HomeMy WebLinkAbout040-1242-60-000
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y
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 4✓^-YAle ~P, Sey
ADDRESS ,Fd ~/~-0~~ ~•o~ 5 e J?
F
SUBDIVISION / CSM# LOT # '17
SECTION T af- N-R /9 W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
~SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
r
I^~
3 d D sG~~-, G
l a uL
3 Nc1 n5 oNrCoe? 4~ "-4
J
S
Tyr: cr M k Al INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: ~Ca~ aS' r/S
ALTERNATE BN:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: ,l rdwe,57'PvrJ Liquid Capacity: J,2Qd
Setback from: Well SSa'+ House 3y' Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: J,2 Length 72- Number of trenches
Distance & Direction to nearest prop. line: Setback from: well: /AG E House 4 ~ f • Other
ELEVATIONS
Building Sewer ST Inlet: ST outlet:
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION: ~Z Q/
PLUMBER ON JOB: ,(Up
LICENSE NUMBER:
INSPECTOR:,
3/93:jt
~:ww
Safety and Buildings Division
e.•■~r■r,< 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 8 112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
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
.)dL$e Owner Name
Property
C A- 01/~ Location
1/4, S T~~ , N, R / E (Or)~o
Property Owner's Mailing Address Lot Number Block Number
a V ,rd d ~7 7
City, State Zip Code Phone Number Subdivision Name orCSM Number
H t-~ 5,0 37~~eloje 1( d eo,4,* 7-kNIP Ld d 40 e C ar =4~
11. TYPE OF BUILDING: (check one) ❑ State Owned City Neare
Village Rd
Public 1 or 2 Family Dwelling - No. of bedrooms own OF acv R
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) f 2
~6~1 ~2~. l~✓~
1 ❑ Apartment/ Condo ~ 1
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 1.0 ❑ 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. RINew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. El 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
1 rVI-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
atoo %w& 6 111 , rJ .vim- Feet Q P~4-Feet
VII. TANK Ca
in gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank oZ O6 ` d ❑ ❑ ❑ ❑ ❑
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.
usiness Phone Number:
T__
Plumber's Name: (Print) Plumber's Signature: o Stamps) ra;p?'7 RSW No.: B
r 1-6 3rr-~- 312
Plumber's Address (Street, City, State, Zip Code):
/,0 7e) SC k Sow l
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit F Iude,Groundwater Date Issue Issuing Agent Signature (No Stamps)
XApproved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination !O
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SHO-6398 (R. 05/94) DISTRIBUTION: Original to Counly. One copy To: Safety & Ruiidings 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 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.
Wisconsin Department of Industry, SOIL AND SITE EVALUATION
Labor and Human Relations Page / of Z
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION - Please print all information. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
e!. Govt. Lot 50 1145,er 1/4,S j T,,-7 F N,R / E (or)
Props Owner's Mailing Address Lot # Block# Subd. Name or CSM#
- ® 77 eo"c v` 1 o').00 d
city State Zip Code Phone Number City ❑ Village Town Nearest Road
❑
Yl" d-S 11 A-1 G✓~ $Y6 G ) L. owe Y
New Construction Use: ❑ Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow OQ gpd Recommended design loading rate 7 bed, gpd/ft2_r ~trench, gpd/ft2
Absorption area required 7 bed, ft2-,,7S trench, ft2 Maximum design loading rate j 7 bed, gpd/ft2_,_F' trench, gpd/ft2
Recommended infiltration surface elevation(s) 05 y r ft (as referred to site plan benchmark)
Additional design/site considerations ' /3 2 ✓J~ ~ ~~y 70 G ' k -/'o A o t✓ a r' SVS-,"e ^1 E,( e //7-0
Parent material 0/ti-/-/.)a,$4 u Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
U ❑ S ®U ❑ S [9 U
U = Unsuitable for system Z S ❑ U 2 S ❑ U ®S ❑ U ®S El
SOIL DESCRIPTION'REPORT
Borin # Horizon Depth Dominant Color Mottles Structure GPD/ft2
g Texture Consistence Boundary Roots
/ in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
l C I -/P / d i. ~l ltd F
ld-l3 a Sl r- a- S
.2 E-C2,t
Ground 3 3,//0 7, ~o c CGS / aC
elev., ,
Depth to
limiting
factor
Remarks:
Boring #
'04 10 -06 _MIR .212 e) d
Ground
pelev.
Depth to
limiting
factor
//6' in. Remarks:
CST Name (Please Print) Signature Telephone No.
Address Date CST Number
PROPERTY OWNERZ SOIL DESCRIPTION REPORT
Page 2 of Z
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
'El ff
2 1*j1 J IQ y "141, ea 0 1 ce 7;,
Ground
elev.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
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
elev.
