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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS
SUBDIVISION / CSMW___.,. LOT ZI/
SECTION~_TN-R W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
\t~
r ~ ~6
~uSH.
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
z ~
R~cV s
VED
C%j
199
BENCHMARK: 1 r ST
c
h'€i OBE
ALTERNATE BM:
SEPTIC TANK 11/ PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer:Liquid Capacity:
Setback from: Well .JO House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
:SOIL ABSORPTION SYSTEM
Width: Length_Number of_trenches _
Distance & Direction to nearest prop. line:
Setback from: well House .e Other
ELEVATIONS
Building Sewer ST Inlet._ 9^-- ~ ST outlet ~j
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system-
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB: J
LICENSE NUMBER:
INSPECTOR:
3 / 9 3 : j t
Wiste%MA9_P~artrrten4f4ustry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT - IX
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan o.:
HOFF, TODD 1k
CST BM Elev.: Insp. BM Elev.: BM Description: HUDSON Parcel Tax No.:
TANK INFORMATION Cl/ E EVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark ws,~
.2.2a~S /aCJCG ~
r
Dosing
15.4
Aeration Bldg. Sewer -r 99. 5 r
Holding St/ Ht Inlet 9~ d r
TANK SETBACK INFORMATION St/ Ht Outlet a 5s' g_ o
Vent
TANKTO P/L WELL BLDG. AirIto ntake ROAD Dt Inlet
Air
Septic NA Dt Bottom
Dosing NA Header / Man. X166 ( r) r
Aeration NA Dist. Pipe
Holding Bot. System p(o b,.p Z/'
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
oss mead
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length, r, f No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ~ C/ " G DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manu a
SETBACK cturer: INFORMATION Type O Y $ l08 r ~f q r CHAMBER /l1 ~ OR UNIT Mode Number:
System:
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 7 xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center A Bed/ Trench Edgef'~ , _--''J Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCA'T'ION: HUDSON-24.29.19W. SE, NE.. JANE CIRCLE
44
.,_J
111 ~ C:'. .1,.._,.+ jn j f• L, 1~t'"/C,t,... ~ l
Plan revision required? ❑ Yes rrNo Use other side for additional information. v..i~ r~u o to
SBD-6710 (R 05/91) Date or's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH s
SANITARY PERMIT NUMBER:
® Safety and Buildings Division
of Building Water Systems
r.~■`■■■~ SANITARY PERMIT APPLICATION Bureau 201 E. Wash i ngton 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.
• See reverse side for instructions for completing this application State Sanitary PPermA N Y.-
The erg,
Check if r visionCt,~ofJre aion
information you provide may be used by other government agency programs E] p pP
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property O er Nam Property Location
t /a 1/4, 5 T , N, R 91(orjN
Property Owner's iling ddress Lot Number Block Nu ber
,97
City S ate Zip Cod Phone Number Subdivision N e or CSM Number
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ ity rstRoad
❑ Village
Public 1 or 2 Family Dwelling - No_ of bedrooms Town of
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
QCs - /~S > 7
1 ❑ Apartment/ Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 1.1 ❑ 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. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
------System ____-___System_----- _______TankOnly 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/day/sq. ft_) (Min./inch) Elevation
Feet Feet TANK Capacity
VII. INFORMATION in gallons Total # of Prefab. Site Fiber- Ex er.
New Existing Gallons Tanks Manufacturer's Name Concrete strutted Con- steel glass Plastic App
Tanks Tanks
Septic Tank or Holding Tank El ❑ ❑ ❑ D
Lift Pump Tank /Siphon Chamber ~ El ❑ ❑ [E] I ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for ' stallation of the onsite sewage system shown on the attached plans.
Plumb is T N e: (Prln Plum is Ign ur (No mps) MP/MPRSW No.: Business Phone Number.
Umber` s Addr s ( re t, City, State Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater 115Re_ slue Issuing Agent Signatur o ~nc1
Surcharge Fee)
❑ Approved ❑ Owner Given initial ev~ /J-~!'
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SOD-6398 (R. 05/94) DISTRIBUTION:.Original to county, One copy To: Safety a Ruildings Divaion, 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 theJegal description and parcel tax number(s) of where the
system is to be installed.
ll. 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 smallerthan 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 oflndustry, 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
ST c,po~ X
Attach complete site plan on paper not less 9 irl c es size. Plan must include, but
not limited to vertical and horizontal refer ~ Cs nt (BM), direction' % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location n~Ostance to'r easest road.
