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ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
i_n
Owner q I h cl 57 -a W"*-
Address
City /State &yx W2 p i
Legal Description:
Lot �_ Block Subdivision/CSM # - -�
'14 , Sec. -.5, T �9 N -RAW, Town of _ 5Y as-e h PIN # 0:5 0 - / 01 ? -
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer Size ST/PC / Setback from: House /S• Well 7S P/L / � •
Pump manufacture_ r„ — 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: &%0 Width Length 7S Number of Trenches ---'
Setback from: House - 0 Well /,ZD P/L Vent to fresh air intake /1 T '
ELEVATIONS
s//
Description of benchmark W E/ /ofl Elevation
Description of alternate benchmark Elevation
Building Sewer ST/HT Inlet ST Outlet- 99 3 PC Inlet —"
PC Bottom Header/Manifold 9y� Top of ST/PC Manhole Cover
Distribution Lines () 9 () () 9
9
Bottom of System () 9 57,5
Final Grade
Date of installation 6 /5 /g �Permit number State plan number
Plumber's signature License number a.dp S Date / 9 B'�
Inspector d
complete plot plan
,
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
'
Safety and Buildings Division
INSPECTION REPORT 9T CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitayfggp �o.:
Personal information you provice may be used for secondary purposes [Privacy w, s.15.04 (1)(m)].
Permit Holder's Name: pp City p Villa e Town of: State Plan ID No.:
INDSTROM, DEAN ST. JOSE'
CST BM Elev.: I Insp. BM Elev.: BM Description: Parcel o.'
616
1 o 6 ► off ti (— "�a
I J
TANK INFORMATION ELEVATION DATA A9800212
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic �{� 1 Bench mar l0'
Dosing
Aeration Bldg. Sewer .PiX
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ 4 Outlet - 7 , �(
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header / Man. 8.1 °tG
Aeration NA Dist. Pipe
Holding Bot. System c f , Zp 9 S
PUMP/ SIPHON INFORMATION Final Grade 5-52-1 q ,
Manufacturer D and
Model Numbe GPM
TDH Lift Friction S ste TDH Ft
Forcemain Lengt Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
<VDITRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. I Liquid Depth
DIM NSIONS 1 1 75 DIMENSION
SETBACK
SYSTEM TO P/ L I BLDG WELL LAKE / STREAM EACHING Manufacture .
INFORMATION Type O � CHAMBER Mo e um
Syste hU ll; 0 �p 8 UNIT
DISTRIBUTION SYSTEM
Header/manifold Distribution Pipe(s) � x Hole Size x Hole Spacing Vent To Air Intake
Length �P Dia. Length ; Dia. Spacing � _ S
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade
Depth Over Depth Over epth Of xx Seeded/ Sodded xx Mulched
Bed/ Trench Centers Bed /Trench Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: ST. JOSEPH 5.29.19.74A,NE,NE 481 BLUE BIRD DRIVE
Lt y It
Plan revision recluiretl? Yes N0
Use other side for additional inforrfiatioIn. �Q Gj
SBD -6710 (R.3/97) Date spector's Si ature e
Vi sconsi n SANITARY PERMIT APPLICATION 201 E w shingtonAve
In accord with ILHR 83.05 Wis. Adm. Code P.O. Box 7969
Department of Commerce Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 1/2 x 11 inches in size. S�T Cr i
• See reverse side for instructions for completing this application State sanitary Permit Number
3 l The information you provide may be used by other government agency programs ❑Check if revi ion to previous application
[Privacy Law, s. 15.04 (1) (m)]. S A v� State Plan I.D. Number
L APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Propert Owner Name Property Location
A rlo ivy /V G1 /4 fU5 1 /4, S j T t�q , N, R I 4Wr) W
Property Owner's iling Addres>� t Lot Number Block Number
i City, State Zip Code Phone Number Subdivision Name or CSM Number
ll. TYPE BUILDING: (check one) ❑ State Owned 0 cit Nearest Road
❑ Village
Public 1 or 2 Family Dwelling - No. of bedrooms &Vrown OF
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment / Condo S. a 9- / T 711 3 Q —1 01 7 --1
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 - --------- 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 C] Holding Tank
12 Seepage 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
4 1 s ® Required (sq. ft.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min. /inch) C Elevation
(rQ , .i .7 Feet gy, S Feet
acct
VII. TANK in Cap allon Total # of Prefab. Site Fiber- Plastic Exper.
INFORMATION Gallons Tanks Manufacturer s Name Concrete con Steel glass App.
New Existin structed
Tanks Tanks
Septic Tank or Holding Tank I V l Q�� �` ❑ ❑ ❑ ❑
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.
