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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
569572 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes[Privacy Law,s.15.04(1)(m)).
Permit Holder's Name: City Village X Township Parcel Tax No:
Simon, Laurie A. I Star Prairie, Town of 038-1182-10-000
CST BM Elev: Insp.BM Elev: BM Description- Section/Town/Range/Map No:
/t)&,. I Am I G5`r 20.31.18.911
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER /�. CAPACITY STATION BS HIL FS ELEV.
Septic �z� Bench?/k
ar J
Kole-M 15" 41.21 �'7
Aeration Bldg.Sewer L'�7 g 7.$3
Holding St/Ht Inlet J
S % C�7.sy
TANK SETBACK INFORMATION St/Ht Outlet 4, 17 27- 33
TANK TO A.\\ P/L WELL BLDG. Ve it Intake ROAD Dt Inlet
Ab 0A, / 0 '4?/k- ---, _\
Septic -7Z /65 /O j 67 / Dt Bottom
Dosing Header/Man.
-7,ZS y c. . a
Aeratl n Dist.Pipe
Holding Bot.System
$.zs
Final Grade
PUMP/SIPHON INFORMATION y33 '
Manufacturer Demand St Cover r`� G J • b,
Model Nu r
TD H Lift tion Loss System Hea TDH t
Forcemain Length Dia. Dist.to well
I
SOIL ABSORPTION SYSTEM
BED/TRENCH Width / Length/ No.Of Trenches PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth
3 -
DIMENSIONS
SETBACK SYSTEM TO I P/L G'BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION Type Of System: II r7 ! , )� CHA uBER OR MModel Number
Lj
DISTRIBUTION SYSTEM
Header/Manifold IDistribution x Hole Size x Hole Spacing Vent to Air Intake
If t1 Pipe(s) ` �__ �_ �` �QS
Length 7 Dia 7 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 ? L Bed/Trench Edges Topsoil Yes 0 No \Yes E No
COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2: I /
Location: 2014 100th Street S merset,WI 54025(SE 1/4 SE 1/4 20 T31 N R1 8W) Country Living 1 st Add'ion Lot 1 Parcel No: 20.31.18.911
1.)Alt BM Description
2.)Bldg sewer length= ��
-amount of cover
Plan revision Re uired? ❑ Yes No QQ pp
Use other side for additional informatio>
SBD-6710(R.3/97) Date I Sig ture Cert.No.
,�Br�ar County t
41./ Safety and Buildings Division -�-'�eG
3 y A� 201 W.Washing v P.O. BOX 7162 Sanitary Permit Number(to be filled in by Co.)
WX
Mad0
\► 2 Q
Q ta.1y Permit Application State Transaction Number
In accordance with 538 Wis.Adm.Code,submission of this form to the appropriate governmental unit
is required prior to obtain" ltary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address)
the Department of Safe rofessional Servies. Personal information you provide may be used for secondary
purposes in accordance w' e Privacy Law,s.15.04(1)(m),Stats. 00/
I. Application Infor tion—Please Print All Information J �)
Property Owner's Name Parcel#
J.
- rte cz 9 L. -
Property Owner's Mailing Address roperty Location
AN / loo Govt
-s 1` _ ! '
.Lot
City,State (,t,�� ZippCode Phone Number Q 7 S '/<, S,� Y<, Section
Ur !ar Q' !3� T 31 N R circlE on
H.Type of Building(check all that apply) Lot# r
All or 2 Family Dwelling—Number of Bedrooms v Subdivision Name
Jr�
p Block � /
❑Public/Commercial-Describe Use t
U � ❑City of
El Owned—Describe Use C Number El Village of
v I K Town of
III.Type of Permit: (Check only one box on line A. Complete line B if applicable) z
A. A New System ❑Replacement System ❑ Treatment/Holdin g Tank Re p lacement Onl y Other Modification to Existin g System(explain)
B. ❑ Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Owner - R L — �+
IV.Type of POWTS System/Component/Device: Check all that a
Non-Pressurized In-Ground 11 Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil
❑ Holding Tank Other Dispersal Component(explain) ❑Pretreatment Device(explain)
V.Dispersal/Treat ent Area Information: o�?
Design Flow(gpd) Design Soil Application Rate(gpds Dispersal Area Required Dispersal Area Propos sf) System Elevation
7 7 10 ,5 �o l /46� 16D ,s
VI.Tank Info Capacity in Total #of Manufacturer
Gallons Gallons Units Q �./ o
New Tanks Existing Tanks [ /
aU iz h 4, 0 P.
Septic or Holding Tank r:
Dosing Chamber O�J
VII.Responsibility„Statement- I,the undersigned,assume responsibility for installation of the POW TS own on the attached plans.
Plumber's Name(Print) Plumber' gnature ,6RS Number Business.Phone Number
L. s-7 ?�6
lu is Add res (Street City,State,Zip Code)
If
a
I Count /De artment se Only
Approved Permit Fee Date Issued Issuing nt Signatur
O ' $ I 75 5 ZZ j
IX.CondiffiyWp%h^GReasogs for Disapproval
I.' Septig tank,effluent filter end'
dispersal cell must all be servtces tmaintained
as per management plan provided by plumber.
