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HomeMy WebLinkAbout038-1179-40-000 3 o 3 (5 a O 69 p e» C o 0 U p N C E— @ m c 3 O c 0 N U O O 3 ~ U C ' N c C y O ° a a) E y oc) o LO o c Lt.. x U ° r ir> CL y 3 0� Z co c U O �O O a z '2 2 V Z N C N O C M a0 LL C a U N LL C m C O N O O O,w E N Y -O O ' _ 'D y o c 'O y C C .:6 Q N lD 7 C , M p M N N W Z E E O = O z a m a m co z c +: ° I O Z d' v o Y o cn w m 2 d c c ° N E E N O N (h N a = N a U 7 U U 0 � N i N ° a C 0 a c 0 U o Q ° ° Z� Z Z Z ID L! CO f6 E c (6 f0 E CD CL ..0+ a w w C N d N Lo d i N C a a a �w1 Q N E U) F H ° v H H(n _° U �i 0 0 0 d 0 0 0 0 z • IV m a d d IL L 6. d a y ►`a a z (D (D N x W W O O fn J {.� C O N O) O Z > 0) Cl z O LO r C N O N D N Q N a) r 4)?� are. of N 7 r O O 3 C U) C Cl) N C 00 .O O c c ° W o H U -0 O U 4f 0 0 °D N O fl. �. O N LL O O C 00 C N E E 5 rn rn O C o O O N �(D �,w (D r 4) rti (r @ ?i a�0 'w y E E °2f N O w O O «g v N O z N L 9 - 7 co O Z N a' Z U) r d £ L a, m d o y 4 dt a .. a u a L W ttww � O m O 3 .�. O 3 O `�1 A va 0 0 0 vsv ST. CROIX COUNTY ZONING DEPARTMENT° - 1 AS BUILT SANITARY REPORT Owner X4 Property Addre s 10, City /State _a .; Legal Description: Lot .---,25 , - Block Subdivision/CSM # - ".,, ' /4 '/4, Sec., TAN -RAW, Town of "r PIN # SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer N � Size ST/PC/ / 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 Type of system: Width Length Number of Trenches Setback from: House Well P/L Vent to fresh air intake ELEVATIONS Description of benchmark Elevation Description of alternate benchmark Elevation Building Sewer ST/HT Inlet ST Outlet PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover Distribution Lines () () ( ) Bottom of System () () ( ) Final Grade () () ( ) Date of installation / / Permit number State plan number Plumber's signature License number Date Inspector ) I cj j & 0 j, n � "�k e Complete plot plan � vim' STC - 104 �., 11� AS BUILT SANITARY SYSTEM REPORT ✓,� OWNER — R T �C�J�/VSDA/ j , D^ 3 ADDRESS 115 Az , A L C v ~ G A SUBDIVISION CSM# � /7/Ji n LOTY# / SECTIO �L -R1 &_W, Tawn of 57AR APAA,?� ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM z_5`x ?REN�N�S 1 1 1 � w 11 1 �-c sr PRope, n �r?op�s'- ff�crsL" 56!9 7 Saf 13 M TOP 5F 1-0 T S �� xL INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. Wisconsin Department of Industry PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX ' Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284210 Permit Holder's Name: ❑ City ❑ Village El Town of: State Plan ID No.: SWANSON, ROBERT I STAR PRAIRIE CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic GS Benchmark SU /�.0 Dosing Aeration Bldg. Sewer p, 7.5 � Q �, 75 Holding Stotf Inlet TANK SETBACK INFORMATION StIRR Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Q3 8 3 0 ' Holdinl§ Bot. System S�?' PUMP/ SIPHON INFORMATION Final Grade {s, T, Manu Demand �P��e Model Numbe GPM TDH I ft Friction SVSte TDH orcemain Length Dia. Dist.Toweil SOIL ABSORPTION SYSTEM BED/TRENCH Width / Lengths 7 r No. Of T nches PIT No. Of Pits Insid ui I Depth DIMENSIONS s IME LEAC Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM _ INFORMATION Type Of 1)A, ' 7 J , O BER Mode Number: System: -61e, )C.teS OR UNIT DISTRIBUTION SYSTEM Header / e Distribution Pi e(s x Hole Size x Hole Spacing Vent To Air Intake P „ /� Length Dia - Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Gr ystems Depth Over Depth Over xx Depth Of �r xx Seeded/ Sodded xx ed Bed /Trench Center Bed /Trench Edges Topsoil C] Yes ❑ No El Yes 1tltT` COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: STAR PRAIRIE.15.31 NW, SW, LOT 25, COUNTY ROAD CC a Plan revision required? ❑ Yes P o Use other side for additional information. r SBD -6710 (R 05/91) Date Inspector's Signature Cert. No. �J • vi�� : Safety and Buildings Bui Wa Div SANITARY PERMIT APPLICATION Bureau of Buildin Water System! 