HomeMy WebLinkAbout038-1182-20-000
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AS BUILT SANITARY SYSTEM REPORT
OWNER ZL-,-
ADDRESS
S_
SUBDIVISION / CST-" LOT # 2
SECTION `p T 31 N-R__ff_W, Town of -
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
HOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~r°d°r 7
T ~z 3 C,'Nr
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It ( /a CC N , t Nr /i ICt (C dCilr^~ > /'°~~J
zoo
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INDICATE NORTH ARROW
c~ ~ GL
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
1
BENCHMARK: Z": ~ n ~or S ZI , ~isSl~~y t /OU. D
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity: Zoa
Setback from: Well House -'?D Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: / Length 7y Number of trenches
Distance & Direction to nearest prop. line: /1 y /Urr>/,i r „fv
Setback from: well: l°6 House Z Other i
ELEVATIONS
Building Sewer ST Inlet: SCI ST outlet: ~6, 3z
PC inlet PC bottom Pump Off
Header/Manifold 7~ p, Bottom of system
Existing Grade J Final grade 9~.D
DATE OF INSTALLATION: G- /D f7
PLUMBER ON JOB: Jq
LICENSE NUMBER:
INSPECTOR: ~*~+/~s~"`
3/93:jt
Wisconsin,DepartmentofIndustry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations
Safety and-Suildings Division INSPECTION REPORT ST. CROIX
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION 289327
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
KEY-LAND HOMES STAR PRAIRIE
CST BM Elev.: , Insp. BM Elev.: BM Description: Parcel Tax No.:
GU ~9 038-1182-20-000
TANK INFORMATION ELEVATION DATA A9700143 &11L197
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic S Benchmark p~
Dosing 014 CL /3. or,
Aeration Bldg. Sewer
Holding St/ Inlet /a, ZZ' 96,2171
TANK SETBACK INFORMATION /ffl Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header- -2'
Aeration NA Dist. Pipe Vv,d/.,
Hol g Bot. System o ~3 9/,96
PUMP/ SIPHON INFORMATION Final Grade /
Manufactur Demand °P ° 9r 7 rJ'
Model Number GPM
TDH Lift F ' on stem TDH
pmzrr n Length Dia. Dist. To Well
For
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length ,r No. Of Tr nches P No. Of Pits Inside Dia. ]..Liquid Depth
DIMENSIONS DIMEN IEAM
SYSTEM TO P / L BLDG WELL LAKE /STR L G Manufacturer:
SETBACK
INFORMATION Type O r 7__t_ i MB del Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header / roands2td Distribution Pipe(s) i~ x Size x Hole Spacing Ven Air Intake
Length Dia Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound r At-Grade Syste I
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: fSTAR PRAIRIE 20.31.18,NE,SE 2036100TH ST. LOT 2
6,Q./4✓~.." asp' C-~ ^ r._.. f3"►"+.Gt-'(_ ~„k.... 1, 4{ / ` 7/~ V ' , /
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
• v~Gi'i i SANITARY PERMIT APPLICATION Bureau ofBuilding WaterlSystems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, Wl 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. cAegx
6 See reverse side for instructions for completing this application State Sanitary Permit Number
g 324-
The information you provide may be used by other government agency programs ❑ Check it revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
ji2rvZaml N~ 1 /4 E 1/4, S 20 T N, R /,?E (or&
PropertOwner's Mailing Address Lot Number Block Number
/70 6C
Aj: I
City, State Zip Code • Phone Number(6/.2 Subdivision Name or CSM Number
44xc 5'3 72- ( P`f'O L o y enzAjrg"
. TYPE OF BUILDING: (check one) ❑ State Owned E] itia Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms Town of - C -fW III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/Condo D3 - S",z - zD
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel /Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1, New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) A Sanitary Permit was previously issued. Permit Number ,ZfYea Z 3 Date Issued /mot p,r
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
110 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
k sf .7 1.0 Feet Feet
VII. TANK Capacity
INFORMATION in gallons Total # of Manufacturer's Name Prefab. - Fiber- Plastic Exper.
