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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS.
,2~~
SUBDIVISION / CSM# LOT
SECTION e7 T ,Z 9 N-R-/f _W, Town of_
ST. CROIX CO TY, WISCONSIN
PLAN VIEW
S OW EVERYTHING WITHIN 00 FEET OF SYSTEM
fc'01LLF / 30
7-Il Sa~~r yob 's
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INDICATE NORTH ARRO
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tangy; manhole cover.
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BENCHMARK: I.' p 10a.O _7~r Ae ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: G~fYfCS Liquid Capacity: / ,0O U
Setback from: Well ^044_= House .2 Other
Pump: Manufacturer Mo ;i~ Size
Float seperation ~onns/cycc
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length 5"3 Number of trenches 2-
Distance & Direction to nearest prop. line: 3L-,/ESl
Setback from: well: / lMe House d/,Z j' I Other
y '
ELEVATIONS
Building Sewer /Ojr, p ST Inlet. / p,2, ( y / ST outlet 1,0.Z. yf'
PC inlet - PC bottom Pump Off
Header/Manifold ;'j;/ Bottom of system
Existing Grade /a/ Final grade fp/.
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER: y~ 2 y
INSPECTOR: ~rH
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations ST. CROIX
Safety and Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
Permit Holder's Name: ❑ City ❑ Village I Town of: State PI
DELTA CONSTRUCTION X iTy-eN CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
O - ~J
TANK INFORMATION E EVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
6k, 1.
Dosing
Aeration Bldg. Sewer 3,Cjz~
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet 64,35'
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic >;257 NA Dt Bottom
Dosing NA Header/Man. 9G' qq, 7
Aeration NA Dist. Pipe 12- Z 29, 91;
Holding Bot. System 7.
PUMP/ SIPHON INFORMATION Final Grade U~ o
Manufacturer Demand
Model Number GPM
TLift Loss System DH Ft
Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches 11 PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMEN I N
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of lno_v 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.)
LOCAATIOy,Nr-7{:HLTDSON.17.29.1t9W. ATE. fSE, LOT 109. CTY. HWY A
. -
CAS/ 6 Wg' , D6
p ~
Plan revision required? ❑ Yes ® No
Use other side for additional information. 1-1/1 J 2,116
SBD-6710 (R 05/91) Date spe or ignature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
A
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION Safety and Building l ng Water Sn
Bureau o of f 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. .5771,
• See reverse side for instructions for completing this application State Sanitary Permit Number
0259y5_X
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
Prop rty Owner Name Property Location
1/4 1/4, S 17 T Llf , N, R E (or
Property Owner's Mailing ddress Lot Number Block Number
AftState Zip Code Phone Number Subdivision Name or CSM Number
C~:= Dl ( > w
IL TYPE BUILDING:' (check one) ❑ State Owned larcel City Nearest Road
Vll age it r_Z Public 14 1 or 2 Family Dwelling - No. of bedrooms J Town OF
III. BUILDIN USE: (If building type is public, check all that apply) Tax Number(s)
1 ❑ Apartment/ Condo ADZ- " p
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. Z New 2. Q 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 [Z Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 Q 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
0 Z , • Feet D. Feet
VII. TANK Capacity Total # of Prefab. Site
App
INFORMATION in g Manufacturerrs Name Con- Fiber-
Gallons Tanks Concrete Steel glass Plastic Exper.
New Existing structed
Tanks Tanks
Septic Tank or Holding Tank JAW ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the nsite sewage system shown on the attached plans.
P tuber's Name: (Print) Plu ber' gnature: tamp ICIPTMPRSW No.: Business Phone Number:
lumber's Address (Str et, City, State, Z Code):
Apk D GAL jrl/ozj
IX. COUNT / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Ag nt Si ature o Stam
Approved ❑ Owner Given Initial chargeFee)
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to county, One copy To: Safety & Buildings Division, Owner, Plumber
4 T
INSTRUCTIONS
t
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. Onsi'te 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-
11. 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 narne, 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 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 _ of 3
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but C
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. %01
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APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REV
4
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PROPERTY OWNER: PROPERTY LOCATION 1WEI
A-L'1> GOVT. LOT 1 /4 SE ~ 7 T 9 N, I
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. OR~
sr, /o - w~ x-
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE MOWN a~MNIQOAD
New Construction Use V ] Residential/ Number of bedrooms 3 [ J Addition to ti it in
Replacement [ ] Public or commercial describe
Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2 . ,P trench, gpd/ft2
Absorption area required V3 bed, ft2 S-G 3 trench, ft2 Maximum design loading rate _~bed, gpd/ft2_--J _trench, gpd/ft2
Recommended infiltration surface elevation(s) / It (as referred to site plan benchmark)
Additional design / site considerations G
Parent material Flood plain elevation, if applicable It
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable for system 1 , 3 S ❑ U ❑ S O U R I S ❑ U ❑ S ~ZU ❑ S E U ❑ S o 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
k{h
Ll~ 2 1 10 - 7/2- S G ? s 2
Ground
elev.
ft. Z L- Y si3,C vfe S . Z
Depth to
limiting
factor 3 el /r "e, L -
Ij
Remarks:
Boring #
0 3 L C S~Y lZ S
Z
/p0•~' Z 19-ZD - C i L
Ground
elev.
