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038-1112-10-200
STC - 104 AS BUILT SANITARY SYSTEM REPORT C:~ (r{ ErE -97 OWNER aEW,\I 1A(N1Ar-N ADDRESS f~~~~ ` .0,,,jj'4G OFFICE /0 7 SUBDIVISION / CSM# q7C3Hj, 0559 LOT SECTION Tj_N-R _W, Town of5rfl{Z 4RARi C i ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYS EM poe 30.5 I I &ARR6E i i I - hbueE I ( AC- /6 x50' '3e D L , II f J0S /DOD 6AL IWE6IC5 S.T ZS INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: L Q + $TCE< ~I L153j, /O/. 03 ALTERNATE BM: 7)ff F(7 ) UNOr~T~it,1 51I3 SEPTIC TANK / PUMP CHAMBER / HOLDING TANK`INFORMATION Manufacturer: WEEKS Liquid Capacity: 10&) U~4L. Setback from: Well House Othera5'C,eonn j~ PROF ~10&- Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: $ Length 50 Number of trenches Distance & Direction to nearest prop. line: ? IoM ,5011TH t RnP Setback from: well: House Other ELEVATIONS Building Sewer `/S:Z ST Inlet: `x.555 ST outlet: $0 PC inlet PC bottom Pump Off - Header/Manifold /d,23 Bottom of system 23 Existing Grade 7</ Final grade 7 DATE OF INSTALLATION: 7///!7 PLUMBER ON JOB: MEFF Fo x LICENSE NUMBER: -:T-P R$ b $ p[., INSPECTOR: SNA, -NOMn SoN 3/93:jt Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count 'ST. Safety and Buildings Division CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar Personal information you provice may be used for secondary purposes [Privacy L V, s.15.04 (1)(m)], is WPn t ~%Ier',Slame: Y [ (Zyty,~ [lpgej T~wn of: State Plan ID No.: CST BM Elev.: ~1~ Insp. BM Elev.: BM Description: titc rtcA Parcel lMW:L;1112-10-200 TANK INFORMATION ELEVATION DATA A9700283 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer St/ Ht Inlet Holding 17 TANK SETBACK INFORMATION St/ Ht Outlet Vent ir Ito ntake ROAD Dt Inlet TANK TO P / L WELL BLDG. A Air 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 System TDH Ft FFo_ rcemai n Length Dia. H H Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside 7 Liquid Depth DIMENSION DIMENSIONS SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION TypeO CHAMBER Mode 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 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 28.31.18,SE,NW 1960 104TH ST LOT 1 Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R.3/97) Date Inspector's Signature Cert. No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ~~i~'■•i~+'i SANITARY PERMIT APPLICATION Bufereaauu of of B uiildiinWater Systems ngWater Bu201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8112 x 11 inches in size. t . C-4, d-x • See reverse side for instructions for completing this application State Sanitary Permit Number Wry The information you provide may be used by other government agency programs ❑ Check it revision to previo s 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 -155_fa f /4, S Q 110 T t , N, R1,C E (or)dD Property Owner's Mailing Ad ress Lot Number Block Number 1,71,40 r 157" Ot , State Zi ode Phone Number Subdivision Name or CSM Numb r EVlR/eH Numb P II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road Q ❑ Village >1 y T* ❑ Public 1 or 2 Family Dwelling - No. of bedrooms Town OF to 2C) III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)) 1 ❑ Apartment/ Condo 0:5 8 - ///.;2 /0 -aOO 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. XNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 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/da /sq. ft.) (Min./inch) Elevation 001 j'O 61'06 Feet Feet VII. TANK Capacity acits Total # of Prefab. Site Fiber- Exper- INFORMATION g Gallons Tanks Manufacturer's Name Concrete Corr- Steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank Iwo /O it,/6-6 S ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signatur Stamps) MP/M4A&ALNo.: Business Phone Number: i yes 6 2 71s 7 Ste'-3 6z Plum b 's Address (S eet, City, State, Zip Code) IX. UNTY / DEPARTMENT USE ONLY ❑ Disapproved Sa ary Permit F~eg (Includes Groundwater Date e Issuing Agent ignatur A roved ~j UV Surcharge Fee) pp ❑ Owner Given Initial //ll