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STC - 104
AS BUILT SANITARY SYSTEM REPORT J
OWNER
ADDRESS J3
Sliy~Q-c.~
SUBDIVISION / CSM# S LOT
SECTION 2 T,?q N-R~W, Town of f7~L't-z ~
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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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.
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BENCHMARK:
p'( S = -
ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity: Ao~ (o
Setback from: Well House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location e---
SOIL ABSORPTION SYSTEM
I
Width: Length Number of trenches
Distance & Direction to nearest prop. line: Sr,,.;tk -),-'5-
Setback from: well: House Other
ELEVATIONS
Building Sewer ST Inlet: ST outlet:
PC inlet PC bottom Pump Off
Header/Manifold 8.05--MOBottom of system -
Existing Grade Final grade
DATE OF INSTALLATION: p? -
PLUMBER ON JOB:
LICENSE NUMBER: /'zJrJ ~Y~
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
LaboraLiHuman Relations
Safety and Buildings Division INSPECTION REPORT ST. CROIX
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 284312
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
JOHNSON, WILLIAM & ARLETTA HUDSON
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
020-1316-70-000
TANK INFORMATION ELEVATION DATA A9700082
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St / Ht Inlet 97,0-7
TANK SETBACK INFORMATION St/ Ht Outlet 0769 , q
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
9 dG
Dosing NA Header / Man. 9 Z ,
Aeration NA Dist. Pipe / 9y
Jw 9 7
Holding Bot. System 93'9, d
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand / oa 91
Model Number GPM
TDH Lift Friction System TDH Ft
Loss Forcemain Length Dia. F f 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 Manufacturer:
SETBACK CHAMBER
INFORMATION Type O model 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 ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON.24.29.19,SW,NE BENOY DRIVE LOT 52
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:
E
SANITARY PERMIT APPLICATION BuSafetyreau o oand ff BuiluildiinWater S ngWater Division
stems
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 t
than 8 112 x 11 inches in size.
-57,
• See reverse side for instructions for completing this application State Sanitary Permit Number
s~ia
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 erty ocation
Pro ~ tZ 1/4, S;P y T d c- , N, R E (orCW
}irk
Property Owner's Mailing Address Lot Number Block Number
r
City, State Zip Code Phone Number r Subdivision Name or.,CSM Number
lilt J, r~ tt4Z ( 7/157 - y 18!iii ~ ~11 t
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ ity Neare t Road ~i
❑ age ` .
❑ Public 1 or 2 Family Dwelling - No. of bedrooms To Town of
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) A q. aq.
1 ❑ Apartment/ Condo zf) ~z if - -3 t _ 70
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 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 f 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trencl~3) 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 S. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) qy cf~> Elevation
Q%- Feet Feet
VII. TANK Ca
in gallons Total # Of Prefab. Site Fiber- Plastic Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass App.
New Existing strutted
Tanks Tanks A 17,
Septic Tank or Holding Tank(j C ❑ ❑ ❑ ❑ ❑
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 nature: ( Sta ps) Pi PRSW No.: Business Phone Number:
t 7Z~AXA 7/7 7115--~-F -6 s
Plumb d ress (S reet, City, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing ent Signature (No s)
pp roved F1 Owner Given Initial Surcharge Fee)
/~C
Adverse Determination & p 9----
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SHD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Ruildings Divi ion, Owner, Plumber
INSTRUCTIONS
y i
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit maybe 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:
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.
11. 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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abor and Human angel bons stry,
L SOIL AND SITE EVALUATION REPORT Pap -of
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
ST, c,Po~'X
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distanc 48 t o
REVIEWED BY DATE
APPLICANT INFORMATION-PLEASE P
PROPERTY OWNER:
?i iH 3 ~~jp y OPERTY LOCATION
,t • _ .LOT 114 1/4,S2-9 T 2-9 N,R E010
PROPERTY OWNER':S MAILING ADDRESS .{g # BLOCK # SUED. NAME OR CSM A
~yl~ 3RD S T- 4. Sv,v (Z i
CITY, STATE ZIP COD .PH UMBER `4 ~ te, ITY F-Ml IAGE OWN NEAREST ROAD
hfi u p.S o,J W i , 5~l 0 / ~ T`~ =~is) 3 1~ - 3~ v,0S 0A.,; [q'New Construction Use (v]-Residential / %r~ber,of badrooms Addition to existing building
I ] Replacement [ ] Public or commercial"deserU 1-~
yS6 -
Code derived dally flow j~e o 0 gpd Recommended design loading rate , bed, gpd/ft2 trench, gpd/ft2
Absorption area required / 2-0 0 bed, ft2 /60 trench, 112 Maximum design loading rate S bed, gpd/ft2 - L trench, gpddt2
Recommended infiltration surface elevation(s) Y-z-<_ e 3 ft (as referred to site plan benchmark)
Additional design I site considerations 0,91-9 , f of 13 4 - rya Vv p S Vs T. ]2 eo u i le t~V
Parent material 5~5 J` S T7;'e_ . $i/ 3 /04.-rs Flood plain elevation, if applicable ~ A- ft
7Uunsultlabloerfor abe system C~ONyExrZONAL MOUND IN_GgOUN❑D U ESSURE AT_GR~BE❑ U S~YSTE FILL HOLDING TANK
system [EM O U [ ❑ U 12S l~ C~ C~ U 11 S
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed tench
2- S- / / o ,t 313 Si/ Z ,d,~ C 5 5 • G
Ground -3 4- y /o !~e y/`~ / ~5~~ cwt of a w • Y . S
elev.
Drepl 9to s / D [I R 6 /CLf,H V { S . S' GQ S - S
factor v
i
7
Remarks:
Boring #
-yp
z z %-1 /AYR 313 s~ ~fsbk C~ , s;,6'
Ground 5-0 7, 55 Yle
elev. '0 / o Os ::Qv - . 7 "9
/a. ft.
Depth to
limiting
factor I/
> (va
Remarks:
CST Name:-Please Print J2o (3 ER T- L(LQ I? t'C L. T Phone:
716-- 3 A; 603-
Address: z l' 9S csr•4, 2 yP
Signature: L 1 _7 1 _ .,_e.. c...unwn f`nnaultant8 data MT Ni mhor
4
PROPERTY OWNER ~N FU SC's-- SOIL DESCRIPTION REPORT Page? of 3
PARCELI.D:! Lo 7- Z- S(~~v/2/DG~
Boring # FHorl-zon Depth Dominant Color Mottles Texture Structure Consistence Bounchy Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed oich
/o,,~ 1fs6& ~.f e- es j f- , q . s
o 3/ Si/. Z f S ik n.4-f, S f uf- , 5 . G
Ground 7, S X0 e s S ef CS 1
elev. GQQ , 7
Depth to
limiting l
facto
T-T
Remarks:
Boring #
Z z / o yle 313 C'S l F S j
Ground
elev. -y~ A5 ye S S C' S - 7
gyp, it.
5 _ y 0 i s o s Q- .71
Depth to }
limiting
facttoo~ „
Remarks:
Boring # _
10 / 0 Y"e 3 2-1%o c w iL)f . 5 . G
2, s Y - s/ 1 fsd t o fe cw s
Ground
elev. 3.? 7, 5 V /40 5
f"g, .~y ft.
Depth to
limiting
~facttoorn
Remarks: DES/t ~~~fyi b Af727- OF fi4' ~Se WS C-v
Boring # 1.1- /O r/4 3SV /-FSb~ ~n-P72 S ,
S
E'l
-10 /0 3/.3 Ground
A%-F,-
elev.
it. 36 ` Fi 4C E-,P Dd d.~t~. , ~U~
Depth to e,#
limiting
facto „
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STC-105
SEPTIC 'TANK MAINTENANCE AGgEEMEN T
St. Croix County
OWNERBUYE:R
MAILING ADDRESS ~I s sl
PROPERTY ADDRESS u 1
(location of septic system) Please obtain from the Plan ' ikPt
CITY/STA'T'E
N-Ii W
1/4, 1/4, Sectioa4 T ^~Ql
'P'ROPERTY LOCATION
TOWN OF, ST. CROIX COUNTY, WI
SUHDTVISION` LOT NUMT3ERS~__
CERTWMDSURVIEY MAP VOLUMz , PAGE , LOT NUMBER
Improper use and maintenance of your septic system could result in its premature failure to handle ner, ded
wastes. Proper maintenance consists of pumping to the septic tank otthree,
t ie functionrof the septicetank
by licensed septic tank pumper. What you pu Ystem can afI'
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 978.
St. of replacement of a failing system, which was in requirement Firthat ownersldflall new sy teros agree to
accepted this program io August of 1980, with the
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 licena d (2) pafter umper veii png that (1) and
the on-site wastewater disposal system is to proper operating conditon
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 ethe grciovate sewage
disposal system in accordance with the standards set forth, herein, as set by
Certification stating that your septic has been maintained trust be competed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED: 4'L,
DATE: f
St. Croix County Zoning Office
Government Center
1101 Carmichael Road 11193
Hudson, W1 54016
1C
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11 d AT 8 V ; 3L~T5 V LF - - r rn i .f '-I?
STC - 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 of property ,I.- N+ -N i
Location of property_ ~ 1/ 41/4, Section,, , T.N-R_L.LW
Township ULk~~ Mailing address
Address of site uv-
Subdivision name6LAkly- _111Z Lot no..
Other homes on property? -Yes- No ~I
Previous owner of property
Total size of property
Total size of parcel T
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes Z_No
Volume_ and Page Number 4~ as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWXNG:
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) an (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
$ , and that I (we) presently
beads as Document No. 52 _
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.
Si atu a pplicant Co--Applicant
bate of Signature Date of Signature
H "Ari~~ ) C cr:q A -1 rr.T/QT/"A
PAU
VOL
sM
WARRANTY DEED H~G!5 i cn 3 Cry ~C 2
-Vil
g~ 0110"X C-0:'
5525'78 Fed IMPA=d
Document Number. NOV 2 5 1996
10:00 A•M '
Return Address: William Johnson, 2575 Brittany Lane, Woodbury. M M- 55125
Parcel I.D. Number
rises, Inc, a W-Mm sa, orporation, Grantor and William A. Johnson and Arletta
THIS DEED. made between Greenwood Entarp marital prsre y. Grantee.
M. Evans Johnson- husband and wife as survivorship
consideration of e~ dollar and other good and val"ble consideration conveys '.~3b • r '
WITNESSETH, that the said Grantor, for a valuable Ssaat q/isconsin
to Grantee the following described real estate in St. Croix Canty.
Lot 2. 1996
52, of the plat of SunRidge III, filed in the Office of the Register of Eked. for St. Croix County, Wisconsin, on January
in volume 6 of Plats, At Page 46, as Document Number 538046. x
This is not homestead property A'
tlar~o belonging: and Greenwood Enterprises, Inc. warrants
Together with all and singular the herediwmits and appurtenances
that the title is good, indefeasible in fee simple and free and clear of ~hraaces except tWements, restrictions and reservations, {
F
if any, of record and will warrant and defend the same. `
TRAoIFE'1' k
Dated this n day of November, 1996. s ' : t
RIS , INC. FEE
GREENWOOD ENTERPRISES, INC. GREENWOOD
By: By: ~ry r N sf .
7 E. Rusch, its president ' Y
ACIQ~IO'rVLEI]GMENT AQ OWLEDGEMENT
IRTATE OF WISCONSIN STATE OF WISCONSIN ) v`,
ss.~~'r.
ML
COUNTY T. CROIX COUM1f OF ST. CROIX ) .C~;~
)
- ones before me this o~ Q_ day of November;
Perso bebefore- this day of November, Perso~y
1996 , its secretary.
E. Rusch, its president 1996, rve named Ma Rusch
~T '3~nuies t
executed the foregoing to me to be the who executed the foregoing ~t t
K
to tt; _
e same. and acimowl
l
t61 , d`io ry Public r R
S oESasconsin
My won
bly' xp 1-16-97. expires
3
D BY:
` Brenda Poulin
THIS INSTRUMENT WAS DRAFTS
Lois A. Murray Notary Public ' ' %
Zilz, Estreen & Ogland State of Wisconsin
304 Locust Street
Hudson, WI 54016 '
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