New Existing Gallons Tanks Concrete Con Steel glass App-
New
Tanks Tanks
Septic Tank or Holding Tank - ~pv ® ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installati of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: Stamps) PRSW No.: Business Phone Number:
Plumber's Address (Street, City, Stat , Zip Code):
IX. COUNT / DEPARTMENT USE ONLY
❑ Disapproved San ary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
VA roved E] Surcbargefee)
pp Owner Given Initial o ~f
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SOD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
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 authurity.
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 sewagV 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.
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 8 112 x 11 inches must be submitted to the county. The plans must
include,the following:,A) plot plan,.drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county;-E). soil test data on a 115 form; and F-) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which _can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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Wisconsin Department Industry,
` SOIL AND SITE EVALUATION REPORT Page
Labor and Human Relations _L 0(_3
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
[PARCEL OUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but -57
<
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or I.D.#
dimensioned, north arrow, and location and distance to nearest road. _ g.2 - 7 a
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
/00 ny GOVT. LOT 1/4 _ 114,S T N,R E (offl
PROPER OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM If
Zv . z - f=`
CITY, STATE ZIP CODE PHONE NUMBER 1.2- []CITY []VILLAGE VjrOVVN NEAREST ROAD
C-S-X27_ (,ffd 4_3eq S_,?;~A le-Z& ay -'e
New Construction Use JA Residential / Number of bedrooms [ ] Addition to existing building
j ] Replacement [ ) Public or commercial describe
Code derived daily flow j&51 gpd Recommended design loading rate • 7 bed, gpdit2 j trench, gpd1ft2
Absorption area required _ 557 bed, ft2 750 trench, ft2 Maximum design loading rate bed, gpd/ft2 . Y trench, gpd/ft2
Recommended infiltration surface elevation(s) 97,0 ft (as referred to site plan benchmark)
Additional design / site considerations t t .Md,:~
Parent material Flood plain elevation, if applicable It
FU= itable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
suitable fors stem LPS ❑ U PS OU 4 S❑ U S❑ U ❑ S m U ❑ S VI 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
Ground
elev. • 8
Depth to
limiting
factor
Remarks: L > .s07, Cod , R~'~ ~S'ouL~,c 2
Boring #
j L ..s'
Z
4 e) .0
Ground
elev.
ft.
Depth to
limiting
factor
7 lD Z
Remarks:
CST Name: Please Print Phone:
Address:
Signature: Date: ~f7 CST Number: j?.23j
PROPERTYOWNER ~V6Y4V ~ ,65 SOIL DESCRIPTION REPORT Page? of -3
PARCEL I.D. # 6,M -
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounclary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed rench
ISMS ?.tiC
Ground 3 .S 4 a L .7
-
elev.
Depth to
limiting
factor „
>97
Remarks:
Boring #
O k •
Nc"';f: w
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Vii{
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
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1 1 NOY 18 '96 01c43PM p,4
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Soil 'hest PI -it Plan
r Pra ect Name Charles Bor strum
j ~ Byron Bird ~r
address 2033 Co. Rd G
Somerset Wi 54025 M #3479
Lot 2B Subdivision Country Livin Date 9/25/96
NE 1 /4SE 1I4S20 T 31 N/1116 W Township Star Prairie -
Boring 0 Well PL Property Line County ST. CROiX
`BM or vRP Assure Elevation 100 ft. Top of Property Line Marker
System Elevation 98.0 *HRPSame as Benchmark
B.M. 615' Property Line
0'
25' 13-1 15' 5, B-4
0%
Pri A Rep A
~B-3 0% Slope
w
C ~
80' 80'
B- 30' B-5
County Roa
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-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 284223
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
KEYLAND HOMES STAR PRAIRIE
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9600478
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
TANK TO P/ L WELL BLDG. A
irito ntake ROAD Dt Inlet
Septic NA Dt Bottom
Dosing NA Header/Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction Syetem TDH Ft
Forcemain Length Di a. FFii Dist. Towels
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM
INFORMATION Type O CHAMBER Moe Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia- Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of T 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.20.31.18W.NE.SE.COUNTY RD C
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
a
Safety and Buildings Division
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 81/2 x 11 inches in size. T
• See reverse side for instructions for completing this application State Sanitary Permit Number
R3
The information you provide may be used by other government agency programs
❑ Ch c If revision to previous. application
(Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Name~ Property Location
//fly 1/4 s2E 1/4,S T , N, R E (or
Propertwner's Mailing Address Lot Number Block Number
d2 Z
City, State Zip Code Phone N 6~? Subdivision Name or CS, M Number
t L ) - v sac!/ ~ !7.
