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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ✓ yr~ ~~d J~yL.SLJr-i
ADDRESS
SUBDIVISION / CSM# LOT #
SECTION T ~N-R~W, Town of -Gt/ l
ST. CROIX COUNTY, WISCONSIN 039- 'ODD
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
3
5 23
Zd
f
IND CATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
t
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer _ Liquid Capacity:
Setback from: Well House ~3 Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location-
SOIL ABSORPTION SYSTEM
Width: Length Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well:.Z5j:Q House_ Other
ELEVATIONS
Building Sewer~S-3 ST Inlet: ST outlet:
PC inlet PC bottom Pump Off
iic?uV
a~
Header/Manifold Bottom of system
Existing Grade Final grade Q~
DATE OF INSTALLATION: ~X
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin,Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor
fety and Relations
Safety and Buildings Division INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary
284348
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
JOHNSON, TORY & MARILEE STAR PRAIRIE
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
/I rte Cw ...1 038-1179-60-000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic cr 37~c Benchmark i /!o,$
Dosing a
Aeration Bldg. Sewer
i
Holding St/ Ht Inlet 611 /0 q, a 3
TANK SETBACK INFORMATION St/ Ht Outlet 6 0~. 163.
q
TANKTO P/L WELL BLDG. ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe ' 103. /a r
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM !~l TDH Lift Los System Head TDH Ft
Forcemain Len Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS '4/ DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Typeo CHAMBER ~il OR UNIT Moe Number:
System: 3 -/l
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: STAR PRAIRIE.15.31.18,NE,SW 1152 212TH AVE. LOT 27
Plan revision required? ❑ Yes LJ'IVo
Use other side for additional information. (o 6
SBD-6710 (R 05/91) Date Ins a is Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH t
SANITARY PERMIT NUMBER:
f
wo
ureau o off B Building Water Systems
SANITARY PERMIT APPLICATION Bureau and Building Systems
In accord with ILHR 83.05, Wis. Adm. Code 201 E. Washington Ave.
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 81/2 x 11 inches in size" I G rvr %
• See reverse side for instructions for completing this application State Sanitary Permit Number
The information you provide maybe used by other government agency
IPrivacy Law, s. 15.04 (1) (m)1. programs ❑ Check if revision o previous application
" e._ / State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Ow Name Property Location
cth
l4 tcf 1/4, S T , N, R E (o
Property Owner's fling Address Lot Number
9 Block Number
fir` r7
City NateZip Code Phone Number Subdivision Name or CSM Numb r
II. TYPE OF BUILDING: (check one) E] State Owned El city/ Nearest Road
Public 1 or 2 Family Dwelling- No. of bedrooms C
on OF 5/cc r/'~tir`y G
v
III. BUILDING USE: (if building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo O !17A 9tJ
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. E] Replacement 3. E] Replacement of 4_ E] Reconnection of 5 0 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 eepage Bed 21 ❑ Mound 30E] Specify Type 41 ❑ Holding Tank
12 ]Seepage Trench 22E] In-Ground Pressure 42 Pi Pr'
13E] Seepage Pit ❑ t Ivy
❑
43 Vault Privy
14E] 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
C_/ 5-° 6
VII. TANK Capacity l Q Feet E+ -Feet
INFORMATION In gallons Total # of Manufacturer's Name Prefab. Site Fiber- Ex per-
New Existin Gallons Tanks Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holding Tank L I ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber, ❑ ❑ Ei ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT E_1
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans"
Plumbe ' Name: (Print) PlumbersSignature: (No Stamps) MP/MPRSW No.: Business Phone Number:
_
Plumb s Ac!d ess (Street, City, State, Zip Code): ( 7
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Indudes Groundwater ate Issue =7 No Sta s
Approved ❑ Owner Given Initial surcharge fee)
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SHD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division; Owner, Plumtw
T
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 administr~ to 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 maihng 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 testdata 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.
PLOT PLAN
PROJECT )l~1/~~r'~'ADDRESS_ 5
1/4~ / 1/4/Sjrj"/T~/ N/FV6'W TOWN COUNTY
MPRS Byron Bird Jr. 3318 DATE -S Gra
BEDROOM CLASS PERCH CONVENTIONAL---<IN-GROUND PRESSURE
CONVENTIONAL LIFT MOUND HOLDI G TANK
SEPTIC TANK SIZE ~ LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA PERC RATE BED SIZE
'x
Benchmark V.R.P. Assume Elevation 100'
Location of Benchmark ; e
* H.R.P.
