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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER"
x
ADDRESS - , t-h !e
SUBDIVISION / CSM#- LOT
t
SECTION 9 3 T .,ZL) N-R- W, Town of ,t r--M
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
/j
'2 3
w
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: % I
ALTERNATE BM:
r
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer:
Liquid Capacity: ~,a--Z-Z,
Setback from: Well House Other
Pump: Manufacturer -
Mode1# -Size
Float seperation Gallons/cycle:
Alarm Location-
-:SOIL ABSORPTION SYSTEM
Width: Length Zj Number of trenches .112
Distance & Direction to nearest prop, line:
' 1710
Setback from: well
House Other
ELEVATIONS _
Building Sewer
- YE T2 ST Inlet. ST outlet „_1j,~
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade (,,71
DATE OF INSTALLATION:
PLUMBER ON JOB: LICENSE NUMBER: A ~~~/1
r A
INSPECTOR:
3 / 9 3 : j t
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
Permit Holder's Name: El City El Village a Town of: State Plan o.:
SLETTEN, ROY R
CST BM E v.: Insp. BM Elev-: BM Description: Parcel Tax No.:
/l) gad ~ ~ I~" "s ~
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
GU . C(J
Septic Benchmark 1,77
Dosi 7e
Aeration Bldg. Sewer ~J"
Ing St/~f inlet , gl
TANK SETBACK INFORMATION St/A Outlet ( S
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic >Sj} ill) f+ NA Dt Bottom
Dosing NA Header*Wbw.
Aera A Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
odel Number GPM
TDH Lift Fr' 'on estem TD Ft
oss
Force Length Dia. Dist. To well
SOIL ABSORPTION SYSTEM
BED /TRENCH width i Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS S o? DIMENSIONS
ACHING Manufactur
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREA
INFORMATION Typeo 0,,, T_. CHA INumber.
OR
System: 7 /
DISTRIBUTION SYSTEM
Header /mfg- Distribution Pipe(s)/ x Hole Size x Hole Spacing Vent To Air Intake
Length 1- Dia Length k7 Dia. Z Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulc e
Bed /Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: EMERALD.33.30.16W, NW, SW, 230TH
Plan revision required? ❑ Yes [31N'o
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signatur Cert. No.
-s^...
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 8 112 x 11 inches in size. , G
• 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 if r2IpteGfoui/
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location /
Q e w1/4 ~ 1/4, S T30 r N, R ~,e tbr) W
Property Own is Mailing Address Lot Number Block Number
9 v
City, State Zip Code Phone Number Subdivision Name or CSM Number
A4 A( I .6^ 4'.2 > ?6~ 6
y o
IL PE OF BUILDING: (check one) [j State Owned El city ,1w / Nearest Road ~i.
Village e)fh I/ t!
Public 1 or 2 Family Dwelling - No. of bedrooms Town of
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo 0 A0 A4 I? ~o
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10E] 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. EX New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of S. ❑ 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
11E] Seepage Bed 21 ❑ Mound 30E] Specify Type 41 ❑ Holding Tank
12 X Seepage Trench 22E] In-Ground Pressure 42 ❑ Pit Privy
13E] Seepage Pit 43E] Vault Privy
14E] System-In-Fill
V1. 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 Q 9,00 Feet Feet
VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Exper-
INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- steel glass Plastic App
New Existing strutted
Tanks Tanks / .
Septic Tank or Holding Tank D7J~ W e to ® ❑ ❑ ❑ ❑ ❑ _4 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.
Business Phone Number:
M
Plumber's Name: (Print) Plumb r'sSignature: o Stamps) P/A~GeA}o.:
G L e ~r 7"
Plumber's Address (Street, City, State, Zip Code): ,
2 o C9,-Le w 00a/ c y` L~
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
Approved E] Owner Given Initial T
,,N Adverse Determination V
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SHD-6398 (R. 015/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Dive ion, 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. nc m:er of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Cor plete for .,A/ ;e laic, pump/siphon and
holding tanks for this system. Check experimental approval only'if tanks received experirr:ent product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriai:r 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 end specifications not smaller than 8 1/:'x 11 inches must be subrnitied t,, "ie r .inty. The plans must
inclucle the following: A) plot plan, drawn to scale or with complete dimensions, loratioi f i,t lding tank(s), septic
to i u-)Ihcr _reatment tanks-, building se, I wells; water mains/water service; st.rF,i lakes; pump or siphon
tank ~ ution boxes; soil absorption system-; replacement systern areas, anc: the',o ~,r cf the building served;
B) korizo ~J; tard vertical elevation re erenf points; C) compete spec,icatiors for f)Ur7~:): ,=.1 controls; dose volume;
eleva ions dJ'erE:nces, friction loss; pump pe rformanc.e (:urve; pump mo,- el and pum;) m; ~i i,.firer; D) cross section
of the soil absorption system if required by the county; L) soil test data on a 1 15 `oral, arc; ) d sizing information.
GROUNDWATIER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated prai:'1ices, which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contaminaticr7 investigations
and establishment of standards.