II. TYPE F BUI DI G: (check one) ❑ State Owned o v ila a Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF G
Ill. BUILDING USE: (If building type is public, check all that apply) arcel Tax Number(s)
1 ❑ Apartment/ Condo 1 0"- //S2 -Aa
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. 16 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank OnlyExisting 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 V] 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
® J^dd Feet ,D ~ Feet
VII. TANK Capaci y
in gallons Total # of r Prefab. Site Fiber- Ex er.
INFORMATION New Existin Gallons Tanks Manufacturer s Name Concrete Con- structed Steel glass Plastic App
Tanks Tanks
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑
.4 1 Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the nsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No Stam 101F/IVIPRSW No.: Business Phone Number:
Tr 1~ 24-
ber's Address (Street, Cit , State, Zip ode) :
M~ O OX9E)VT 4_0= 5,Y8.2-1.7
IX. COUNTY / 13EPARTMENT USE ONLY
❑ Disapproved Sanitary ermit Fee (Includes GroundwLU Date F~uing Agent Signature (No S mq5)
)4Approved [3 Owner Given Initial Surcharge Fee) O
~
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
,
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Divrion, Owner, Plumber
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 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.
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.
1X. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 81/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on-a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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Wisconsin,Department of Industry, SOIL AND SITE EVALUATION
Gabor 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 c J ` i
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I
f ,
APPLICANT INFORMATION - Please print all information. Revi Bitty
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). r, l «v
Property Owner Property Location f =
ll- . f' ~j Fr Govt. Lot ~i 1 /4 1/4,S( F ' 3 / N E (or
Property Owner's Mailing Address Lot # Block# Subd. %Lt; e~c~r CS~AI~+
77
3 L~ 02 - ~.4 .
U -
City State Zip Code Phone Number ❑ City ❑ illage ~To
°,nGrs - - ) 0~1 (ass ~.Sl~ .5 r _N7 _ °rzcl L~
.New Construction Use: Rasidential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow _pd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2
Absorption area required4/5-7-.gybed, ft 2S,b3 trench, ft 2 Maximum design loading rate __bed, 9Pd/ft J trench, 9Pd/ft2
Recommended infiltration surface elevation(s) 4' A~e a 0 ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material 4~~ 5 y Flood plain elevation, if applicable `1 bq ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Ta
U = Unsuitable for system ❑ U -0~ ❑ U ~ ❑ U 3& ❑ U ❑ S U ❑ S U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2
in. Munsell ou. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed ,Trench
Ground _11
elev.
Depth to
limiting
factor
in.
Remarks:
Boring #
Ground
Bleu i
Depth to
limiting
f alAo Remarks:
CST Name (Please Print) Signature Telephone No. r
Address Date CST Number
7
;F ,L DESCRIPTION REPORT Pa a of
PROPERTY OWNER rvyw g
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
Ground
elev
Depth to
limiting
factor
n.