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County ` „ Q I than 8 1/2 x 11 inches in size. C • See reverse side for instructions for completing this application State sanitary Permit Number The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Ow er Name Property Location 114 5W v4, S 5� T 3 1 , N, R f E (or)�V Property Owner's Mailing Address Lot Number Block Number � io City, State Zip Code Phone Number Subdivision Name o CSM Number '(�� ( ) LC / e D ' II. TYPE OF BUILDING: (check one) ❑ State Owned Vllla lt Nearest Road e Public 1 or 2 Family Dwelling - No. of bedrooms —3-- To of 5 "- f}l l.0 Gc 111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) L 1A 1 ❑ Apartment / Condo 0 38' _ �/7 _ 7 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. X 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 fgSeepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 E] 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) 96- O Elevation s� r4 3 ' 6_70 f J O y,O Feet ft 710 Feet Capacit VII. TANK in Ca gallo Total # Of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete con Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank ' 000 � IN ❑ ❑ ❑ ❑ I ❑ Lift Pump Tank /Siphon Chamber ❑ I ❑ I ❑ I ❑ I ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage s stem shown on the attached plans. Plumber's Name: (Print) Plu is Signature: (No Stamps /MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Cod / _ I it T- r O IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved San�ry Permit Fee (Includes Groundwater D ate Issue Issuing gent Si nature (N tamp surcharge Fee) Approved I [:]Owner Given Initial Adverse Determination U X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber t APP I avv I� pppaax CL. 9c zs W, &P f< s, ._ kc S' ,SUGGES ?�D CL. �yo O , /1 I I c � aT •2 S ' ' a 2- 5X6- 7 " Mew c# s p � A 0 ' MeA 1 1000 PROPS PRopos Top S E LdT 14OUSt coRNe2 S Tif R'Aw D ©u 8/y ARAwrnrG- foR � /I /B - 9'G A/li�cu� ��r /f 613e127 Sup,+ms&v - f�6 UAc t e y voe-au rA �31�s S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. ------------------------------------------------------------------- Owner of property R.0ffg P P" SZ11 /,4AISdi Location of property 1 /4 34V 1/4, Section - % g> , T 3 / N -R Township Sjh g &A &E Mailing address Address of site l/ S 3 ,�l:t 7/1 40E /kEW Subdivision name ,AP����,q�%4 /3&,i /p Lot no. 1Z Other homes on property? Yes Previous owner of property d; RAl2Q S D 41 i Total size of property % 2.2 Total size of parcel /, 21 Date parcel was created / Z/Z/, j q Are all corners and lot lines identifiable? _` Yes No Is this property being developed for (spec house) ? _Yes No Volume and Page Number V/5-- as recorded with the Register of Deeds. ------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. A Signature of Applicant Co- Applicant Date of Signature Date of Signature STC -105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER f?d ri ff. r X 511Q /y t ©/y MAILING ADDRESS b3ox /.' PROPERTY ADDRESS I I S3 �. / . T AG ;j�F (location of septic system) Please obtain from the Planning Dept. CITY /STATE Nea_} &L-Al -iovi-) PROPERTY LOCATION A['(V 1/4, :5W 1/4, Section 1Y T __3 L_ N -R _j6 TOWN OF S LM A /l? ,e ST. CROIX COUNTY, WI SUBDIVISION A n4 1 , . - �j _4 LOT NUMBER CERTIFIEDSURVEY MAP , VOLUME , PAGE , LOT NUMBE 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: ' DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 c+ %L) rti L CC C STATE BAR OF WISCONSIN FORM 1 — 1982 WARRANTY DEED DOCUMENT NO Q _ ? 07m, A 1 5 REGISTERS OFFICE ST. CROIX CTY., WI This Deed made between Richard O. Stout Psedbpa=d NOV 6 1996 Grantor, 10:20 a and Robert W. Swanson `�rayf�luM.,�bw 441 rmr of Deeds Grantee, Witnesseth That the said Grantor, for a valuable consideratio conveys to Grantee the following described real estate in St. Croix THIS SPACE RESERVED FOR RECORDING DATA County, State of Wisconsin: NAME AND RETURN ADDRESS Lot / � /` / LL/ Lot 25, Plat of Apple River Bend First 1 F/ Addition, Town of Star Prairie, St. OX /Z7 Croix County, Wisconsin. oo?S � PARCEL IDENTIFICATION NUMBER i a I, I T NSFER This is not homestead property. (is) (is not) I I Together with all and singular the hereditaments and appurtenances thereunto belonging; !! And Richard O. Stout warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, Restriction, rights -of -way and covenants of record, if any I and will warrant and defend the same. � it Dated this 4th day of November ' 19 96 CD i VIC (SEAL) (SEAL) l Richard O. Stout (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT ii Signature(s) State of Wisconsin, ss. St. Croix 4th ii authenticated this day of , 19 Personally came before me this day of ATnwamhrar Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary�e�rr gle.: Personal information you provice may be used for secondary purposes (Privacy , s.15.04 (1)(m)]. .ii bb ��ii bb Permit Holder's Name: � City❑ wn of: State Plan ID No.: M & G INC. AR KKAA CST BM Elev.: Insp. BM Elev.: BM Description: Parcel lax 0.:1179-40-000 TANK INFORMATION ELEVATION DATA A9800576 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake 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 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 SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING Manuf acturer: INFORMATION TypeO CHAMBER mod Num er: 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.) LOCATION: STAR PRAIRIE 15.31.18,NW,SW 1153 212TH AVENUE Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. V isconsin Safety and Buildings Division SANITARY PERMIT APPLICATION 2 1 Box Washington Avenue Department of Commerce In accord with tLHR 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 than 81/2 x 11 inches in size. /' • See reverse side for instructions for completing this application State Sanitary Permit Number Personal information you provide may be used for secondary purposes El G Ff revision to prev O.S application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Pro wrier a e Property Location A1 0 2 1 14 11 /4, S — T , N, R E (or& Property Owner's Mailing Addre Lot Number BI ck Number City, S ate Zip Code Phone Number Subdivision Na a or SM Nu er ( ) TY PE OF BUILDING: (check one) ❑ State Owned C] It� Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms : ::I � V own o f I o III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑Apartment /Condo IS. 3� ') `d, g�� C��Rq— �� ?� -�76 �� 3 �• ��- �' ° l 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 j&Reconnection of 5. ❑ Repair of an - _____System -------- ------------- 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 Weepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 []Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill .P�XI S 2. — �� �C 57 r 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.yinch) 0 Elevation — 1 y . 