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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADORESS f
4
SUBDIVISION / , CsMf
LOT f
SECTION -. N -R _ W, Town of
ST. CROIX COUNTY,. _WISCONSIN 0- 050
_ _.._.._. PLAN._VIEW.
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
X23
to LS�c
®GAL• lI
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
Wisco Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division CounttT . CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanita2$141* -:
Persona in you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)].
BELI S E , s 1 8DID 1 9+M❑P Rqb of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel "PIG-1080-60
TANK INFORMATION ELEVATION DATA A9700225
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic �� y r, Benchmark / /0 9,
Dosing
Aeration Bldg. Sewer f F9 ' ID/.
Holding i St /Vt Inlet � 60 L/'
TANK SETBACK INFORMATION St/41t Outlet 1 100, 0 Ll'
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic >ay' 7� ' , NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe �J
Holding Bot. System 93,
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand i
Model Number GPM
TDH I Lift Lricti System TDH Ft os
Forcemain Len g Dia. Fi 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
INFORMATION Type Of ��' CHAMBER Moe Number:
System: w j? !D6 �a� OR UNI
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Lengthy 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 E] Yes E] No ❑ Yes E] No
COMMENTS (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRAIRIE 19.32.18,NW,NW 2035 80TH STREET LOT 4
Plan revision required? ❑ Yes EfNo
Use other side for additional information. 13 71
SBD -6710 (R.3/97) Date nspectiu' Signature Cert. No.
Safety and Buildings Division
v�■�n■. SANITARY PERMIT APPLICATION Bureau of Building Water Systems
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
than 8 112 x 11 inches in size. _S]L� , V
• See reverse side for instructions for completing this application State Sa nitary Permit Num gr
The information you provide may be used by other government agency programs ❑ Check it reviision t / r �lo t u us s L application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Prope Owner Nam Property Location
1/4 1/4, S T , N, Ror
Pro erty Owner's Mailing A s Lot Num er Block Number
Cit State Zip Code Phone Number Subdivision N m or CSM Number
I o
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ cit Nearest Road /
❑ vil i
❑ Public 1 or 2 Family Dwelling - No. of bedrooms .3� Town of r
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
0 38— /e�G' L eS�'
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/ Mote[ 9 ❑ Office/ Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box online 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 ❑ 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
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/ q. ft.) (Min. /i ch) Elevation
Feet Feet
VII. TANK Capacit gall Total # of Prefab. Site
g Fiber- Exper
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existin strutted
Tanks Tanks
Septic Tank or Holding Tank ❑ El ❑ El 1:1
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
r
I, th undersigned, assume responsibility a t
for insti f e nsite sewage system shown on the attached plans.
Plu ern Na e: ipt Plumber i ture m MP /MPRSW No.: Business Phone Number:
^ /
lumbers ddress treet, Ci State, Zip de):
C
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sa I ry Permit Fee (Includes Groundwater ate Issued Issuing Ag 't Sig re No s)
Surcharge Fee)
pproved Owner Given Initial / (/0
A dverse Determination Qv
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SHD -6398 (R. 05/94) DISTRIBUTION: original to County, one copy To: Safety & Buildings Division, Owner, Plumber
Q / t
7- 7-- 97,���
D
L
Lam'
5 -3 ,
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i
Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Pa a of
D bor and Human Relations g
ivision of Safety & Buildings
In accord with ILHR 83.05, Wis. y �� UNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. PI t inclu, is /
not limited to vertical and horizontal reference point (BM), direction and % o , scale kie`. '' f I.D. #
dimensioned, north arrow, and location and distance to nearest road. <Iq
RE D BY DATE
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATIO y�
PROPERTY OWNER: ER Lam,
0 �FF� 4 1 T N,R ff (ore
PROPERTY OWNER':LI G ADDRESS LO # OR CSM #
CITY STATE ] ZIP CODE PHONE NUMBER OWN NEAREST R06D
�(] New Construction Use Residential / Number of bedrooms Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow ..;ZTi gpd Recommended design loading rate _bed, gpd /0 gpd/ft
Absorption area required bed, ft trench, ft Maximum design loading rate bed, gpd /ft , .S trench, gpd /ft
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design / site considerations "
Parent material Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL I HOLDING TANK
U= Unsuitable for Sys m ® S ❑ U 5 S ❑ U 21S O U EIS ❑ U ❑ S 0 U cis ❑ U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BoundEry Roots GPD /ft
in. Munsell Qu. Sz. Copt Color Gr. Sz. Sh. Bed Trerich
Ground IV a
elev.
Depth to
limiting
factor
Remarks:
Boring #
S S�
�ti2,.• 7
Ground
2
elev. _ _
� ft. $
Depth to -
limiting
factor
>TR
Remarks:
CST Name: — Please Print Phone:
A ddress: �a
Signature: Date: CST Number
A / �.
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552807 ti OM)
CERTIFIED SURVEY MAP
LOCATED IN THE NWJ of the SWJ of 'Sectioh.I19, ..T31N:, ...R18W,
SM LL TOWN OF STAR PRAIRE, ST. CROIX COUNTY, WISCONSIN;
fi UT I being LOT 1 of CERTIFIED SURVEY MAP VOLUME 10, PAGE
1 2880 at the ST. CROIX COUNTY REGISTER OF DEEDS OFFICE.
'
I
Wk CORNER OF SECTION 19
-
M :N89 °33'08 "W - 554.48' .IlNeLA.-CTEIl LAND M - -� 2QaIU A1/ERUE
M M N0� RTH LI OF TH E Swk
K-33 N89 0 46'40 "W 521.98' iv
M
r
,... ................. OWNER
LOT 3 Marcel Plourde
1� 807 205th Avenue
10.63 ACRES INC R/W SEPTIC Somerset, WI 54025
43122. SQ FT
C/) CDi 1369 7 SQ FT co ACRES EXC R/W
41369 Bearings are referenced to the
.—.I o
Lu H—I �o ^ O west line of the SW4 of Section 19,
LLJ 00 assumed to bear S00 ° 22 1 52 11 E
APPROVED
21 C/)I m (0'
l 1.1 a.J
1 0l A
—¢� O, CO HOUSE x--11 EEC 2 ' 761 1
—JI I D JJ
Lv N WELL C> —JI � SHED ST. CROIX COUNTY
Comprehensive Piaruiir
�� Zoning and
cn
Priarks Committee
v)� A� m ill ,nI U�
^
ZI ¢, NI if rot recorded
—� S89 0 29 1 02 11 E 565.20' within 30 days of
z1 33.00' �� L E GE D approval date
1 shad
b3 6 6 3' 532.20' 12' p !x�tr Jr be
County onu t nd
• LOT 4 • 1" Iron Pipe Found
C:)1
W 6.37 ACRES INC R/W 0 1 X 24" Iron Pipe set, weighing
.
• 277661 SQ FT 3 1.68 lbs. per linear foot
_ 6.00 ACRES EXC R/W
N
261539 SQ FT ^ ;�° ;*X yhW Exi sting Fenceline
0 00 co & z - •100' Roadway setback line
001
F--I
01 6 6 .
� 333' '
33.00' 538.52'
589 0 29 1 02 "E 571.52' SCALE IN FEET " =200'
SOUTH LINE OF THE NWk 8' .
9' OF THE SW>k 0 50 100 200 400 600
S T C - 100
This application form is to be completed in full and signed by
owner(s) of the property being developed. Any inadequacies w.
only result in delays of the permit issuance. Should ti
development be intended for resale by owner /contractor, (sj
house) , then a second form should be retained and completed wl
the property is sold and submitted to this office with
appropriate deed recording.
---------------------------------------------------------------
Owner of property - J
Location of property 1 /4 Si4 7 1/4, Section, T_N -R /
Township g >G r r Mailing address
Address of site ; ; : , �, y r
Subdivision name Lot no. y
Other homes on property? Yes �/� No
Previous owner of property � C C /Q r a l e
Total size of property
Total size of parcel _ ,�,, t r
Date parcel was created / 2
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? -7(d Yes
Volume and Page Number 3/ 0 as recorded with the Regis
of Deeds.
-- -------------------------------------------------------------
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND 1
NUMBER. AND THE SEAL OF THE REGISTER OF DEEDS. In addition,
certified survey, if available, would be helpful so as to av,
delays of the reviewing process. If the deed descript
references to a Certified Survey Map, the Certified Survey
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to
best of my (our) knowledge that I (we) am (are) the owner(s) of
property described in this information form, by virtue of
warranty deed recorded in the office of the County Register
Deeds as Document No. , and that I (we) presen�
own the proposed site for the sewage disposal system or I
obtained an easement, to run the above described property, for
construction of said system, and the same has been duly recorded
the office of the County Register of Deeds as Document
Signature of App scant Co- Applicant
_ ` —
Date o Sign tur- Date of Signature
STC -105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS v ? ;.. ? , a `' _... C�`� },
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY /STATE T4--r (fir a , r ; e , L—" S . ;
PROPERTY LOCATION 114, S 1/4, Section -- 1--� - T N -R W
TOWN OF cc r �C �c c l e
ST. CROIX COUNTY, WI
• C /
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP , VOLUME // . PAGE / Y , LOT NUMBER �I
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) aflcr inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
1/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 c. ' ation date.
SIGNED;
E�
DATE: 7/Z zf�z
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93