '
Remarks:
Boring #
3 s
Ground —
S� r �
Depth to
limiting
factor
yin.
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 #
L a
Ground h Y —
elev. _
Aw
Depth to
limiting
factor
? 24in. Remarks:
Boring #
Ground
elev.
ft. ,
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R. 07/96)
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer Michael & Donna Smith
Mailing Address 1103 Cty Rd C New Richmond, W15 4017
Property Address _ t`�! q j g
(Verification required from Planning Department for new construction)
City /Stat New R ichmond, WI Parcel Identification Number C�2 e - X&2J - 9S
LEGAL DESCRIPTION
Property Location cW _ ' /,, S F _ ' /,, Scc. 6 __ , T30 N- R 12 _ W, Town of Richmond
Subdivision , Lot #
Certified Survey Map # :5 , Volume -2 , Page # `
Warranty Deed # 7A , Volume iZ-9 / , Page #
Spec house ❑ yes [3 no Lot lines identifiable ® 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, plurubcr, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on - site wastewat rdisposal 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.
1 /we, the u 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 (ace within 30
days of the ee ye r expir ion date.
5/ 6 /98
SIGNATU i:F. OF APPLICANT DATE
OWNEI CERTIFICATION
I ; ve) 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 propel desc ' ed abov , by virtue of a warranty deed recorded in Register of Deeds Office.
— 5/ 6 / 98
SIGNA APPLICANT DATE
* * * * ** Any infnrmatinn that ie mie rrprr,rntrd may result in t1 ;initary permit being revoked by the Zoning Department.
** I111'llh�l' \\ith thll 111►11111'i1111111 .I .I,II11) J � III - r1) fjol11 Ilir 1'•rl'l•.irl of Dr(-d office
a copy (it the certified survey map it reference is made in the warranty deed
�acre-5
i U - 'I4- acres
QQ 4 t9
ST !'
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�GOFFICE
-- - - -
CERTIFIED ,S`URVEYMAP
Located in the SWIM of the SE1/4 of Section 6, T30N, R18W, Town of Richmond, St.
Croix County, Wisconsin.
Owners: Donald & Renee Carufel '
NUM caner, SecOm a 2056 60th Street
(RR. apk fnd.) r - . Somerset, WL 54025
�$ Bearings referenced to the North -South V4 Section line
of Section 6, T30N, R18W. Previously recwded as S02
21'09'E and assumed to be NW21'09"W.
�! NoM.9eKd111/4 S�cllon IM
I oc I _UYPjAJ �Q LANDS_
r 66 &%W M13 •13
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>� I LOT
�lal I 2 7,804 squam feet hch kV R-O-W
5.000 acres) - Ip
U! W I 3 I 18 swm fed excWhg R-O-W I
�i � � I (4.302 acres) v
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W
VI I Z Raw..�.�,.
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S SW 20' 55' W 432.13' — — — — — SE axnw. Secdw 6
( RK nal found
S,H comer, Sectlon ¢ '� awaf. wMh Ve sh"Q
(RA "k ftWj
_ I 2, 64.
�— 84'
� I r
I I ,S1NPL,ATTEO LANDS SwM Me of u» SE114
I I
LEGEND
- indicates section corner monument SCALE IN FEET 1" = 120'
( as noted )
0' 60' 120' 240' 360'
• - indicates 1" X 24" iron pipe weighing
1.68 lbs. / a & set.
(R) - indicates previously recorded �5C O S�
information.
G
GRANBERG SURVEYING Ne - , Wy OHD
1239 C.T.H. "E 99 O� nds men dratted by Richmond, W1. 54017 O J U R � ti's Jo.h W. Grabn
Phone (715) 246 -7529
Job No. 98 -.005 3 SHEET 1 OF 2
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CERTIFIED SURVEYAMP
Located in the SW1/4 of the SE1/4 of Section 6, T30N, R18W, Town of Richmond, St.
Croix County, Wisconsin.
DESCRIPTION:
A parcel of land located in the SWl /4 ofthe SE 1/4 of Section 6, T30N, RI 8W, Town of
Richmond, St. Croix County, Wisconsin, further described as follows:
Beginning at the S 1/4 corner of said Section 6; thence NO2 1'09"W ( bearings referenced to the
North -South 1/4 Section line of Section 6, T30N, RI 8W. Previously recorded as S022 1'09"E
and assumed to be NOT21'09 "W) 466.70' along the North -South 1/4 Section lime; thence N88°
20'55 "E 465.13'; thence S02 °21'09 "E 469.90' to the South line of the SE1 /4 of said Section 6;
thence S88 ° 44'33 "W 465.18' along said South line of the SE 1/4 to the point of beginning,
containing 217,804 square feet ( 5.000 acres ) more or less and being subject to all easements,
restrictions and covenants of record.
SURVEYOR'S CERTIFICATE
I, Joseph W. Granberg, Registered Wisconsin Land Surveyor, hereby certify that by the direction
of the owner, Donald Camfel, I have surveyed and divided the lands shown hereon in accordance
with official records, Chapter 236.34 of the Wisconsin Statutes, the Town of Richmond
Subdivision Ordinance and the St. Croix County Subdivision Ordinance and that this map and
description are a true and correct representation thereof
This instrument drafted by Joseph W. Granberg
Dated March 23, 1998.
NOTE: Each parcel shown on this map is subject to State, County and Township laws, rules and regulations ( i.e.,
wetlands, minimum lot size, &own to parcel, etc. ). Before purchasing or developing any parcel contact the St.
Croix County Zoning Office and the appropriate Tows Board for advice .
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= S -2295
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GRA"MG SURVEYRV
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1239 C.T.H. "E"
New Richmond, WL 54017
Phone (715) 246 -7529
Job No. 98 -005 SIMT 2 OF 2