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CROIX COUNTY ZONING DEPARTME AS BUILT SANITARY REPORT (9 Owner Property Address City /State COLJ � ''` �C7hHNC.iOf Legal Description: Lot / Block Subdivision/CSM # A/ — IIA 14, Sec. �, TAN -R /� W, of / �r d2, r PIN # nil —4,1 61; /-*� SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION Tank manufacturer Size ST/PQO Setback from: House / Well Pump manufacturer Mod Alarm location (HOLDING TANKS ONLY) Setbacks: Service road V air mtake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: idth Length. Number of Trenches Setback from: Hou e ' Well A P/L ly?d Vent to fresh air intake Zr' ELEVATIONS Description of benchmark ElevationfQd D Description of alternate bench;iatf Elevation - 7 Building Sewer l / ` ST/HT Inlet 3 ST Outlet ©� PC Inlet PC Bottom. -- Header/Manifold :� Top of ST/PC Manhole Cover2 Distribution Lines () () ( ) Bottom of System Final Grade ( ) ( ) © ( ) Date of installation / / er it number � ;J State plan number Plumber's signature License number / xy Inspector r Complete plot plan a 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. /A/s ( / PLAN VIEW 3 uo /2d� x5g, 0 INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM ' Safety and Buildings Division Count y ST . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary3P Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)]. ft,R J�k ft j� N T CKY E � �fjk a ] rn o : State Plan ID No.: CST BM Elev.: Insp. BM Elev.: S#A- Qescription: KK Parcel Tax No.: �D 0 TANK INFORMATION ELEVATION DATA A9800525 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic idt(;I, Benc Dosing till 18 7 /Cr- 19 Aeration �'"! Bldg. Sewer 06 • /9 l 446 Holding St/ Ht Inlet 7- '7 9- -' — TANK SETBACK INFORMATION St/ Ht Outlet 7 3 9y•33 TANK TO P / L WELL BLDG. Air Intake R7NA Dt Inlet Dt B ottom Dosing NA Header/ Man. �Q,� t A?( Aeration NA Dist. Pipe Holding r — .� Bot. System 9 , PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand 5 � � � S,7s /40. Model Number �� GPM ' TDH Lim Friction System TDH_ Ft Forcemain Length Dia. Fi Dist. To well SOIL A TION SYSTEM BED Width Lengt No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION 3 6.2 aP DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: % INFORMATION Type CHAMBER Mo a Numb cyst d OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing I Vent To Air Intake Length / Dia. l ' Lengt&4�f Dia. , 2 4 Spacing & Agee lin6� 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: VILLAGE OF STAR PRAIRIE 6.31.17,NE,NW vv�l 14 ofe tj a j 40 tot Plan revision required? ` [� Y No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Anature Cert. No. i Vt scons i n Safety and Buildings Division SANITARY PERMIT APPLICATION 201 E. Washington Ave. 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 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number , � I, � 32 � �Q� � The information you provide may be used by other government agency programs ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. Cf State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Owner Name Prope y oc tion 1 /4 1 /4,5 WBck , N, � E W Property Owner's Mailin Address Lot Number l Nu mber Z� City, S e , r Zip C de Phone Number Subdivision Name or CSM Number Lo v�6 I1. TYPE F BUILDING: check one) ❑ State Owned ❑ It� ea est Road Public 1 or 2 Family Dwelling - No_ of bedrooms own III. BUILDING USE (If building type is public, check all­­ apply) Parcel Tax Number(s) O{v � 3/- 7• 1 ❑ Apartment/ Condo /V / — (oo Vld 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. E] Replacement 3, ❑ Replacement of 4. E] Reconnection of 5_ E] 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) 1 rlIC % /fya_oe � k /� _•�� "S�lGvui " , 31 -f5 1 Pure6mber Non - Pressurized Distribution Pressurized Distribution E rimental Other 11 []Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 1205eepage Trench ,5 El In-Ground Pressure f 42 [] Pit Privy 1 E] Seepage Pit / ( 7 2' 3 X Sao• 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION ,,'' 1. Gallons Per Day 2. Absorp. Area 3. Absorp.Are 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade ! Require (sq. ft.) Pro ed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevatio L• �a _ ,J G / Feet Feet Ca acct VII. TANK