CI Borehole Well Scale = Feet
O Perc Hole System Elevation
Vent
12
TYPAR COVERING
f 2"
12" 3, 4 6, O 3,
1 6 " Sewer Rock
12'
L,
MIJ
0
sly
3► I
Wisconsin Department of Industry,
.-Labor end Human Relations SOIL AND SITE EVALUATION REPO Page / of 3
Diviston of Safety a Auitdngs In accord with ILHR 83.05. Wis. Adm. al /
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must i but R O 1, K
not limited to vertical and horizontal reference point (BM), direction and % of slope, L I.D.
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION' VI ^ BY - DATE
PROPERTY OWNER: PROPER
Xi'G h A pD STO U T" GOVT. LOT 114 1/4,5E N,p /9 E (010
PROPERTY OWNER':S MAILING ADDRESS WT BLOC 9 If
353 4w,4 7-0 A-7 41RsWAISW 164- V
CITY, STA,TSEO ZIP DE PHONE NUMBER ITY []VILLAGE RMR' NEAREST ROAD
ms's (715)5gj_(0731 PRAiPuE- //W. cC
jptfJew Construction Use ( residential I Number of bAdrooms 3 +0 4 Addition loexisting building
( ( Replacement (I Public or commercial describe
Code derived daily Now y °o[~ gpd Recommended design loading rate bed, gpd$ trench, gpd/ft2
Absorption area required bed, 1`12 75-0 trench, 112 f bArrium design loading rate • ? bed, gpolR2 ' S Iench, gpdM2
Recommended Infiltration surface elevation(s) SEA }'SaL . 3 N (as referred to site plan benchmark)
Additional design / site cons rations
Parent material SCS i 1 py t,fl , Flood plain elevation, it applicable R
0
S =Suitable for system CON tu
YMIONAL Ot1ND U IN•GRQMD U PRESSURE AT-G E SYSTM IN FLL HOLOM tTAW
U = Unsuitable for stem S O U [ 0-T 11 LoO U 9-37-11 U ❑ S
SOIL DESCRIPTION REPORT 1f`1=
Boring # Horizon Depth Dominant Color Mottles Texture Structure Roots GPD/it tence Boundary In. Munseil Qu. Sz. Cont Color Gr. Sz. Sh. Bed 0-13
/-0 YK 3 - s . /f~s!✓.E~ v~iP G's ? of Tkinch
s!
Z 3 -24 0 3/ Si / Z fshk- fie Cs /vf s
Ground 3 Z( -361, Y/
G~S CS /U` • 7
• g
elev.
Depth to
limiting
facto d
Remarks:
Boring #
/ '9-7 /0y/e 342- s/ I~sl,~ vf.~ cs zof . y~ • s
Z..... 2 " 10 /0 0 3/3 /s y ~s ec&v /f . 7 .00
Ground 3 D /0 l? .8
elev. O
o y/P
CS GC~ - 7
y It.
Depth to
limiting
factor
Remarks:
ST Name:-Please Print POSER T 2A L Q R t'C k T- Phone. 71s=., 3 a& - S 18 5 i
Address: 2, CST 1`,/~~
L/- fG
Signature: Ulbricht Date: CST Number:
w , i private soweae Consultants
PROPERI'l omtm R,;~44,W SOIL DESCRIPTION REPORT Page Z of 3
PARCEL I.D. # LD T 2 "7 iE ! 11EIC SL.V f~
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourdary Roots GPD/ft
In. Munseil Qu. Sz. Cont Color Gr. Sz. Sh. Bed
Ground 7 -S 7s t? G S. O f eS
elev.
/67.5 rg
Depth to
smiting
factor
Remarks:
Boring # o /o /o yR 312- .5/ /fsl~ /,P e5 a , y , s-
2- D-lZ 10Y13/3 S/ Z+sd,~ es ,41
AV.
Ground 3 m S
elev. /o 7 .g
/as •S it.
Depth to
smiting
factor
7
Remarks:
Boring #
z rrF . ~ ~ ~ s
2 l3 /0 4/R 31III-ii? CS laf . S G
S
Ground 3 3 /O w 3 15 / ~s cw /jam . 7 IS
elev. Yle
• g
Depth to /d -3 GS d - - . 7 ~g
smiting
facto
Remarks:
Boring #
Ground
elev.
tt.
