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STC - 104 VED AS BUILT SANITARY SYSTEM REPOR ST CR-DX
OWNER (e(b
ADDRESS
SUBDIVISION / CSM# wyn,~, X,a/ f~ ~l c3 LOT #
SECTION .',-'~7 T 2? N-R W, Town of ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions 'to center of septic tank manhole cover.
w c
BENCHMARK: srt G
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: & ag o Liquid Capacity: /tea
Setback from: Well
t~y House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length 75-- Number of trenches
Distance & Direction to nearest prop. line: gJ'
Setback from: well: 3~. House Z -d t--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:
A
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR: - A7
3 / 9 3 : j t
W
4 a
-1FbdDepartment Industry, PRIVATE SEWAGE SYSTEM County:
bor or and Human n Relations
Safety and Buildings Division INSPECTION REPORT ST CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Permit Holder's Name: 11 City El Village ❑ Town o : P State an o.:
BENNETT MARIE X
CST BM Elev.: Insp. BM Elev.: BM Description: arcel Tax No.:
/0 UJ r U
TANK INFORMATION EVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ! .
e t (1cJ ; Benchmark r a. a l /do
.
Dosing `
Aeration Bldg. Sewer 7~ -
91 =f_Z
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet
rl
Septic >12 - NA Dt Bottom
Dosing NA Header/Man.
o'f W. / 7
Aeration NA Dist. Pipe y-57"
Holding Bot. System ~l3" 5
,off
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Lriction System TDH Ft
Head
Forcemain ength Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Zrenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 5" ~ DIMENSIONS
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O CHAMBER
Model Number:
System:44Gr1._r_/✓ g0' -,5o' 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 36 Bed /Trench Edges _ Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON.27.29.19W, NE, NE, LOT 41, ORIOLE LANE
-a =/P CZ Z:!~U) 0
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. /U b ! L. L I
SBD-6710 (R 05/91) Date , Ins ctpr's Signature Cert No.
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ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION BureaSafetyu aofnd Bildi uildininggWaterlSystem!
.O E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O.E. 201
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. _-)L , cro %
• 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 cg(qa39~
(Privacy Law, s. 15.04 (1) (de E] Check if revision to previous application
State Plan I.D. Number
L APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Pro erty Owner Name Property Location
i4 1/4, S 2-7 T , N, R E (ore
Property Owners Mailing Address Lot Number Block Number
jOej- 3 )9F'7 0.,&/
City, State Zip Code Phone Number Subdivision Name or CSM Number
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ Ity Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms o Village
Town OF 4
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo d 6 3
I 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 [g_New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System___---__--_--_TankOnlyExisting 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
~Sd Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) rJ Elevation
75-6 ` 4; 1J Feet Feet
or. 5".d
VII. TANK Capacity
INFORMATION in gallons Total # of Manufacturer's Name Prefab. Site Fiber- Ex er.
New Existin Gallons Tanks Concrete Con- Steel glass Plastic APp
Tanks Tanks strutted
Septic Tank or Holding Tank 4 ❑ ❑ ❑ ❑ ❑
lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
Vill. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se ge system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: ( St
amps) PRSW No.: Business Phone Number:
A /M
W/gig
-,7 - - -.11- - - j
Plumber's Address (Street, City, State, Zip Code):
a ci
V7 4 I
IX. OUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issue Issuing Ag t Signa St ps)
Approved ❑ Surcharge Fee)
Owner Given Initial ~
Adverse Determination
X. CO DITIO OF APPROVAL / REASONS F R DISAPPROVAL:
s ~o-e 4,~
SBD-6398 (R. 05194) DISTRIBUTION: Original to county, One copy To: Safety 8 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 ,,3e 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 numbe-(s) of where the
system is to be installed.
It. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwe ling. I
lil. 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 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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90256;
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION-- R E PORT` Page ~ of 3
Labor and Human Relations
Division of Safety a Buildings in accord with ILHR'-83.05; Wis. Adm. Code
NTY
' ' ST. G~orx
Attach complete site plan on paper not less than 81/2 x 11 inches in siie,'Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and % af,slope. "a or PARCEL I.D. if
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: l jl yg/,QQ //il f ea-40- PROPERTY LOCATION
GOVT. LOT //9 1/4 1/4,S 27 T 2.9 N,R /J E (or) W
PROPERTY OWNERS MAILING ADDRESS LOT BLOCK # SUBD. NAME OR CSM if
331: ~e )-4o.1PoB-,r47PTS ST Aium'Bi PD H t'l/ (Pti'ASL-
CITY, STATE ZIP CODE PHONE NUMBER CITY []VILLAGE N NEAREST ROAD
T 191f ~JN• S5 /0/ (Gri) ~2- 2"55,55 +fUv-so") i;lE 41/
New Construction Use 14-Aesidenial / Number of bedrooms 3 Addition to existing building
Replacement [ ] Public or commercial describe
yso - 4
Code derived daily flow as gpd Recommended design loading rate / bed, gpolit2 . trench, gl
Absorption area required / bed, ft2 16W trench, 112 Maximum design loading rate bed, gpd/h2 - trench, gpo4t2
Recommended infiltration surface elevation(s) s-~ 3 It (as referred to site plan benchmark)
Additional design / site considerations 2lSE L a rr- ~l/1J7M eo R , A., ads! S
Parent material SCS (o6 /3 U~P.E'LI/1 e P 77 Flood plain elevation, if appliFable .1/4- ft
S = Suitable for system COViWTIMAI. MOUND ❑ U IN L~d'-GR~S OQ1N❑ D PRESSURE AT-GRADE SYSTEM N FILL HOLDING TANK
U= Unsuitable for system S o u [~o u a S at- ❑ S
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Roots GPD/It
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed tends
13 Yk ti /e~M z f s.C ~,e s 3 >c , S
2 10.27 /D y,f s,/ 2,ki s,,C /m iP q5' 17c , s
Ground 3 /d ///2 % l~ S . 0, S ~fL
elev.
q2 Z~ It.
Depth to 444 APP a
limiting
factor for a n tional So do $ M.
Remarks:
Boring # O -~5 /Q, Z Z A~ f S6,r /rh { S Z f S
2- /S- /0 3 .Si Z~► S,G, f' err 7~iP c'S 1,,-7c
Z
Ground y
elev. jc
S C'
V ki /0
Depth to
limiting
factor
/
~ r
PROPERTY OWNER _ SOIL DESCRIPTION REPORT Page 1 of 3
PARCELI.D.t
Depth Dominant Color Mottles Texture Structure Cons!stence Bouux~ry Roots GPD/ft
Boring # Horizon In. Munsell Qu. Sz. CorRt. Color Gr. Sz. Sh. Bed rends
/ D-/L /O i L ~~r~ d9H .2 f S -f~ S [ S 6
3v -L /6 - S/ /4- onlrf~ cs 's
Ground 3 /Q f/ `1 6v, -,P 13. 5ft. y 6 S d W-R-
Depth to
limiting i
factor 't
r
Remarks:
Boring #
2 Z~- y~ icy y 5 AV- e7i,' f e 'Cs
/OYR
Ground
elev =
9/- & ft.
Depth to r
limiting
factor~ t
y
Remarks:
Boring # _ /O y/'t 2~Z °.PG~U,i 2
_3 ~o yle y s/ Z f s,6~r fie s /f s 30 -ff /0 rX
Ground =
elev. ~7- / p s o , S
yl.5p ft. i
i
Depth to
limiting
factor
> t
Remarks:
Boring #
Ground j
DoT y I
14-o ,A L3 i p1)
scht E ; 1 y0
Pi'T5
y
36 -
9
/33
N
cS , 86-
l~
~oTo 13 i
7ee-e- N.c
E I ~ u,~T~o~ s
/3 2.2
/32-
X/ 3 l`3 S(
39
S si , 5 4 '
S89°26'42"W 1617'
h15.00' 205.00 34
Q. 220.00' 332.34
po 65.00' g~57
LOT 40
2.$2 ACRES
23! ".9 122,949 SQ. FT. 6
f c
~'CJ0 N
2wn46 AFyRE$ C~ M N
N
'QtiT OS, - ~ c
, r
1 q'tiF,~ ..Fs ~3~ LOT
1y 39
j Fq \ i 3.68 ACRES
SF~`p~~/ \ # 160,279 SQ. FT.
p 2ja_
2
a
_'198 5i'
26857~H w 4. `o o
OR IOLoE W
89049'46"E
g _ s• d E
.400
LOT
2.17. ACF2ES
o a /94 94,642
SO. FT
~f t` ~S p9 96F
LOT EAS~
43 ASS,
` 2.34 ACRES ~o~ r S i
101,995 SQ. FT. rL / \
S I
44
2 _ ACRES I
i i
6 PONOING 98 2 So'
FT.