2 AI wQpqk tequit'etnenta must be.maiintalrAd
as per cods 1 ordinalhcas.
Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size
SBD-6398(R. 11/11)
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CONVENTIONAL'COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name:
Owner's Name: .�-
Owner's Address: D /00 ;%
S
;A4-Z7 , 5-yoaS--
Legal Description: So6" 5.4 — 5 A 6 ` 7-31
Township: 5 1p�
County: sr. C44 <-
Subdivision Name:
Lot Number:
Parcel ID Number: 039 —t J 8P - /0^13 ado
Page 1 Index and title
Page 2 Plot Plan
Page 3 System Sizing&Cross-Section
Page 4 Filter Specs
Page 5 Maintenance Information
Page 6 Management Plan
Page 7 St. Croix Cty Septic Tank Maintenance Form
Page 8 Warranty Deed
Page 9 CSM or Plat
/p�pp Attachments:✓Soil Test&House Plans
Designer/Plumber: ONTO V uAlo License Number:
Date: Phone Number 7/-5-- 7,6
T. r_
Signature
Designed pursuant to the In-GrtQnd Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P(N.01l01).
Page 1
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Manufacturer And Model /(,1 !
EISA Rating s9 per umber -�
' Soil Application Rate---_L__gpols4 ft
gPd neslgnFWW -' 7- .Soil Application RateA � ��
EISA=_!§,2 Chamber
2 rows of chambers,
each.
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Quick4 Plus Standard Chamber Side and End Views
48"
(EFFECTIVE LENGTH)
FAR
F
34"�
Quick4 Plus All-in-One 12 Encap Front, Side and End Views
11.2"
13"
INVERT NV
8"IE _;;.I 8"INVERT 5.3"INVERT
l + t
�--1-8.2" 33"
Quick4 Plus All-in-One Periscope
QUICK4 PLUS
ALL-INANE PER ISCW
.436WSWIVEL )
12.7"INVERT oulcK4 PLUS
ALL ONE 72
ENDCRCAP
Quick4 Plus Standard'Chamber Specifications
S¢e (W x L x H) s 34"x 53"x 12" (86 cm x 135 cm x;31 cm) k"'A Height Q 6", 5 3
Effecfive Len th 48" (122 ern) ;~ ( 5 cm,=8 4 ern, 18 5 cm, 22 6 ern)
INFILTRATOR SYSTEMS,INC.STANDARD LIMITED WARRANTY '
(a)The structural integrity of each chamber,end plate,wedge and other accessory manufactured by Infiltrator("Units"),when installed and
operated in a leachfield of an onsite septic system in accordance with Infiltrator's instructions,is warranted to the original purchaser("Holder")
against defective materials and workmanship for one year from the date that the septic permit is issued for the septic system containing the Units;
provided,however,that if a septic permit is not required by applicable law,the warranty period will begin upon the date that installation of the
septic system commences. To exercise its warranty rights.Holder must notify Infiltrator in writing at its Corporate Headquarters in Old Saybrook,
Connecticut within fifteen(15)days of the alleged defect.Infiltrator will supply replacement Units for Units determined by Infiltrator to be covered
by this Limited Warranty. Infiltrator's liability specifically excludes the cost of removal and/or installation of the Units.
(b)THE LIMITED WARRANTY AND REMEDIES IN SUBPARAGRAPH(a)ARE EXCLUSIVE.THERE ARE NO OTHER WARRANTIES WITH RESPECT
TO THE UNITS,INCLUDING NO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE
(c)This Limited Warranty shall be void if any part of the chamber system is manufactured by anyone other than Infiltrator. The Limited Warranty INFILTRATOR"
does not extend to incidental,consequential,special or indirect damages.Infiltrator shall not be liable for penalties or liquidated damages. S t e m S inc.
including loss of production and profits,labor and materials,overhead costs,or other losses or expenses incurred by the Holder or any third party. S y
Specifically excluded from Limited Warranty coverage are damage to the Units due to ordinary wear and tear,alteration,accident,misuse,abuse
or neglect of the Units;the Units being subjected to vehicle traffic or other conditions which are not permitted by the installation instructions;failure
to maintain the minimum ground covers set forth in the installation instructions;the placement of improper materials into the system containing 6 Business Park Road• P.O. Box 768
the Units;failure of the Units or the septic system due to improper siting or improper sizing,excessive water usage,improper grease disposal,
or improper operation;or any other event not caused by Infiltrator. This Limited Warranty shall be void if the Holder fails to comply with all of the Old Saybrook,CT.06475
terms set forth in this Limited Warranty.Further,in no event shall Infiltrator be responsible for any loss or damage to the Holder,the Units,or any 860.577.7000• FAX 860.577.7001
third party resulling from installation or shipment,or from any product liability claims of Holder or any third party. For this Limited Warranty to
apply,the Units must be installed in accordance with all site conditions required by state and local codes;all other applicable laws;and Infiltrator's
installation instructions. 800.221.4436-
(d)No representative of Infiltrator has the authority to change or extend this Limited Warranty. No warranty applies to any party other than the www.infiltratorsystems.com
original Holder.
