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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER-
ADDRESS.
l~-
SUBDIVISION / CSM# LOT #
SECTION T N-R~W, Town of /P.
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
o `l
vV I¢ 3v
0
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
r a
BENCHMARK:.
~p O i"~y ~w • c~~~
ALTERNATE BM:
SEPTIC TAN / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: e Liquid Capacity:
Setback from: Well House 2Z -other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: fa4 Length 6 Number of trenches
Distance & Direction to nearest prop. line: 3
Setback from: well: r House4'~{2 Other
ELEVATIONS
Building Sewer y~,rs ST Inlet: ST outlet:
PC inlet PC bottom Pump Off
Header/Manifold q Bottom of system
Existing Grade "Final grade
DATE OF INSTALLATION: L1- 3 D
PLUMBER ON JOB: J fz`,
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labdr and Human Relations
S
. Safety and Buildings Division INSPECTION REPORT ST. CROIX
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 284245
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
LEMIRE DUANE SOMERSET
CST BM Elev.: Insp. BM Elev.: r BM Description: Parcel Tax No.:
/Ga cz / /cL),G,~) S-,ne QS 032-1099-30-000
TANK INFORMATION ELEVATION DATA A9700018 V3 0 19 7
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic S C , g Benchmark wr
Dosi n rn . O• y 7
'
Aeration Bldg. Sewer / X09 ' Z-03,
Holdin St/ ~t Inlet
TANK SETBACK INFORMATION St/ Outlet 5l sa' /(1v,a3''
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
NA Dt Bottom
Septic I YI
44
Dosing NA Header/99s:v--
Aeration NA Dist. Pipe -A 7 W/
H Bot. System 76r pQ '
PUMP/ SIPHON INFORMATION Final Grade
s ~,7~" /doZ.Oa
Manufacturer Demand
Model Number GPM
TDH Lift Fri Ft
Force Length Did. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width r Length No. Of Trenches PM No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 1~ N
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM ufacturer: CHA INFORMATION Type O nQ, /~j /f®I ® OR' NIT R Mode Number:
System: Cowe- ~ UJ l~
DISTRIBUTION SYSTEM
01 Header / , r Distribution Pipe(s) Size x Hole Spacing Vent To Air Intake
Length A--! Dia. Y Length -4-1' Dia. Spacing 6p /
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Sys s Only
Depth Over ,r Depth Over xx Depth Of Seeded/Sodded xx Mulched
Bed /Trench Center 'd _ Bed /Trench Edges v1`4 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: SOMERSET 36.31.19.461A.NW.NE 190TH AVENUE
CI ,r•
C wo-co ~f
Plan revision required? ❑ Yes Zlgo
Use other side for additional information. 7 Q
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
R
SANITARY PERMIT NUMBER:
f
w" Safety and Buildings Division
vti.iyGR 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 1.1-%
than 81/2 x 11 inches in size. ~ T
• See reverse side for instructions for completing this application State Sanitary Permit Number
02 (~<2-/S
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)]. -755 f 9 O ""`h ~ . (3CrrYi[,
` s,/~ l State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property er Name Pr perty Location
/4~g 1/4,5l T 3.1
N, R/9 E(O try
Prope y Owne,r'/s,Mailing Address Lot Number Block Number
8 9 7 Ste- -
Ci tate Zip Code, Phone Number Subdivision Name or CSM Number
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road
~f ❑ Village /v
❑ Public 1 or 2 Family Dwelling - No. of bedrooms °C 'Town of :5e/rE^__5 -&4- $t~ 1-k 9,1114
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo S47.:3 l 9. 4& 1 A ® -3t4 - / e 9 9-30
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
19 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 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_ System Elev_ 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation e-9 el 5W Feet lam. (eFeet TANK Capacity
VII. FORMATION in gallonTotal # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper_ Site
New Existing Gallons Tanks Concrete strutted glass App.
Tanks Tanks
❑ ❑ ❑
Septic Tank or Holding Tank (.~C/ - ❑ El
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
PI mber's Name: (Print) Plu er's Signature: 24o Stamps) MP/MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
3214 lo ff ak- All-49--
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing Agent Sig N to
A roved Surcharge Fee)
pp ❑ Owner Given Initial
/r/C%
Adverse Determination (D l
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to county. One copy To: Safety 8 Buildings Dive.ion, Owner, Plumber
INSTRUCTIONS ,
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 owttefr'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. Buiiding 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.
nn PLOT PLAN
P R`OJ E C T N u a~ r~., 2 e~ ADDRESS 1er q cFy V-4 ASV. se>rn ¢.-s(.-74, cy~ ~z s~
NcJ 1/4 tiE 1/4/S N/R /9 W TOWN sue. - COUNTY SV -Cro,'x
MPRS Byron Bird Jr. 3318 DATE/
-iS-9
BEDROOMS CLASS PERC -Z~r- CONVE ` NAL~I -GRO D RESSURE
CONVENTIONAL LIFT MOUND_ HOLDING ANK
SEPTIC TANK SIZE _60o LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA Loo PERC RATE BED SIZE i x
► Benchmark V.R.P. Assume Elevation 100'
Location of Benchmark 6A„4)
* H.R.P. v~-~ 4S 6 n~
C] Borehole Q Well Scale = Feet
O Perc Hole System Elevation
Uent
12"
Grndp
TYPAR COVERING
2"
12" 3- 4 6' 4O 3'
1 6" Sewer Rock
1.2'
yY, P,L
0
V
3a 8-e;
U Qe1L2~an / So
+,La-us i e l5 J n
3 co)
~ 8.•rr~
0
W.isCtn Department of Industry, SOIL AND SITE EVALUATION
Labor and Human Relations Page of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County ,
include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I .D.
t r
g
AIN&
APPLICANT INFORMATION - Please print all information. Reviewed bV,-' Da
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
Govt. Lot 1/4,4~~ 1/46 T,: W f°., E (o~
Property Owner's Mailing Address Lot # Block# Subd. Name or CSW-4
City State . Zip Code Phone Number E] City ❑ Village Town Nearest Road
ew Construction Use: `tesidential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow , 30 U gpd Recommended design loading rate bed, gpd/ft2-~-Itrench, gpd/ft2
Absorption area required 0 bed, ft2 S04) trench, ft2 Maximum desi oading rate bed, gpd/ft2! trench, gpd/ft2
Recommended infiltration surface elevation(s) TJ % ~T~q ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material Flood plain elevation, if applicable /1/1&-4Yt7 ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
U= Unsuitable for system s❑ U ❑ U ❑ U >Qrs U ❑ s ❑ s -idu
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
1 0 ~s
Ground -3
/ b 0 ft . /
Depth to
~f limiting
/ in.
Remarks:
Boring #
2S1
Ground
Depth to
limiting
r
'Ein. Remarks:
CST Name (Please Print) Signature Telephone No. /
r ,
l `07 6 4
Address Date CST Number
89'9 6 lr~ -32171
lop
PROPERTY OWNESOIL DESCRIPTION REPORT Page of
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots G~pjft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
z s ~'S S
Ground r ,t
)VA
Depth to
limiting
fac
Remarks:
Boring #
4-x ,
3
Group ;
Depth to
limiting
in.
-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 # 1 O_L ) v IL
5 a 6-~~ id f a
3 4 5', 17
Groin
ft.
Depth to
limiting
in. Remarks:
®r
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBDW-8330 (R. 08/95)
t
Soil Test Plot Plan
Project Name Duane Lamere Byron Bird Jr.
Address 1894 80th St.
Somerset Wi 54025 IJCSTM #3479
Lot Subdivision Date. 10/5/96
NW 1/4NE 1/4536 T 31 N/R19 W Township N. Somerset
❑ Boring ()Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Base of 1" Wood Stake with Orange Ribbon
System Elevation 97.0/93.5 * H R P Same as Benchmark
Property Line
7% B-2 30' B-5
y 1
Slope
25'
300' ep A
Pro 2 B-3
40' Bedroom
House Pri A
5'
1 Id- 220' 26' 25' B- 30' IhL B-4
5'
M.
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
/ St. Croix County
OWNER/BUYER N z L e- P7 (r
MAILING ADDRESS
PROPERTY ADDRESS e
(location of septic system) Pleas6 obtain from the Planning Dept.
CITY/STATE S Vh ~t SL
PROPERTY LOCATION b~d 1/4, V~5' 1/4, Section 3. (o , T_aL_N-R ~ W
TOWN OF ~O 1'►~ C r L~ 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 eexp~ation date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
STc-~o0
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 L pit 4) e L r-c-
Location of property N01/4 AJ Ell 4, Section (o , TAN-R~
Township SE k-v\ erSc:`f Mailing address /S gy w
Address of site 13t Ay`Q -
subdivision name Lot no.
Other homes on property? YesNo
Previous owner of property
Total size of property
Total size of parcel
Date parcel was created ; 'S r Oct,
l SS
Are all corners and lot lines identifiable? -Yes No
Is this property being developed for (spec house)? Yes No
Volume S4rO and Page Number 5-23 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. __3a/,3(5/ , 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 Applicant Co-Applicant
Date of Signature Date of Signature
DOCUMENT NO. QUIT CLAIM DEED
STATE OF WISCONSIN-FORM 11
321 3 0 THIS SPACE RESERVED FOR RECORDING DATA
THIS INDENTURE, Made this 15th _ day of April REGISTERS OFFICE
A. D., 19 between Duane Leldire ST. CROIX CO., WIS.
Need for Record this_ lath
day of_-Aril A.D.19-7L-
part of the first part, and ___21 A ! M.
&nn,e, T.auire mne, ]ilfarlor► Tt~lfir~i~-pint tenZn+e3 l(~~
R!eg or of
part ies of the second part. , RETURN TO
W f t n e s s e t h,,.That the said part _.y__ of the first part, for and in consideration
of the sum of
Onp Dollars, to in hand paid by the said part ie8 of the second part, the receipt whereof is hereby
confessed and acknowledged, ha S given, granted, bargained, sold, remised, released, and quit-claimed, and by these presents do give
grant, bargain, sell, remise, release and quit-claim unto the said part ies of the second th@
following described real estate, situated in the County of . CrOX part, and to heirs and assigns forever, the
and State of Wisconsin, to-wit:
The Northwest Quarter of the Northeast Quarter (NWJ of M' Z_/ of Section Thirty-six (36)
Township Thirty-One (31) North, of Range Nineteen (19) West, St. Croix County, Wis.
EXEMPT
To Have and To Hold the same, together with all and singular the appurtenances and privileges thereunto belonging or in anywise
thereunto appertaining, and all the estate, right, title, interest and claim whatsoever of the said part __'Y_ of the first part, either in law or
equity, either in possession or expectancy of, to the only proper use, benefit and behoof of the said part ieS of the second part,
_ their heirs and assigns forever.
In Witness Whereof, the said part _Y_ of the first part ha 8 hereunto set his hand _ and sea] this. 15th
day of April , A. D., 19 74
SIGNED AND SEALED IN PRESENCE OF
C (SEAL)
Duarte LeMire
(SEAL)
_ (SEAL)
(SEAL)