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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
•Lahr.,and Human Relations
* �•inn of Safety Buildings in accord with ILHR 83.05. Wis.Adm. Code
COUNTY
St. Croix
A4tach complete site plan on paper not less than 8 1/2 x 1 , i f. Plan must include,but
not limited to vertical and horizontal referencepoint B• W 1.i: . , PARCEL I.D.x
( y• �'' pe,scale or
dmensioned, north arrow,and location and dista t' at road. 'w� 030-2096-00
APPLICANT INFORMATION-PLEASE PRI• L ION REVIEWED 8Y DATE
.
PROPERTY OWNER: 1" • P•=� LOCATION
Vernell A. & Stephen L. Skogl F, G G. •T NE 1/4 NW 1/4,824 T 30 ,N,R 20 *Or)W
PROPERTY OWNER':S MAILING ADDRESS --1- Cox L r rt BLOCK a SUBD.NAME OR CSM$
149 High St. f cc lYY \' na Country Side Estates
CITY,STATE ZIT CODE P tmIV 'Aj [PILLAGE [OWN NEAREST ROAD
New Richmond, WI. 54017 ( e5+ 1 ; . Joseph Hy. #35-64
tot New Construction Use 1x1 Residential I Number of bedrooms 3 [ 1 Addition to existing building
1 1 Replacement 11 Public or commercial desaibe
Code derived daily lbw 450 gpd Recommended design loading rate •5 bed,gpdAt2 •6 trench,gpalt2
Absorption area required 375 bed,ft2 375 trench,fl2 Maximum design loading rate •5 bed,gpdnt2 •6 trench,gpo/ft2
Recommended infiltration surface elevation(s) 104.12 ft (as referred to site plan bendmark)
Additional design/site considerations na
Parent material pitted glacial drift Flood plain elevation,if applicable na ft
=Unbfor osOSlaI ° PRESSURE I AT-GRADE
I Ius le system � ❑S U ®S ❑u O ® ®U SYSTEM
®U HOLDING
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structureem , Roots GPD/ftZ
in. Munsell Du.Sz Cart Color Gr. Sz. Sh. Bed 1Trench
1 41 `0-15 10yr3/3 none sl 2msbk mfr gw 2f .5 .6
ititimmtit 2 15-31 10yr4/4 none sic1 2msbk mfr gw if .4 .5
Ground 3 31-52 7.5ry4/4 c2p 7.5yr5/8 scl M na na na np .2
elev.
103.12it
Depth to
limiting
31"
Remarks:
Boring* '
1 0-13 10yr3/3 none 1 2msbk mfr gw 2f .5 . .6
2 ': 2 13-29 10yr4/4 none sil 2msbk mfr gw 1f .5 .6
3 29-60 7.5yr4/4 c2p 7.5yr5/8 sicl M na na na .2 .3
Ground
elev.
103.12ry.
Depth to '
limiting
29"
Remarks:
CST Nam.:—Please Print PhGary L. Steel 715-246-6200
Addna: 155• '00th. Ave. New Richmond, WI. 54017
Signature: cz, / / 8-10-95 Dap' cstm 02298CST Number:
PROPERTY OWNER V. 2 3
S. Skoglund SOIL DESCRIPTION REPORT P age�Tnf ti
PARCEL I.D.s 030-2096-00
Boring # Horizon Depth I Dominant Color Mottles Texture Structure Consistence i� Roots Bed DT/ft2
in. Munsell au.Sz.Cont.Color Gr. Sz. Sh.
1 0-10 10yr3/3 none 1 2msbk mfr gw 2f .5 .6
3 •
2 10-26 10yr4/4 none sil 2msbk mfr gw 1f .5 .6
Ground3 26-48 7.5yr4/4 c2p 7.5yr5/8 scl 2msbk mfr na na .4 .5
1051�$2ft.
Depth to
limiting
factor
26"
Remarks:
Boring
mom
•::sa
Ground
elev. '
ft
De9Cr to
YrrrMg
fader
Remarks:
Boring# •
lifittern
era ,:x
as s •
Ground '
elev.
ft.
Depth to
liming
facto
Remarks:
Boring #
l r
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel 1554 200th Ave.
CSTM2298 Vernell A. & Stephen L. Skoglund New Richmond, 0 54017
MPRSW-3254 1 1�W S24-T30N-R20W
town of St. Joseph (715) 246-6200
q. lot #10-Country Side Estates
NI
1"=40'
BM.= top of SW lot stake @ el. 100'
1 1
t0
01 M
W o �
V S I
tsq
/
IL 0
a
\41 In
PIO
55 ' 39 ' Zz ' 53
Bl�
Gary L. Steel
8-10-95
4 1 t/
9 'O
RECEtvEll
N
STC - 104 AUGz6 Igor
AS BUILT SANITARY SYSTEM REPORT 'D ZON ST
-I
/ / IVr
Opp
OWNER �,aah i,)
ADDRESS )4 3 , 371
.�ii.s,A) tom),t S ly
SUBDIVISION / CSM# ell, �,,„- , g24-^5 LOT # /Z,
SECTION 9-' T 2 N-R--7, W, Town of „�sr;.of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
s
() r----
__AZ W :26,
,re j •-•
.b I 3
1 ,,,i4.,.... ._____,,_
a�'
Dr ! ge".
r q
1
do Iasi
a
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
I !
BENCHMARK: 4, T":
ALTERNATE BM: 7t, m71111,,es. /! a/i.r-
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: A.47 ;,k/S Liquid Capacity: Arm} S,r/
Setback from: Well 7r House Other
<J/ice //G /
Pump: Manufacturer a„g Model# ?g'n /Size �f/�
Float seperation Gallons/cycle: /3 7
Alarm Location /j4) .16
SOIL ABSORPTION SYSTEM
Width: Length 7 5 Number of trenches
Distance & Direction to nearest prop. line: 1-47j-
Setback from: well : House h Other
ELEVATIONS
Building Sewer /,A' ST Inlet . /7 ST outlet 9• �/
PC inlet PC PC bottom 9s 3 Pump Off
Header/Manifold / ,22 Bottom of system 9 's
Existing Grade 97 S/s Final grade
DATE OF INSTALLATION: , g-- /5--9
PLUMBER ON JOB: �(()&L,'ai�
LICENSE NUMBER: _s�
INSPECTOR:
3/93 : jt
ti r
,wisc . ''epartment0 ndustry, PRIVATE SEWAGE SYSTEM County:ST. CROIX
. nd Human Relations INSPECTION REPORT
.la"fety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION �g�
P 1 bt Eq'OP; DAVE 0 City 0 Village C1 Town 01: State PlZ)ISIJo4
St Joseph parcel Tax No.:
CST BM Elev: Insp.BM Elev.: BM Description:
/00 /00 r n U 'ktf l • ' D9500327
TANK INFORMATION ELEVATION DATA q=3L.)
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic U/e..e J �,... Zq C !i rt > , ,1; Benchmark cP . . .d ei,,,> /DD, 6,0
r
Dosing /-t�-.Fd Lifh it-e f ;..),!J:;s C
Aeration Bldg.Sewer ‘/, J'i' gq/...kl
Holding St/Ht Inlet 49./7•
TANK SETBACK INFORMATION St/Ht Outlet --,S y• eig,gi "
TANK TO P/L WELL BLDG. vAuenttoIntake �• -�ROAD Dt Inlet l ' 9(„f 5'
Septic .. -' ,5� a.�r > ; NA Dt Bottom /./. /S • Q3.3
Dosing ,d5' > ',' 39 . ,,Z 5 , NA Header/Man. 5,3 ?? 4'9- /2. '
Aeration NA Dist. Pipe , F 31 9 . 13 '
Holding Bot. System G.0 ?,U 5
PUMP/SIPHON INFORMATION Final Grade (4,3` /oo. /3. '
Manufacturer • Demand
Model Number /, / 2 /% ,)/-1,`(. GPM
TDH Lift ;'g')• Loss on.`l' SY Headm, TDH/1-7 Ft
Forcemain Length S ) Dia.,_;' Dist Towell
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No.Of Trenches PIT No Of Pits Inside Dia Liquid Depth
DIMENSIONS Co ' -2 = / DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM
LEACHING Manufacturer:
INFORMATION Type Of iY'J / CHAMBER Model Number:
System:�Yr"'' '.� �/G;) G S `JS
' " -d OR UNIT
DISTRIBUTION SYSTEM
He, Qer I Manifold Distribution Pipe(s) I� 2 v x Hole Size x Hole Spacing Vent To Air Intake
Length �I Dia I Length 'jd Dia I Z Spacing )(• I l/(,l 1, i //
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over I xx Depth Of xx Seeded/Sedded' xx Mulched
Bed/Trench Center /g" Bed/Trench Edges •/,)-/y Topsoil t — 3es 0 No B ies ❑ No
COMMENTS: (Include code discrepancies,persons present,etc.)
LOCATION: St. Joseph.24.30.20W, NE, NW, Lot 10,
r, /' ,, . ) o , .
zi
Plan revision required? 0 Yes gNo
Use other side for additional information. �. 0 r.J if „/(_c�+ �'
SBD-6710(R 05/91) Date In ctor'sSignature Cert No
ADDITIONAL COMMENTS AND SKETCH ,
SANITARY PERMIT NUMBER:
_._
r
on
O1r :IR BurSafeau oanfBuilding Waters System:
�� .,., SANITARY PERMIT APPLICATION 201 E.Washington Ave.
In accord with ILHR B3 05,Ails 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 1
than 8 1/2 X 11 inches in size. C/S ,L l7
• See reverse side for instructions for completing this application State Sanitary Permit Number
A 10i
The information you provide may be used by other government agency programs ['Check II r ISNxt to q s appl cat xI
(Privacy Law,s 15 04(1)(m)I State Plan I.D.Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION .'Ws — 1�//8d
Propjy Owner Name Property Location
l /4rJF /I/�, rr/.a A/� 1/4 r/�f/ 1/4,5_9,,y T �G ,N, R 21 E(or
PropertyO er's I�g A e A Copt Numb Block Number
SC itiveiL :61, Phone Number Subdiv .n Nanr or CS 2(}er �
ivt
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road
❑ Village /
❑ Public pi 1 or 2 Family Dwelling- No. of bedrooms 3 x Town OF_ --- n<iP}r/
Ill. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s)
0/, v6)ib—cli—Cz z
1 0 Apartment/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 0 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. is 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 2(1Mound 30❑Specify Type 41 ❑Holding Tank
12 ❑Seepage Trench 22❑ In-Ground Pressure 42 0 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.) I Proposed(sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
/`?3 i 7> Il '.. /.�7 . �/A 97si) Feet /f.e,iS Feet
Capacit
VII. INFORMATION in gallons Total #of Prefab Site Fiber- E<per
Manufacturer's Name Con- Steel lass Plastic App
New Existing Gallons Tanks Concrete strutted 9
Tanks Tanks �1
Septic Tank or Holding Tank / /un0� ! k1I.r.el' _� 0 0 0 ❑ ❑
lift Pump Tank/Siphon Chamber fere s?/M / I , /=fk.i 3 ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for' stallation of the onsite sewage system shown on the attached plans.
Plumber' Name:(Pri Plum es Si n zra/Z-Zmps) MP/MPRSW No : Business Phone Number:
tea' a .�rY 7/— 721 - ?2 /
Plum rsA dress Streeity, to Zlpy )
.?Cril3 / d:,v.i . Tr1/ S e �.9i6e.r /i.)-r _S--; ' 'l
IX. COUNTY/ DEPARTMENT USE ONLY
❑Disapproved Sant ryPermitFee ilea1une Gro,ndwater 15:ate ssue issuing AgentSigna /pI(� amps)
Star argef eel
Approved ❑Owner Given Initial �t/`� t� /o -i > 5 L. 13
Adverse Determination
d�
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SND.6398IR 0S/941 DISTRIBUTION: Original to County.One ropy To: Safety 6Rui1.hngs Diwvon.Owner.Humber
0 INSTRUCTIONS 1 . .
•
1. A sanitary permit is valid for two(2)years.
r
1' 2. Your sanitary permit may be renewed before the expiration date,and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
fR 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form(SBD-6399)to be submitted to the
county prior to installation
E 5. Onsite sewage systems must be properly maintained. The septic tank(s)must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
i
1 6. If you have questions concerning your onsite sewage system,contact your local code administrator or the State of
Wisconsin,Safety and Buildings Division,608-266-3815.
•
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s)of where the
system is to be installed.
` II. Type of building being served. Check only one and complete#of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public,check all appropriate boxes that apply.
1 IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection,or repair.
I V. Type of system. Check appropriate box de depending on system type.
YP YP 9 Y Yp
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new/or existing tank,list the total gallons, number of tanks and
manufacturer's name,indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix(e.g. MP,etc.),
address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan,drawn to scale or with complete dimensions,location of holding tank(s),septic
tank(s)or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
i.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges(fees)for a number of regulated practices which can
f effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
SAFETY&BUILDINGS DIVISION
State of Wisconsin
Department of Industry, Labor and Human Relations
September 29, 1995 2226 Rose Street
La Crosse WI 54603
K 0 CONSTRUCTION
KIM 0 CONNELL
308 MIDPINE CT
STAR PRAIRIE WI 54026
RE: PLAN S95-41189 FEE RECEIVED: 180.00
MIDDLETON, DAVE
NE,NW,24,30,20W
TOWN OF ST JOSEPH COUNTY OF ST CROIX
MOUND SYSTEM
The Department has reviewed the above-referenced submittal .
Conditional approval is hereby granted for the system plan submittal. All
noted items must be corrected. The review and approval of the system is based
on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin
Administrative Code, and is contingent upon compliance with any stipulations
shown on the plans. This system has not been reviewed for the code
requirements set forth in chapter ILHR 82 or in chapters ILHR 50-64, Wisconsin
Administrative Code.
This plan submittal approval will expire two years from the approval date, or
if a sanitary permit is obtained, plan approval will expire on the day the
initial sanitary permit expires. The licensed plumber responsible for this
installation shall keep one set of plans with the Department's stamp of
approval at the construction site. The installer shall notify the appropriate
inspector when inspections can be made.
All permits required by the city, village, township or county shall be
obtained prior to installation.
Inquiries should be directed to me at the number listed below. Please refer
to the plan number shown above.
Sincerely,
Ce;404-"Sa
Dennis Sorenson
Wastewater Specialist
Section of Private Sewage
(608) 785-9336
BBDA.71071L 111.91,
Wisconsin tepartment epartment of Industry. PRIVATE SEWAGE SYSTEM Safety and Buildings Division
Labor add Human Relations REVIEW APPLICATION Bureau of Building Water Systems
•
Hayward Office La Crosse Office Madison Office Shawano Office Waukesha Office
2Q9 W 1st Street 2226 Rose Street 201 E Washington Ave 1340 E Green Bay Street 401 Pilot Court.Suite C
Rt 8,Box 8072 La Crone,WI 54603 P 0 Box 7969 Suite 300 waukesha,WI 53188
Hayward.WI 54843 Phone(608)785-9334 Madison,WI 53707 Shawano,WI 54166 Phone(414)548.8606
Phone(715)634-4804 Fax(608)785-9330 Phone(608)267 5119 Phone(715)524-3626 T6x(414)548-8614
Fax(715)634 5150 Fax(608)267.0592 lax(715)514 3633
INSTRUCTIONS. To save time.schedule your review with one of the offices listed above prior to submittal Fill in all applicable data and submit this
form together with fees and plans/information Your submittal must be received at least one working day prior to the appointment at the office
where your review was scheduled Please call any of the listed offices if you need help lilting out the form or,hwq qu5ions on4hat information to
submit PLEASE PRINT VERY CLEARLY. A sample of a completed form is on the reverse side for your refer
eRa V �' 1 1 8 9
1. APPOINTMENT INFORMATION-If you have scheduled an appointment,fill in the information requested below to save time
Appointment DateReviewer� Nime Plan Identification Number(
/-�7- �9 -1 Ji;Lbu., _�7-.) - �/tS"
2. PROJECT INFORMATION If this review is a revision or extension to your existing
plan identification number,provide that number here:
Projec Name
/�y/J 4 0 City ❑ Village [i Town Of: County
/2Ltr ///, ��F..4j,r
Project Location /� /
GOVT LOT�/S 1/4)1/(/ 1r4,S-'/ T .7/7 N,R -'-,2,.". E(or)(srv, -3-1_ ,/y,/ _ -'1 (),412,
3. APPLICATION FOR 4. FEE COMPUTATIONS FEE SUBMITTED
System Type (check one): System Type 1 (include new and existing tanks)
Up To 1,500 gallon septic tank S 110 00 f/C -
A 0 At-Grade 1,501 - 2.500 gallon septic tank . S 120,00
H 0 Holding Tank 2,501 - 5,000gallon septic tank S 160 00
M ® Mound 5.001 - 9,000 gallon septic tank $20000
N 0 Non-Pressurized In-Ground(con.ention.) 9.001 -15,000 gallon septic tank S 300 06
P Pressurized In-Ground Over 15.000gallon septic tank S 500.00
O ❑ Other: _ Up To 1,000gallondosechamber S 1000 ) i -
1,001 • 2,000gallondosechamber S 8000
Building Type (check one): 2,001 • 4,000 gallon dose chamber S 100 00
4,001- 8,000 gallon dose chamber S 120 00
D Dwelling.1 or 2 Family 8.001 -12.000 gallon dose chamber S 140 00 -
P Public Building Over 12,000 gallon dose chamber S 160 00
S El State-Owned Building Up To 5,000 gallon holding tank ... S 60 00 .
/ 5.001-10.000 gallon holding tank . S10000 .
Code Derived Daily Flow 75J� 9pd Over 10,000 gallon holding tank S 150 00
Check If Replacing Existing System Experimental System(additional one time fee) S 300 00
Revisions To Approved Plan 7 S 60 00
Petition For Variance: Setback . . RE^E/'$100 000 .
Site Evaluation ll++C NvEEp
0 Petition For Variance Plumbing cr 2 S223 00
Revision � SEp 6 SQw00 __
Groundwater Monitoring•Per SiteSAFETV& BLD s 60 00
Groundwater Monitoring (other than a proposed subdivision) GsS.
D/y
ElSite Evaluation in Lieu of
Groundwater Monitoring Site Evaluation in Lieu of Groundwater Monitoring S 60 00
Subtotal: J -
Priority Review: Enter same amount as Subtotal: .... ... /4fi -
MAKE ALL CHECKS PAYABLE TO: SAFETY AND BUILDINGS DIVISION Total Fee: IRO —
5. SUBMITTING PARTY INFORMATION
Telephone No (include area code&extension) Comp ny ame l Co ail Pers
/ /
No &Street Address Or V O Box City.To n or Vij ge,State,Zip de
1 Aerobic or prepackaged treatment system fees are calculated based on equivalent sue septic tanks and dose chambers
z Revision fees are not applicable to temporary holding tanks or extensions to existing approvals
NOTE: Fees are pursuant to Wis Adm Code,Chapter ILHR 2,and are subject to change annually
The information you provide may be used by other government agency programs(Privacy Law.s 15 U4(1)(m)I
SBDW-6748(R 09/94) OVER --Ai-
Wisconsin tlrapartrrentofIndustry, SOIL AND SITE EVALUATION REPORT Page / of J
Labor aril Human Relations
• Division of Safety 8 Bul6ngs in�� 1�!�th'L H4 0 m. Code
+J �/ 0 J (1.011t.
COUNTY /z 2
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include,but '5 / —� 1X
not limited to vertical and horizontal reference point(BM).direction and%of slope,scale or PARCEL I.D.e
dimensioned,north arrow,and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROP TY OWNER: PROPERTY LOCATION .
/ ',Ali': i.b,2c‘ra..i GOVT.LOT )j IAA; va,B,2/T 6, ,N,R��,, 'o(
PROPERTY OW E ':S MAILING AD RESS LOT I BLOCK I SUBD.NAM OR CSM e
CTTY, ZIP CODE PHONE NUMBER ❑CY ` 4. GE OWN Jr, NEARE O
�,i1L�-/,-� g '✓ �3-r.e_) Z,-2) y ? ._s .,.;�.;/ - s .-)75-"-c.'.-V
IA New Construction Use [XI Residential/Number of bedrooms .3 I I Addition to existing building
[ I Replacement [ I Public or oommerdal desaibe
Code derived daily flow -'4 gpd Recommended design loading rate /..,-; bed,gpd/ft21_2 trench,gpdfft2
Absorption area required i 75" bed,ft2 ;75' trench,ft2 Maximum design loading rate /,.7 bed,gpd/K2 L.-2 trench,gpd/ft2
Recommended infiltration surface elevation(s) .7 R ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material1i)L T /.I'J'A')i.. - 6/ .:// 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 ❑S JD w S ❑U ❑S , I U ❑S 1.2U ❑S II U ❑S FI U
SOIL DESCRIPTION REPORT
Boring# Horizon Depth Dominant Color Moftes Texture Structure Consistence Bouncily Roots GPD/ftz
Ea,.,,,.„_,
in. Munsell Du.Sz.Cont.Color Gr. Sz. Sh. Bed Trent
C- `/ /G5�-z4 <1 /_; if,-d / .1__• ,7-„, _ -, .(
9-.?7 / V'// AI AL ; r. / c'v1 .1w - 7 8
Ground 5 ay_3�_/D � �r� s ��.,.i, h,/ a_ j1 . 7 .s r. -
.4 ff. -/ ,31;�' .r.�Yl/ ,.1.3 :1"rr., . s/ 0 �m �.. 1I.- - .l f NP n/P
Depth to
Milting
factor
/ -
Remarks:
Boring# /+ .11 1/// /// _
=..::::::• / 0-A-2 /I) i/J A/.? / /[_Z ,l. / La1 , 3,. . .Lt
§' .-2 A2-,as /1^1f'y/ .fr A- .ii / _, . 1., 7 ...9
Ground ,- --.?? /GX'.� _s Z'.., , , / e,c /f . 7 . g
ssPG/8
9e ?7-�C sx.'s� ,�,? ssc'7l _ / G�..., �L.•� — ,t i '' Ai,"
Depth tD
limiting
factor '
,'9
Remarks:
CST Name:—Please Prim f/ Phone: _
Address:
Signature: / Date: CST Number:
PROPERTy 0*NER .1 /KI.a., SOIL DESCRIPTION REPORT Page -. )of _Y
PARCEL I.D.is
S 95 - 41189
• Depth Dominant Color Mottles Structure GPD/ft2
Boring# Horizon . Texture Consfstence Bcxrciary Roots
in. Munsell Cu.Sz.Coat Color Gr. Sz. Sh. Bed Trench
iW
/4)x
idA / 7 Lic"
Sle419
Ground - - iyi)
elev.
,/It
Depth to
limiting
factor
Remarks:
Boring#
II
Ground
elev.
ft
Depth to
limiting
factor
Remarks:
Boring#
Ground
elev.
ft.
Depth to
factor
Remarks:
Boring#
•
Ground
elev.
ft.
DePttl 10
limiting
factr
Remarks:
S8D-8330(R.05/92)
' f/'��• '. ,y� S 9 5 " 41189 T •.�,F .?
.1) m /iagi awe. ....)
c // 44.e.,..,4 u A Aff4,fit)%d/ _1.-4_-,7- .r. eA(,,,Z )
sAi, , /17/✓ Esc '5.1CS,/
Al / /A1e- 401',,2)0A-.F1Abv ' ..J.,:
X ,./0c4, 4.J di sl s, .s
A Sp"/// As cl1A s 3t-L
oZ ilk. /
. /./...56, .$(4.4 _ ,
�' ems-9s' ,lam
1 (211
CSTh a?3�7 moo Jd/A/,.,a , 3 101i..
1
1
1 1 32' I /
J 7.r G f a� �L—.� ' s7L.78 v. 1.� 1,'anq -- --- t 1114#04-5
Z.D. 0-1
---4'- &' I )\1
a
4 Go
3g'
1, 5Z7/
As / of !C
S95 " 41189
• WORKSHEET - MOUND SYSTEM DESIGN
PROBLEM:
Design a mound system for a /vd ///•,04U17,,; •
The site characteristics are:
Depth to groundwater or bedrock / in.
Landslope 3 % .
Percolation rate , 5 4 L ?. k
Distance from dose chamber to distribution system �� ft.
Elevation difference between pump and distribution system ' ft.
• Step 1. WASTEWATER LOAD • -2A '- /.sC^l,/ _
Step 2. SIZE THE ABSORPTION AREA
A) Area required ■ </5� �� /..��,/li h1'y c— sq. ft.
B) Bed or trench length (B) ■ 7s' ft.
r. ;. C) Bed or trench width (A) ■ 1� ft.
ti'
.: ' .•D) Trench spicing (C) ■
7t T?t-- Wastewater load .24 gal/ft2/day B ■ ____ ft,
metre�c� e�Fi ss
Step 3. MOUND HEIGHT
A) Fill depth (D) - /,l ft.
B) Fill depth (E) ■ D t 6 slope cAJ'f'g,% ha. ft.
/•t 03(6) =) i/8
C) Bed or trench depth (F) ■ A s' ft.
D) Cap and topsoil depth (G) •
E) Cap an -tops° 1 depth. (H) • /.-`;' ft.
•
• I,icenuo Nu:
Jane '—-._�'1� 2\
tittity Of .1G.'
S 95 4 41 1 89 //1. ia.) •
Step 4. MOUND LENGTH
A) End slope (K) ■ rD + E) + F + H x 3 • /G, T ft.
Lam'
B) Total mound ngth (L • B + 2(K) • ',,i ft.
Step 5. MOUND WIDTH
Al) Upslope correction factor in
A2) Upslope width (J) ' (D + F + G)(3)(factor) • Z,_ ft.
(/ 7(, .3). /)0) (, 9/s) = y, 74s
81) Downslope correction factor • 2I
B2) Downslope width (I) • (E + F + G)(3)(factor) • ..? ft.
(1.18.-.83 1)(3) (/.4 /D,i
• Cl) Total mound width (W) for bed ■ J + A + I • _ ft.
7stGr/4-2 =
C2) Total mound width (W) for trenches is •;
J + + (no. trenches -1)(c) + A + I • 04 ft.
•
Step 6. BASAL AREA •
A) Infiltrative capacity of natural soil • ga1./ft2/day
B) Basal area required • wastewater flow
natural soil infiltrAtiy, capacity 44_ sq. ft.
Cl) Basal area available for bed for sloping sites •
•
B x (A + I) ja,.),.'5 sq. ft.
G,9s ria;i)_ b20
C2) Bas are avail) le for trench for sloping sites •
Bx _ �J + A • . sq. ft.
3) Basal area available for trench or bed for level
�s • x W • sq. ft.
Sign:
Liconso A'u: „
Dato:
of
- S 9 5 41 18 9 fog
.14,' Step 7. DISTRIBUTION SYSTEM
7A) SIZE DISTRIBUTION SYSTEM
1) Hole size • i4/ in.
2) Hole spacing • s in.3) Distribution pipe length • 4
Li
4) Distribution pipe diameter • /`2- in.
5) Spacing between distribution pipes ■ 34 in.
6) Distance from sidewall to distribution pipe • 7..' in.
7B) DISTRIBUTION PIPE DISCHARGE RATE
1) Number of holes per pipe •
2) Flow per pipe • 8% /7/et/a- ; 9i' GPM
7C) SIZE MANIFOLD
1) Manifold is central/ end
2) Manifold length •
3) Number of distribution lines -
4) Manifold diameter - ? in.
70) SIZE FORCE MAIN
1) Minimum dosing rate • ,ZZ 2'GPM
2) Force main diameter • ,i , in.
3) Friction loss - = �?s '.475` , , ft.
/00
7E) TOTAL DYNAMIC HEAD
1) Vertical lift • _2' ft.
2) Friction loss •
3) System head 2.5 ft. - ,2 c ft.
• ) Total dynamic head - SR�C�I VFD /J9 ft.
SAFETY E D 1995
Licerge: GS 0/V
Dato:__ j 24-
S 9 541 18 9 Nye
,// . of /
••
•
7F) PUMP SELECTION
1) Pump selected will discharge 7 Sr GPM at /. :,? ft.
total dynamic head.
2) Pump model and manufacturer
J1
7G) DOSE VOLUME
1) 10 times void volume of distribution lines • i! gal ./cycle
/0 I:Y(7o)(O 9J2J _ //4/
2) Daily -Wastewater v lume ; 4 doses/24 hrs. • //,7, 5-gal ./cycle
/�'o./ .' -.5/- s/>rh = -44 s-
3) Minimum Zose volume • //C gal ./cycle
)
711) DOSE CHAMBER
1) Minimum capacity required u 5?'-7sy1./ gal .
