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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNERi K~ ~r
ADDRESS
F~-~d~Sarf ~,~.~A~ ✓~fUl~a
SUBDIVISION / CSM# E~ d, d Ad LOT # 4/7
SECTION Z7 T71 N-RAG W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
• E~s~r~ tJt L(
40
B` c
i
SY ~18us--
d
3d
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: _ -..eC/is- ,P Liquid Capacity: 1-2,,-o
Setback from: Well House 33~ Other
Pump: Manufacturer rW Model# Size
Float seperation Gallons/cycle:
Alarm Location
:SOIL ABSORPTION SYSTEM
Width:_ -61 Length. -2!5 Number of trenches 2
Distance & Direction to nearest prop, line: 8
Setback from: well: /;I House 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: /o_ F4
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3 / 9 3 : j t
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division ST CROIX
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION 262375
Permit Holder's Name: ❑ City ❑ Village [A Town of: State Plan ID No.:
HUDSON
CST BM Elev.: Insp. BM Elev.: BM Description: y Parcel Tax No.:
A9600186
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic j Benchmark
Dosing
w► r~, ~/~3,Gs,
Aeration Bldg. Sewer ~0'y 9~ aSr
Holdin St// Inlet i/ n 1 6S'
TANK SETBACK INFORMATION St/ Outlet 9/ S!~'
Vent
TANK TO P/ L WELL BLDG. AirIto ntake ROAD Dt Inlet
Air
Septic S~f 33 1% NA Dt Bottom n
Dosing NA Header r
Aeration NA Dist. Pipe
Holdin sUC
9 Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer 92,13
Model Number GPM
TDH Lift Friction y dF ~ a / a'~ji5/ V. i,57
H Ft bEa ~.7 3, ® S.
Forc ain Length Dia. Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width i Length No. Of T enches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS S
DIMENSIONS-
SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM LEA u acturer:
INFORMATION Type O C4,T nv` CRAM Mo m er:
System: 117,4- OR IT
DISTRIBUTION SYSTEM
Header /Distribution Pipe(s) x Hole Size x Hole Spaci ent o ke
Length Dia. Length ___[_L! Dia. 5[ Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Sy I
Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx
Bed /Trench Center Bed /Trench Edges Topsoil E] Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON.27.29.19W, SE, SE, LOT 47, ORIOLE LANE
Plan revision required? ❑ Yes QXNo
i
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
r
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
t
e
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-0. 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.
• 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 Tri3vi`srofifdiousrapp (ion
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Prope y Owner Name Property Location
5- 1/4 1/4,S 2,7 T 2 , N, R (or)
Property Owner's Mailing Address Lot Number Block Number
735` ov Y7 I
City, State Zip Code Phone Number Subdivision Name or CSM N,uber
fil~~sor! S4~o ~7
IL TYPE OF BUILDING: (check one) ❑ State Owned ctyl Nearest Road
V i age f
Public 1 or 2 Family Dwelling - No. of bedrooms Town of J~icdScrt a rv
SII. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo 6 ~ ) 30 fP -
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. p4 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ 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
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 JR Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION: T r.6?
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) "C 4fooft Ele ati n
(00,0 75- 754 i 6? 12 &7,/7 Feet y ~Z',c Feet
Cap cit
VII. INFORMATION in allo s Total # of Prefab. Site Fiber- Exper-
Gallons Tanks Manufacturer's Name Concrete Con- steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank+ ❑ El El ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ~ 1:1 1:1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumb 's Signature: (No amps) MP/MLR W NQ.: Business Phone Number:
2 (5 7-17- -5 21
Plumbe s less (Street, City, State, Zip Code):
t1.1 o.Z
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved S Itary Permit Fee (Includes Groundwater ate Q"-7,b U Agent Signature (No Stamps) ,
Surcharge fee)
Approved [-I Owner Given Initial /~p - U a/
Adverse Determination "
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Div,,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 roust 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.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Far-nil / Dwe ling.
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, reo--nnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information equested for numbers': Ihrcuugh '
VII. Tank information Fill in the capacity of every new/or ex sting tank, list the total aallon s, n., -tr:! of tanks and
manufacturer's name, ndicate prefab or site constructed and tank material Complete for , 'I s; ic, pump/siphon and
holding tanks for this s/stern. Check experimental approval only if tanks received i:xperim.:r.ta oduct approval from
DILHR
VIII. Responsibility statement. Installing plumber is to fill in name, license number vvitl approp-i U efix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County; Department L,se Only.