Adverse Determination ; V ~177 F//,/ ONDITIONS F APPROVSOR DISAPPROVAL: 2/96 - SBD-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 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 li -ensed 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 riurriber(s) of where the system is to be installed: IL 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, et), 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 plansmust 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. r ~E RR WAA L.c-. of SE ley Al W SEL' Z 8 rws?3/, Al, X J8 bd I Floe /ay r, Sr sT~ PePfIR/E r~sP P/CHMvnI/J . K/-r c n(Y62- i i LsAAC-E />r'6dEvl/fl q 0-3 Z`~~ Hb /1~D~osED u A12)jt6'E /B)(SD &FD 9w -5o Fr ,4a I ice, /DOD GAL WZC-K SE~Tie 7An/~' O REAi!OgAll R RK TD%' / STEEL P)PE- r l? 16ORI» 1 (0S simL c 30 -m r- /oo Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings page -0f-:: of Integrated Services 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 Count include, but not limited to: vertical and horizontal reference point (BM), direction and ~-21 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # 6 1- 7 APPLICANT INFORMATION - Pleasfl informs Reviewed by Data Personal information you provide may be used for on purposes ( s. 1) (m)). Propertyer rty Location o . Lot 1/4 1/4,S T ,N,R R'(oi Property ailing Address hy Wt # Bloc Su . Name or tW C~ f A 1 S City Statr Zip Code P e N r /El city ❑ v ge Town Neatest Road Z", V New Construction Use: ® Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate 5 _-bed. gpd/(12trench, gpd* Absorption area required 19QWbed, ft2 ~SC~ trench, ft 2 , Maximum design loading rate _ gibed, gp&V,. ~ trench, gprW Recommended infiltration surface elevation(s) It (as referred to site plan benchmark) Additional design/site considerations ft Parent material , ' - Flood plain elevation, if applicable _ /41 S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system © S ❑ U 2 S ❑ U JZ S❑ U 0S ❑ U ❑ S O U ❑ S 9 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. C nt. Color Gr. Sz. Sh. Bed , Trench I Ground ft• Depth to limiting factor Remarks: Boring # < r S , Ground elev. 1 Depth to limiting factor /,min. Re arks: CST Nam (P ase P nt ' 7igna Telephone No. - Address,, Date CST Number SOIL DESCRIPTION REPORT PROPERTY OWNER Page PARCEL I.D.# Boris # Horizon Depth Dominant Color Mottles Structure Geplft2 Boring in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench Ground ev. Depth to limiting factor Remarks: Boring # Ground elev. n. ; Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots PD/f2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Ground elev. ft. ' Depth to limiting factor in. Remarks: Boring # L Ground elev. ft. Depth to limiting factor 'n' Remarks: SBD-8330 (R. 07/96) A IMO S6~', 7ve 7 30 -,g 7 I , l ~6.6a 33 ~ n/ J v ~ l o J o a ~ f 71 /8 l4 p BJr ~ / 35' Ib0 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division tT. CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitari.: Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)). rg mL lder's1 pyiY & TAMI (H~ ~S g Town o : State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel TP3W-~1112-10-200 TANK INFORMATION ELEVATION DATA A9700269 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Ns 1, Bldg. Sewer Holding St/Ht Inlet Or' TANK SETBACK INFORMA N St/ Ht Outlet Vent TANK TO P/ L WELL BL A ir Ito ntake ROAD Dt Inlet Air Septic NA Dt Bottom Dosing NA Header/ n. Aeration NA Dist. P' Holding Bo ystem PUMP/ SIPHON INFORMATION 4inal Grade Manufacturer Deman Model Number TDH Lift Friction System TDH Ft Forcemain Length Dia. Fi Dist. To I SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN I SYSTEM TO L BLDG WELL LAKE / STREA LEACHING Manufacturer: SETBACK INFORMATION -Typ_e_07__ OF CHAMBER Moe Number: System: UNIT DISTRIBUTION SYSTEM Header /Manifold Di ibution 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 System my Depth Over Depth Over xx Depth Of T xx Seeded /Sod xx Mulched Bed /Trench Center Bed/ Trench Edges Topsoil El Yes E] No ❑ Yes El No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: STAR PRAIRIE 28.31.18,SE,NW 1960 104TH STREET LOT 1 Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R.3/97) Date Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH ` SANITARY PERMIT NUMBER: w Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County. than 81/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number 081453 The information you provide may be used by other government agency programs ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number. 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location p CO E (or)~ F~ 4 7Ammy le- 1/4 ~ 1/4, S ~8 T,31 . N, R PropsertLy Owner's~aili Ad~r' ~ Lot Nymb ~ Block Number Ci y, State ff~~l rXl[V Zip Code Phone um er Sub'w ion Name or CSM Number lby C? p(o. a:55 41 WT7 .22 11. TYPE F BUILDING: (check one) ❑ State Owned ❑ City Nearest RoPa ❑ village IR n✓ Z - E] Public 1 or 2 Family Dwelling - No. of bedrooms own OF ITA III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 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. LVt New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5, ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 410 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 1 -7c? Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min Inch) e~ Elevation l fSV D a0 Feet Feet VII. TANK Capacit in gallo s Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank 1 1aeo I ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ~0 at < G ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plu b is Signature: (No Stamps) MP/.NPR`sb'd11M., Business Phone Number: zZ 715--7S~'3 Stn t, ity, tate, Zip Cod ( umber's Ad !Z0x_ IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Issuing Agent Signature (No Stamps) Approved E] Owner Given initial 1.6 Surcharge Fee) Adverse Determination a X. X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: original to county, One copy To: Safety & Buildings Di-ion, Owner, Plumber INSTRUCTIONS F 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- IL 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- VIL Tank information- Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks-, distribution boxes; soil absorption systems,- replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system ilf 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- r ~ ► o m~ I r ~ o ~ h ~ n d o Z, G S z o r ~ O ~ ~ o ~ .tom n ~n DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, G DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 76 HUMAN RELATIONS N WI 53707 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: NS UNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION MME- -5;IC7 i/a KII COUNTY: OWNER'S BUYER'S NAM MAILING ADDRESS: , C 5 rvm I o T iv USE DATES OBSERVATIONS MADE - /S_ NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DE RIPTIONS: R A ION TESTS: Residence - 1XNew ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system / l7 CO)ENTIOaNAL: MOUND: IN-GROUN~P~ URE: SYSTEM-IN-FILLHO❑LDING TANK: RECOMMENDED Si~TEM:(optional) If Percolation Tests are NOT required DESIGN RATE: DJ If any portion of the tested area is in the under s.H63.09(5)(b), indicate: :i7: Floodplain, indicate Floodplain elevation: ~o PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHES TO BEDROCK IF OBSERVED (SEE ABBRV. N BACK.) ©--S a s ~o " 7 .f 7 -7 -,4'0 B- ~ o? o/ 72/f B- 7 B S A* ~ 7 13- -7 B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD PER INCH P- P-12 P- .G P_ I P_ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 9/9' 7 u . I I ~ T i r _'t 1 ?11 !o-a!