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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS f
SUBDIVISION / CSM# _ LOT #
SECTION,-,,7,0 _T~N-RW, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
\ o
)JV
&
9
~f eft./f/~`~/
~rr rf
+ I
j INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK :
ALTERNATE BM:
SEPTIC TAN / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: /t> Liquid Capacity:a
Setback from: Well House .S Other //0.L,
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: / Lengthy Number of trenches
Distance & Direction to nearest prop. line:
Other
Setback from: well: /,j House 6' Z
ELEVATIONS
Building Se ST Inlet: 7 ST outlet:
inlet -l Pram - P€ /
Header/Manifold Bottom of system
Existing Grade ® Final grade es- !;2a
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
L'abor and Human Relations
Safety INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 284350
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
KACZMARKSI, ROBERT CYLON
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
006-1044-30-000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark L l h j~ , 6
uZ
Aeration Bldg. Sewer -1 L q j,7
Holding St/ Ht Inlet 1 , , 5_1
TANK SETBACK INFORMATION St/ Ht Outlet 207- G
TANK TO P/ L WELL BLDG. Ae Intake ROAD Wnlet 7, ( f
Septic 1> 'NA BC Bottom - 7, S
Dosing NA Header / Man. 7, f Z l j tom`"
Aeration NA Dist. Pipe g,ZO
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand !~i•,~ ~Z? ~J~~. `1
Model Number GPM q-X3 28,7/ 5
TDH Lift Lrictio S Stem TDH Ft
oss ad
Forcemain Length Dld. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manu acturer:
SETBACK
INFORMATION TypeO CHAMBER Mode Number:
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 C] No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: CYLON.20.31.16.304B,SW,SW 2021 HWY 46 t -
"ta
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. F_ [TI 11
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH r
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION Safety and Buildings Division
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.
• See reverse side for instructions for completing this application State Sanitary Permit Number
02 8X. 50
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)I.
State Plan LD. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner me Property Location
r /1/!4.Za/ 1/4,S Zri .T -rN,R E( W
Property Owner's Mailing Address Lot Num er Block Number
U 4t e
City, State / Zip Code Phone Number Subdivision Name or CSM Number
(71 e,
II. TYPE OF BUILDIN : (check one) E] State Owned ❑ city Nearest Road
E] Village
Public 9,1 or 2 Family Dwelling - No. of bedrooms 4 Town of 14 4,
Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Numbe (s)
d E 3 0
1 ❑ Apartment/ Condo Z.N 3 6
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 online B, if applicable)
A) 1. ❑ New 2. "Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an
System `_`_'_SystemTank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 :Seepage Bed - 21 E] Mound 30 ❑ 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/sq. ft.) (Min./inch) l Elevation
4rd
- Feet Feet
ev ~**,J -
VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank >e-
4c; ~e Ll ( ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's, n ture: (No Sta s) MP/MPRSW No.: Business Phone Number:
177 1 --"7
Plumber's ddress (Street, City, State, Zip Code):
45 X1/9 ww" le I- Or?
IX. COUNTY / DEPARTMENT USE O Y
❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issue Issuing A ent Signature (No S s)
Approved E] Owner Given Initial Surcharge fee)
Adverse Determination ~d v ~ Ij SOS/9
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPRO
- 4 -
SRD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & Ruildings Divi ion, owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
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.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be ptoperiy maintained The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concernincl your onsite sewage systern, contact your local code administrator or the State of
Wisconsin, Safety and Buildings 'D ire ision, 608-266-38 i 5
To be complete and accurate this sanitary.permit application must include:
L 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.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
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 vvith 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.
GROUNDWATIER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
F'LUT PLAN. / y z
PROJECT ~1f' ADDRESSic: C~'r J r.