The above represents the Standard Limited V,Iarranty offered by Infiltrator. A limited number of states and counties have different warranty
requirements. Any purchaser of Units should contact Infiltrator's Corporate Headquarters in Old Saybrook,Connecticut,prior to such purchase,
to obtain a copy of the applicable warranty,and should carefully read that warranty prior to the purchase of Units.
e - - • 6e e • - - • - Ifs . � �
U.S.Patents:4,759,661;5,017,041;5,156,488;5,336,017;5,401,116;5,401,459;5,511,903;5,716,163;5,588,778;5,839.844
Canadian Patents:1,329,959;2,004,564 Other patents pending.
Infiltrator,Equalizer,Quick4 and Quick4 Plus are registered trademarks of Infiltrator Systems Inc.Infiltrator is a registered trademark in France.Infiltrator Systems Inc.
is a registered trademark in Mexico.Contour Swivel Connection is a trademark of Infiltrator Systems Inc.0 2009 Infiltrator Systems Inc.Printed in U.S.A. PLUS0510101SI-2
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 2
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner s Septic Tank Capacity Q gal ❑ NA
Permit # Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer 110 ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA
Number of Public Facility Units J�NA Pump Tank Capacity al A NA
Estimated flow (average) gal/day Pump Tank Manufacturer RNA
Design flow (peak), (Estimated x 1.5) gal/day Pump Manufacturer *NA
Soil Application Rate 'W7 gal/day/ftz Pump Model XNA
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ❑ NA
Fats, Oil & Grease (FOG) :530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD5) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) <_150 mg/L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BODS) 530 mg/L In-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) <_30 mg/L ❑ NA ❑ At-Grade ❑ Mound
Fecal Coliform (geometric mean) <10'cfu/100ml ❑ Drip-Line ❑ Other:
Maximum Effluent Particle Size YB in dia. ❑ NA Other: ❑ NA
Other: ❑ NA Other: ❑ NA
*Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
years)
Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ji�NA
Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
Aj'year(s)
Clean effluent filter At least once every: S X month(s) ❑ NA
❑ year(s)
Inspect pump, pump controls & alarm At least once every: ❑ year(s)month(s) NA
0 month(
Flush laterals and pressure test At least once every: ❑ year(s)s) 12�NA
Other: At least once every: r❑ month(s) [I NA
❑ year(s)Other: ❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one-third (Y3) or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of:512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
Page 2 of 2
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals
that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
within 15 feet down slope of any mound or at-grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or:must be taken, to provide a code compliant
replacement system:
• A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
• A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
T
ev_aluat* g
a o in ank
be ' e failed R lTE� D�!�/�b✓ i�NS7?ZtJ�?L t�
❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time.
<<WARNING>>
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name ur�Ax Name
Phone 7X-f- 7e-6— d G Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY /
Name Name 15t. Gkb l !�(l N 2 �
0R��
Phone Phone "71S— 3e6v-
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(fl and 83.54(1), (2) &(3),Wisconsin Administrative Code.
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STATE BAR OF WISCONSIN FORM 3-2000 BETH PABST
QUITCLAIM DEED REGISTER OF DEEDS
Document Number I ST. CROIX CO., WI
THIS DEED,made between Gary R. Simon and Laurie A. Simon 08/19/2011 3:59 PM
both single persons, Grantor, and Laurie A. Simon, a single person, EXEMPT#: 8M
Grantee. REC FEE: 30.00
Grantor quit claims to Grantee the following described real estate in St. PAGES• 1
Cro County,State of Wisconsin(the"Property"):
Lot I Country Living First Addition to the Town of Star Prairie, St.
ounty,Wisconsin.
Said conveyance is being given pursuant to Judgment of Divorce in St.
Croix County Circuit Court Case No.2010FA000625. Recording Area
Name and Return Address:
First National ommunity Bank
PO Box 89 5C61 New Riehmon , WI 54017 S J
Together with all appurtenant rights,title and interests. 038-1182-10-000
Parcel Identification Number(PIN)
This is homestead property.
Dated this 2a day of July,2011.
* * R. tm
* curie A.Simon
AUTHENTICATION ACKNOWLEDGMENT
STATE OF WISCONSIN )
Signatures) COUNTY ST.CROIX )ss.
authenticated this Personally came before me this 29 day of July,2011 the
above named Gary R.Simon and Laurie A.Simon,both single
* persons to me known to be the person(s) who executed the
TITLE:MEMBER STATE BAR OF WISCONSIN
foregoing instrument and acknowledged the same.
(If not,
authorized by§706.06,Wis.Stats.) _• C Bri Campbell
THIS INSTRUMENT WAS DRAFTED BY Notary Public,State of Wisconsin
My commission is permanent. (If no _�jp1�iA
Robert L.Loberg 09/11/11 `
Loberg Law Office aim/
(Signatures may be authenticated or acknowledged. Both are not necessary.) NOTARY
'Names orpersons signing in any capacity must be typed or printed bebw then signature '—a.