Depth to
limiting
factor
in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
SBDW-8330 (R. 08/95)
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Laborahd Human Relations INSPECTION REPORT ST. CROIX
Sailety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 284241
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
KEISER WAYNE TROY
CST BM Elev.: Insp. BM Elev.: Description: Parcel Tax No.:
/DUB 0J/ BM 040-1242-60-000 Z~Al -kp ea.-, 4Z TANK INFORMATION EL VATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic) Benchmark e/' o
Dosing
Aeration Bldg. Sewer 10d,c29
Holding St/Ht Inlet D/./,?
TANK SETBACK INFORMATION St/Ht Outlet z /00,-7.?-
TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet
rl
Septic S NA Dt Bottom
Dosing NA Header/Man. 1~3~► ~dQ, 2
Aeration NA Dist. Pipe
Holding Bot. System /O,y~ 9Q, d
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Loss Head
Forcemai n Length Did. Dist. To Well
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 TypeO CHAMBER Model Number:
System: S/U" OR UNIT
DISTRIBUTION SYSTEM
[Heagdeth r / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
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 , V t, Topsoil E] Yes El No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: TROY.3.28.19 SE SE 530 TRILLIUM LANE
6twy,U /bl-t-a„J e~-L~,.,.L! _ ~v ~ t~-c1~ '~.,.U r, ! ~'-~,1. . f ,~,1; ~,-C✓@! . a..,~ ~ c.fo'~.l.~J-+f
~-Gf c~'~..Fy c~s3... r:lV.cd-~'t %F' •~C..i,1~6
6M - f
Plan revision required? 5 ❑ No
Use other side for additi information.
SBD-6710 (R 05191) Date I s or's Signature Cert. No
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:'
I
c 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 8 112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
4_ L
The information you provide may be used by other government agency programs ❑ Check if r ms o 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 Prope~rt,Y Location
- 1 i4 ~r,1 1/4, S j T , N, R l f E (or VW
Propertwner's Mailing Address Lot Number Block Number
e c 4 ~i,
City, State Zip Code 1 Phone Number Subdivision Name or CSM Number
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ ,ty Nearest Road
❑ vIl age Yt1 w dt~ '
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF
Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Numbers
1 ❑ Apartment/ Condo a q0 _ a q d~J &0 -6(;o
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. go 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 ❑ 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
17 . ~,r Feet Qom/ 175, Feet
VII. TANK Ca
in gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank P( U~ a sJ ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: No Stamps) ~P^MPRSSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
;7,7 12P
I COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
Approved 1-1 Owner Given Initial Surcharge Fee)
Adverse Determination gggi/a~~ -
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
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 maybe renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3_ All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608-266-3815-
To be complete and accurate this sanitary permit application must include:
1. Property 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 of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
Latwr aqd Human Relations
Division-of Safety & Buildings in accord with ILHR 83.05, VyJB.
J ~l 7 . COUNTY 141 "Z~~
St. Croix
Attach complete site plan on paper not less than 8 1 /2 x 11 inches in si _RI mu%clude, b PARCEL I.D. #
not limited to vertical and horizontal reference point (BM), direction an slo_Von N
dimensioned, north arrow, and location and distance to nearest road~4 ~ fending
VIEWED BY DATE
APPLICANT INFORMATION-PLEASE PRINT ALL INFORM iidN r,PROPERTY OWNER: PROPERTY1600oN
Richard Stout GOVT LOl'`v r 1/4/ 1I4,S 3 T 28 N,R lg E (or) W
PROPERTY OWNER':S MAILING ADDRESS ° LbT#' BLOCK ' B .NAME OR CSM #
1353 Awatukee Trl.,Country Wood Second Addn.
CITY, STATE ZIP CODE PHONE NUMBER ONTt_ V(L [SOWN NEAREST ROAD
Hudson WI. 54016 (715 549-6731 Troy Tower Rd.
(x] New Construction Use [x ] Residential / Number of bedrooms 3 ( j Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate • 7 bed, gpd/ft2.8 trench, gpd/ft2
Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2 .8 trench, gpd/ft2
Recommended infiltration surface elevation(s) 103.00 ft (as referred to site plan benchmark)
Additional design / site considerations alt. system el.= 101.35'
Parent material outwash Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE TAT-GRADE SYSTEM IN FILL HOLDING 7TANK
U = Unsuitable fors stem EIS ❑ U EIS ❑ U ®S ❑ U ®S ❑ U ®S ❑ U ❑ S SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Bourd3y Roots GPD/ft
Boring # Horizon in. Munsell Clu. Sz. Cont Color Gr. Sz. Sh. Bed Trends
1 0-10 10 r2 2 none fill
2 10-13 10 r5/4 none sl 2f r mvfr na .5 .6
Ground 3 13-80 7.5yr5/4 none cos os ml na nn .7 .8
elev.
