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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNERD,:2,I11',- / r.Co d
x
ADDRESS y/~2
SUBDIVISION / CSM / '
-ZIa S
rQ - , LOT 32
SECTION T
-~'~fj N-R ~I W
Town of-
ST. CROIX COUNTY, WISCONSIN
SHOW EVERYTHING WITHIN I
100 FEET OF SYSTEM
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this
form.
Provide 2 dimensions to center of septic tanl: manhole cover.
BENCHMARK. D.2 , yZ
ALTERNATE BM: 110 & 96 T15V of 6)eck Ok !L4yaq-r-
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: t'-e C Liquid Capacity: J ~)n
Setback from: Well t0~ House 41 Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
.SOIL ABSORPTION SYSTEM
,
Width: '5 Length Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: + House Other
ELEVATIONS
Building Sewer 7, ST Inlet. , ST outlet
PC inlet PC bottom Pump Off
10,52 //,3s
Header/Manifold ?,y a Bottom of system /0,15
s + ,
7'.26
Existing Grade Final grade
DATE OF INSTALLATION: 42 4196
PLUMBER ON JOB: ,a jN p
LICENSE NUMBER: `7 ~ 00 0
INSPECTOR: y~_,~~►~{^
3/93:jt
F)o Sca~~ 30,
r
a
t
1
1
tle us
(56 rn
Uleeks rc~s~' t~
1; 60
t~
a~ 32
j i
3~ Trcxr14 8~'~oka,
i
E
Z-/ /16
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION 1/4, 1/4, Section , T N-R W
TOWN OF ST. CROIX COUNTY, WI
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 completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
Wisc2nsinv7ep}rtmentofindustry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations
Safety and Buildings Division - - - - INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar 262455
P - lWa ❑ City ❑ Village Town of: State Plan ID No.:
HUDSON
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
A9600111
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark r '
Dosing 9S,5o2
Aeration Bldg. Sewer y-7/
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Verit
TANK TO P / L WELL BLDG. A
ir Ito ntake ROAD Dt Inlet
Septic NA Dt Bottom
Dosing NA Header / Man. 9 ;
Aeration NA Dist. Pipe C
Holding Bot. System A/. UPI ,
. sf
f2
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction Syesatem TDH Ft
Forcemain Length Dia. FFii Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length,,,-, No. Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ' gDIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O CHAMBER
Model 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 Centers Bed/ Trench Edges v - Topsoil E] Yes E] No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSONa27,29,19W, SE, NE, ORIOLE LANE
J
Plan revision required? ❑ Yes [INo
Use other side for additional information.
SBD-6710 (R 05/91) Date I p a6,r's Signature Cert No.
SANITARY PERMIT APPLICATION
sn■■ ■
v'~~Illrfalllr~ In accord with ILHR 83.05, Wis. Adm. Code COUNTY
5~ ~Q I
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than a? ~
8% x 11 inches in size. ❑ Chec(ro114?previbus plication
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY WNER PROPERTY LOCATION ey
~0 Y PROPERTY Ta/,N,R E
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
C e Lb g, 1302 1
CI STATE ZIP CODE PHONE NUMBER SUED VISION NAME OR CSM NUMBER
u i 6,' ; 1
it ljsf~ft II. TYPE OF BUILDING: (Check one) ❑ State Owned B NEAREST ROAD
tc 6 r /',e ka n -e
❑ Public 91 or 2 Fam. Dwelling- # of bedrooms PARCEL TAX NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply) ' 2
1 ❑ Apt/Condo V J
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 ❑ Off ice/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. F\7 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
y~ System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit # 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 El In-Ground 42 El Pit Privy
13 R Seepage Pit Pressure 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) Q/, Q ELEVATION
00 7._~-Q 8 An 7 0. A Feet Feet
VII. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank boo /.706 / We s [Z I
Lift Pump Tank/Si hon Chamber
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plu is Signature: ( o Stamps) MP/MPASW No.: Business Phone Number:
lu bDer's Address (Street, City, State, Zip Code):
O 2 3D 7113' 51r,cr 17l11?Y /461r all- `12
IX. COUNTY/DEPARTMENT USE ONLY '
E] Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued Issuing A nt Signature (No Sta
Surcharge Fee)
Approved ❑ Owner Given Initial
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
-98(R.08/93) 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 the 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 s f
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 adm nistrator or the
State of Wisconsin, Safety & 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 in 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 in ##1-7.
VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of
tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Compete for all
septic, pump/siphon and holding tanks for this systern. Check experimental approval only ii tanks received
experimental product approval from DILHR.
Vlll. 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% 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, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
t Pl0h
v i
Li he,
>aale-
~ouSG
lkoo dal Selpi;c, TaK.k
83
Of 3 lob
Tod o f Su r d fors l ron .a
CoVne✓
,Fko•
r 87 5Z' 16
01 EL. = 969
- I N
PONDING
` EASEMENT 6
U)
~ N ♦ ~
" U) - cD
LOT 29 N _
O O
2.00 ACRES N89° 3942° E 223.78
N N 87,16 4 SO. FT.
N EE-LANE `
CHICKADN69°39'42"E 230.51
w
S8 4°30'57"E 317-62' °
• ~ N
t
6I6 O
rn
' I
LOT 32
w
oD ~ 3O CT) I I 2.01 ACRES
LO 87,649 SO. FT U,
N
2.00 ACRES D m
00
87, 162 SO. FT 0~
r, 2
- - 15
o / i
OQ'~ FONDING /
EASEMENT
fi<~ ~ / ~ Oq35„Q
00~ / ~ 2QQ QO.
LOT 31
< S 45 50 00 `W
2.01 ACRES
86.02 87, 556 SO. FT
33 i
a5
o
h
°
S44010 E
66.00
S76°2741 E
/ 463 /3,
.y
u
SCALE IN FEET -
Ilk
c
Wisconsin Department of Industry. SOIL AND SITE EVALUATION: REPORT -'Pagel of 3
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, :Wis. Adm. coa9
COLWY
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan mtat;include
,awi~ ARCEL I.D.
N
not limited to vertical and horizontal reference point (BM), direction and % of slope, sale o:
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: ~U,l~~/,PD ~i/S ,9•ri~ D.P~ PROPERTY LOCATION
41 L- j 0 A/ - GLiA/rP.N y GOVT. LOT 1/4IVA~- 1/4,S 2 7 T 2.9 N,R /,f E (or) W
57' C/ ✓2/8 fiD.v£ Ayuf) LOT BLOCK+f UMRi X17 H NIS 04'ASF 2
336TM1N~os~Ts ADS
CITY, STATE ZIP CODE PHONE NUMBER l []CITY []VILLAGE 9MWN NEAREST ~ L~
=/•~gv1-111N• 55/0/ (G'&) 2Z2-5SS5 ~tuflso,.J
New Construction Use (4-Aesidential I Number of bedrooms ` 3 [ ] Addition to existing building
I ] Replacement I ] Public or commercial describe
YSa -
Code derived daily flow o0o gpd Recommended design loading rate / bed, gpddgt2 ' trench, gPdt2
Absorption area required 4=- bed, «2 7~0 trench, 112 Maximum design loading rate gybed, gpd/«2 trench, gpdjft2
Recommended infiltration surface elevation(s) J5,w- - 3 It (as referred to site plan benchmark)
Additional design / site considerations 5-d~- S c c ;:;f 4 S )~e 1 o w
Parent material S 136'ee "'p r- Flood plain elevation, if appmable It
S - Suitable for system C0NVB1n0Nk I MoUIe- IN-G D PRESSURE AT-G SYSTEM IN HMDNIG TAW
S[] u ITS u u ❑ s a s
U= unsuitable for s stem 'S 0 U a
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Bourxfary Roots GPD/ft
Boring # Horizon In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed iench
D-/3 /o ye S / S6C~c s • S
S/ z,y., s.6,f .H=am C s 3f s
3 -13 /0//( 316
Ground 3 a , s c?
f5 Iev.
. go
Depth to
limiting A ROyg
factor for COnV
' m•
Remarks:
Boring #
El y 2/, /6 y1(' 31r" S/ Lei f~~ tic' c s 3 f • s 1.
Ground S cQ~
y3 ~ ft.