APPLICANT INFORMATION-PL o f PRI' TfiALL'INFWM REVIEWED BY DATE
J
PROPERTY OWNER: v PROPERTY LOCATION
1 H /y/t/P 7 GOVT. LOT SF 1I4 N~1 /4,S2 y T 2-1 N,R /1r E (o io
PROPERTY OWNER':S MAILING ADDRE LOT If
BLOCK SUED. NAME OR CSM If
J # I
trE
/y,/l, 3P-0 lo/ sum R t O
CITY, STATE zip COW PHONE ❑CITY []VILLAGE [ffOWN NEAREST ROAD
[`f u pS o W l , 5X10 f (o ` / )i 7 /f v OS o AJ yo .c~ G. R'9
g"hew construction Use (a'Residential I Number of b6drooms 3 'ho f/ [ ] Addition to existing building
[ ] Replacement [ ] Public or commercial describe i,v "C4- 131- B y _ 135
yS6 -
Code derived daily flow _(oo o gpd Recommerded design loading rate bed, gpd4t2 trench, gpd4t2
Absorption area required /bed, 112 trench, ft2 Maximum design loading rate _Lbed, gpd/ft2 trench, gpd/ft2
Recommended infiltration surface elevation(s) 5-e1 3 ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material SC 5 S5 - R u R K~ih RD T- Flood plain elevation, if applicable N A- ft
S = Suitable for system CONVENTIONAL MOUND INGRDUND PRESSURE AT-GgADE U O T IN FLL4 Bs I O S NG T
U = Unsuitable fors stem W*T 11 U [a'$ 11 U R ❑ 0'S B'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 rends
0 /0 Yle 311 .2-f sbl<' /v--F9
1 iNn
/0 rR 3 /3 -5// Z fP- c s t , s
Ground 3 /.~-.a /o vk y 1 f sA& ,w~i' a S Zf S , G
/ao, ofG it. 9 7, S !/R y/Cr q ~a~/S S a~Q . ? ' •
Depth to l
limiting
factor
i.
Remarks:
Boring # / 0-7 i o YR ,3// si/ z f S he 2 f
z 7-/y 0 YX 313 s//. 1-f she ~.f2 CS
3 1y_ 3v o rig s Z f 'S
Ground
~9. ~Glev. ft. 30 -5 7, s I/P 'Y/ 9 S. S X11 s '
d s' Q . 7
Depth to 5 0 - /D yve f/6 S'
limiting
factor #
Remarks:
CST Name: Please Print j2p(3E-FTU1
13 R t•CL, T'-' Phone: 71,5-- 3,0(;.
Address: 11-16 - f CSTiy Z!>/~QZ
Sianature- e- no cnnsultants Date: CST Number:
PROPERTY OWNER J- 3 M IRU Sctk- SOIL DESCRIPTION REPORT Page 201 3
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Roots GPD/ft
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed m-n
3..... D lO /2 311 s'//. 1 f s b,r A,.4 R. s f
z / p 10 R 313 S/. f S' & ,,-r/Z Cs z f , s ~
Ground 3 /f-
elev. /o rle -5// '24si ~4 ,w,~
'
9,~, ?6 ft. y / y /a R y!~ .G ,w, I VGA a,.5
Depth to S - /O yle 5 S
limiting }
factor
Remarks:
Boring # 2 f
l o'y /O YR 311 s,/ L -F Sit ,4,4 P- -5
Ground
elev. 1-'16 7, S yp-
Depth to R S16 S . d S d1 SZ - _ .1
limiting
factor rr i
Remarks:
Boring #
/ o- ~r - S~ 1, 2~shk nM-F~ S w, , = y /0 y23 1S . (0
y-~y /oVR 38 sll• ZT"shk 44.,-fR
i
y-.71 /ore
Ground
elev. )7-5c 7,5 y,2 y/ S OQ Q cS i
/oo• f/G ft.
Depth to i `
limiting
factor
Remarks:
Boring # i
l
Ground
elev.
it.
Depth to -
limiting
factor
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
Ri
OWNER/BUYER • MAILING ADDRESS _ Inc. . p 51
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE. _jAuXs&j,, IK5 L 55/ot (.o
PROPERTY LOCATION 1/4, _ 1/4, Section T~.N-Rj
'SOWN OF ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER (o
CERTIFIED SURVEY MAP VOLUME PAGE , LOT NUMBER.
Improper use and maintenance of your septic system could result in its premature failure to handle
wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed
by licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED:
..en~' - / C/
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
I
STC-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 -7'onki doF
Location of property 5E-_1/4_ A& 1/4, Section RT2_j_N-R• LQ
Township b1LdL-4&,Ae Mailing address SRg9 7 ~~oT~ 5~' Y1a
Address of site 1 -
Subdivision name flu, „,.:dam Lot no. (o
other homes on property? Yes__K_No
Previous owner of property ~R~&r,L
Total size of property ~o 07 AC. .