Plumber's Name: (P Plumber's Sign e: (No Stamps) MP /MPRSW No.: Business Phone Number:
tu o x, S" �7 1 S Q -51
Plumber's Address (Street, City, State, i Code):
Ile
IX. COUN TY / DEPARTMENT USE ONLY
❑ Disapproved S itary Permit Fee (Includes Groundwater ate slue Issuing A ent Si N tamps
A roved surcharge F ee)
pp []Owner Given Initial y) (
Adverse Determination C/
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -8398 (R.11196) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
4 - _
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yvisconsh Department of Industry SOIL AND SITE EVALUATION
Labor and Human Relations Page t l 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
include, but not limited to: vertical and horizontal reference point (BM), direction and -5 f
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
030 - / all -/ 6
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
uM oL S Govt. Lot /vC 114 /4,S T °r / ,N,R �� 4Wr) W
Property Owner's Mailing Address Lot # I Block# Subd. Name or CSM#
I r C1 IQ v` ~—
City State Zip Code Phone Numberr,� Ne rest Road
U1C1 l�S S'/0 / ( 57 /'4 67 ❑ city ❑ Village Town
❑ New Construction Use: Residential / Number of bedrooms °3 Addition to existing building
pl. Replacement ❑ Public or commercial - Describe:
Code derived daily flow T� gpd Recommended design loading rate _ bed, gpd/ft _ trench, gpd/ft
Absorption area required !�QL bed, ft 2-5 trench, ft Maximum design loading rate bed, gpd/ft trench, gpd /ft
Recommended infiltration surface elevation(s) 95'_G ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material Pi &A Flood plain elevation, if applicable A ft
S = Suitable for system I Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system I JNS ❑ U 0 S El U PQ S ❑ U I ❑ S N U 1 ❑ S 5 X U ❑ S 0 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
U '
l d�lly /� R 2 f K C�
37 /o 51 ! 6 K C w ! ,,,,, 5 ► L
Ground .3 37 �a s G Vw U Sz � 7
elev.
Depth to
limiting
factor
Remarks:
Boring #
14 36k hx in
1-0 41k
-3 31 S D d s o f
Ground
elev.
ft.
Depth to
limiting
Y 4 in. Remarks:
CST ame (Please Pri Si at Telephone No.
Address Date -�'3T Nulliber
- 5'ydr S - e S
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C rc) Ss J�c�lUr1 d� 2 (�
�'l 4Jr1� J�S�00-1
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� 4 ct r\ c t. 1'\ a
� 'S -t
Fra►h Air Inl•I► And OD►uvalton Pipe 't � �� i � �� 1`.-
�(�dsm>1, Lem S yo / (�
Approv:a V.nl Cap A) /./ y ,��
final C,aC. S 1. ��� N�� '..
20- 42' Abo Pip' 1' Coat Iron
To final Ora•e Vent Pipe`
Ma M rino — To•
pau0 0 o PatlOr•1a• Pips 11,10,v o Covginy T"aninollnp At
Bollom 01 Syelem
p(Nopo�ot �Ifla I
99s
SOIL FILL
01STRIBUTIO►.1 PIPE '
APPIIOVED S I WT14 ETIC COVCR
2 "OFI%G6 REGAlE --�� - _ - /lATI:Rpl- OR 9" OF STRXW
OR MARSU HAlJ Q� A
O P lz - Z/, 1 /Z A G G E G AT E.
L
EV OF FEfr.Y_..
DISTRI15UTIOU PIPE TO BE AT LEgyT _ .� INCHES BELOW ORIGIMAL GRADE
AUU AT LEASTLO IUCHEe BUT 1.10 MORE THAU 42. IuCF1ES BELOW FINAL G RAD E
M LMUTA DaPrvi OF F�XCAVATIOO FX oRl ti NAL 6j� noF WILL BE _ INCHES
nNIMVM 05FI ti OF EXCAVATION r-KOM. Olk'60AL CjRAPF- WILL B �— INCHES
SIGUED:
LICEMSC ►.1UMBER: 6
DATE: g1 S 1p.C,_
1 10
ST. CROIX COUNTY!'; ZONING_OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently
serving the Qe.aorz L r�,- v - o � - residence located at:
A) 1/4, Sec. -5 , T a� N, RW, Town of
' Upon inspection, I certify that I have found the
tank and baffles to be in good condition, and it appears to be
functioning properly.
Last time serviced - 122 7
Did flow back occur from absorption system? YesA,�No(if no, skip
next line)
Approximate volume or length of time: -SQD gallons /D minutes
Capacity:
Construction Prefab Concrete _ Steel Other
Manufacurer (if known):
Age of Tan f known):
Oa- L) n P.
(Signature) (Name) Please Print
(Title) (License Number)
(Date)
Form to be completed by licensed plumber (x.145.06, Wisconsin Statutes)
or Licensed Disposer (NR 113 Wisconsin Administrative trative Code)
— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
condition, I certify that the tank to the best of my knowledge will
conform to the requirements of ILHR -83, Wis. Adm. Code (except for
inspection o ening over outlet baffle). Si natu
g re MP /MPRS
Name i + �5 �Y OS3
.[8. U N c� 7
5/88
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address
Property Addres
(Verification required from Planning Department foryw construction)
City /State / I L dSvvt LA� Parcel Identification Number 3 � l d l 7 ) D
LEGAL DESCRIPTION
Property Location ' /4, kC ' /4, Sec. , T ` N -R W, Town of S 7, _To S f
Subdivision Lot #
Certified Survey Map # ey - 3 , Volume g , Page # a Q 3 6 .
