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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER,
ADDRESS 973
L,4 aAQ
&LuA S O M " S Qy /6
SUBDIVISION / CSM#_ C~/PAS AA, 6! A D f LOT #
SECTION T?-N-R__/J_W, Town of gQs'oA/
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
N _ C GORKCs2
i N ^ r1 rt •~a'
\ 'c
S pR ~Ncr~E S
Ouse
\ h
fr
C~
$LC y~ INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: Lc i -57AP aP 14a,d
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: WE• :-A Is Liquid Capacity: /DDO
Setback from: Well MO r, 1A, House 3 9' Other
pump. cturer Model# Size
Float seperation Ga e:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length S 7 Number of trenches
Distance & Direction to nearest prop. line:--Ab/1TN 34
Nor /k
Setback from: well: eT House____?
1, Other
ELEVATIONS
Building Sewer ST Inlet: ST outlet: lQ~,Z[
PC inlet- A4 PC bottom AIA Pump Off IYA
/O/. 7O /,42.6s,
Header/Mani foldT 3 0 Bottom of system /Qo, >b
Existing Grade L1 Final grade /Q 2
DATE OF INSTALLATIO ® - -
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
WiscrosinDepartment ofIndustry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary PermitNo.:
GENERAL INFORMATION 199065
Permit Holder's Name: ❑ Cit p Village Town of: State Plan ID No.:
BEDDER, SIEGFRIED HUBSCIN
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
020-1020-90-000
TANK INFORMATION ELEVATION DATA A9700386 /4910719
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ceroC. Uj~q6% Benchmark //.53' Cd
Dosing 16.1yi 0.
Aeration Bldg. Sewer
Holding St/VInlet TANK SETBACK INFORMATION St/ ICE Outlet
Vent
TANK TO P/ L WELL BLDG. Airito ntake ROAD Dt Inlet
Septic 4 NA Dt Bottom
Dosin NA Header /Man.
SSG S,Y3 p 3.0~
Aeration NA Dist. Pipe /U X969
Hold Bot. System G3 090e~
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand .{wfi s.T 3,7p /,477S
'
Model Number
TDH Lift Loss Iction stem TDH t
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of renches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN I N `J D
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEA Manu
SETBACK f INFORMATION TypeO CH AMBE
2 ~J,¢ CH U Mo er.
System: OR
DISTRIBUTION SYSTEM
Header /Manifold Distribution Pipe(s) Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or A ade Syste my
Depth Over " Depth Over xx Depth Of xx Seeded/ Sodded ed
Bed /Trench Center Bed/ Trench Edges Topsoil--' ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 14.2/9.1j9.95,NE,NW 973 LABA/RGB RD LOT
V Y~ "'r~`=- ~F..-E LK. /r'~Qt'C ,L 4-~`, a _dCO ~j ,-C',, f ~i _..N C~.... - _~l-, ~ •r ~C.~"`L-" C11 11", Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
Viso6onsin SANITARY PERMIT APPLICATION 201 E. WashinlgtonAve'sion
P.O. Box 7969
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code 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. CK0
• See reverse side for instructions for completing this application State Sanitary Permit Number
aq9 00 5 -
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
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
eAzieo g, is w4, S 110 T Z , N, R I E (oro
Property Owner's Mai [in Address Lot Number Block Number
, I A14
Cit , State Zip Code Phone Number Subdivision Name or CSM Number
II. TYPE F BUILDING: (check one) E] State Owned ❑ it
E] Vll Nearest Road
rage
t
Public 1 or 2'Family Dwelling - No. of bedrooms Town OF
III.- BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo 016 4-14116 ko
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. pt New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank OnlyExisting 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 00 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 it. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 1W, 6 2 Elevation
Y-5-0 1 45-4/3 Q a 8 Feet Feet
VII. TANK Capacity gallonTotal # of site Fiber- Manufacturer's Name Prefab. Con- Steel plastic p.
New Existing Gallons Tanks concrete structed glass App.
Tanks Tanks
Septic Tank or Holding Tank :~4 /1"10 1 1 -5 X ❑ ❑ ❑ ❑ ❑
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) Plumb s ignature: (No St rL PRSW No. Business Phone Number:
` - _
P umber's Ac dress (Street, City, State, Zip Cod(
R E
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved San' ary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee)
Q/~y 7
I Adverse Determination QLl
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R.11/96) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, 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 properly 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 concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608-266-3151.