.1/41S~/T / N/R1,6 W TO G o.Uir r> COUNTY
MPRS Byrop, Bird Jr. 3318 DATE r t~ ,
rBEDROOM CLASS PERC CONY ONAI,X IN-GR ND PRESSURE
CONVENTIONAL LIFT_ MOUND_ HOLDING TANK
SEPTIC TANK SIZE 62 - I"" LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE: t
ABSORPTION AREA PERC RATE
1116 BED SIZE
Benchmark V.R.P. Assume Elevation 100'
Location oV Benchmark
* H.R.P.
r.
L7 Borehole Q Well - Scale = Feet
0 Perc Hole w'
System Elevation _ - S
Uent J
12"
v -i+t ' b
Graffe
TYPAR COVr-RING
►it
12 3, 4 6 ® 3 f v•Sewer Rock ,
1 6 12' t u eC.ar ,a c/ 0
19Q~
r
%sconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
"&bor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUN?k
r
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but P I tit
not limited to vertical and horizontal reference point (BM), direction and /e of slope, scale or c s.t f
dimensioned, north arrow, and location and distance to nearest road. ! r ` 006-1044-30
Elf#EWE , / '.F, t'? DATE
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION
PROPERTY OWNER: PROPERTY LOCATION IT",
Robert Kaczmarski GOVT. LOT SW 1/4 SW 14S.~p 11', ofa~ q fir) W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME "CSMIk
2021 State Rd 46 na na na
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE [MOWN NEAR ROAD
New Richmond, WI. 54017 ( 246-5298 C lon I Hwy. 46
New Construction User-] Residential/ Number of bedrooms 5 [ ] Addition to existing building
131 Replacement [ ] Public or commercial describe
Code derived daily flow 750 gpd Recommended design loading rate • 7 bed, gpd/ft2 .8 trench, gpd/ft2
Absorption area required 1071 bed, ft2 938 trench, ft2 Maximum design loading rate .7 bed, gpd/ft2_.a_trench, gpd/ft2
Recommended infiltration surface elevation(s) 94.50 ft (as referred to site plan benchmark)
Additional design / site considerations backf ill to be to code depth, or use extra rock for pipe depth
Parent material outwash Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U=Unsuitable fors stem ®S ❑U ®S ❑U ®S ❑U ®S ❑U G~1S ❑U ❑S CCU
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. Bed Trerich
`....1...-: 1 0-12 10 r3 3 no sil 2f 1 mfr cs 2f .5 .6
2 12-34 10 r4 4 none sicl 2msbk mfr gw if .4 .5
Ground 3 34-45 10 r4/6 none sl 2mgr mvfr 9W if .5 .6
elev.
99.4 ft. 4 145-96 7.5 r4/4 none cos osg mvfr na if .7 .8
Depth to
limiting
factor
+96"
Remarks:
Boring #
1 10-10 10 r3 3 none sil 2msbk mfr cs 2f .5 .6
2 € .4 .5
2 10-22 10 r4/4 none sicl 2msbk mfr gw if
3 22-43 7.5 r4/4 none scl 2mgr mvfr gw if 05 ;.6
Ground
elev. 4 43-90 7.5 r4/6 none cos osg mvfr na na .7 .8
99.0 ft.
Depth to
limiting
factor
+90"
Remarks:
CST Name:--Please Print Gary L. Steel Phone: 715-246-6200
Address: 1554 200 ve. New Richmond, WI 54017
Signature: Date: 10-1-96 CST Number: m02298
PROPERTYOWNER Robert Kaczmarski; SOIL DESCRIPTION REPORT Page 2' ..of 3
PARCEL I.D. # 006-1044-30 c°
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 0-10 10 r3 3 none sil
3
2 10-32 10yr4/4 none sicl 2msbk mfr C1w if .4 .5
Ground 3 32-52 7.5 r3 2 none scl
elev.
98.83ft. 4 2-92 7.5 r4/6 none cos os mvfr na na. .7
Depth to
limiting
factor
+92"
1 1 1 1 1 tl
Remarks:
Boring #
1 -10 10 r2 2 none mfr c1w
2f .5 .6
4 2 0-28 10yr4/4 none sicl 2msbk mfr gw if .4 .5
Ground 3 8-56 7.5 r3 2 none scl 2m r mvfr na na 1.4 .5
elev.