/�i .:o �, /)J'EEs
SioCn: s
Lictnse ::u:_
Date:_ / 7-QC— ._ —
Sys " 41 189 / £ 5 -C/O
.9Jr ,a�crrw if'.l N su,-,/.�30�.� ✓
t�// 1f/3 �Jc �a:4 ce-lex1 r9i/
S// P Ad sso3Z
4 •c/ ege+e„1S
-5;7=4 -:...�,1- h/ navy/
/1-'/',s474.; - L 2Ezs JtvJf/
/,44.o sde-ot4y8,'i
?/7-yr 10..le r/sa./,/-K
Lia&--.1/
/9?"441 -7..45 31
a
.J-
/7./S , Inn .
�o � 1
/
4 C:015-04,1 it.1^0p5
- /s-rt*:"4) ,36
Lo'N''''''......,.,..._ 41/1/4''
ON&TE SEWAGE SYSTEM
At /4Conditiotuitly
S
APPFIOVED
CEPAk N-i iic !'9CUSTRi. LABOR MD ftl_N!+.AN RELAT10i.LS
-�m t/G' �,'"N a - LA: Cr:�� • MD Bacx:ss
St' `1iE CCRtt+S1+QWEI:CE
I
• Page 1„ or /4
•
. S95 '" 41189
Straw, Marsh Hay, Or
Synthetic Covering Distribution Pipe
Medium Sand
H ' F .G
Topsoil '
ollek
Force Main Plowed Layer
t slope
Bed of 1/2"-21i"
Aggregate
Cross Section of a Mound System Using Ft.
E � G,
A Bed For The Absorption Area D 9 Ft.
F . Rs Ft.
A G Q Ft. G / L. Ft.
B /2 55- Ft. 6, H /s- Ft.
Signed: K 'A S Ft.
I, g3 / Ft.
Ft.
License �5` I /D, Ft.
-, ergs i$SEWAGE SYSTEM
Date: � �7-f� w ,,QQ
n�iiinnu�tl.,
I
APPROVED em
DEEPAR ',.. %I f ui T!.CJSTRY. LAF:%f? AND I'IAMN Ii:LAT C 1S
Alternate Position of %T
Force Main E C' PF.:IE'OPa.,F.'".:E
I L , I
J Observation Pipe
I---- BI___K—.
A i Force/Main
W � IBedPipe of 1/2"-21/2"
Aggregate
ion
I Pipe Permanent Marker
L.,____:_w_.____ -...., _,....--------------/
Plan View of Mound Using a Bed For the Absorption Area
. w
S 95 - 41 1 8 9 P4g.2 o
,[ ni,' /n.wou yew
Perforated Pips Detail
0jMVIN
Perforated...../
W CNo PVC Pipe
NilesLocated On Bottom,
•,^ �d AA lavas
Spiced
4
i.E SEW AGE
'►it
PVC Fora Moir `l7t ett }
gisir„.——0 ^pill
7.4 r to*
Manifold Pip K , / ry ...al
� ,r4
�"�:._.:n�s"" �STfiY. tp�t,R 0 E�1LLr,�CS
p�FAR ��rtll�:� rc
Otatrit slicn 1 loVo'M ty- T3Crc
Lea, Hell Should Si
Neel Ts EMI Cop
End Cap Distribution Pipe Layout P _.? Ft.
R �' r
S 3 ' tr
X �/� Inches
• Y - /-P Inches
Signed: ////!////��!/� Hole Diameter /i} Inch
Lateral ,f_ Inches)
License Number: "? s.--i Manifold " V Inches
Date: 6;/ l'z_is Force Main " Inches
/ of holes/pipe 3
Invert Elevation of Laterals ', Ft.
ro
LI.] ;
�. v.J
J 1 ,11
b' \\
1 oro
k to
Lc 0
I 1 1 I t
rr
I -�m w 1.1
)1. : i n
M-
�y
R` to
M W
A N
1.
....... a 11 9
,,,
r o
M
_ -- <a cu ��
V " \i SI n
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. ip, >
r'7 _y .J rr
' 4 T O
so N p In
rnLIO a 1')
1 . * X
r r- COZ).. D rrC\ri -' .. 0 o
11 n
• r
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K.
70
rn
r- "r
a
r
4.13
M
a
r9
PAGE 2 OF.,l�.
PUMP CHAMDER CROSS SECTION AND SPECIFICATIONS A/ad" oilAw
•
•
��VENT CAP S 9 5 " 4 18 9
4. VENT PRE
WEATHERPROOF APPROVED LOCKING
~ JUNCTION DOX MANHOLE COVER WITH
25' FROM WAµIN. LABEL
DOOR, ILMIU. •`
' 7- �
WINDOW Olt FRESH \\AIR INTAKE
I GRADE —
4, �� V'Mlu. j
I D'1KI U.