/O It.
'OIL
3 20~2- -
A/
Depth to
limiting
factor
Remarks:
CST Name:-Please Print Phone: 1 36~
Address: d 20 T 11/0 -19s3__233
Signature: ate: CST Number:
PROPERTY OWNER ~GT SOIL DESCRIPTION REPORT Page 2 ofd ,
PARCEL I.D. # '
Boring# Horizon in. Depth MuDominantnsell Color Qu. SzMottles Cont. Color Texture Structure Consistence Baxxiary Roots GPD/ft
.
Gr. Sz. Sh. Bed Trench
3
LS OS
L s-
••9fsr ~
Ground
elev.
ft. 2- - 9 0
Depth to
limiting
factor
Remarks:
Boring #
114 Z-
Ground
elev. Z /y) L - -
ft.
Depth to
limiting
factor
Remarks:
Boring #
i 3
Ground
elev.
2 ft.
3 17- L rY S 7
Depth to A4 37 /2
limiting
factor
r - S rG
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
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103 ~ 104 Q°1 106 ~ f3~71-AC. V!
1.317 AC. in 1.2 5 4 AC. °
I AC. ° 1 .308 AJC,.,~
° cv N m m m 209.84 206.62
j82.gPASS bb elT
.E8't9; 282.32
OVERLOOK • db elt
221.66 11O
122 vo 1.233 AC. tn
ao 107 to m
to
1.093 AC. Q .4 to 1.267 AC.
cv o
i to 123 to t6, N LO't6Z cv z
xj W! 1.543 AC. of 90g
1 01 v _ . 00' 0rZ J
121 0
1.165 AC. oo III
O1 0 1.086 AC.
O
• 9• N N m 108
i 8T ' T8Z 00.551 9 Sbe N 1.360 AC. e
.se•rtz .bE.Etz L~ a
120 b
Cl! 1.4'58 AC. ~ 65Z W
O 112
1~~1 a 77 AC. to 1.049 AC. O N
• h 119 S~ 1g '
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' M N 28.23 1.532 AC. ~p~ a
F- 2 ~oj• .0 2 1 .290 AC. .r 1
17 W -
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R ( W I . 51 O qrs, 206 , (kOto ~1 A 66 •S~ 1.287 AC. m '3~/ l 6'
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1.025 AC. ~0 v s3
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1.130 AC. 0
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WILLOW RIDGE EAS~'
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER 12F1-7w r yA r,%
MAILING ADDRESS =P y* ~z ~ `r ST
PROPERTY ADDRESS f4,1~1A461
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE /1Gf&o1V Cz&= 5' Yd/G
PROPERTY LOCATION VE 1/4, %E 1/4, Section /7 T Al N-R
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION 4y=16mcN LOT NUMBER /Of
W- 7. itt
53 7 ft f , VOLUME PAGE LOT NUMBER
C-Ru
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 st be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year xpiratio da .
SIGNED:
DATE:
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 Etr'*- 4: a S'n
Location of property_&&_1/4x_1/4, Section /,7 T_21
Township u~Sd y~ Mailing address ?0 if
4 -t h %*P"~
Address of site-
Subdivision name C44re,& y Lot no. /D
Other homes on property? -Yes ___L,, No
Previous owner of property Out A -6ECo?resivT
Total size of property /,.Z ar'~!Ps
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes No
Volume //51~ 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. 5-37 a f , 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 o fice of the County Register of Deeds as Document No.
r ) ti
Signa ure Applicant Co-Applicant
Date of Signature Date of Signature
li
State Bar of Wisconsin Form 2 - 1982 i
537889 WARRANTY DEED 'i
DOCUMENT NO. `vjt ~1 S L. j~'+
v -t STCn0IXC3.,1A
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AG. Ra ;'d S:;r Rt~co:d
II B & H Oevel%ment, Inc. ~.a-iiscoasin-corparatiQn,;, p EC 2 8 1995 `
- - I' _
!I ~ fry 9:30 A.
I, conveys and warrants to - belt-3 QnS trur-ti Qn f'.rx4kin L ii (ag Cf t}E-e3
1•)'
1 O-
I~ THIS SPACE RESER"EO FOR RECORDING DATA I)
NAME AND RETURN ADDRESS II
- - ',,Attorney Kristina Ogland
the following described real estate in St Croix ii P O Box 359
County, State of Wisconsin: Hudson W1 54016
I
(Parcel Identification Number)
I
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Lots 109, 115 and 116, Willow Ridge East 11 is the Town of Hudson' St. Croix
County, Wisconsin.
. S ~FER
This is not homestead property.
)CM (is not)
Exception to warranties: Easements, restrictions and rights-of-way of record, if any.
Dated this Ste. day of 19-95--
B & H Development, Ir!c.
(SEAL) Bar' 'op- a o'~'"''""" (SEAL)
Willi m C. Harwell
(SEAL) (SEAL)
~ I
I
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) William C. Harwell STATE OF WISCONSIN
ss.
County.
authenticated this day ortllr ~ y 19 95 Petsemay came before me this day of
19- the above named
Kristina fg aid
TITLE: MEMBER STATE BAR OF WISCONSIN
(Ii not,
authorized by §706.06, Wis. Stats.) to me kam>• so be the person who executed the
foregoing in5emn eat and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY