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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
t~ LAI,
~rS
a-
ADDRESS
SUBDIVISION / CSMI
Aie- LOT Z
SECTION
y T N-R_Z Town of
ST. CROIX UNTY, WISCONSIN
PLAN VIEW
HOW EVE HING WITHIN 100 FEET OF S~
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I ICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tan}
f '
BENCHMARK: s
ALTERNATE BM: K,l ~~y - ~fyyT ~pki•t~ /03
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer:__ Liquid Capacity:
Setback from: Well House_ yP7 Other
t Pump: Manufacturer - Model Size
Float seperation Gal cle:
Alarm Location
:SOIL ABSORPTION SYSTEM
Width: /Z Length_ S~ Number of trenches
Distance & Direction to nearest prop. line: g
ire
Setback from: well : House__Z,4L ` Other
ELEVATIONS
Building Sewer Qf' ST Inlet. 9s.s / ST outlet
PC inlet PC bottom - Pump Off
Header/Manifold !/C3 Bottom of system fo4 _
Existing Grade_ Final grade 5pVo
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor'and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION 299161
Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.:
FEYEREISEN, THEA ST. JOSEPH
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
DDS l U0 ?a o-~ ~Vh e T.S 030-1015-30-100
1e e TANK INFORMATION ELEVATION DATA A9700475
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic yJ tK S ppv Benchmark 2 goD2.%o OD
Dosing
Aeration Bldg. Sewer Iot170 s(o 4$ 35<
Holding (:S;/49InIet {02 R0 7.
TANK SETBACK INFORMATION QYSOutlet EOZ•90 7 sT 9'S 3 t'
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic 20' n2 n~ NA Dt Bottom
Dosing NA Header / Ma p` q7 &1 t 27' 7/.60,3
"
O 91.
Aeration NA Dist. Pipe q 91-41-
Holding Bot. System Q7-bq 770`f 10.45-
4s ~
PUMP/ SIPHON INFORMATION Final Grade ql b 7
:6Wnow- 3 -r '73 .9-7
Manufacturer Demand gf, IMak ~ (o W S•C1 ?(O 99
Model Number GPM A/ f- fA4 --r o.0 ate- 103 36~
TDH Lift L n stem TDH Ft Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
B TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
-151-MENSIONS ~s _ DIMENSIONS
LEA ING nuf urer:
SYSTEM TO P / L BLDG WELL LAKE /STREAM
SETBACK
INFORMATION Type O 3, `(5' 2 CHAMBElt Model Nu r.
System 1 OR UNIT
DISTRIBUTION SYSTEM AI>Tm Z-7 29
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Int
Length Dia. Length 4jy Dia. Spacing to
SOIL COVER x Pressure S stems Only xx Mou d Or At-Grade Systems Only
Depth Over Depth Ov epth Of xx Seeded/ Sodded Fx Mulched
nter Bed /Trench it Yes ❑ No Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: ST. JOSEPH 4.29.19,SW,NW 1171 SUNDANCE PASS - LOT 2
~ ~s~ec~-ti~Y1
b,/e l/ 1,16S n04 iiIs-fulled r f
2) The. -1V m-~ 'tf1a- h e er/ ~o l n fi.
1nIZ S a 1u, v set r S Ct 4-or- - v 3
Plan revision required? ❑ Yes No 62 ' g~
Use other side for additional infor Ion.
SBD-6710(R 05/91) Date Inspector's nature Cert.
ADDITIONAL COMMENTS AND SKETCH
` r
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
~~i~i7■"7 SANITARY PERMIT APPLICATION Bureau of Building Water System.
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 8112 x 11 inches in size. 57e C c
• See reverse side for instructions for completing this application State SanitarypPe`rr~lmit6NNu1mber
The information you provide may be used by other government agency programs E] Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
S OW• vGi State Plan I.D. Number
1. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION
Property Owner Name Property Location
N, R E (ore
1/4 k/1/4, S tumber
Property Owner's Ma ing Address Lot Number City, State Zip Code Phone Number Subdivision Name av-am}~tr
D/tJ av o (j) 22 l 43,2
arest Road
11. TYPE BUILDING: (check one) ❑ State Owned ❑ it~r T3_,~&A1,0Wyye&_
Public 1 or 2 Family Dwelling - No. of bedrooms 3 E] VIIa Townge OF >7. ~ I11. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
O a 9. / 9' &V,4 1 ❑ Apartment/ Condo B.;d O 0 -zoo
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. Z 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 m Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
1 ❑ 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) Elevation
V51-a 3 J 7 17 9G M Feet Feet
VII. TANK Capacity
in gallons Total # of Prefab. Site Fiber- Ex per.
INFORMATION New Existing Gallons Tanks Manufacturer s Name Concrete con- steel glass Plastic App
strutted
Tanks Tanks
Septic Tank or Holding Tank 0,0 - p®d 4" ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑
VI11. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the nsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No S mp IFAP'MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zi Code):
IX. COUNTY/ DEPART ENT USE ONLY
❑ Disapproved S nitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
VApproved Surcharge Fee) Ll A
NJ E] Owner Given Initial ~
~ gb - I i • ~p ~q~ Ira(/W_ ®VJf,,
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUI:TIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renevved 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 isto 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.
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COR 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 #
dimensioned, north arrow, and location and distance to nearest road. ,r d i n
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION ^
PROPERTY OWNER: PROPERTY LOCATION _
Bill Fe en GOVT. LOT SW 1/4 N ,,1 ,S 4 T,1 " N,R '(or) W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK# SUED. ~KFR~* C;CEFiCE
1171 2 na csm N, SundancL_ Pass
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE DOWN T
d.qnn. WT_ 94016 (715 386-2268 St. Joseph ance Pass
[x] New Construction Use :c ] Residential / Number of bedrooms 3 [ ] Addition to existing building
Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate • 7 bed, gpd/ft2 •8 trench, gpd/ft2
Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate . 7 bed, gpd/ft2 .8 trench, gpd/ft2
Recommended infiltration surface elevation(s) 90.85 alt. are=98.52 ft (as referred to site plan benchmark)
Additional design / site considerations na Ivichativ v►o6i+af gq 46
Parent material outwash Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND 1 7 IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem ns ❑ U C3S El U KI S El U R] S El U CAS 1:1 U El S ® U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
'...1. 1 0-10 10 r4 3 none s i l 2msbk mfr CS 2f .6
2 10-32 10 r4/4 none sicl 2msbk mfr if .4 .5
Ground 3 32-84 7.5yr4/6 none cos os ml na na .7 .8
elev.
94.35ft.
Depth to
limiting
factor
+84"
Remarks:
Boring #
1 0-9 10 r3/3 none sil 2msbk mfr cs 2f .5 .6
2 9-33 10 r4/4 none sicl lcsbk mfi Cfw if .2 '.3
Ground 3 33-84 7.5 r4 6 none cos s m n na .7 :.8
elev.
94.35 ft.
Depth to
limiting
factor
+84"
Remarks:
CST Name:--Please Print Gary L. Steel Phone: 715-246-6200
Address: 1554 200 ve. New Richm d WI 54017
Signature: Date: CST Number: m02298
10-8-96
PROPERTYOWNER Bill Feyereisen SOIL DESCRIPTION REPORT Page? of 3
PARCEL I.D. # pending
Depth Dominant Color Mottles Texture Structure Consistence Bounday Roots GPD/ft
Boring # Horizon in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 0-8 10 r4 3 none sil 2msbk mfr cs 2f .5 .6
3
2 8-35 10 r4/4 none sicl lcsbk mfi if .2 .3
qo•q
Ground 3 35-88 7.5 r4 6 none Cos 0scr Ml na na .7 1.8
elev.
93.85 ft.
Depth to
limiting
factor
+88"
Remarks:
Boring #
1 0-9 10 r3 3 none sicl 2msbk mfr 2f .4 .5
Lj 2 9-24 10 r4 4 none sicl lcsbk mfi C1w if .2 .3
~~•55 3 24-80 7.5yr4/6 none cos osg ml na na .7 .8
Ground
elev.
91.55ft.
Depth to
limiting
factor
+80"
L
Remarks:
Boring #
1 -9 10 r3/3 none sicl 2msbk mfr cs 2f .4 .5
.2 .3
`...5..`' 2 -22 10yr4/4 none sicl lcsbk mfr gw if
3 2-78 7.5yr4/6 none cos osg ml
Ground na na .7 .8
elev.
91.55ft.
Depth to
limiting
factor
+78"
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel William Feyereisen 1554 200th Ave.
CSTM2298 SWQNW4 S4-T29N-R19W New Richmond, WI 54017
MPRSW 3254 town of St. Joseph (715) 246-6200
lot #2-csm
t
N
1"=40'
BM.= top of 1" pvc pipe C el. 100'
Alt. BM.= top of wooden corner post C el. 103.45'
too
k
h Z
31 3
33 3 3' -zo' 2 0' od'+-
X
Gary L. Steel
10-8-96
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9 ro y ' FILED
CL . LD N -E: _ e APR 1.7 .1997 ► 4
bg a' ` KATHLEEN H. WALSH
Hepisw of Deeds
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER _
MAILING ADDRESS /I ~Zj All r./ ~
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE 6
PROPERTY LOCATION _3-".) 1/4, _,eval 1/4, Section T-~N-R_ j&_W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP 55-Cl36 , VOLUME _//9 PAGE 323 , 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 113 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 11/93
Hudson, WI 54016
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.
Owner of property
Location of property e/ 1/4 1/4, Section S~ TZ9 N-R17W
Township _ - Mailing address /17/ fArzOD~ /'ids
o w ~
Address of site
Subdivision name 5?4%1t)Ag1er p,#-55' Lot no.
Other homes on property? Yes ___V No
Previous owner of property
Total size of property 8Trz~s
Total size of parcel ~~j_2cs
Date parcel was created
Are all corners and lot lines identifiable? ✓ Yes No
Is this property being developed for (spec house) ? Yes t~No
Volume /~23 7 and Page Number 395_ 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.B,-d , 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.
Signature of ApVlicant Co-Applicant
II oocuMENr No STATE BAR OF WISCONSIN FORM,-1"2
~i WARRANTY DEED
it
559020
ThiS Deed, made between 7 199T
a MAT
r---
• ► - 1::00 A to
and
Witnesseth, That the said Grantor for a v uabie consideration _ aN TO
111 Tu•c~a.+•-{ F3:sy
conveys to Grantee the following described real estate in 7
County. State of Wisconsin -
ai
t\a Ta, Parcel No: i
W,
of `I 0 1.
L
ff , , 3235 '
G0 P6lh9e.
F
r.
This •Zar
y C r homestead property. I
3 (is) (is not)
~ I with all and singular the hereditaments and appurtenances tre•e+~+rto bC,pngang.
Together I
And except
_ l lI
warrants that the title is good, indefeasible in fee simple and free and clear of encum
and will warrant and defend the same.
day of
Dated this- (SEAL)
(SEAL)
Q 1:
• ~l~~tQ r'i Sra_~-
(SEAL)
- (SEAL)
1 ~L !1
j 1' ter'e S .
. Aav,
ACKNOWLEDGMENT ii
AUTHENTICATION 1
STATE OF wscc"SIN
a 1
55
Signature(s)
County.
w ed tA(I hi 0 t1ar F A'~l Perso aMy came before me this_- day of 11 ,9_ ---the above named
auit~enticatthis day of
c~,- r
his