`A VUBLIC *;`
QtIIT CLAIM DEED STATE BAR OF WISCONSIN FORM
1 of 1
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r. UM COUr+17Y
Iii!UnSNANCE AGREEMENT
AND
OWNERSW CERTIFICATION FORM
T,21�yOwner/Buyer
U
Mailing Addres5 �7
Property Addrs!ss
(Verificati=requbed fine,Mwains do for tow conssuctioa.)
C /State Patctrl Idea cation Number
LEg"
Property Location S/.,4Z %,Sec.p7,0 ,T S L—N R 149 W,Town of
Subdivision Plat: . -,Lot#
Certified Sur+aey Map# , Volume ,Page#
Warranty Deed # (before 2U07)Voltune . Page# _- ---
spec house n yes KM Lot lines idoutifuabieky"to no
�yS %jA,WTENANC't AND OWN_EA CW1TIICATIQN
traproprr use aa�d naa»m03 of ywaf sapna ttyataatt eaAcid ctatak 1n:ts pce►tpsiaat+a faihara 9p hsttel3e wastes Proper
matrrrenancr consists of pwnping out tlta septic teak*my dim yms ar sooner,if needed,by a licamcad pumper- Wlist"M put paew
the:systemn cant affect the lu=tkm of%L segdic tsatk U s hostile at usge in the wastaa dispow system. owner maintenance
itsp rssibiti.ies are specified in&Comm. 83.52(1)and in Cltmpt+tr 12-St.Croix Co"Sanitary OrdirAme.
The property awnet greed to submit to St Croix County phwieg&Zoning DWatiment a certification form,signed by the
ownzr and by a rrastsr pluntw,lourneyinw Phs"*w,retstriend phwAo►or a licensed pumper verifying that i t)the arsite
wastewater dtspo tal system is in proper attcrating condition atu ltor(Z)fthr mspect on end ptnnping(if stecessruy►,the Septic tank+s
sss rhail 1/i firtl=)f sludge.
i/we.the undersigned kwc read the:above jvquKcmi ms and a@=to muaiataia Ilse private sew*V+disposal system with the
stamtdwds set fords.burin.as set by data Doparmceat of Carom ves and the Depar of Nstutral Rasonrces,State of Wisconsin.
vrrci matior,stating that your septie syssam hss beet amintsined must be completed and ratims"to tba St.Croix County Plann,ng&
Zon Departimrit.within 30 ftys of the three ym exvnatioea dote.
i/we certi€y that all stmeomb an thin fates are true to the bear of ray/our kttawledge. Urge attNatt the owner(s)of%be
;)roitcsty describe)above,by virtue of a wwranty deed recorded to Register of Deed
s Offiec.
Nuinber bedrooms ,
51Q.t r ?PLICANT(Sk) �,� DATE
n jnfo,fnai•on that is misrepresented may result in tile:santtary permit beutg revok*d by the Plrtaonag&Zoning Depactateat.
include with this tpplication a recorde d warranty deed from tine Register of D=du Officc and a copy of the certified wTvcy map It
.-eferersce is matte ikt the wana+icy deed.
(RF.V.08/05)
Property Owner O C. Parcel ID# Page of 3
F�l ❑ Boring I Boring# V
Pit Ground surface elev. ft. Depth to limiting factor in. Soil A lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Donsistence Boundary Roots GPD/ft
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ff#1 * fF#2
1 d•1a jpyR3 A ---- '� -s L- alDbk MF v- aw v" . V 1, to
:1 1;L-4D 7.SYR 14 c 5 4-S L G vY r y I,
)Y
I t
F] Boring# ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor 1n Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence oundary Roots GPD/ft z
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. * ff#1 * ff#2
Boring
Boring# Ground surface elev. ft. Depth to limiting factor in.
F-1 E] pit
[Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft z
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. * ff#1 ff#2
*Effluent#1 =BOD 5>30<220 mg/L and TSS>30 <150 mg/L *Effluent#2=BOD ,<30 mg/L and TSS <30 mg/L
The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to
access services or need material in an alternate format,contact the department at 608-266-3151 or TTY throush Relay.
SAD-8330(R 11/1 1)
Wis.Depf offSSafety nc�gENT ssional Services UATION REPORT
��n gg Page�of
Divisj MutAjv DE--- in accordance with SPS 385,Wis. Adm. Code
,pM County �, /l..�L,Q
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size.Plan must IC
include,but not limited to:vertical and horizontal reference point(BM),direction and Parcel I.D.
percent slope,scale or dimensions, north arrow,and location and distance to nearest road. 038—/19;)— p —pooc,
Please print all information. Revi ed by Date
Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)).
Property Owner Property Location
C z EC-k Govt.Lot s E 1/45E 1/4 S a T 31 N R E(or l0�
Property Owner's Mailing Address j, Lot# Block# Subd.Name or SM# ,+
City State Zip Code Phone Number
❑City El ®Town Nearest Road
5'a r : c Ott"
New Construction Use:❑ Residential/Number of bedrooms Code derived design flow rate C D N V en)I E NGC hQfRGPD
❑Replacement ❑ Public or MMcommercial-Describe. 'sh tco
Parent material 0 1�.� l C�S i'�. Flood Plain elevation if applicable
Genera!comments P T�crL�, I `-)�
and recommendations: �IJ• %r 0 V+% ( 5e-+ ,o%+ g y.5$ �
Boring#
I ® Boring
t
pit Ground surface elev.R8.5�j v ft. Depth to limiting factor !a V in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft z
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ff#1 " ff#2
t 0-12 10'IR3 SL -�F6 10
-0 a-3%6 7 SI-014 - 5 a-S w1 L- C r ►� ! �.
3 38 Io0 1 D 4 k -7 /, to
1t �
Boring# Boring
51 Pit Ground surface elev.-!aa
•1%% ft. Depth to limiting factor 10 0 in.
Soil A lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Donsistence Boundary Roots GPD/ft Z
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ff#1 ff#2
3 q;t-rop toy R�/L s o- L. — — -7 t ,
Effluent#1 =BOD 5>30:<220 mg/L and TSS>30 <150 mg/L `Effluent#2=BOD <30 mg/L and TSS <30 mg/L
CST Name(Please Print Signature CST Number
C9 Address a t Y top
o -I S" , Date Evaluation Conducted Telephone Number
a� e 4'
. c w
a y (65 -.)39-Y6IS
SRD-8330(Rl l/11)
Property Owner J O �L Parcel ID#
Page of
Boring#
❑ Boring
❑ � v
Pit Ground surface elev. q$,Q ft. Depth to limiting factor 1 0 0 in. Soil A lication Rate
Horizoni Depth Dominant Color Redox Description Texture Structure onsistence oundary Roots ff#1 GPDfft2
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh.
J c�-4D -7,$YR 1q -°'""'_` L t'�?° N^ L G J
L ti ,-7
i+
❑ Boring
F-1 Boring# Depth to limiting factor in,
❑ Pit Ground surface elev. ft. P g Soil A lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence oundary Roots * ff#1 GPD/ft 2
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh.
Boring
Boring# Ground surface elev. ft. Depth to limiting factor in.
❑ Pit Soil A lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence oundary Roots GPD/ft z
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ff#1 ff#2
I
I
*Effluent#1=BOD ,>30<220 mg/L and TSS>30 <150 mg/L *Effluent#2=BOD 5<30 mg/L and TSS <30 mg/L
The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to
access services or need material in an alternate format,contact the department at 608-266-3151 or TTY throush Relay.
SaD-8330(R11/11)
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Wisconsin 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 rt
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. Paroil,.(:D:`# r; ow~'~
APPLICANT INFORMATION Please print all information. FC-vieifed by r-jDate
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location r
le-s- S42 Govt. Lot 1/4,S 'T, 1, A E (o OW
Property Owner's Mailing Address Lot # Block# Sub )pr CSM#
903 e'a. 112 ~B -
City State Zip Code Phone Number µ
❑ City ❑ Village own Neare oad
S6~c 5y 015 7/.SS,2~/~ S6 zeQ(t►
J~New Construction Use: 59:pesidential / Number of bedrooms Addition to existing building
❑ Replacement ~l~ ❑ Public or commercial - Describe: k
Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2 VQ trench, gpd/ft2
Absorption area required 6 bed, ft25 2 trench, ft2 Maximum desi n loading rate bed, 9Pd/fit O trench, 9pd/ft2
Recommended infiltration surface elevation(s), r i jo/9 Y23; ft (as referred to site plan benchmark)
7
Additional design/site considerations
Parent material D u~t4>c Flood plain elevation, if applicable A 61A ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
U = Unsuitable for system S❑ U S❑ U IS F1 U P S❑ U E:1 S AU ❑ S )R U
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
Ground V_
Depth to
limiting
fact r
in.
Remarks:
Boring #
O-z 'Jz -5
Ground
Ma.
Depth to
limiting
factor
in. Remarks:
CST Name (Please Print) Signatur Telephone No.
7/5"o76
Addr s a Date CST Number
8'~ S 0 3-9~ 3 7
QIL DES PTION REPORT
PROPERTY OWNE a O Page of
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots Mft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Ground
el
Depth to
limiting
fac
Remarks:
or`fn9 #
h lo,
Ground
X4.
Depth to
limiting
Remarks:
3 Horizon Depth Dominant Color Mottles Structure GPD/ft2
Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring #
Ground
Depth to
limiting
f~ctpyj
n. Remarks:
Boring #
Ground
elev.
ft. ,
Depth to
limiting
factor
in.
Remarks:
SBDW-8330 (R. 08/95)
Soil Test Plot Plan
Project Name Charles Borgstrom B ron Bird Jr.
Address 2033 Co. Rd. C
Somerset Wi 54025 C TM #3479
Lot 1B Subdivision Country Liv Date 9/25/96
SE 1/4SE 1/4S20 T 31 N/R18 W Township Star Prairie
❑ Boring 0 Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of Property Line Marker
System Elevation 97.7/97.3 me as Benchmark
* B.M. 100' 747' Property Line
20'
B- 80' lope B-2 30'
Pri A Pro 3 or 4
15' B-3 Bedroom
40' 0, House V
15' Rep A B-4 -5
0
r
0
0
r,
747' Property Line
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of
Labor,and Human Relations -
z Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but Gj-'o not limited to vertical and horizontal reference point (BM), direction
and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
t r r GOVT. LOT 1/4f~ 1/4,SV T N,R E
/
PROPERTY OWNER':S MAILING ADDRESS G LOTJ,,, BLOCK # SUBD. NAME 0R CSM #
'~2'0 _7 14 4fC2 CCITY, STATE
_ ZIP CODE PHONE NUMBER CITY ❑VILLAGE WN NEAREST ROAD
a T l c r+r O
4-1 r
[New Construction Use [ Residential / Number of bedrooms [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flowr~gpd Recommended design loading rate gibed, gpd/ft2,ss trench, gpd/ft2
Absorption area required 6 ct 3 bed, ft2 5-6 3trench, ft2 Maximum design loading rate gibed, gpd/ft2Sltrench, gpd/ft2
Recommended infiltration surface elevation(s) 97 It (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable T ~ It
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem 19S ❑ U ®.S ❑ U 2-6 ❑ U ;M S ❑ U ❑ S Al'! ❑ S -®'U
SOIL DESCRIPTION REPORT
Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
10Z .4 an. ~2 n. o222
!b C /L 7f~ O
Ground A ,
elev. ,
Depth to
limiting 3 1f r,.l
factor
Remarks:
Boring # F
!o sx Ot G -3
Ground
elev.
Depth to
limiting
factor
0?" 7 Remarks:
CST Name:-Please Print Phone: / 7G<~
Address:
Signature: Date: CST Number:
j 3coe
PROPERTY OWNER ~ r4-!~!~5/b~'6O1L DESCRIPTION REPORT Page - of
PARCEL I.D. #
Depth Dominant Color Mottles Texture Structure Consistence Bourbay Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
40 7'
Ground
elev.
ft.
Depth to
limiting
factor
51 Remarks:
3, 5
Boring #
l a i to ~ / •n- r► G ~ ,
Ground
el
~ft.
Depth to
limiting
factor
°?r 3 Remarks:
Boring #
Ground
elev.
9 ft.
Depth to
limiting
factor
o? Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
L
Soil Test Plot Plan
Byron Bird Jr. Property Owner G~`-- /{5 ry S rr°~,
896 68th Ave. Address~33
Amery Wi 54001 k / .SG-1114 Xe1 /4/S~2o /T,?/ N/R & W
CST #3479 Township
Date_ z County 51' ~ 4:
C1 Boreing ► Benchmark H.R.P. System Elevation 7 -41
1~ 7 A
L
-~f w
74 7
i
Parcel 038-1182-10-000 03/18/2005 09:48 AM
PAGE 1 OF 1
Alt. Parcel 20.31.18.911 038 - TOWN OF STAR PRAIRIE
Current X', ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): Current Owner
SIMON, GARY R & LAURIE A
GARY R & LAURIE A SIMON
2014 100TH ST
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 2014 100TH ST
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 6.380 Plat: 0204-COUNTRY LIVING FIRST ADDITION
SEC 20 T31 N R1 8W PT SE SE LOT 1 COUNTRY Block/Condo Bldg: LOT 01
LIVING FIRST ADDITION 6.38 AC
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
20-31 N-1 8W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1209/480 WD
2004 SUMMARY Bill Fair Market Value: Assessed with:
31103 288,800
Valuations: Last Changed: 10/13/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 6.380 53,900 247,700 301,600 NO
Totals for 2004:
General Property 6.380 53,900 247,700 301,600
Woodland 0.000 0 0
Totals for 2003:
General Property 6.380 26,300 138,700 165,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 126
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 6Q-y"
a 1m ,
rp~
ADDRESS o9, 35- Gc J//)1C1 r r
550
n
SUBDIVISION / CSM J-
1
SECTION a 0 T 31 N-R__ W, Town of 1 o
ST. CROIX COUNTY, WISCONSIN ye
PLAN VIEW
SHOW EVERYTHING WITHIN 1 OT-SYSTEM 2 O
.2" 5
2.S
~a
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
C [
DENCHMARR• 7 6 Lk
ALTERNATE DM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: We-Q--0A Liquid Capacity: ldj\.
Setback from: Well House c` J Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
width: /p? Length 15Y Number of trenches
4ed,
Distance & Direction to nearest prop. line: '01.-I el-
Setback from: well ~~w
House Other
ELEVATIONS
Building Sewer . 7 ST Inlet: ST outlet: .3
PC inlet PC bottom Pump Off
Header/Manifold 6• Bottom of system
/
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER: 3,~5 3
INSPECTOR:
3/93:jt
t
` Wisconsin DepaFtment of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations
INSPECTION REPORT ST. CROIX
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) SanitaryPerm itNo.:
299054
Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.:
SIMON, GARY STAR PRAIRIE
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
038-1182-10-000
TANK INFORMATION V I/ ELEVATION DATA A9700371
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic, a/ Benchmark //,L3 ` .a•3 D
Dosing
Aeration Bldg. Sewer 163, 9
Holding St/ Ht Inlet
S 8 0 .os'
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
TANK TO P/ L WELL BLDG. Air Itnto ke ROAD Dt Inlet
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe 160-F,11
Holding Bot. System 5 3' _Z1._7 q 9.
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
7G goy y~,
Model Number GPM
TDH Lift Fri System TDH Ft
Forcem Length Dia. Dist. To Well
Head
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O 4,,_,) CHAMBER Model Number:
System: mil' , 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 e, Bed /Trench Edges v Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR
~g 20. 31 . 18, SE, dSE 2014 10 H ST LOT 1
PRAIRIE
in
J V a C ~A1 } f~ LG•r'4 t CI7 X ' L~~/~L( U/h~ /,00 Plan revision required? ❑ Yes [D-IN o 01
Use other side for additional information. 1,12 ,19'/ Z
SBD-6710 (R 05/91) Date In pe is Signature Cert. No.
s
S ' Safety and Buildings Division
Vsconsin SANITARY PERMIT APPLICATION 201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Department of Commerce Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County f
than 81/2 x 11 inches in size. r !
• See reverse side for instructions for completing this application State Sanitar Permit Number
The information you provide may be used by other government agency programs f l Ch. revision to previous application 49
[Privacy Law, s. 15.04 (1) (m)). tate Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION
Property ner Name Property Location ~~II
Taw / _ 1 /a 1/4, S oL T , N, R l E (o
V~yr 171 491 -
Property Own ' Mail g Address Lot Number Block Number
-
:1 -7
CI , State / Zip Code ~j Phone Number Subdivision Name or CSM Number
Vll!trage Nearest Road
II. TYPE F BUILDING: (check one) ❑ State Owned
p
Public or 2 Family Dwelling - No. of bedrooms own OF ~r
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
3 - 8a- 10
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
l~System System Tank Only Existinq 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;2$eepage 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) a Elevation
Feet a Feet
z4z i
VII. TANK Capacity
in gallonTotal # of r Prefab. Site Fiber- Plastic Exper.
INFORMATION Gallons Tanks Manufacturer s Name Concrete con- Steel glass App.
New Existin strutted
Tan S Tanks
Septic Tank or Holding Tank an d ❑ l ❑ 1:1 ❑
Lift Pump Tank /Siphon Chamber ❑ 11 ❑ n
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for ins Ilation of the o to sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber' i ure (No Stamp MP/MPRSW No.: BPhN (tuber:
Plumber's Address (St ee C" y, State, Zip Co e):
IX. COUNTY / DEPARTMENT USE ONLY V /
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
r/~~
Approved C] Owner Given Initial Surcharge Fee)
Adverse Determination
hu-
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: UUV
SBD-6398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division. Owner. Plumber
INSTRUCTIONS t .i
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 Almi€4tr 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, 608-266-3151.
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. "
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
11.1. 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 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.
PLOT PLAN
PROJECT ADDRESS
51 1 /4 sEz 1 / /So?U /T 3 > N/R /A TOWN ar 7~r ~ ~ COUNTYs-/ ~'•-aix 0ti
M P R S Jor - DATE f S 2 7- ssx2 8
BEDROOM CLASS PERC f 7 CONVENTIONA - IN-GROUND PRESSURE
CONVENTIONAL LIFT_ MOUND HOLDING TANK
SEPTIC TANK SIZE DU _ LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA y PERC RATE , BED SIZE l / 5
1116 Benchmark V.R.P. Assume Elevation 100'
Location of Benchmark
* H. R. P. S?-~~~----- - -
O Borehole (2) Well Sc
0 Perc Hole System Elevation
Uent
12"
Grndp
TYPAR COVERING
2"
12- 3' 4 6' O 3-
Sewer „ Sewer Rock
12'
3
v
3Cc~f~o V \
2D
-o~? - ,
~ Xsy ~3~ ZS ~
95 ~ ieala
v 5,
,~~rA- zl~
Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page of
Bureau of Integrated Services t -w.th s. ILHR 83.09, Wis. Adm. Code
County
Attach complete site plan on paper not less /2 'nm&s in size.' Pj 0 must
to
include, but not limited to: vertical and ho ' o referx directi and 4. 1- 0
percent slope, scale or dimensions, north , and location nce tol rest road. Parcel I.D. #
SEP 038-1/ a- 6
APPLICANT INFORMATION - P pdnte/l("Ajon r ; r Reviewed by Date
Personal information you provide may be used fo cy Law, 15.1)4 (1) (m)).
Property Owner Property Location
G "I Govt. Lot 1/4 SF 1/4,S,2U T3) N,R $ E (or)&V
Property Owners Mailin dress LotBlock# Subd. Name or CS/M#
C2 CAL. ~ a, I I ct4L ..L le_OUA,~,-q -
City State Zip Code Phone Number ❑ City: ❑ Village Ig Town N ~est
New Construction Use: sidential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow gpd Recommended design loading rate o 7bed, gpdHt2 - 8 trench, gpd/ft2
Absorption area required bed, ft2 6;513 trench, ft2 Maximum design loading rate =bed, gpd/f12_-_E_trench, gpMt2
Recommended infiltration surface elevation(s) iJri 1 9 ~Ze_jA,:& ft (as referred to site plan benchmark)
Additional design/si considerations
Parent material e %C.l.C.7'7 Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In-Ground Pressure AT- rade System in Fill Holding Tank
U = Unsuitable for system A<S ❑ U MS ❑ U XS ❑ U XS ❑ U ❑ SU ❑ S P5 U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2
g Texture Consistence Boundary Roots
in. 1 Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
57
Ground
el v.
Depth to
limiting
fa r
Remarks:
Boring #
-0-1,2 r A~
Ground
ft.
,,2.-2
Depth to
limiting
__;r in. Remarks:
CST Name (Please Print) Sign re Telephone No.
a.. ~ ~ ~/r Jr 02~
Address Date CST Number
042/ c
~~1 6~
i
SOIL DESCRIPTION REPORT
PROPERTY OWNER Q Page of
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots G~ptft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
1 0-/ 00 ;7-
Ground
jj~~ele//v.~~
Xz3ft-
Depth to
limiting
favor/ ,
G Remarks:
Boring #
S (o
1 3/1
37n
Ground
/0I-1
Depth to
limiting
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots PD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # 0
Ground
lev.
Depth to
limiting F-T
fac
fin. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBD-8330 (R. 07/96)
1• I
Soil Test Plot Plan
Project Name
Address
K~~l~ i~✓ -5 CSTM
Lot Subdivision O P-/;7 1/4 1/4S T N/R W-*- Township
r
Boring Q Well PL Property Line County X
BM or VRP Assume Elevation 100 ft. ,~~;..•c~
System Elevation 3*HRP_5,~2r
Za4
„e
i
TTr p j ,e4
0 \.O
go
nwr )119
- '
V
J
t d
i
STC ' [0 0
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 J
l W
Location of property 1/4 1/4, Section T N-R l
Township a mailing address G,A
~ s
Address of site
Subdivision name no.
Other homes on property. Yes No
Previous owner of property
Total size of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Jam- Yes No
Is this property being developed for (spec house)? Yes No
Volume-/;2 O9 and Page Number 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.
<5~5 3
J
Si nat e of Applicant C pAplican
47-97 - (7-II
Date of Signature Date of Signature
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
loe-
MAILING ADDRESS a~c? f 4~1~ S~ 1 p~
PROPERTY ADDRESS c~-Q H 1 d)O SI
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION 1/4,5 1/4, Section C;o T N-R__ _W
TOWN OF ~t ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP , VOLUMk'~20?PAGE y~aLOT 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 xpiration date. -Xf-~
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
VIL 1?(l9rx~~0 -
WARRANTY DEED
5523'-3
14
Document Number
ziT. CRCIXC0.,V4
Return G~Addrem NOV 2 0 1996
~~:G►,I►Jf /f/~ at 8:30 A#A
pt , P.t~ , ;sr ~f : ee?y ` JV
Ft
Parcel I.D. Number.
h - L t ,
' Charles H. Borgstrom and Delores Borgstrom, aWa Dolores Borgstrom, husband and wife, conveys and
A warrants to Gary R. Simon and Laurie A. Simon, husband and wife, as survivorship marital property,
the following described real estate in St. Croix County, State of Wisconsin:s
Lot 1, Country Living First Addition in Town of Star Prairie, St. Croix County, Wisconsin.
This is not homestead property. '
Z" Exception to warranties: Easements, restrictions and rights-of-way of record, if any.
Dated this T~ day of November, 1996.
(SEAL) l.~s ~ir:ca s ~,c~ (SEAL): ,mss
Charles H. Borgstrom Delores Borgstrom, Ik/a Dolores Borgstrom `
ACKNOWLEDGMENT
:A .
STATE OF WISCONSIN ) 3 N~FER - ,h
)ss
ST c!'IUiJC COUNTY )
1'- 70-
Personally came before me this 7 day of kovi,enb--/t 1996, the above named Charles H.
Borgstrom and Delores Borgstrom, a/k/a Dolores Bogptrom, husband and wife, to me known to be the
{ person(s) who executed the foregoing instrument and acknowledge the same.
Notary Public s T- c-ito; y County, o! pTA A
ti Ry
My commission expires to - A-0 - 99
"P pUBLIG
THIS INSTRUMENT WAS DRAFTED BY: le ,OF w1SG0 %
4 'e
Attorney Kristina Ogland
Hudson, WI 54016
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