-� Warranty Deed # .56 / ? ,Volume 1- ,Page # 7
Spec house ❑ yes( 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 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 e xpiration date.
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 o described above, by virtue of a warranty deed recorded in Register of Deeds Office.
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 deect from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
VOL 6 i PACE ?79
56617
9 STATE BAR OF WISCONSIN FORM 3 — 1982
a�C7V QUIT CLAIM DEED
DOCUMENT NO.
REGISTER'S OFFICE
rl
Dean K. Linatrnn anti Linda r- T.inlatrnn hu;hmd and wife ST. CR OIX CO., WI
' Roo'd for Record
OCT 01 1997
quit - claims to span x_ J.inr1. *t- , and Linda C Linrlstrcm RPVocablP 9 A M
Tn,sr dared August 19, 1997
L t .star of Deeds
the following described real estate in Sr. rrnix rount4r County,
State of Wisconsin:
THIS SPACE RESERVED FOR RECORDING DATA
NAME AND RETURN ADDRESS
Located in part of the W of the M of Section 5, T29W, R1 Iieywood & Cari, S.C.
Town of St. Joseph, St. Croix Cotmty, Wisconsin; being Lot 1 of 204 Locust St.
Certified Survey Map.recorded in Volume 8, Page 2236 at the St. Croix P.O. Box 125
County Register of Deeds Office; further described as follows: Hudson, 141 54016
Camlencing at the NE Corner of Section 5; thence S00 0 49 1 14 "W, along
the East line of the NFr of said section, 513.00 feed; thence
N88 738.82 feet to the NE corner of Lot 1 of Certified en ,3 0 -- 1012-22
Survey Map recorded in Volume 8, Page 2236 at above said office, PARCEL IDENTIFICATION NUMBER
being the point of beginning; thence continuing N88 °42 "W, along
the North line of said lot 1, 320.00 feet to the MI corner of said
Lot 1; thence S01 °29 "W, along the West line of said Lot 1,
230.00 feet to an angle point in said West line; thence S66 °52 "E,
along said I.1est line, 107.57 feet to an angle point in said West line;
230.00 feet to a North line of said Lot 1; thence N88 0 42 1 44 1 W, along said
North line, 355.58 feet to a Mi corner of said Lot 1; thence S00 0 53'24 "W,
along the West line of said Lot 1, 272.98 feet to the SW corner of said FEE
Lot 1; thence S89 °39 "E, along the South line of said Lot 1, 936.15 #
feet to the SE corner of said Lot 1; thence N07 0 52 1 28 11 E, along the Fast• —••
line of said Lot 1, 229.55 feet to an angle point in said East line, EXEMPT
182.87 feet to a NE corner of said Lot 1; thence N88 °42'44 "W, alonga
North line of said Lot 1, 422.89 feet to the Fast line of said Lot 1; Lot 1 CSM 8 -2236 is
thence N01 59 "E, along said line, 350.00 feet to the point of beginning n /k /a Lots 3,4,5
Described parcel contains 10.30 acres (448,718 sq. ft.). CSM Vol. 11 pg 3124
Above described parcel is subject to Town Road Right -of-way (48th Street)
and all easements of record.
This i8 homestead property.
(is) (IXM)
Dated this 19th day of August 1 19 9
t " L&
(SEAL) a w�► (SEAL)
Dean K. Lindstrom
(SEAL) % AA & A!% ) (SEAL)
Linda C. Lindstrom
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) Dean K. Lindstrom State of Wisconsin,
ss.
Linda C. Lindstrom
County.
authenticate s day of August 19 97 Personally came before me this day of
ST. CROIX COUNTY
- WISCONSIN
ZONING OFFICE
ST. CROIX COUNTY GOVERNMENT CENTER
N N N p p
Pollan 1101 Carmichael Road
�_ Yro , NIIN IIG
Hudson, WI 54016 -7710
— (715) 386 -4680
June 10, 1998
Dean Lindstrom
1183 Rolling Hills Drive
Hudson, WI 54016
RE: Septic Inspection for Dean Lindstrom located at 481 Blue Bird Drive, Town of St. Joseph,
St. Croix County, Wisconsin
Dear Mr Lindstrom:
A septic inspection of the above referenced property was conducted on June 5, 1998. This property
is located in the NE' /a of the NE' /a of Section 5, T29N -R19W, Town of St. Joseph, St. Croix County,
Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a
three (3) bedroom home.
If you have any questions regarding this, please contact our office at (715) 386 -4680.
Sincerely,
1�-
Rod Eslinger
Assistant Zoning Administrator
/sm