103.5 ft.
Depth to
limiting
factor
+80"
Remarks:
Boring #
1 0-20 10 r2 2 none 1 fill if nn
2 2 20-84 7.5 r4/6 none c
Ground
elev.
104.5 ft.
Depth to
limiting
factor
+84"
Remarks:
CST Name:--Please Print Gary L. Steel Phone: 715-246-6200
Address: 1554 200th. Ave., w Richmond I 54017
Signature: Date: 8-10-96 CST Number: m02298
PROPERTY OWNER Richard Stout SUiL Ur.,SUKl!' r IVN rnr-rvn a rays 2 A_
PARCEL I.D. # pending
Lot #77
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 0-14 10 r2 2 none 1 fill if n n
2 14-84 7.5yr4/6 none cos osg ml na na .7 .8
Ground
elev.
105.4 ft.
Depth to
limiting
t4
la
Remarks:
Boring #
1 0-8 10 r2 2 none 1 fill if np np
4 2 8-16 10 r5/4 none sl if r mvfr gw na .4 .5
Ground 3 16-84 7.5yr4/6 none cos osg ml na na .7 .8
elev.
105.4 ft.
Depth to
limiting
factor
+84"
Remarks:
Boring #
1 0-6 10yr3/3 none sil 2msbk mfr gw if .5 .6
5 2 6-14 10yr5/4 none sicl lcsbk mfr gw if .2 .3
3 14-27 10yr4/4 none is osg mvfr gw na .7 .8
Ground
10 31e0 ft 4 27-42 7.5yr3/4 none scl 2mgr mvfr gw na .4 .5
Depth to 5 42-84 7.5yr4/6 none cos osg ml na na .7 .8
limiting
factor
+84"
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel Richard Stout 1554 200th Ave.
CSTM2298 SE4SE4 S3-T28N-R19W New Richmond, WI 54017
MPRSW 3254 town of Troy (715) 246-6200
lot #77-Country Wood Second Addn.
1"=40'
BM.= top of SE lot stake C el. 100'
3-'
Gary L. Steel
8-6-96
b lY - IOU
• 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
Location of property~5 1/4_1/4, Section ,TN-R~W
Township Zi,-4 Mailing address
Address of siteT;
Subdivision name Lot no.
Other homes on property? Yes No
Previous owner of property
Total size of property
Total size of parcel f a-e"e ' c s
Date parcel was created '~7 /
Are all corners and lot lines identifiable? A Yes No
Is this property being developed for (spec house) ? _X Yes No
Volume 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. Sand 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.
Signa re of Applicant Co-Applicant
Date of Signature Date of Signature
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS S ?~J
PROPERTY ADDRESS L
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE 5 ye %tf
PROPERTY LOCATION%'4-- 1/4, Section i T :51-) N-R /Y,y W
TOWN OF % V, -i ST. CROIX COUNTY, WI
SUBDIVISION ~Ou v~~y G,~~. LOT NUMBER .77
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 expiation date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
. VOL1"2PACE183 10 5553'77
STATE BAR OF WISCONSIN FORM 1 - 1982
WARRANTY DEED
DOCUMENT NO.
EGISTM
ST COOL`; CO., 0
This Deed, made between R i c-h ^ rri p , $+-put. Wd for Roma
FEB 7 1997
Grantor,
and Wayne Kei armor r n t , Inc sli 10:50 A. ;v'
1`legistsr vt Ua;~c~
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration
THIS SPACE RESERVED FOR RECORDING DATA
conveys to Grantee the following described real estate in R j (I r n I X
County, State of Wisconsin: NAME AND RETURN ADDRESS
(,tJ~1 y n ec E ~'5
Lot 77, Plat of Country Wood Second S $ o t 9 ~~°l9~ De.
Addition, Town of Troy, St. Croix ,L~valsm~~ Gc,r
County, Wisconsin.
PARCEL IDENTIFICATION NUMBER
TRANSFER
FEE-
This i -q nnt- homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements, restrictions, rights-of-way and covenants of record
and will warrant and defend the same.
Dated this 6 t- h day of vebruaxy 1997
71 %CJI " 12 , (SEAL) (SEAL)
* Richard O Stout--
(SEAL) (SEAL)
*
AUTHENTICATION ACKNOWLEDGMENT
State of Wisconsin,
Signature(s) ss.
$t rxniX County.
.>,o, ,.o,~ ~a~ ~f 19 Personally came before me this ~}3 day of