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AS BUILT SANITARY SYSTEM REPORT ~-tz- MAY 2 22 19997
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OWNER
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ADDRESS
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SUBDIVISION / CSM# LOT #
SECTION j T a-f N-RW, Town of NG~ ,e S'd
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
e 4L, 7-el ee.,-- /QG4
N
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INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: _15'o:.-, el a- s l / ~
ALTERNATE BM:.
C ,c,7,d
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: ~1jew~sfev.~ Liquid Capacity: lea t'
Setback from: Wel1_5~D v`- House el_5 Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: 12 Length S'Y Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: D House O~- Other
ELEVATIONS
Building Sewer ST Inlet: ST outlet:
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB: ,
LICENSE NUMBER: /1.1 J 2
INSPECTOR: ,
3/93:jt
WisconsinlDepartmentofindustry, PRIVATE SEWAGE SYSTEM County:
• Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 289323
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
BENDY, WAYNE HUDSON
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
020-1025-10-000
Oct ~ v ~t,
TANK INFORMATION ELEVATION DATA AQ7n
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic / j. Benchmark
Dosing , S
Aeration Bldg. Sewer ,dp
Holding -St /WInIet 9r,v8
TANK SETBACK INFORMATION St /,611 Outlet 4.G o 6
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic 'a?6 r 745/ 15' NA Dt Bottom
Dosing NA Header/ Man. e q. Yg~
Aeration NA Dist. Pipe QGy'
q, y5!
Holding Bot. System 10" ?6
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Head
Le Dia. Dist. To Well
SOIL ABS RPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMEN I N
LEACHING Manufacturer:
.11 SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION TypeO CHAMBER Model Number:
System: ~~SO -Sp' ":70 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 0 ` Bed /Trench Edges6 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON r15.29.19.109B,SW,NE 671 MCCUTCHEON ROAD
Plan revision required? ❑ Yes [3/No
Use other side for additional information. i
SBD-6710 (R 05/91) Date ns is Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building Water Systems
201 E. Washington Ave-
In accord with ILHR 83.05, Wis- Adm. Code P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. 5~ e r ye,
• See reverse side for instructions for completing this application State Sanitary Permit Number
,2 8 `j3 a3
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)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
A t d .~4J 114,ZIX 1/4, S / .S T2 f , N, R ' E (or)~17
Property Ofvner's Mailing Address Lot Number Block Number
7 t .rJ R d
City,, State Zip Code Phone Number Subdivision Name or CSM Number
II. TYPE F BUILDING: (check one) E] State Owned ❑ cityage Nearest Road
E] Public 1 or 2 Family Dwelling - No. of bedrooms ❑ VllTown of
Ilr. BUILDING USE" (If building type is public, check all that apply) Parcel Tax Number(s) )C. t 0.9 6
1 ❑ Apartment/ Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church / School 8 Mobile Home Park 12 ❑ Service Station / Car Wash
5 ❑ Hotel / 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. 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 ❑ 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. Sly/ m Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) PI C0 Elevation
7 100, 6 3 3 JCL- Feet Feet
VII. TANK Capacity
in gallons Total # of r Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Exist in strutted
Tanks Tanks
Septic Tank or Holding Tank W >e El El
11
Lift Pump Tank /Siphon Chamber El 1:1 1:1 Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: ( Stamps) MPRSSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
0 g 77- X" eJ
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ra~ sueIssuing A ent Si nature (No am
Approved ❑ Owner Given Initial ,~tlt~dt0Surcharge fee)
p'7
Adverse Determination -d~~
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
S8D-6398 (R. 05/94) DISTRIBUTION: original to County, One copy To:.Satety 8 Buildings Diui 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 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, 608-266-3815.
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.
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.
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 rr,onitoring groundwater contamination investigations
and establishment of standards.
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Wigcorisin Department of Industry, 44
*&of
Labor and Human Relations SOIL ATION Page
dm. Code
Division of Safety and Buildings in accord~arac ' vith ss0 83.0 JRer,
7~'' Att
ach complete site plan on paper not less than 8 1/2 x 11 ir)chet in size. Plan must C'~ nty
include, but not limited to: vertical and horizontal reference ' -h BM) ,d' ectioh 6d f 5- ~
percent slope, scale or dimensions, north arrow, and IocatioN,64distan~d to flea ;toad0 cel LD. #
f ~ o APPLICANT INFORMATION - Please print all inf or~w'"' iewed by Date
Personal information you provide may be used for secondary purposes (Priva Laws. j
Property Owner ° Location
O Govt. Lot 57!,J 114Wt-- 1/4,S ~6- T 2 q, N,R l E (oric
Property O ner s Mailing Address Lot # Block# Subd. Name or CSM#
! C~ C_ e0AJ A - -
City State Zip Code Phone Number ❑ City ❑ Village WPQ Town Nearest Road
❑ New Construction Use: ❑ Residential / Number of bedrooms Addition to existing building
IN-Replacement ❑ Public or commercial - Describe:
Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2
Absorption area required bed, ft2 , ~trench, ft2 O Maximum design loading rate r 7 bed, gpd/ft2~trench, gpd/ft2
Recommended infiltration surface elevation(s) O 9. do ft (as referred to site plan benchmark)
Additional design/site considerations 5e- e~q 2
Parent material <a a r_r 4L 1 Cc_ F~ S,~ 7 ~ 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 gj S ❑ U IL S ❑ U ®S ❑ U IRS ❑ U ❑ S ❑ u ❑ S ❑ U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2
9 Texture Consistence Boundary Roots
- in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
_T . 5- /e 3 s L s l G~ 2
Ground G
elev.