Depth to
limiting
factor
I
PROPERTY OWNER SOIL DESCRIPTION REPORT Page L of 3
PARCEL I.D. ! 3 Z U R Q C P l 1 1 s
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounc3y Roots GPD/ft
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tench
10 /
T7 /7
v _ 30 /o l3 G S / 1-f sf ,n s l _s . co
Ground 3 ~V- SS /0Y eF5 ' Y S
elev.
14116 5-1 - 6,
i
Depth to =
limiting
factor
I
Remarks:
Boring #
a-zv /a /~,y rfs6~C-~~ s Zf , y 5
Ground /1" jrl 6MfA-
elev.
~
~p •~Yft. 3
Depth to
limiting f .
facctorr'' i/
/w
Remarks:
Boring 16 ~Q S~ /f S,~jr n►nf' 2 $ y i 5
2-
/0-1-11 416 cl Z40 sit- 411f oS 3 ~ • S
?P CS .7
71
Ground i
elev. D S 1~
f),, k6 it.
Depth to
limiting I
factor
7
Remarks:
Boring
i
i
Ground =
LoT 3Z
- ~ I e uhT oJJ -
/3,~z 93 Y~
/-33 5o0
/3
~ 7U yy
50 6 6,~5 T E~UG~ ~/~l/~-lio v S • = ~~~l~ Q ~;Ts
lt,ee,- 13, - t3 5
law TREK)".
• 96
_ ~3 y
!33
k~. - 1 330 r7
r. "7
N . _
• 0l EL. = 969 ` oaf I I ro
R pONDING I i
EASEMENT
u
IN
LOT 29
o
ACRES C' U! E 223.78
Q) 2.00 I N89° 39'42°
° N 87,16 4 SQ. FT.
N CHICKADEE -LANE E
- - CHI -
uj
N89°39'42°E 230.51--
v 1
r Z
S84°30'57"E I Lp
317.62' °
I N
a I 616, (OAJ
LOT 32
0 m T m r I 2.01 ACRES
0D LO 0 N 87,649 SQ. FT.
I N ~
D m
2.00 ACRES O
87, 162 SQ. FT. I z 0 Q'
m [2 :
15
F°
S57
PONDING /
t EASEMENT
l<~ i 04,35„E
0~
°LOT 31
ah~'L 2.01 ACRES
u _ 56.82 5 i. 00 87, 556, SQ. FT.
J,O D,
5440IOC Oa' E 3,. rah ti'`
66.00 S76°
274/ E
463
SCALE IN FEET - -
_
200
00
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNERBUYER ~ JA~J FYL
MAILING ADDRESS Li (7 Ot CA A l A~w /c k4' u %2 S,
PROPERTY ADDRESS 7Y3 O r/'o / e It 6 Ja -e
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE W V Ind C~-1 % `J G ov'." t> rv-)
PROPERTY LOCATION 6- 1/4, N1( :r 1/4, Section '2;-?, TI_N-R_L_I_W
TOWN OF 4 o VV3 , ST. CROIX COUNTY, WI
SUBDIVISION y 02t YL►Q N4 t 4. L, !~p LOT NUMBER !Z
CERTIFIED SURVEY MAP 9 VOLUME 9 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
t
a '
County Zoning Officer within 30 days of the three Zyepir
SIGNED: DATE: 5 - ` -
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 :PA" 1 n U ga-PM k9
Location of"U property~l/4 W C- 1/4, Section ~,T 3: j N-R 4 5_W
Township io!! J Mailing address '-C61 C_rgjgAr g LAr4fs,'
Address of site 7q3 0rar& (_a.,-tie .
Subdivision name V-~ Lot no. 3-2,
Other homes on property? Yes No
Previous owner of property yyN P,-3V& O Wr E `/-~rN b Gbx, 167
Total size of property 2. CD -1 A e-r-4e'7,
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 __.tX 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. , 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 o plicant Co-Applicant
5 -14-- R4
Date of Signature Date of Signature
f. k
DOCUMENT NO STATE BAR Of WISCONSIN POOH! I-I/M !!1 rrA
a 1i+• S v t .i
f FICED
r 3041 rte ~ ~ ~ ' sTcRO~c c Jti ~ t _
r.., • _ _ . _ -=---T-- _ - - _ - . _ Redo klr Fwcc
This Deed .a. r.l.ee. _
tfuabi~rd t.altda~tlaraxisrn, s Mtintlsesata_Cocpnratia~,
UN 13 1995
Graassr
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