Remarks:
Boring #
11-8 ,a L
Ground
Depth to
limiting
factor
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 #
Ground
Depth to
limiting
factar
Remarks:
Boring #
Ground
elev.
n. '
Depth to
limiting
factor
in. Remarks:
SBDW-8330 (R. 08/95)
f
Soil Test Plot Plan
Project Name Charles Borgstrom Byron Bird Jr
Address 2033 Co. Rd C
Somerset Wi 54025 C M #3479
Lot 2B Subdivision Country Livin Date 9/25/96
NE 1/4SE 1/4S20 T 31 N/R18 W
Township Star Prairie
R Boring Q Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of Property Line Marker
System Elevation 98.0 * H R P Same as Benchmark
B.M. 615' Property Line
30'
25' B-1 15' 15' B-4
L J- -A
0'
Pri A Rep A
~B-3 0% Slope
w
w N
to 00
O
80' 80' o
O ~
r
B-2 B-5
County Roa
j
01
at z:v to Re r
106
VI1
ZIP
r I,
~N
I r ~ ~ ~ Ill
N
i ~Iz
I
I
~'1 SG 4/,,yC
* * Q 919h MN 55120
PION6Eq LAND SURVEYORS . CIVIL ENCINEERS 881'-1914 FAX: 681-9488
* G1Ag-tear ng LAND PLANNERS. LANDSCAPE ARCHITECTS 625 Highway 10 N.E.
* * yfr Blaine. MN 55434
(612) 783-1880 FAX: 783-1883
Certificate of Survey for: KEYLAND HOMES
03653 A
J0003Q,1 1 wW 350.39 BENCH MARK J
-TOP
x 93.2 100TH STREET - of PIPE
~ ELC V.=100.00
_ry 98.1 99 99.8
96. _ ,4 N
99.8 99.5 98.9
9a pX x 9'526 x 997 _
7 6 7 x 99.9 98.8 x 98.2 97,E Inn 96,12 913 - -w - ^ M 1•(s
BE LK
TTOPCOF PfPE
ELFxV,=100.18 O
\ \ PROPOSED 99.9 P P~ 2><O
99, \Q 00 \ O
` DRIVEWAY x 100
\ 99.9 ~ ~ i
99.5
tJta 9958 9(4.4 TOPCOFMPIPE 95'0 X99. \ 7.`Lpp OQpS~~- 6`~
R' \ ELEV.=99,52 0•
/ Q~NO~ 1o pp
x 98.7 89.1 88. 99.4
tJ tam \
x 96,2 * 99.0 1 Q~pp~
~i 99.3 jJ x 98.3 P\~
x 97.1 P\~
x 98,4 98.1 O
\ x 95.2 do
\ x 88.1 ~
• p0
,gyp.
\ 9Z 9J.2 x 97,1
99 \
x95'' LOT 4
C) \ 96,1 f
Z. ip-
.A \ \
4,,Q'~ \ tad
f \ 92.0 ~Z N
X95. 94.0
LOT 2
r~ JOHN
'7
LAR30N
p/ 8-2317 i \ 79C
LAKEVILLE. J a \ 9~.5 q'0 3j'- 2 ~ 2.2 92.8
NIN 1b x
t 'o
••0 L'A_ 95N2 91.9 (^~JO
s u R%j e ~QSe taC9 \ \ 95.1 -
0 ~OT ISO
NOTE: PROPOSED GRADES 514OWN PER GRADING PLAN BY. 2.8
9 7 x919 PROPOSED HOUSE F TI
NOTE: BUILDING DIMENSIONS ION SHON ARE FO
ARCHITECT UAL HORIZONTAL
PLANS FOR BUILDING AND CATION LOWEST FLOOR ELEVATION:
FOUNDATION DIMENSIONS.
TOP OF BLOCK ELEVATION: U Z. U
NOTE: NO SPECIFIC SOILS INVESTIGATION HAS BEEN COMPLETED ON THIS LO BY THE
SURVEYOR. THE SUITABILITY OF SOILS TO SUPPORT THE SPECIFIC HOU E GARAGE SLAB ELEVATION: /0/
Co
PROPOSED IS NOT IIHE RESPONS161L11Y OF THE SURVEYOR.