in allon Total # of Prefab. Site Fiber- E INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App xper. New Existin structed Tanks Tanks Septic Tank k ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ 1 ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's e: (Print) Plumber' 1 nature: ( No mps) MP /MPRSW No.: Business Phone Number: �t Plumber's dress (Street, City, Stat , Zip ode): oe IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued ssuing Agent Signature (No Stamps) rf A Surcharge fee) Adverse Determination ���CCC""" pp roved El Given Initial /�D °0100 6 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 IRA 1/96) DISTRIBUTION: Original to County. One copy To: Safety 6 Buildings Division, Owner, Plumber PLOT PLAN PROJECT Rickv Roettaer ADDRESS Box 102 Star Prairie Wi 54026 NE 1/4 NW 1/4s 6 /T 31 N/R 17 W TOWN Star Prairie COUNTY ST. CROIX 10/21/98 3 MPRS Shaun Bird 226900 DATE BEDROOM CONVENTIONAL XXX IN- GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .8 ABSORPTION AREA 572 # of chambers 18 IL BENCHMARK V.R.P. Top o f white stake ASSUME ELEVATION 100' ❑ BOREHOLE O WELL *H.R.P. NE corner of property SYSTEM ELEVATION 94.9 Alt. BM Top of Wood Fence Post with Orange Ribbon @ 103.8 Alt. Polk/St. Croix County Line Road 60' 75' 60' B -5 15' -4 0 ' Rep A Vents _3 2- 34" x 57' Trenches B -2 with 6' Spacing between 7 % Trenches lope o Garage 40 B -1 30 , B -610' B.M. Pro-& 10' 1E, 10' Bedroom System to be >25' Vent House from House >12" Sidewinder High of Cover Capacity Leaching Chamber with 31.8 ft ^2 per chamber 6' Long 16" Grade at System Elevation 34" Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in accordance with .1� 1R 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 1 `n in si must `' County include, but not limited to: vertical and horizontal referen ��" t (BM),j 5 l� i"o / X percent slope, scale or dimensions, north arrow, and to is 'and distantte bst road Parcel I.D. # APPLICANT INFORMATION - Please print forma , Re R ed y Date Personal information you provide may be used for secondary pu s "eriva ,VINb104 t r `ti � G Property Owner ation 1 /4,Wl /4,S T N,R 'E ( Property Owner's Mailing Address # Block# Subd. Name or CSM# Q38 to � Ci State Zip Code Phone Number Nearest R d city � Vill a ,� Town o� ' r S oaG (J /�' �?�$ 7 S�ar � 4 �� t New Construction Use: residential / Number of bedrooms _ ? Addition to existing building ❑ Replacement LJ Public or commercial - Describe: Code derived daily flow '� ©gpd ��' Recommended design loading rate bed, gpd/fi J L trench, gpd/ft Absorption area required bed, ft .7 trench, ft2 9Pd �1 Maximum design loading rate bed, gpd/ft /ft Recommended infiltration surface elevation(s) / ly. It (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 AT -Grade System in Fill Holding Tank U = Unsuitable for system ❑ U ❑ U ❑ U ❑ u ❑ Su ❑ S SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD/ft g Texture Consistence Boundary Roots ` in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench Ground l eev. y � ft. , Depth to limiting factor Remarks: Boring # Ground ft. Depth to �� b limiting factor J X 26 1n. Remarks: CST Name (PI ase Print) i ature� Telephone �0 hone No. /z.GL�� / ?-,/5 — e Address i Date CST Number • SOIL DESCRIPTION REPORT PROPERTY OWNER Page of PARCEL I.D.# Boring# Horizon Depth Dominant Color Mottles Structure 2 in. Munsell Qu.Sz.Cont.Color Texture Gr.Sz.Sh. Consistence Boundary Roots GPD/ft Bed Trench / �' � am/ -xnti � n r Li- 1 , S . /.3/y/Z77-,7z �-'i1 -art/ " a27,__5 /y) l ,x--/l/9 n/04 - Ground 0173ft. Depth to limiting factor //rin. 212 Remarks: Boring# RE / p"/t 10/(2/3 / /Y(L-€- s/ rtiy,- cs / , 3 g1201( ,/ ` L ( nyi_s /1/l t4 , 7; , �Grround /(y ft. Depth to • limiting factor j/.20 in. Remarks: S ) Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GP.D/ft2 in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. Bed , Trench Boring # / O / /4J: 5": 2 /A4f, 71/1./ - 2 Ground ele . • Depth to limiting factor 7//Uin. Remarks: Boring# eS .3 je(-te)/4,- 11.///7 //1 /11( :1 Ground ele .• ft. Depth to — ! limiting actor �" 'n' Remarks: SBD-8330(R.07/96) Soil Test Plot Plan Project Name Ricky Roettger Shaun ird Address Box 102 Star Prairie Wi 5 CSTM #226900 Lot 1 Subdivision - --- -- - - -- -- Date 9/ 10/98 NE 1 /4NW 1/456 T31 N /R W Village of Star Prairie Ej Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of White Stake Orange Ribbon System Elevation 94.9 * H R P NE corner of property Alt. BM Top of Wood Fence Post with Orange Ribbon @ 103.8 Alt. Polk/St. Croix County Line Road 60' 75' 60' C7 B -�10 -4 ' Rep A TB-1 - CD 7% lope Garage 40 , 0 , B -610' B.M. Pro 3 Bedroom House ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer R i c 1' R o e- f 4 f e- Mailing Address /50X /4.2- 54o.r U, //e ta•`tl' -e. Imo,, Property Address (Verification required from Planning Department for new construction) City /State Spar ern: r '� z W Parcel Identification Number 1 Co LEGAL DESCRIPTION Property Location %a, NW ' /., Sec. 6 T_j I N -R 1 7 W, f Subdivision Lot # Certified Survey Map # 5' 1 `/ L 3 , Volume ) 3 . Page # 3 5 3 0 Warranty Deed # S !K 'r( ? j Volume i 3 44 , Page # 2A I Spec house W yes ❑ no Lot lines identifiable 0 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. ,;&�r�( _ / 0 1.201 9 ( SIGNATURE OF AfPLICANT 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. " /o /xo/ 9Q SIGNATURE OF APLICANT 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 STATRA OF WISCONSIN FORM 2 — 1982 II ji WARRANTY DEED DOCUMENT NO. ' Garry H Russell and Gloria E Russell husband and ST. CROIX CO., W1 wife OCT��1999 �d conveys and warrants to Ricky A Roettger II � 30 M 4 k J Ro 14tor of Dq4 �I THIS SPACE RESERVED FOR RECORDING DATA - -- NAME AND RETURN ADDRESS the following described real estate. in St. Croix County, State of Wisconsin: j VAN DYK, O' BOYLE & SILER, S.C. Post Office Box 127 Part of the Fractional NE 1/4 of the NW 1/4 of Section New Richmond, WI 54017 6 -31 -17 in the Village of Star Prairie described as follows: Lot 1 of Certified Survey Map filed October 5, 1998 in Vol. "13 ", Page 3530, Doc. No. 588423. 182- 1021 -60 �i PARCEL IDENTIFICATION NUMBER t? TRANSFER This is not homestead property. Xtbdx: (is not) Exception to warranties: Subject to all easements, restrictions and covenants of record. li Dated this day of October A.D., 19 9 (SEAL) (SEAL) /* carry H.-Russell Gloria E. Russell (SEAL) (SEAL) * * AUTHENTICATION ACKNOWLEDGMENT Signatures) Garry H. Russell and Gloria E. State of Wisconsin, ss. Russell County. authenn tted this 13 _ �Oay gf October_ lg 98 Personally came before me this day of +� 0) OO 11 RA 0. 199 Ck SH 588423 ST. CROIX COUNTY CERTIFIED SURVEY MAP PART OF LOT 4 CERTIFIED SURVEY MAP VOLUME 12. PAGE 3379. IN THE FRACTIONAL NORTHEAST QUARTER OF THE NORTHWEST QUARTER SECTION 6. TOWNSHIP 31 NORTH. RANGE 17 WEST. VILLAGE OF STAR PRAIRIE ST. CROIX COUNTY. WISCONSIN UNPLA LANDS C/L COUNTY L I N E AVE. POLK \ ST. C ROIX ROAD N89 °33'27 "W 2780,52' NORTH L I N E NW I /4 SEC. 6 33.00 NI /4 COR. SEC. 6 T31N. R17W .................... ..............................� FD. SURVEY NAIL �C $89'33'27'E 640.96• 673.69' \ :66.01 574.95' SOO *23'16'E NW COR. SEC. 6 33.00• T31N. R17W FD. ALUM. MON. z) W ` W 3 L O T 1 a m .� z : w M �• ca a 262.094 SF. o E-- I o : 0 6 . 02 AC . n. _ �. LLIOTT t ` ~ : `^ N ° — S - 1300 i cy SPO NE , WI a. o .. i� �. LL >° I ''� SuNe _: N 89'33'27' W 574,71' J H: WEST LINE LOT 4 3� CSM VOL. 12. PG. 3379 EAST LINE LOT 4 SCALE 1" - 200' CSM VOL. 12. PG. 3379: BEARINGS REFERENCED TO THE NORTH LINE NWI /4 • FOUND I' IRON PIPE SEC. 6. T31N. R17W. (ASSUMED N89 °33'27 "W) o SET 3/4" X 24" REROD. WT. 1.50 LBS /FT. 1. LYLE L. ELLIOTT. REGISTERED LAND SURVEYOR S -1300 DO HEREBY CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF. THIS PLAT IS A TRUE AND CORRECT REPRESENTATION OF PART OF LOT 4 CERTIFIED SURVEY MAP VOLUME 12. PAGE 3379 IN THE FRACTIONAL NORTHEAST QUARTER OF THE NORTHWEST QUARTER. SECTION 6. TOWNSHIP 31 NORTH. RANGE 17 WEST. VILLAGE OF STAR PRAIRIE. ST. CROIX COUNTY. WISCONSIN DESCRIBED AS FOLLOWS: COMMENCING AT THE NORTH QUARTER CORNER SAID SECTION 6. THENCE N89 °33'27 "W ALONG THE NORTH LINE SAID SECTION 6 673.69 FEET: THENCE S00 °23'16 "E 33.00 FEET TO THE POINT OF BEGINNING: THENCE S00 ° 23'16 "E 456.00 FEET: THENCE N89 ° 33'27 "W 574.71 FEET: THENCE NOO °25'07 "W 456.00 FEET: THENCE S89 °33'27 "E 574.95 FEET TO THE POINT OF BEGINNING. SAID PARCEL CONTAINS 6.02 ACRES MORE OR LESS. AND SUBJECT TO ANY EASEMENTS OR RESTRICTIONS OF RECORD.