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SOIL AND SITE EVALUATIQ"~ Papof
v
In accord with ILHR 83.05, WAdm. Code
11.D LH
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but ~R 0
not limited to vertical and horizontal reference point (BM), direction and % of alope, scale or PARCEL I`D. ti'
dimensioned, north arrow, and location and distance to nearest road. 4 A0 8/_ A®
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION'' GOVT. LOT jc.J 114 3 T 2,9 N,R ~6 W
P OPERTY 01~NER:'S MAILING ADDRESS LOT N BLZK,j.` NAME OR CSM N
/ca e V os ~ ~
CITY, STATE ZIP CODE PHONE NUMBER CITY []VILLAGE (MOWN NEAREST ROAD
0 8' (Aw 6- a 6 d/ a,3o t h. )44
t4 New Construction Use (M Residential I Number of bedrooms 3 Addition to existing building
I I Replacement ( J Public or commercial describe
Code derived daily flow 'lD gpd Recommended design baling rate o bed, gpd$ . S trench, gpd/ft2
Absorption area required bed, ft2 96P0 trench, ft2 Maximum design loading rate ~~bed, gpolft2 trench, gpd/ft2
Recommended infiltration surface elevation(s) 7 ft (as referred to site plan benchmark)
Additional design I site considerations
Parent material 6~1- A d I A L /~L Flood plain elevation, if applicable N4 It
S = Suitable for system CONVENTIONAL MOUND IN GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U=Unsuitable fors stem WS ❑U ®S ❑U ®S OU ®S ❑U ❑S 01.1 ❑S WU
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence 8ourr~ry Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
a n mypq
Ground aO-P ! sC,4 M A J.K W LC W ~J-
3 V
elev. S M . 7 1 •
G9' 6
Depth to -
limiting
> factor
Remarks: -
Boring # Ski k M r l~ S l M S" e~
Via- s 2 1 0 3 SiC 1- M C 1 v , 01
4}ynv:.:ti
41 A- MVFA~
Ground
elev.
9~f t.
Depth to
limiting
factor d
Remarks:
CST Name:-Please Print Phone:
o /3
Address: rJ p ~G eK o o All
Signature: ,~dz Xvp, ^ Date: /4 1/ CST Number: f
PROPERTroww Ro X SL e ttewy SOIL DESCRIPTION REPORT Page Of
PANCELLMIr D /O /D --/0
Boring# Horizon Depth Dominant Color "Mottles Texture Structure Roots GPD/ft
In. Munsell Qu. Sz. Copt Color Gr. Sz. Sh. ,M Bound3y Bed
0, 8' o S1"L a s6 ~.r
3 :
Ground I R 3 SGr .2 6 M S
elev.
Depth to I
limiting t
factor
Lfl~ !
Remarks:
Boring 1# o- /
;L 2S
S/~ /Gl IBS /M . ' • 6
F , -
4 .2- 3I
? Ly 31Z 1e L /vFT ea)
/o
>:s
Ground
eie ,3- 6 rive d. M
g171ft.
Depth to
limiting
factor „
7 ff)-
Remarks:
Boring #
d~11 3 .Sly ZU As IM "5-
3 yew -Nr ~_t , 8
.2,
Ground -
IW
Depth to
limiting
factor
6
Remarks:
Boring #
S
Ground
elev.
it,
Depth to
limiting
factor
Remarks:
I
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
~J St. Croix County
OWNER/BH~R &:%e
MAILING ADDRESS . #4 Al 2i 5 -15o-W
PROPERTY ADDRESS -20 r,j SJ`'
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE L-~/~i ~~1 o O
PROPERTY LOCATION Uw 1/4, SW 1/4, Section 33 , T 3e N-R__14~_W
TOWN OF ST. CROIX COUNTY, WI
r
SUBDIVISION LOT NUMBER
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 com eted and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration
SIGNED:
DATE: X S"- - 910
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
Location of propert1/4 SJV 1/4, Section T.,?N-R /6 W
Township O'M d At,+ Mailing address
) 6 9~ 3 Pc R e 5-7`' A?,l ko1 & Nygo, MN ~'~038
Address of site f fia t.4 Si-
Subdivision name Lot no.
Other homes on property? Yes No
Previous owner of property y
Total size of property ;?o AerR W,
Total size of parcel .2 o h a g'e'
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes __X No
Volume and Page Number :20 7 as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. # , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
e
Si 6n
,pfur-?'of Appl nt Co-Appli an
Date of Signature Date of Signature
DOCUMENT • 1UL 63 rVE2 4 1
WARFLANTY DEED STATE BAR OF WISCONSIN FORM 2_.1982 THIS SPICE RESERVED FOR RECORDING DATA
ST. CROIX CO., WI
Rrc,d for Rfrord
Helen-M, __Sletten- a~lcla Helen_.Sl~tte Single. Person,- - MAR 3 0 1993
- -
conveys and warrants to _ Roy- A,_._Sl1e_.- 11:00
ttexi._,Tr, and..~Ztta_-Sletten,._.
husband ..and_.wife,.--as_. joint.-te~tst------.-•--
' Register of Deed
-
. RETURN TO
a the following described real estate in
State of Wisconsin: _St.'-~ County,
South Half of the Northwest Tax Parcel No:
Quarter (Sh of NW' of SW34 Quarter of the Southwest
NW' 4 of Section Thirty-three (33),
T"nship Thirty (30) North, of Range Sixteen (16) West.
i
FTA
EX T
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This
1S,71Qt---------- homestead
(is) (is not) Property.
Exception to warranties:
f•.
Dated this
day of
v - r?arel~.--------------
-
(SEAL) M,_ Sletten-- - (SEAL)
(SEAL)
* (SEAL)
- -
AUTHENTICATION
Signature (s ACKNOWLEDGMENT
) f -Helen • M. Sletten
STATE OF WISCONSIN
Z
authenticated s.
/ _._da~ of_~ -----March.-------, ---------------County.