___C C~ FILED OCT 1619920, 4 O JAMES O'CONNELL of Di" S 6 ReglsIX Co., VW 490116 a aUr, co, wi CERTIFIED SURVEY MAP LOCATED IN THE SEI OF THE NW6 AND THE NEI OF THE SW4 OF SECTION 28, T31N, R18W, TOWN OF STAR PRAIRIE, ST. CROIX COUNTY, WISCONSIN. OWNED BY: SURVEYED BY: SCALE: I" = 200' Charles Borgstrom A & E Land Surveying 1951 104th St. P.O. Box 325 200 loo 0 200 New Richmond, Wi. 54017 New Richmond, Wi. 54017 LEGEND • 1" Iron Pipe Found 0 Set 1" x 24" Iron Pipe weighing 1.68 LBS per linemzr foot. \ S51°4P 56 E ",--70.21 _S64014;01"E \ oo ' , 120.86 N I/4 CORNER N SECTION 28, T31 N, R18W N25045'59'E ALUMINUM CAP IN CONCRETE ,►cF , -17.00 I~ tirFR \ ; _N7245 07„E rF0 Ifrl 4NF 9.23' O 1 '0 10 1z -4 , l s 'C T IN Im tW0 No sFTB ~\b~ RAINA(i 0 IN I(A O ACk N;O - I--~ o ' - o _S3404T'35-E ID A - :l- 127.46 A LOT F -N t LOT 2 go \ ; Z `"=gym S88047'00"W S88°47'OO~~W \ a v 445.00 505.71 ro ~z Acom-------~ EAST/WEST - yNLo. 1/4 LINE o W u~ O I ' . ,m= -00 LOT 4 LOT 3 1 13 m / z m 0 38.x8'•, m'" S88047'00"W m (A= IC 375.00 S31059'16"W ' r" / 1117.56 ' o IZ 204.87' 305.13' 301.80' ' yv 1~ fl S88047'00'7 .865.52' ' 4-51 02- 0 Jr- yl NE CORNER C 1~ ~1 I LOT 7 ' oI RED PINE ESTATES /ee• N iv z LOT T 6 i LOT 7 . LOT 3 0 ID I 3 1/4 CORNER IZ m~ SECTION 28 10 f T31N, R18W AI 3" X 8' IRON PIPE Radius Central Angle Arc Length Chord Bearing ;Chord Length curve 1 600.01' 12°27'05" 130.39' S58°00'28.5"E 130.14' curve 2 total 388.28' 43°00'52" 291.50' S85°44'27"E 284.70' Lot 1 388.28' 25°17'18" 171.37' S76°52'40"E 169.99' Lot 2 388.28' 17°43'34" 120.13' N81°36'54"E 119.65' curve 3 253.54' 72°27'18" 320.75' S71°01'14"E 299.80' STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 4_ I/ (,Jitwt. MAlLJNG A')DRESS S2 X16 7 N tat/ 2q fnr ~ ('j S ypp l PROPERTY ADDRESS 9 /D ST (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION SE 1/4, 1/4, Section T-, N-R f~ W TOWN OI Aij~ e $ ST. CROEK COUNTY, WI SUBDTYLSIQN C'5 rh UOL pyi~ LOT NUMBER CERTIFIED S URVEY MAP VOLUME PAGE s.y 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 neater 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: 4wu DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, VVI 54016 11/93 03,'28/96 10:19 -Ty COU TI CLERK LOU02/003 • STC - loo This application form is to be completed in full and signed by the 3 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 3E~Ry ~✓W4LEK) _ Location of property ~j~ 1/4 IJkll/4, Section 2 1~_.,T 31 N-R~~ W Township STAR, TRHRR) - Mailing address _ 15'20 Y67 Address o f site T• Subdivision name ~10. Other homes on property? Yes-- -No Previous owner of property Total size of property Trotal size of parcel Date parcel was created Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house) ? Yes _~<_-No Volume 47 and, Page Number 55 as recorded with the Register of Deeds. - INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY but) 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. PPOPERTY 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 offzc2''of the County Register of Deeds as Document No. W S' n ure of Applicant Co-Applicant '7-lq-q7 - 'I- t~Jq~ Cate of Signature C te. of. Signature /O STATE BAR OF WISCONSIN FORM 2 - 1962 5623(;5 WARRANTY DEED DOCUMENT NO VOL fUff 33J a• ST. CROIX CTIC W) Charles R Borg,S-tram and Kath een e Rnrp~ram husband and. wife_,I_~~ 'JUL 15. 1991 r tdaal an and _ 8:00 A. M conveys and wan-ants to Jerry WA& Tami A. Waalen husband and wife -~K.A 1..- Muytstw of Deeds THIS SPACE RESERVED FOR RECORDING DATA ;i NAME AND RETURN ADDRESS the following described real estate in C t rr ri 1 X CA-C1y- II State of Wisconsin: 038-1112-10-200-----!i PARCEL IDENTIFICATION NUMBER ~i Part of the SE1/4 of NW1/4 of Section 28, Township 31 North, Range 18 West, St. Croix County, Wisconsin, described as follows: Lot 1 of Certified Survey flap filed October 16, 1992, in Vol. 9, Page 2554, Doc. No. 490116. i This deed is given in fulfillment of that certain land contract between eptember h l parties in ereto dated September m351, 8Doc99No. recorded 533647. ~I S ~I ~ffE I 1EXEWT This _ i s not homestead property. XIM (is not) Exception to warranties: Easements, restrictions and rights-of-way of record, if any. f July ,A.D., 19 97 ~I Dated th' day o II (SEAL) EAL) I,I • Charles Borgstrom Ka"t"hleen A Borgst om (SEAL) (SEAL) • ~I ~i i jI AUTHENTICATION ACKNOWLEDGMENT i Stage of Wisconsin, Signature(s) ss li St. Croix County. authenticated this day of 119- Pers-rally came before me this ay of the above named Ii