Depth to
limiting
factor 1 7-1
iL ` in.
Remarks:
Boring #
Ground
elev.
Depth to
limiting
8ctor
min. Remarks:
CST Name (Please Print) Signature Telephone No.
Cam' Soh ~e, v
Address Date CST Number
s Z1 4 ?O G -2 -7 g YD
PROPERTY OWNER & -'vo ~Z SOIL DESCRIPTION REPORT
Page ~ of 3
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
QS ! Gw ;
elev. Ground
'S YG /D 92 P r l G 7 , .1 ir
Y3~ ft. ;
Depth to
limiting
factor
in. ;
Remarks:
Boring #
Ground
elev.
ft. ,
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring #
Ground
elev.
ft.
Depth to
limiting ,
factor
'n' Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
SBDW-8330 (R. 08/95)
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Ya'` m~ x Goi)er 6t,Pv ~c so j►~
8 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.
Owner 0: f property
Location of property,Sj~ 1/4 Ve 1/4, section T 2211 N-RW
Township WcA- cL fe) Al Mailing address f!5'71 &I e wee-
Address of site
Subdivision name Lot no.
Other homes on property? Yes-,iC_No
Previous owner of property y1 r' x- 7; /~Q r
Total size of property
Total size of parcel _ I, Cf r-
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes No
Volume 299 and Page Number 2 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. f , 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.
02 ~ ,yz °l
Signa re of Appl' Co-Applicant
~ A
Date of Signature Date of Signature
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNERBUYER
MAILING ADDRESS o 7l 1~1 G ~ u~`"c li eat X
PROPERTY ADDRESS l~G-d so,J C~ << i' y416 -
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE 5,~_2 m .e C2 5' &/0.0 V -e-
PROPERTY LOCATION 1/4, _'VC- 1/4, Section 1 s T o't N-R
TOWN OF 41t-d -51o ,J ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
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 maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED:
DATE: St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
4 l t
r( r WARRANTY DEED
DOCUMENT NO, Vol 3,~r.J
STATE OF WISCONSIN-FORNI 9
THIS SPACE RESERVED FOR RECORDING DATA
THIS INDENTURE;, Made by Lyle A. Baer and Crystal A. Baer,
his wife and -in her own behalf,
i
i i
grantor ' of St. Croix County, Wisconsin, hereby conveys and warrants =
to Wayne A. Benoy arid Helen I. Benoy_, IIIIs_wife, -as
,joir;t tenant:.,
s -
St. Croix grantee RETURN TO
of _ County, Wisconsin, for the sum of
Nine Hundred and no/100 - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - - - - - - - -Dollars i`
the following tract of laud in - - St. C,-oix County, State of Wisconsin; r~
A parcel of 1.98 acres located in the Northeast corner of the Southwest
I" Quarter (SW,) of the Northeast Quarter (NE,i-,) of Section Fifteen (15),
Township Twenty-nine (29) North, Range Nineteen (19) West, described
as follows: beginning at the Northeast corner of said Southwest Quar-
ter (SWD of the Northeast Quarter (NEI), thence South a distance of I
315.0 feet, thence West a distance of 275.0 feet, thence North a
distance of 315.0 feet, thence East along the centerline of the town
road a distance of 275.0 feet to point of-beginning.
~rr "~I , rf III
i
IN «'ITNFSS WHEREOF, the said -r ntor S_._ ha ve_ hereunto set their hand S and -cal S this ~
day of M:1rCtI A. D., 19 63
I
SIGNED 'D SEALED IN PRESENCE OF 1 Cl i/ (SEAL)
• /t Lyle A. Baer
o n e o (SEAL)
Crystal A. Baer
.i yd Johnson
SSE AL)
I
(:TEAL)
STATE OF WISCONSIN, 1
ST. CROIX } ss. i
county.
i
li
Personally came before me, this 28th
_ -_-_---day of March A. D., 19 63
_ f
the abovenan,ed Lyle A. Baer and Crystal A. Baer, his wife and in her own behalf,