Total 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 2 and Page Number :E-17 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. -C , 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.
Signature of A cant Co-Applicant
• V/ JV 4 ~J/
h /9
hit•a of rtnn7t-ii- F Rinnit-iirP
FROM`: GEHPKE ? PHONE NO. 715 3869774 Mar. 18 1996 11:13AM P1
la v
SIX COUNTY7 WISCONSIN
OTE ON UTILITY EASEMENTS: A 12' UTILITY EASEMENT SHALL
RUN PARALLEL WITH ALL RIGHT-OF-WAV LINES, EXCEPT THAT
j SUCH EASEMENT SHALL NOT EXTEND CLOSER THAN 1.V TO
r ANY SURVEY MONUMENT, LOT CORNER IRON, OR :NY IRON
WHICH MARKS ANGLE POINTS OR ENDS O CURVES.
T-AL NUM CAP, FOUND
JD
qD
WEIGHING 3.65 Ibs,/ft. SET Owner & Developer-
MONUMENTED WITH 1~~ X 24!' Greenwood pzt:exprises, Inc.
l.68 lbs./ft 1416 Third. St.
~SEMENT PARALLEL WITH LOT LINES SHOWN THUS -Hudson, Wi. 54016
.Y MAP _ VOL. 9j PAGE 2629
S 89'25051"W 1028.22'
395.00' ~e 329.65'
co
00
P1 Q
' N
• 0 61
APPROXIMATE LOCATION Z 89,983 SQ Ft.
OF EXISTING WELL M O
~ M 62 WELL
• QQ • OQ 2.07 Ac. 0 ~
CU N Q ,00
Uj 88156i Sq. Ft. 15 , 00 m
C 2.03 AC. O+~ N '706000 5, I
~2 6g . I
S?go \ o 3s14`''9g,,
c~ 9p . 0 60 p4 ~ F ;
1® ~~a rLQ OQ O' 89,328 Sq. Ft.
o ' P9 ti(02.05 Ac, - -
G O OI
G\~ N8 85I P~120~ S s 00 -
e 109,858 Sq Ft.
v
S ~30 o ca N86 000\0 E 0.52 A-.
STATE BAR OF WISCONSIN FORM I 1982
WAR,ffRANTI' DEED
DOCUMENT NO. l1 / 1 2PASE 34`
This Deed, made between _ Greenwood Enterprises,
Inc., a Wisconsin corporation APR 16
- - - - - r5 10:15 ~A.
Granc)r. r) -sj.
Todd A. Hoff and Kristine M. Hoff, husband `•~.Qa+. +
and - - - and-wife as survivorshi marital ro ert
- Grantee.
Wit nesseth, That the said Grantor, for a valuable consideration of one THIS SPACE RESERVED FOR RECORDING DATA
dollar and other good and valuable consideration ,IME AND RETURN ADDRESS
conveys to Grantee the following described real estate in St-. Croix GreenwQo,e Enterprises, Inc.
County, State of Wisconsin: 1416 T rd Street
Hudson, WI 54016
(Parcel Identification Number)
Lot 61 of the Plat of SunRidge III, filed in the Office of the Register of Deeds for
St. Croix County, Wisconsin, on January 2, 1996 in Volume 6 of Plats, at Page
46, as Document Number 538046.
T q This is-not homestead property.
06) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And Greenwood Enterprises, Inc.
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements, restrictions and reservations, if any, of record
and will warrant and defend the same.
Dated this 27- day of . April---------- 19 96 .
GREENS OD ENTERPR 'S, INC. GREE`'1;001 EN ERPRISE
By. (SEAL) By. t~G~h15£AL)
James E. Rusch, its president `tarp c 1 S retary
- (SEAL) - - (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(sF[ __-James E. Rusch, its president STATE OF WISCONSIN
u.
- - - ST. CROIX
County. ~.L
P
authenticated is 4411dav of A p - 19 96 Peraalh came before me this day of
April 1996- the above named
- - -
ZIA
is A. Murray Mary R Ruch,--its §ecretary
LE: MEMBER ST E BAR OF W SCONSIN
(if not.
authorized by §706.06, Wis. Stars.) tom cr n to he the penu crated the
fore_.:, trument and no>vlcdee the sar , •11s~~;.
t
THIS INSTRUMENT WAS DRAFTED BY -il ~1 `Cv ~GL 'l, ~•-•`'t'