9 - !K l e Feet 9 Feet aot VII. TANK in Ca gallo Total # of Prefab. Site Fiber- Exper INFORMATION Gallons Tanks Manufacturers Name Concrete con steel glass Plastic App New Existing structed Tanks Tanks eptic Tank — ( ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber VI11. RESPONSIBILITY STATEMENT I, the nclersigned, a sume responsibility for i to tion f th nsite sewage system shown on the attached plans. Plum s Name: r Plumber's ure: s MP /MPRSW No.: Business Phone Number: PIumber'sAd �� clres tre t City tate,Zip e): Yp� k' C IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Inclu des Groundwater ate Issued Issui A ent Signature (No Stamps) X 4pproved ❑ Owner Given Initial I OOJ Surchar Fee) .IG � Adverse Determination / (7 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber n� J �fs�ic � j� onssrn L Human Relations "sue' SOIL AND SITE EVALUATION REPORT Page / of 3 Division of safety a eutidings in accord with ILHR 83.05, Wis. Adm. Attach complete site plan on paper not less than 8 1J2 x 11 inches in size. Plan m r. cRo r x u e, but PAR A not limited to vertical and horizontal reference point (BAH direction and % of slo or dimensioned, north arrow, and location and distance to nearest road. 0 APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION F IEWInj DATE PROPERTY OWNER: PRdf0tY LOCATION C Xi'G S"To 7— t3 /IJIV ''17 SW Y4 3 / ,N,R /9 E(qo PROPERTY OWNER':S MAILING ADDRESS LOT ft D. N M / , 553 Za CITY, STATE ZIP CODE PHONE NUMBER Ifv .Soo bo'5. Syoua (�!5 )541 - G73! . , I ivy. CC (i,}�ew Construction Use ( &+, tesidential I Number of b6drooms 3 + o q (� Addition to existing building ( ( Replacement ( ) Public or commercial describe Code derived daily flow y �� gpd Recommended design loading rate bed, gpol t french. gpd/11 Absorption area required 9SY bed, ft 750 trench, 111 Maximum design loading rate L bed, gpolft trench, gpolft . Recommended infiltration surface elevation(s) SEA .3 it (as referred to site plan benchmark) Additional design / site cons raflons Parent material Flood plain elevation, if applicable It S = Suitable for system �O UL MOUN IN-GRouNl) PRESSURE AT -GRADE SYSTEM IN FILL HOLOMG TAW U - Unsuitable for stem R U 8.5' ❑ U 14 ❑ U CSI - O U O S alt' SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bmindby Roots GPD /ft In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed B- 3e 7, 5 Yke Ground 3 `I�v / Y4 5 16 elev. ` Y t -8 ft. Depth to limiting faces Remarks: Boring # / 0 Rorie 2-13 /s /�, 2- L 0 -2& 7. S Y10 O CS Ground elev. �T 25 fl. Depth to _-.0 R 1 :3 1 N A L limiting } factor `/ � — Remarks: , ST Name: — Please Print R n 8 t R r 2A L Q R I'tr I T- phone. 71s Address: C � 9G Signature: ,, r c Date: CST Number: l Private Sewaas ConliUltants i Ulbrich! & Associates Private Sewage Consultent 665 O'Nsil Rd. Hudson, Wis. 6401 R �I n S 0 trG e- -�-� / " = P t l AP" - - - -- -- Nb . 1 -07- O 133 L o I 9y' I . /3 ,00 � �o sp . Lo 7- / p L10 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNE-RS141P CERTIFICATION FORM Owner/Buyer Mailing Address / �s 9 ���z� f /��A�� %off --t� Property Address t I S 3 a l a. A u� (Verification required from Planning Department for new construction) City /State 4 1 1A ) Parcel Identification Number LEGAL DESCRIPTION Property Location �/ G, • l T N - R U W, Town of *44_� ' /,, dW ' /a, See. A ` 2 & V J , Lot # S . Certified Survey Map # , Volume , Page # Warranty Deed # _ - 9,�,��// , Volume 4379 , Page # -_ o 7 Spec house W yes ❑ no Lot lines identifiable 91 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 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. 