Char es B. Bor);strom and Kathleen A Borgstrom, husband ' TIT LE: MEMBER STATE BAR OF WISCONSIN and wife, (if not,k authorized by §706.06, Wis. Stats.) NO;Rx PUSUC to me kzk-mm to be the person s who executed the foregoing O~ y/1SCONSIh) in% and k edge the same. l - THIS INSTRUMENT WAS DRAFTED BYTr z ~ . WESTBUR SUPPLY INC. Goulds 12 TRIAL RD. 154016 Submersible Effluent Pump 3871 EP05 APPLICATIONS + Fasteners: 3011 series • Fu y submerged in high ■ Motor Housing: Cast iron S eccal designed for the stainless steel gn tie turbine oil for for efficient heat transfer, p • Capable of rut ning lut ication and efficient strength, and durability. following uses: dry without & mage to he 1. transfer. • Eft .pt systems ■ Motor Cover: Thermoplas- cumponents. tic cover with integral handle •,Homes,~Aval able for automatic and ~h • Farms i 4 Motor: man,aal operation. Automatic and float switch attachment Heavy iuty sump • EP04 Single pnase: 0.4 HP, mod als include Mechanical points. F 115 or 230 V, 60 Hz, 1550 ■ Power Cable: Severe duty Water transfer Floa. Switch assembled and dewate ngt ---RPM, built in overload with Ares it at the factory. rated oil and water resistant. automatic res,st• ■ Bearings: Upper and lower 0.5 HP, ~$i OECIt=~CA IONS • 115 EP05 V, 60 Single Hz, 155 ,155 0 RPM, :FEA "URES heavy duty ball bearing Pump: EP04 built in overload with ■ EP04 Impeller: Thermo- construction. • Solids handling capability: automatic reset. plastic Semi-open design 3/4 maximum. • Power cord: 13 foot with rump out vanes for AGENCY LISTING Capacities: up to 55 GPM. standard length, IN SJTO meca+anical seal protection. CO- Canadian Standards Assmiation Total heads: up to 24 feet. with three pro~ig grounding - • Discharge size: 11/2" NPT. plug. Optional 20 foot ■ EF't15 Impeller: Thermo- (CSA listed model numbers Mechanical seal: carbon- length, 16/3 S ITW with plast`c enclosed design for end in "F" or "AC".) rotary/ceramic-stationary, three prong grounding plug imps Ved performance. BUNA-N elastomers. (standard on I P05). ■ Ci Bing and Base: Rugged • Temperature: therr ioplastic design provides 1040F (400C) continuous supe for strength and r. 14005 (6011C) intermittent. corn sion resistance. Fasteners: 300 series METERS FEET - stainless steel. 10 a Capable of running dry without damage to s 30 - ; sGPM components. i Pump: EP05 8 ` UFT Solids handling capability: G 7 25 14" maximum. k"E Capa cities: up to 60 GPM. s 20 Total heads: up to 31 feet. ~ Discharde size:11h" NPT. 6 Mechanical seal: carbon- 5 15 rotary/cerramic-stationary, 4 BUNAN eiastomers. c S- ' Temperature: 0 3 10 104°F. (40°C) continuous' 140°F (600C) intermittent. 2- 5 1 0 00 10 20 30 40 50 GPM 0 2 6 8 • 10 12 m3/h CAPACITY 01995 Goutds Pumps, Inc. Effective May, 1995 B3871 Goulds 6 Submersible '8 Effluent Pump 8 7 6 9 EP04 5 3871 P05 a E 3 2 e k~^ dIME0 NS PARTS {All dimepsions are in Inches. Do not use for construction pu poses.) Item No. Description E 1 Impeller EP04/Impeller EP05 2 Rugged thermoplastic base 3 Rugged thermoplastic pump casing G 4 Mechanical seal 5 Ball bearings r 11 MAX. 1'/2NPT 6 0-rings 7 10b y 7 Power cord Ala 8 Oil filled motor 33/, 9 Cast iron motor housing/ stator assembly 4/z 10 Thermoplastic motor cover YF X., ' 6' MINIMUM WATER LEVEL WHEN SUPPLIED WITH FLOAT SWITCH z PERFORMANCE RATINGS { n MODE ta, Max. Solids Power Cord Wis. Total Head Gallons Per k 0 b No., HP Volts Phase Ampz RPM 'Handling Length (lbs.) Minute (ft. of water) 10' 20 EP04 EP05 115 12 5 53 ~?IA" 115 12 _ 10' 21 10 46 62 4/0 20' 20 tptliiF* 115 1 12 1550 15 36 56 ! F{1AC" 115 12 20 21 20 21 47 EP05fi1F" 115 13 20' 21 24 0 38 ff? 5,1I,AC* 115 13 20' 21 28 - 24 31.5 - 0 "A' yeti automatic operation. Pump includes float switch. dietfiSAlisted with 20 foot power cord. u"QC" de automatic operation, CSA listed with 20 foot pc wer and switch cords. CSA 11~ ljhfts: v 2309We19 consult factory. { [I000LDS PUMPS.INC: WATER TECHNOLOGIES GROUP S0 EG4 FAITS NEW 'VOW 048 $pECIFICATIONS ARE W 7JECT TO CHANGE WITHOUT NOTICE. PRINTED IN U.S.A.