To be complete and accurate this sanitary permit application must include:
1. 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 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.
GROUNDWATER 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.
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Wiscorisih Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor and Human Relations
Div*%ion of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
' COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but St. Croix
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. If
dimensioned, north arrow, and location and distance to nearest road. --0-20- 10211-9 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY ATE
PROPERTY OWNER: PROPERTY LOCATION
Kernon Bast GOVT. LOT NW 1/4 NE 1/4,8.12 T 29 N,R 19 for) W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
948 LaBar a Rd. na Grass Ran a Addn.
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE ®fOWN NEAREST ROAD
(71$ 386-7775 1 Hudson
[ New Construction Use [ x] Residential/ Number of bedrooms 3 [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate gibed, gpd/ft2_,$_trench, gpd/ft2
Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate .7 bed, gpd/ft2__,$_trench, gpd/ft2
Recommended infiltration surface elevation(s) 103.0-102.5-102.0-100.62 ft (as referred to site plan benchmark)
Additional design / site considerations na
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 13 S ❑ U 121 S ❑ U L3 S ❑ U KI S ❑ U [it S ❑ U ❑ S FK7 U
SOIL DESCRIPTION REPORT
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 1 0-13 10 r4 4 none s i
2 13-21 7.5 r4 6 none r cl ml 9W if -7 8
Ground 3 21-28 10 r5 4 none sil lcsbk mfr aw na .4 .5
elev.
106.7 ft. 4 28-84 7.5 r5 6 n
Depth to
limiting
factor
+84"
Remarks:
Boring #
1 0-10 10 r3
non e gil mfr if .5
L2 2 10-35 0 r4 4 none sil lcsbk mfr aw if i.5
Ground 3 35-84 7. 4
elev.
107.0 ft. 1 a.
Depth to
limiting
factor
__j 174 Y
Remarks: z L-4:►71-
CST Name:--Please Print Gary L. Steel Phone: 715-246-6200
Address: 1554 200 e. New Rj;tand, WI 54017
Signature: Date: 4-30-97 CST Num er: m02298
PROPERTY OWNER Kernon Bast SOIL DESCRIPTION REPORT Page__2_,of
PARCEL I.D. k 020-1020-90
Depth Dominant Color Mottles Texture Structure ConsistenceRoots Bed Tre
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bounclary Bed Trench
sil 2msbk mfr if .5 .6
none
0-10 10 r4
3
2 10-22 7.5yr4/6 none cos os ml if .7 .8
Ground 3 122-32, 10 r4 4 none sil lcsbk mfr aw na. .4 .5
elev.
105.5ft. 4 32-84 7.5 r4 6 none cos os ml na na .7 .8
Depth to
limiting
factor
+84"
Remarks:
Boring #
- sil 2c 1 mfr cs 2f n .2
1
019 Joyrin none
if .2 .3
4 2 12-23 10 r4 4 none sicl icsbk mfr Crw
3 23-41 7.5 r4 4 none sl icsbk mfr CFW- na .4 .5
Ground
elev. 4 141-84 7.5 r5/4 none ms os ml na na .7 .8
104.2 ft.
Depth to
limiting
factor
+84"
Remarks:
Boring #
1 0-11 10 r3/3 none sil 2msbk mfr cs 2f .5 .6
2 11-18 10 r4 4 none sil 2msbk mfr Cfw if .5 • .6
U
Ground 3 18-34 7.5 r4/6 none sil/s icsbk o mfr my if .4 1.5
elev. 4 34-82 7.5 r4 6 none cos os ml na na .7 .8
104.'A.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel Kernon Bast 1554 200th Ave.
CSTM2298 NW4NE4 S14-T29N-R19W New Richmond, WI 54017
MPRSW 3254 town of Hudson (715) 246-6200
I lot #1-Grass Range Addn.
N
1"=40'
BM.== top of NE lot stake C el. 100'
Alt. BM. top of 11-21, pvc pipe C el. 104.85,
~l
230 3~~ ZOr9 r 1
P`
Jar
~f
W ~o.Zc
g-5
rnl~ P
Gary L. Steel
4-30-97
FROM: SCHMTT & SONS EXC PHONE NO. 715 549 6651 Sep. 15 1997 03:51PM P2
8TC-UO
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
developiaent be intended for resale by owner/contractor, (spec
house), then a sebond form should be retained and completed when
the property is sold and submitted to this office with the
appi:opriate deed recording.