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. SIGNATURE OF APPLICANT DATE OWNF,R 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. 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 APPLE Rl'A. BEND OC4TEE) IN PART OF THE NW114 OF I HE Swl/ PART OF THE SWI/4 OF Tr-L bWi/-!, Fzl t I ()k I tit- Clt IrIL -Wil-f, r"f% I VEI14 OF THE SWI/4 AND IN PART OF THE NW114 OF THE SE1114 4t IN SECTION 15, T31N, R18W, TOWN OF STAR PRAIRIE, 3T CROIX COUNTY, WISCONSIN. OWNERS 7 T T 1 39 LOT 27 LOT 26 -o 3 56 A 91 B 3 1. 1 � LOT 39 AC sac [S., �c 7--­ � FT l b I E MT 2 15 LOT 28 LOT 25, E 2 o' Ac 90.042 12 c,. E.c E7A) 2 E.C. ES.T 7•. 11 FT LOT as, Its so. 38 2,J2 AC, r IT, 41' , LOT 24, �] ry�� '22 EAC A LOT 29," 'c SI I T I I IT, ' zz S , ID T 23 !7 QT 4 51 FT LOT 37 1 = >, .E K. - S5 AC EIC ES.T i 1; w's FT. 0 LOT 30 �oz AC. 3 <—C E CZ 22 7 FT 6.1•, S, I@ ( 'I- S'' +. IT c, = *� � LEGEND 2 ALI ;G LOT 36 N35'!4 37,-� 384 59' 154 SO LOT 31 4 P IE -I- c 0 1 4. C 335.06 LOT 35 L:)T 2 Ql ZT . I E Z LOT wE 32 'E LOT E. '• 1 IT 33 — Ac LOT 34 -Z LX" - 7 NOTE IT 7 STC - 104 AS BUILT SANITARY SYSTEM REPORT, " : ""'� " „ OWNER �Ol3�/1 T `SGVA&SaAl i � ADDRESS 115 A U ST � x SUBDIVISION / CSM# /`, j�C�,E�o � EN� LOT # SECTION T -R1 W, Town of _57AI? & ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM z- 5x 57 TRE��N�S / 00o jr s - PpoPe n P�? aP 6 $ " ff�c to w !3n Top Si LCD Si�4KC INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. Y1lisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: L Human Relations S INSPECTION REPORT ST. CROIX Safety fety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284210 Permit Holder's Name: ❑ City ❑ Village Town of : State Plan ID No.: SWANSON, ROBERT STAR PRAIRIE CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Gr c f- Benchmark 5, SU r / Dosing Aeration Bldg. Sewer p ?,5' 911, r Holding St /, Itf Inlet yr TANK SETBACK INFORMATION St /,$ Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic Z. NA Dt Bottom Dosing NA Header /Man. y� , 9¢OSr , Aeration NA Dist. Pipe 3 Holding Bot. System /ZIP a� �? PUMP/ SIPHON INFORMATION Final Grade Manu Demand s• T, r rK�r Mode l Numbe GPM TDH Ift Friction Syste TDH orcemain Length Dia. H Dist.Towell SOIL ABSORPTION SYSTEM BED/TRENCH Width i Length r No. Of Tr nches PIT No. Of Pits Insid uid Depth D IMENSIONS s 57 IM SYSTEM TO P / L BLDG WELL LAKE / STREAM LEAC Ma n acturer: SETBACK CHA BER INFORMATION Type O r)z..t� 7$ OR UNIT Moe Number: System: - 6,pe�r�S DISTRIBUTION SYSTEM Header / AAa1%A!Ffd Distribution Pipes x Hole Size x Hole Spacing Vent To Air Intake Length _/ Dia. Length Dia. Spacing 4 , SOIL COVER x Pressure Systems Only xx Mound Or At - Gr ystems Depth Over Depth Over xx Depth Of / . xx Seeded/ Sodded xx ed Bed /Trench Center Bed /Trench Edges Topsoil. � I ❑ Yes ❑ No ❑ Yes COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: STAR PRAIRIE.15.31.18W, NW, SW, LOT 25, COUNTY ROAD CC Plan revision required? ❑ Yes to Use other side for additional information. SBD -6710 (R 05/91) Date Inspector's Signature Cert. No. Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water System! 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County n than 8 1/2 x 11 inches in size. .5 . 61 ro i • See reverse side for instructions for completing this application State sanitary Permit Number The information you provide may be used by other government agency programs AS9a /D ❑ 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 Property Ow er Name Property Location 1/4 ��v4, S 5 T , N, R IS E (or)(g) Property Owner's Mailing Address Lot Number Block Number 13 City, State Zip Code Phone Number Subdivision Name o CSM Number ! _ 'l9:f. ( ) LL ! Lam' Ill TYPE OF BUILDING: (check one) ❑ State Owned ❑ � t� Nearest Road p Vila e Public 1 or 2 Family Dwelling - No. of bedrooms Town OF r GC_ III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) LIA - 1 ❑ Apartment/ Condo O V x/79 , 7 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 p 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. X New 2 ❑ Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an ______System ____ ___System -_____ Tank Only______ ________ Existing System ________ Exist 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 U'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 Required (sq_ ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) g 6� 0 Elevation �5 y,d Feet %4 Td Feet VII. TANK Capacity INFORMATION in gallons Total # of Manufacturer's Name Prefab. Site Fiber- Plastic Exper. New Existing Gallons Tanks Concrete Con- Steel glass App. structed Tanks Tanks Septic Tank or Holding Tank 000 El 11 El 11 El Lift Pump Tank /Siphon Chamber El El I El I El 1 1:1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage s stem shown on the attached plans. Plumber's Name: (Print) Plu is Signature: (No Stamps /MPRSW No.: Business Phone Number: r 1� Plumber's Address (Street, City, State, Zip Code): 01 `7,E. _ Q S IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Per (Includes Groundwater ate Issued Issuing gent Si nature (N tam A pp roved ❑ Owner Given Initial Y�yl Surcharge Fee) Adverse Determination / X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: IF y'' /� tk //ys/� � UE/1• Pljo� - APPR avv'I� Ar OF Cl. 9G•zS c vu�l2 Z yi, (o ` ALI" in � 6r $GGGES «D EL. 9y0 0 i 11 y LoT,ZS � ; a ? - TJI�rc�rEs ,4ppc� ft /e�e2 ��ko ; A IP. t c( r Al2eA ! 1 000 A. PRvP�s P RoFos /•louse ouT ' ORAU IIV6 foR / -/B - 9� p�� u�i /-?Y RoU0127 ,S w,+ vse v - S6'6 UAL L t y rA lVew U)i - ,SYO/ 7 50."VE9 S e7 - 4V, ` ,5 y 40 .2 s - ,ce 3 Is— S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. ------------------------------------------------------------------- Owner of property R G/34AU - . •V IA/Snik' Location of property 1/4 3tV 1/4, Section S , T 3 L N -R __Zd_ W Township 5'r%j jgjgA Mailing address Address of site Subdivision name - &y — Lot no. Other homes on property? Yes Previous owner of property /i / #.412,) 57-0z,17- Total size of property 4 22 Total size of parcel /, ? 2 Date parcel was created N1114 /i96 Are all corners and lot lines identifiable? _ Yes No Is this property being developed for (spec house) ? _Yes No Volume /,ZO 7 and Page Number /$' as recorded with the Register of Deeds. ------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. .S:iJA IA , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. Signature of Applicant Co- Applicant /5`'1'16 Date of Siqnature Date of Signature STC -105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 1FD iL 9 r �5 At f Q MAILING ADDRESS /.�ox /cg �Sv M�j�S' T �/1/ S 191 3 PROPERTY ADDRESS 11 T,41 Aoj�F (location of septic system) Please obtain from the Planning Dept. CITY /STATE Nc-w.' %���.��io vi (' li' S 562 / 7 PROPERTY LOCATION Aa& 1/4, _50 1/4, Section �� , T __3 L_ N -R j W TOWN OF S � �� nip ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBE 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93