NOTE: THIS CERTIFICATE DOES NOT PURPORT TO SHOW EASEMENTS OTHER THAN X 000,00 DENOTES EXISTING ELEVATION
THOSE SHOWN ON THE RECORDED PLAT. ( 000.00 ) DENOTES PROPOSED ELEVATION
NOTE: CONTRACTOR MUST VERIFY DRIVEWAY DESIGN, =7=7:-_ DENOTES DRAINAGE AND UTILITY EASEMENT
nl:KMTVC na AIMAf r n - n.nrn--
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNEIR
MAILING ADDRESS
PROPERTY ADDRESS p % L~/ X _5 Q,¢
(location of septic system) lease obtain from th Planning Dept.
CITY/STATE
PROPERTY LOCATION 1/4, 1/4, Section;! T 3/ N-RL_W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION
jot LOT NUMBER .Z
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 expiration date.
SIGNED:
DATE: W t 19 6
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
• 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
-14ze'
Location of property , -1/4 S?- 1/4, Section _T,?/ N-R_Z W
Township Mailing address Za .2./
Address of site -57 c.,'n. -,,'Yn-.
Subdivision name X Lot no.
Other homes on property. As L.-' No
Previous owner of property
Total size of property
Total size of parcel
Date parcel was created ?C~ ~~j~j fo
Are all corners and lot lines identifiable? ,i Yes No
Is this property being developed for (spec house) ? Yes No
Volume /,Lo$ 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. s-s'r ?S( , 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.
~:2-1 116
Signatu of Applicant Co-A icant
VOL 199, PAPi,1 9,2
111. ' 551981 STATE BAR OF WISCONSIN FORM 11 - 1982
- LAND CONTRACT
ladtvidual and Corrppoorate
• (TO SE USED FOR ALL TRANSAC7fONS WHERE OVER f~c
$2S,0f1015 FINANCED AND IN OTHER NON -CONSUMER
r J Cf f iCG
DOCUMENT NO. ACT TRANSACTIONS)
Charles H Borg-strap and - sa~d1°i1i1O°4
Contract, by and between 'NOV husband :1 1896
Dolores Borf~str(xn, a a Delores BorQstrom,
and wifKe -Land Hanes t~ 10e00 A•*A
whether one or more) and SOU, O.A&
('purchaser'. whether one or more). flay aEK d DMA
Vendor sells and agrees to convey to Purchaser, upon the prompt and full performance
of this contract by Purchaser, the following property, together with the rents. profits,
St. ther appurtenant interests (all called the *property*). my State of Wisconsin
fixtures and o
THIS SPACE RESERVED FOR RECOROINO DATA
- NAME AND RETURN ADDRESS
I \ KRIS'PINA OGLAND
Zilz, Estreera & Osland
P.O. Box 359
Hudson, W154016
t
PAflQEL PENTIFIGATIQN NUM89i_ , i
Lot 2, Country Living First Aaiition in Town of Star Prairie, St. Croix County,
Wisconsin.
SEER
a
FEE
This is not homestead propen)t
(ts not) lace Vendor directs
Purchaser agrees to jrchase the Property and to pay to Venf lowing dor at - maru►er. (a) S~_ =
the sum of$-1-V'--000 .00 14 4W . 00, together with interest from date
at the execution of this Contract: and (b) the balance o[ f. -0- perc ent per annum will paid in full, as "'Wm
the rue 0,
hereof on the balance outstanding (tom time to time ble
on or before March 30, 199'
Principal shall be due and pay
provided. however, the entire outstanding balance shall be paid in fun on or before the 30th day of March
19 97 (the maturity date). 12 annum on the entire amount in default (which shag
Following any default in payment, interest shall accrue at the rated % per include, without limitation. delinquent interest and, Upon acceleration or maturity, the entire
principal balance).