-
Owner cif property t LT- Vr? I V& Aiz V( Xj'h~ L-`2
Lactation of property 1/4
MO 1/4, section Iq T Z q N-R _L2 _W
Towriship 14a ii Ong address W XX 0. R~l e
w to
Address o l! site 11;
subdivision name v~ C Lot no. `
Other homes on property? Xes,_No
Previous owner of property i o,_~~cfi, v "C of
Total size of property
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 441 and Page Number -J./Q as recorded with the Register
of Deeds.
XNCLODE WXTH TBYS APPLICATION THS FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NU'M13ER 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 CERTXFICATION
X (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
c04ptruction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
r /
pp scant Co-Appli n
Date of signature nA~a of s1ryMs~.. ,tea
FRAM : SCHMTT & SONS EXC PHONE NO. : 715 549 6651 Sep. 15 1997 03:52PM P3
STC.-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
MAILING A.nDRESS 119 Z g ~Y be l t t- c o of e
PROPERTY ADDR> S
(location of septic system) Please obtain from the Plann n
CITY/STATE kQ K-_4 L-t PR PERTY LOCAT IONL, 11'6 1/4, - VW 1/4, Section /J4, T N-R,
W
TOWN OF I~ ~0V~'.------._..... , ST. CROIX COUNTY, WI
SUBDIVISION R°~- IC av✓~~ , LOT NUNIDER _
CERTIFIBDSURVEY MAP VOLUME, PAGE LOT NUMBER
Improper use and maintenance of your septic system could result in its premature failure to handle
wastes. Proper maintenanco oonsists of pumping out the septic tank every three years or sooner, if needed
by licensed septic uutk 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 fonn, signed by the owner
and by a mater plumber. journeyman plumber, restriotod 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.
VWe, 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 soptic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year a "ration ate. 'a - .
SIGNED.
DATE:
St. Croix County Zoning Wee
Government Center
1101 Carmichael Road
Hudson, W1 54016 11193
M yat 1:~f PA-210
STAfC• BAR OF WISCONSIN FORM ~ - 1982
~i49 1~. I WARRAN IV DEED
DOCUMENT NO.
- REGISTER'S OFFiCE
_non_alda ,L,_Spee -Bast. _ ST. CROI CO., WI
Rec'd for r Rt.coM
SEP u 4 1997
convrvs and wanants to Siegfried W, _O. Bedder aid _2r~[ 11:30 ` AM
Redder., husband and wife R ter or Deal.
THIS SPACE RESERVED FOR RECORDING DATA
NAME AND RETURN ADDRESS
the following desciibed teal estate in St. Croix County,
State of Wisconsin: - N--q A017
Lot #1 Plat of Grass Range Addition in the
Town of Hudson, St. Croix County, wisconsin.
Lot # 1 Plat of Grass Range lies in a Well Advisory 020-1020-90
PARCEL IDENTIFICATION NUMBER
Area as established by the Wisconsin Department of
Natural Resources. Any home construction wlthtn this Well Advisory Area
will only be allowed as per restrictions placed upon well construction in
accord:_nee with the well variance as granted by the Wisconsin Department of
Natural Resources
NR!F FR
"this is not homestead property.
Exception to warranties. Easements, restrictions and rights-of-way of record;
if any.
Dated this 3rd day of September. _ A.D., 1997
tl~? t L3o., (SEAL) (SEAL)
Donalda J. Speer-Bast
(SEA-) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signatute(s) Sate of Wisconsin,
ss.
St. Croix County
authenticated this day of 19~ malty came before me this _ 3rd day of
_ Sep_iember. , 19 97 . the above named
_Dio-nalda. J. Seer-Bast
'TITLE: MEMBER STATE BAR OF WISCONSIN Brenda Pou
pf not,
authotited by §706.06, Wis Stars.) Notary Pub ehe person __whu ezecutrd the foccgoing
State of WISCowledge th .anti.
THIS INSTNUMENt WAS DTTAPTED BY ~6Donalda J. Speer-Basin