Depth to
smiting
factor
r ~r
0 0
w w
6U 1973 7-
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~ _ • III
01/16/1994 06:05 7152473622 REMAX TEAM 1 REALTY PAGE 01
- 19970i M ISlO X"1169 P.W/003
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c( l n s.:'e.e lot e, m-115 to p+rtsl, ttf.l. 11101;
~::f:tt tnd eppalt,tce':1s 10111 for l1rue.
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N 89'40' -W E lye 2 7138, 39
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LOT 27
2.139 Pfc.
91.+63 iN. IF T.
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• LOT
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f+fl A e., I'm , 111 AC. fxc
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IM fall 'J4, 1' C 1 L3
/ ' OT 24
y; LOT 291 Jr, 'N au.111 10. Fr/ / t.►l
G,
Nwt. 440 Jsi.9•s w. F.
114VII's 9~1 FT 01
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STC-105
Vv
SEPTIC TANK MAINTENANCE AGREEMENT _Sjt1
St. Croix County
OWNER/BUYER / CJ
MAILING ADDRESS
PROPERTY ADDRESS 1~ S z -2
(location off~ septic system) Please obtain from the Planning Dept.
CITY/STATE r6 Ui ~ 61641 S O /7
PROPERTY LOCATION 1/49 JG-J 1/4, Section ~`7S T_j j~_N-R,_Y_~(_W
TOWN OF , ST. CROIX COUNTY, WI
LOT NUMBER v?
SUBDIVISION
CERTIFIEDSURVEY MAP VOLUME PAGE LOT NUMBER_~g -7_
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 disposl 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 11/93
Hudson, W1 54016
1
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 ri C-e A ri /le- -"7
Location of property 1/41/4, Section T~N-R W
Township Mailing address 3y „r j~-fe,- 7;1
Address of site
Subdivision name )1 f -e4 ve r^ e, u Lot no.
Other homes on property? Yes No
Previous owner of property
Total size of property 2 C,-
Total Total size of parcel 1f J -11< /2`'
Date parcel was created da~o k, / /
Are all corners and lot lines identifiable? x. Yes No
Is this property being developed for (spec house)? Yes 7( No
Volume and Page Number Oe 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. 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 o Applicant Co-Applicant
71~ 7
C-D
Date of Signature Date of Signature
a
STATE BAR OF WLSCON'Fa1% CORM 1 - 1982
558 '70 WARNA14-FY DEED
DOCUMENT NO. VIx
_ REGISTER'S OFFlSF.
This Deed made between Richard er St-4: ST CROIX CTY»WI
Ij - nedarn.w
} APR 16 1991
~ Grantor,
Ij and TOT-TD Johnson and Mari lee R T.+hncr~n ~ 11:45 A. M
husband and wi-fe. `3:• 1.).44
- ~ ~ IfM~ of o.ws
Grantee,
Witnesseth, That the said Grantor, for A valuable am n
conveys to Grantee the following described real estate in St _ ~rni X THIS SPACE R'ESERVED FOR RECORDING DATA
County, State of Wisconsin: NAME AND RETURN ADDRESS
I
Lot 27, Plat of Apple River Bend First
Addition, Town of Star Prairie, St. Croix
'i County, Wisconsin.
II
038-1179-60
PARCEL IDENTIFICATION NUMBER
I
li
~ i
TRANSgTR
This i5 nL]t homestead property
(is) (is not)
Together with all and singular the hereditaments aawl
II apQm=e=utnces thereunto belcngmg;
And Rirhart jQ_$tp[[t
warrants that the title is good, indefeasible in fee simple and fim and . Lear of encumbrances except
easements, restrictions, rights-of-way and covenants of record
and will warrant and defend the same.
Dated thiJsJ ~ 1 5th day of _Apri 1 19_92.
/ ~-t t.GIQ.~~rl C1
iSEAt_F (SEAL)
• Richard O. Stout
JSE (SEAL..)
i
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Wisconsin,
ss.
St. Croix County.
authenticated this (S42" day of ArrZIA 19Personally acne before me this 15th day of
Illl ~l I, _ _ Apr i 1 199_, the above named
Richard O. Stout
TITLE: MEMBER STATE BAR OF WISCONSIN _
(If not,
authorized by §706.06, Wu. Stets.) to me known to be the person who executed the foregoing
instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
?anet P. Stout
1353 AWa-tukee Wiz.