CONDUIT � �' g _�
WAIN. V LI\ (�
i _-
;:,
INLET PROVIDE I " -— 4•---A
ONSITE SEN lAGETSaIt$� I 1,17
I I
APPROVED JOINT/ A COntiGhOnaigi I III AP D JOINTS
W/ ►IPE I III w/ ' PIPE
EXTENDING 3' i CI
pp� I '1 ALARM O TO OILIi SONTO SOLID SOIL .5�r ti�I V'E ONTO SOLID SOIL
EPART •"-',1. Of INDUSTRY. 11MR A.) IRIMAN RELATIONt I ou
G DIMS{ 'I - ,'I AU) u!_aRNGS
I
ELEV. FT.---" __J
sit ca�I���l���;rl�t;� , b Off
0 L V
ICONCRETE DLOCK-4
RISCR EXIT PERMITTED ONLY IF TANK MANUFACTURER HAS SUCH APPROVAL
3" APPfloVE.b 6EDDING undsr TANK
SEPTIC II , SPECIFICATIO .JS ,
DOSE _
TANKS MAUUFACTURER: &I '�/'�� NUMBER OF DOSES: i PER DA.1
TANK SIZE: GA LOOS DOSE VOLUME
ALARM MAUUFACTURER: �-�. L� J„ .s �(�' INCLUDING DACKPLOW: GALLONS
MODEL NUMBER: ,M///i✓ / CAPACITIES: A= -,, S' ;7`T INCHES OR � / GALLONS
SWITCH TYPE: ,Z.ay b Z-Vi• / D=�_,Z,INCHES OR ?_G►LLONS
/L'
PUMP MANUFACTURER: '' / C=_ INCHES OR /> > GALLONS
MODEL UUMDER: /,J +/i1 4'Af' 0-4_INCHES OR --7.6` GALLONS
SWITCH T`JPE: i. J 1 NOTE' PUMP AND ALARM ARE TO DE
MINIMUM DISCHARGE RATE-S7: GPM (�yyINSTALLED Old SEPARATE CIRCUITS
VERTICAL DIFFERENCE GETWEEU PUMP OFF AND OISTRIDUTIOU PIPE.. 7iG' FEET
+ MINIMUM NETWORK SUPPLY PRESSURE✓, 2.5 FEET
+ - C— FEET OF FORCE MAIN X L79 F3oe r[FRICTIOu FACTOR.. , --A FEET
TOTAL DyuAMIC HEAD = J//p SfEET
//
!UT ERUAL DIMEN OU K: LW S OF UK: WIDTH •LIQUID DEPTH/
5IGIJE0: LICENSE NumGER: LDS 1 DATE: -V9S.
Y Y
1
: Performance a l I..e
Curves Punt J2 A ,'',.)AIA)/
� � 41189
METERS FEET
- 90
j i -MODEL 3885
25- 80� I I SIZE V." Solids
~
E1SN
2 70 I I I
I 20- -WE10H
f
0 WE07H � I015- � I
IO7 10 `�
30 WE � {
I ��< �•
20 , WE03L ~'��• 1 I
11 1
5 - 18‘. . \
10 yI
0_ 0
0 10 20 30 40 50 60 70 80 90 1001 110 120 GPM
0 10 20 / �/I-� 3_
CAPACITY /'/'/c/J �
,. ` . , • • - 4. ' - redEDS PUMPS, INC.
LJ se.Ecp Fa.s •Ew .r;-.. r.,
METERS FEET
120 ii 1 + { MODEL 3885
35 - SIZE 3/4" Solids
110
1 I
,00
111111111111
30 II I
90
25- 8°11111111I1Ii11H111 III
20_20_ 7o IIIII,,,,,fH� Mil III
60flhIIIH�hI►1hI
15- 50riaurarmsmilom..111111mirNMN• III1IAIIIHNHHHhIHH
5 — :IIII1I1iiNIN1
to 11111,,,,,"',,,,, „ n,,,,
0_ 0
0 10 20 30 40 50 60 70 80 90 100 110 120 GPM
H l 1
0 10 20 30 m'h
CAPACITY
•H966 Goulds Pump.,Inc. Effective July,1965
C18R'
• Wnscpnsio Departrnant of Industry. SOIL AND SITE EVALUATION REPORT Page / of 2
Labor and Human Relators
Division of Safety&Buildings in accord with ILHR 83.05,Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 81/2 x 11 inches in size.Plan must include,but �?� l
not limited to vertical and horizontal reference point(BM),direction and%of slope,scale or PAR 4.74i
tiFo v.
dimensioned,north arrow,and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION R: Ts. DBXEP 2 DATE
JJ 5 i995
PROP OWNER: PROPERTY LOCATION ST �gOek
p ,b�xrinA) GOVT.LOT � 1��/✓ 1l T �� e i'
PROPERTY E ':S MAILING AD RESS LOT I BLOCK! SUE/D NAM 4.A, Ur E �,
// JiyL(t.rn �� //7 l;1.a ITY, TA ZIP CODE PHONE NUMBER []CITY IL GE J�fOWN , 9's�''
sail �� �.✓ _ �� )i _s 5�,� 4wy �'-
f New Construction Use NI Residential/Number of bedrooms .3 [ I Addition to existing building
[ I Replacement ( I Public or commercial describe
Code derived daily flow (5"i5 gpd Recommended design loading rate /,-;1 bed,gpd/1t21_2 trench,gpdAt2
Absorption area required.?7 bed,ft2 ?js— trench,ft2 Maxdmum design loading rate /.,2 bed,gpd/ft2 /, trench,gpd/ft2
Recommended infiltration surface elevation(s) 97 S ft (as referred to site plan benchmark)
Additional design/site,considerations
Parent materia1,42,4e / —j 132.E A,(_?,4 ( .ate// Flood plain elevation,if applicable i/Z ft
S=Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN Flu. HOLDING TANK
U=Unsuitable for system ❑S r.gl U MS ❑U ❑S Z U ❑S 2 U ❑S ®U ❑S 121 U
SOIL DESCRIPTION REPORT
Boring# Horizon Depth Dominant Color Mollies GPD/ft2
Texture Structure Consistence Botfdiy Roots
in. Munsell Gu.Sz.Cont Color Gr. Sz. Sh. Bed Trtarch
l / Q_ 9 /tax!?,� I / I.c<4� ..s ,7.
ti
:zr
»':<:. / 7 R
Ground ��/J/�sf'r� N/ s' Q..,sy., .a,/ Qs 11 . 7 -8
Ivi ft. -� - _IsP-y/i/ ,,,.3, ..5--x'rG s/ 0 ,G., ind '' — /Jr NJ° Abo
Depth to
limiting
factor
_.s/
Remarks:
Boring# //
/ O-J, /ll`(. .,A /s I zI ,, / 1 J ,r, „ . S ,
M» .7- ,AeY)/.; ,4ri Zs- 45. I1, / a.,> J.,. . 7 .S
Ground
+ ? , -..: /43r.<4 'dir✓8 �M a: �/ 4 c / , 7 ..R
9L� 5/ ,?7-1� sses� " �p s 7G s/ Of:, „,.,i - ,t( t// Are
DePth
limiting
factor
.39
Remarks:
CST Name:-Please Print n /� ��/J Phone: 715 _,2 _S
(�eJ� 7Jn/
Address: 3O� , �,C X S. / ll L-
Signature: i5� /� Date: CST Number:
Res'-1S— ---25-yy
PROPERTY OWNER 4/..).00 /22;2d:1.441.J SOIL DESCRIPTION REPORT Pap.:-V.of , ? •
PARCEL I.D.I
Depth Dominant Color Mottles Structure GPD/ft2
Boring# Horizon . Texture Consistence Boirclary Roots
in. Munsell Qu.SzA2nt Color Gr. Sz. Sh. Bed Trent
t:::44i,44
1 CP--/. - Lb',i'6 L j.111.11 ,P,/ a.,..1 . •., . 5--- .4
%. ....
..,? 45-7.31 42,4e Al A /,,,,A4 .1
Ground "? W- •S6 5.3e 14/ 4, .c.x., li (211•7 ,eni.0 ---- /J4 /41g fria
elev.
2--/ft• . •
Depth to
limiting
factor
Remarks:
Boring#
Ground
elev.
ft.
Depth to
.•
limiting
••
•factor . .
Remarks:
Boring#
111U
§:maKii:..:.•
„ .„
Ground
elev.
ft.
Depth to -
limiting
factor
Remarks:
Boring#
l:vs:x*4
. .:.:.
.:
:.i;i4,.;. .:..,::
Ground •••
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R 05/92)
L?e /7Z oat 270A)
a// itte,4/11.40,s6e N, -4,lit):1 se-1 r.2474;
s,G// ,jf' .530,V s24- estsi '/
X ,4crf4.J {s,'145
d Sl l&e54.5 3r-I
i7 . '
../ • J J
/ -"yo .scr
817:25--9-s'
-451094/
CSTh a73y/ tpe,L 4t/,,L 1 3 /31
A. i - - — - —.
i
/7s/.,6.41-l..
y / yo yr, i
3o'
a
Qr4E
.12,arEa
coy
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County 1
OWNER/BUYER i)F.VE P t c &1 e torsi I A t�)do 1J
MAILING ADDRESS O ) N oT.W Li}+.td FAA. , c i N,(1ak. M►i s's o s a
PROPERTY ADDRESS /%,�-9 z/f-" S'/
(location o
f septic system) Please obtain from the Planning Dept.
CITY/STATE 7y�r� /-1../ ' S�f )-
PROPERTY LOCATION )/j 1/4, A/h/ 1/4, Section ‘- 2y , T ---?''' N-R , e W
TOWN OF o -• TC1S+O{4- , ST. CROIX COUNTY, WI
SUBDIVISION �111�►�fty Vtei1 , LOT NUMBER 16
CERTIFIED SURVEY MAP ,VOLUME ,PAGE ,LOT NUMBER
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 main • ed must be completed and r turned to the St. Croix
County Zoning Officer within 30 days of the three a • t)ion d te.
7
SIGNED: , J
DATE: g 0,9,
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
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.
Ownerofproperty tAvjaWrot..3
Location off roperty,(/t 1/4 ,,VA/ 1/4 , Section_-/ N-R „?"7 w
Township SCse41 Mailing address
Address of site /-4,7 ,0�`�',L 4,0 l4/,t
Subdivision name vetoE ks Lot no. �Q
Other homes on property?/ \
Yes ✓ No
Previous owner of property 51611UNGY
Total size of property " / ,4)
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? )L Yes No
Is this property being developed for (spec house) ? Yes f( No
Volume f/, ?,g and Page Number 8e; 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.
%11
YIA
Signat re of App cant Co-Applicant
Date of Signature Date of Signature
p ,l
532691 1 State Bar of Wisconsin Form 2— 1982
•
• WARRANTY DEED
DOCUMENT NO. VOL 1136PAGE 80 __ .
Vernell A. Skoglund and Stephen L. Skoglund Roes)ur r,,,.;..
AUG 1 8 1995 •
11:55 A. • .
conveys and warrants to David B. Middleton and Eileen K. If.. • `,� f , , .,
1
Middleton husband and wife, "te ;- �'•-r'` - I
. ` Cibe:::oi bs..u..i
THIS SPACE RESERVED FOR RECORDING DATA I
NAME,%A�ND RETURN ArDDRRREESSS0 alr _
,
the following described real estate in St. Crni x 13 *(0444-
ii County,State of Wisconsin:
Y I
� (Parcel Identification Number)
.. FEE
Lot 10, Country Side Estates in the Town of St. Joseph, St. Croix County,
Wisconsin.
I
I
This is not homestead property.
WC (is not)
Exception to warranties: Easements, restrictions ane rights-of-way of record, if any.
Dated this /2'�i%/ v day of August , 149_5__.
(SEAL) • (SEAL)
• •(SEAL) (SEAL)
• • Stephen i.. Skngl1Ind
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) Vernell A. Skoglund, STATE OF WISCONSIN
Stephen L. Skoglund 1 ss.
County.
authenticated this day of August . 19 95 Personally came before me this day of II
— I r„ ' , 19 the above named
• Kristina Ogland
( TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by§706.06, Wis. Stats.) to me known to be the person who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
11 Kristina Ogland
I'
Attorney at Law
—_ Notary Public County, Wis.
1.
II (Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration date:
necessary.) , 19_—___..)
Nnmcs of persons signing in any capacity should be typed or primed below their signatures.
WARR%NTY DFFO VTATE BAR OF WISCONSIN Wisconsin Lena'Bh:nk Co Inc