purchaser, mks excused by Vendor. agrees to pay monthly to Vendor amounts sufficient to pay reasarma * anticipated annual taxes, spetW
assessments, fire and required Insular ue premiums when due. To tine extent received by Vendor. Vendor agrees to apply p",,t, to these
obligptions when due. Stich amounts received by the Wndor for paymen, cf sates. assessments and insurance will be deposited lnto on escil
fund or trustee account, but shall not bear interest unless otherwise required by law
balance at the rate specified and then to pticipal. Any amount may be
payments shall be applkd first to interest on the unpaid
without prern um or fee upon principal at any time
vl~ili}f1F~~~
in the event of any prepayment. this contract shall not be treated as in default with respect to payment so long as the unpaid bob= of
interest from month to month shall be treated as unpaid principal) is less than the amount that
principal, and interest (and in such case accruing , been made as first specified above. provided that monthly payments sb2l be
said indeb!ednew would have been had the monthly payments mises being thereafter exchKW hereirom-
continued in the event of credit of any proceeds of insurance or condemnation, the condemned pre purchaser states that Purchaser is satisfied with the title as shown by the title
evidence submitted to Purchaser for examinadOn except:
None
a
01" rod~2(►~Pact
VE
is levied on the Property or upon ndorD trnr :rest in it and to deliver to Vendor
Purchaser promises to pay when due all taxes and messmcn ove rile
a i°°~ Purchaser receipts Showing p~ tpyment. on the Property irouted am w
tact t dama;e oc .atoned by fire. extenS ~ Pe shal acid sock other hazards as Vendor may require, without co-insurance. throul insurers 1E7 o~~i oy Vendor. in the
sum of i p A
q m an amount more than the balance owed under this Contract. Purchaser shall pay the insurance ps t
ies co coverage the standard clause in favor of the Vendor's interest and, unless Vendor otherwise agrees
lbotjArndor shall trot require
when due. The po with Vendor. Purchaser shall promptly give notice of loss to insurance companies
edging of all policies covering the Property shall be deposited aaaa m writminsurance proceeds shat be applied to restoration or repair of the i+topetty
d~tendor~ Unless Purchaser and Vendor otherwise agree
provided the Vendor deems restoration
waste no or lorepair to be w waste toe bco~ committed on the Property, to keep the Property in SPOd ~n~k
din per covenants not to commit vveste not allay with an laws, ordinances and
aoe.drriaet and repair, to keep the Property free (roe fknv superior to the lien of this Contract, and to comply
mW s ions affecting the PropenX rice with interest and other moneys shallbe fully Paid and all conditions shall be funny performed
Vlmdor agrees that in case the purchase p~ Dad, in fee "Ple, d
spaifled-Wndor will on demand, execute and deliver to the Purchaser,
or default of Purchaser. and canape:
as ie rimes and in the tt►snrer above em an lieris or encumbrances created by the ad
cite ~topertg free and clear d all liens and encumbrances, pt _ Y -Of Purchaser agrees that time is of the essence and (a) in the event of a default in the payment of any principal
or inte rest which continues for which
a period of days following the specified due date or (b) in the event of a default in pe&rmance of mailed other certified obligation f P mb entire
asstteaoes 6. a period of -3f 1.__ days b1lowing written notice thereof by Vendor (delivered personally or without notice ( ~ r
full, a V endoA option
to any limitations provided by law) in addition to those
law ~ a e under this contract shall become mime' diatelY due and dies in
~f mss), and in equity. . (i) i) also Vendor mhaveays the at following his option. «n, rights and terminate remContract and edies PurchaseA right. tick and interest in the Property
and
ion to be conditioned u~at Purchaser's 10 Payne 0 (the entire - which
maws" dne Property, back through stria foreclosure with any equity' of redemption ant ad as meal for the
antmanding balance, with interest thereon from the date of default at the rate in effect on x one to fulfill her thamounts due is Contract ha~~ (m
eta aII atoounts previously' Paid by Purchaser shall be forfeited as liquidated damages 161 he
Pbpary if Purchaser fails to redeem): or (A) Vendor may sue (or specific performance of this Contract to compel immediate and full payment
dw,,- interest thereon at the rate in effect on the date of default and other amounts die m P~ at for the ie Property shall auaion<d judicial sale and Purchaser
shall be liable for any deficiency; or (iii) Vendor may
or tv) Vendor may declare this Contract at an end and remove this Contract as a douid title in quiet
and
~ price err any portion thereof: ( and (v) Vendor may have Purchase ejected from P°~10R
aser is insignificant. of an action under (i), (ii) or (iv) above. Notwitbstandirt
time anion if the poinbk interest t any Purchtents,
bone s receiver appointed to waiter issues or during the pertdenrcy tt Y shall only be binding upon VEr+d° if and wlsert
&my o~ a cd or wlitigation ritten stand a nos or actions exp tm s including of say foregoing ~ incurred to enforce any rem hereunder (whether
p
in expanses of title evidence shall be added to prinacipal paid by Purchaser. as Marred.
and shall extent not prohibited by law and be included in any judgment. of action of foreclosure of this Contract, Annthasen wr~rn>3 to the appointment LO
a upon of the comaotettcemud or the p 'ry' any profits of the Property during the pendency of such action
seooeiser d the p~~ hclyding homes tead interest, to wBece the rents. issues, and and such rents, issues, and profits when so collected shall be held and applied as the court shall
rasa tnrnt of arty d flnretnaserE rights undo
Pmc)mser shall not transfer, sell or convey any legal or equitable interest in the Property y Vendor unless either the outstanding under
rites Comma or by option, long-term lease or in arty other way) without the prior written consent of of Purchasert interest under this Contract solely
ment o the entire
is first paid in full or the interest conveyed is a pledge or assign
an seek yfor this Courted ' such transfer, sale or conveyance without Vendor's written consent.
an n for at indebtedness pays le u of Purchaser. c the evert m any due and le in full, at vendor's option without notice.
a~ao wd r shall payable under this Contract shall become immediately spins the Property on the der of this Contract (encept for any
Vitndor shall make Purchaser) payments when due tender any he mortgage by. provided purchaser maL.es timely payment of the amount then due under this
anted ~ gurcha by mu under any note secured teor Vendor fails to do so and all payments so trade by Purchaser shall be
per may make be such payments directly to the Mortgagee
cooddesed payments made on this Contract. or default of Purchase. askm of Vendor
All tear s rosy of waive any default without waiving other to the P~ in the
All tams of this Contract shall be binding upon and inure ure to the benefits of the heir, legal representatives, wccearacs and
area Pwdmer. (1f not an owner of the property the spouse of Vendor for a valuable consideration joins herem to release homesteact rights so bjecs Property and agrees to join in
the execution of the deed to be made in fulfillment hereof.)
g day of Navetttber 19 %
Dried this Rey-;,and Homes
7
~0'7' (SEAL) (SEW
. Charles H. Bor tram
a
MAL) (SEAL)
uildefrs, Ifnc., Psfrtne~
. Dolores Borgstr , a/k/a Delores Borgstrom
ACKNOWLEDGMENT
THENTiCATION _
Bo strum Dolores Stott of Wisconsin.
era.
De ores rgstran - R
fYegrst 54.
Personally came before me this dry of
~S Nvt~t~nber , 19 19 . the above named
N
C'. d
s. r
s:-tristi
IPILI¢ BAR OF WISCONSIN Ir r
Of not, to tent known to be the afro s,seNmed die aotleorixed by !706.06. Wis Sue.) untrume nt and the J ? ~
~
taac *ATRLJUENT WAS DRAFTED By