M EASEMENT R9R6' 1
RQ 06)
h 1~ 1 1
'EN O^ ~q,
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' v
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
n / St. Croix County /
OWNER/BUYER /~~~C 1 • ~~/yrI/~!~
MAILING ADDRESS D~ 13 D t 1' f7 i ~{/.S SAO
PROPERTY ADDRESS 7,S3 o k 16L E L Y) .
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE 1~ yY i-C.Ao ki
PROPERTY LOCATION IY J~- 1/4, 1/4, Section ~7 T _2=q N-R1f_W
TOWN OF 4(((,~ I rz ST. CROIX COUNTY, WI
SUBDIVISION 4 Lk hn 1 '
h h l S LOT NUMBER
CERTIFIED SURVEY MAP , VOLUME " PAGE S, LOT NUMBER S~
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
8 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 M A-R )'E 8, c,~ ne Z 7`-
Location of property_A/ E 1/4 1/4, Section A-? T_aj N-R_j 2_W
Township LkA Vt Mailing address AgC 30 - AF- 09
Igulssool
Address of site ZKY (O,1 b Ln .
Subdivision name u M ,r--C g , )/c Lot no. _
Other homes on property? Yes__X_No
Previous owner of property Pct,~ l_ Bc~ % L& v,
Total size of property y l0 a 0-ye-
Total size of parcel ~ 0'(i:k
Date parcel was created
Are all corners and lot lines identifiable? X_Yes No
Is this property being developed for (spec house) ? Yes __,K_No
Volume 17 4 and Page Number s 3 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. 54131.39 , 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.
55F3/3s
Signa ure of Applicant Co-Applicant
~ -a
Date of Signature Date of Signature
R d r
r
DOCUb1F_t1T NO. STATE BAR OF WT?!-`._ wSIN FORDS 1-1992, Tom" "ACC Rrxwvro r.>w wr..^an,wc oau
WARRAWY DEED
fl f 53 I [ r~ . y i Iy9
r.y
rhis Deed, made between
Humbird Land Corporation, a M=.nneso_a C-orporation
it MAY 3 1996
J
Grantor
I a,,,I Maple L. Bennett, a "single person- 9:30 A.
Witnesseth, That the said Grantor, P:tr a r1.' s.'dt cnnniderntion
C
'I ennce's to Grantee the fnlloa In,; described real estate iw S5;. Croix, F~ I
f'nunty, State of Wisconsin:
I~
~ Lot 41, Humbi rd Hills Seccnd Addition, i
II Town of Hudson, St. Croix County, 4i sconsi n Tax Parcel No:-----------
i' II
it
~I
I~
II
A o ER!
If •
I~
II
I
,I
homestead property. !I
This _ 15 not
Aim (is not)
! Together with all and singular the hereditaments swl appurtenances thereunto belonging:
And
l+
-.I-rnnta that the title is good, indefeasible in fee simple and free and clear of encumbrances except
' Easements, restrictions and rights-of-may of record, if any
i
and will warrant and defend the same. i
I Mated thin . 25th. day ~f April _ 19 96 !
1
(SEAL1 HUMBLRD LAND. CORPOOQR..ATI N (SEAL) I
Ij by-.
- .
Austin J. Baillon, Its President
(SEALt ._,_(SEAL)
I
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) _ - STATE OF)VKK (X)Q7SpxV( M I NNES TA ~I
ss.
- -
• - ---arnsey............ --.County. i
authenticated this ...--..-day of................... 19.._ Personally came before me this -.25th_... day of
Apri.1......... ?9..9.6.- the above named
- -Aust.i n.• J Bai-1.1-on President- of
Humbi rd. La.....Corporation. -
-
TITLE: MEMBER STATE BAR OF WISCONSIN
_
(If not, - I
Ruthorized by 4 706.043, Wis. Stats.) to me known to be the person who ex'echted tIM %
foregoing inssttrumen and acknowledge, the same-
THIS INSTRUMENT WAS DRAFTED BY
_ _
Humbird_.Land Corporati-on---
l Paul A.. ail-lon