99. 0 ft 4 6-92 7.5 r4 6 none ms osg mvfr na na .7 .8
.
Depth to
limiting
+92 or
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
ySTEEL'S SOIL SERVICE
Gary L. Steel 1554 200th Ave.
CSTM2298 Robert Kaczmarski New Richmond, WI 54017
MPRSW 3254 SW4SW4 S20-T31N-R16w (715) 246-6200
town of Cylon
N
111=401
BM.= top of cement sill for gaRAGE DOOR @ el. 100'
t 5 ~m ~
¢~s 154 ,"5
.S~s-Fe m
Gary L. Steel
10-1-96
• u l: ~ 1~u
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 A
Location of property S~w/1/4 Sty 1/1(, Section e,90 ,T_,~ N-RW
Township 9:6~i Mailing address O
-bAcv- / " - ~ f VO/ 7
Address of site e~
Subdivision name Lot no.
Other homes on property? Yes 2~ No
Previous owner of property - 6j^o r~ld.0 e:j d&V
A, k, Total size of property l-}? 2 x" 6f~
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes No
Volume and Page Number 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. :1/33 57--771 , 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.
azA& /f
Signature of Applicant Co-Applicant
7
Date of Signature Date of Signature
y
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS v'1 w""~/
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE }w•w-'G%~%ty '~LY~ r4~d''/
PROPERTY LOCATION SSW 1/4, SW 1/4, Section AO T 3/ N-R /6 W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIEDSURVEY MAP c- , 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 maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED:
0
DATE: - 77
St. Croix County Zoning Office '
Government Center
1101 Carmichael Road
Hudson, Vi 54016 11/93
l'
DOCUMENT NO. STATE 13AR OF WISCONSIN-FORM 2
• WARRANTY DEED
THIS SPACE RESERVED FOR RECORDING DATA
11 1 4 3 5,2F
I'
BY THIS DEED, Gordon H. Munson and Goldie L. Munso t-i = CIESTER5 OFFICE
husband and wife, ST. CRCIX Co.• `wls.
- - Roc' d tor f \,ecc rd tl is
&y of -A.D. 1973
JePt-'-----
Grantor conveys and warrants to Rob2rt S_Kaczmarskl and
wife - - A,
,I Beverly MKaczmarski, husbandand,
- - - f t u, ; (-t o r of Deed c
---Grant ee___.-
iI for a valuable consideration RETU N TO
BANK OF PI[' A Irl ".101"1
the following described real estate in _St Croix _ County, State of Wisconsin: NEW R:C: ...i, tr 5'1017
Tax Key It This is not homestead property.
Commencing at
The Northwest corner of the Southwest Quarter of the
Southwest Quarter (SW4SW4) of Section Twenty (20),
r Township Thirty-one (31) North, Range Sixteen (16)
West; thence East 698 feet; thence South 477 feet;
thence West 698 feet; thence North 477 feet to the
place of beginning.
This Warranty Deed is given in satisfaction of the
Land Contract between Grantor and Grantee, dated
March 2, 1970, and recorded in the St. Croix County
Register of Deeds office on March 5, 1970, in
volume 459 of deeds on page 339.
Exception to warranties: ~f AO-_i
EXEMPT
Executed at -,----New Richmond, Wisconsin.-._.____ this28th day of August 1973
SIGNED AND SEALED IN PRESENCE OF r-2 -LI (SEAL)
Gordon H Munson
NSA
- - - - / Goldie_L L. Munson
l (SFAL)
NfA
(SF,AL)
Signaturesof-__ _Gordon H. Munson and Goldie L_._Munson
authenticated this day of f U 6 ciS T 1973.
G. E. Norman
Title: Member State Bar of Wisconsin (XXtlff>Yir{F_WW
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