Dry
X. Count-Y/ Di-_r„ >e Only.
C nCJs~?E P1 ~'i _;3t!C.;IS not sm l fit? 8 1'2 11 inches 'Y} s.! suk eta j'. ?'le plans must
!Flc,U~, i}Y' it"ik1. UIOt {Marl, dlawr aie or With cor7lp!e, _I SICiI; alt :I ng ltirlk(s), septic
nk,, bu; 1din,, Vv t•~ i r
u
or siphon
- .'I Ori` .C -.i'. rep 3'r'oc' ;y` he k,.,. ding .erved:
;l-r_-Ii (105e volume-
i(- ..1uI ed fJ'y' _'1_''..a on ZInc1 InfOrmatlOn.
GROUNDWATER SURCHARGE
1983 V✓isr - i , ,art 410 included the creation of surcharges"(fee )'or number c r r.,F i : '.ed pr:_I ~ Which ._.)r
effectgrour,.rlv~at_er
The rnoi e~, -1ii :1:2a 'f_ ,Duch Lhese'wrcharges are usecl t(:Ji rn:)n'tanng ground i .'e'st1,D,-tiOnS
and establishment of standards.
JOB dwll- C fen Clew
TIMM EXCAVATING SHEET NO. Z OF 2-
Route 1 Box 192 r- -
I'ZZ- w- DATE ~ J fo
WILSON, WISCONSIN 54027 CALCULATED BY
(715) 772-3214 (715) 386-5443 '
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
SCALE
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PRODUCT 205-1 Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE 1-800-225.8380
• ~ I ~S ~IYV/~
TIMM EXCAVATING JOB VC, P SHEET NO. / OF Z
Route 1 Box 192
WILSON, WISCONSIN 54027 CALCULATED BY ✓iDATE
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
SCALE
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PRODUCT 205-1 Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE 1-BDO-225-8380 ~r / ~'!lL •
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3
Labor and Human Relations
Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY
sr c~orx
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but PARCEL I.D. #
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or
dimensioned, north arrow, and location and distance to nearest road. REVIEWED BY DATE
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION
EPROPERTYOWNER: tip O PROPERTY LOCATION
GOVT. LOTSE 1 /4 SE 1/4,S 2 7 T 29 N,R /f (or) W
NER':S MAILING ADDRESS a~` LOT # TOVILLAGE K # SUBD. NAME OR CSM #
~oBTS S7 C S) }{UMRi PD CITY, STATE ZIP CODE PHONE ~ M 2 8 2 ER 5SS5 ~lu /4f/v- • N N ~EK~E/E
T U 55 /D/
New Construction Use ( k"esidentiai I Number of bedrooms Addition to existing building
j Replacement [ j Public or commercial describe
Code derived daily Now &cv gpd Recommended design loading rate bed, gpolft2 trench, gpo1(t2
Absorption area required gibed, ft2 trench, 112 Maximum design loading rate - 7 bed, gpd/112 • f trench, gpd/f<2
Recommended infiltration surface elevation(s) _55 Zt P 3 11 (as referred to site plan benchmark)
Additional design / site considerations
Parent material SAS 6 61 A Flood plain elevation, if appliFable 414` 11
J!U - Suitable for system l: ONAL MOUND W-GPDUND PRESSURE ATETS -G DE ❑U S-YST~t IN FILL HOLDING TAW
=unsuitable fors stem ~ 5 o u Tr-o u as E 0 u ❑ S
SOIL DESCRIPTION REPORT
De th Dominant Color Mottles Structure Roots GPD1"P
Boring # Horizon P Texture Gr. Sz. Sh. Consistence Bed in. Munsell Qu. Sz. Cunt Color S ? /o y~ Ground -3f /a l/iE' S d'2.
CS' - elev. /D
o/ ft. S/ e S S GQlZ 7
~3.
Depth to
limiting
factor-~-
Remarks:
Boring #
7.s e
3
Ground
elev.
~i• go fl.
Depth to
limiting
factor~-
PROPERTY OWNER SOIL DESCRIPTION REPORT Page L of 3
PARCEL I.D. ! LD f Y 7 b(OR &0910 111115
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bmwlci ry Roots GPD/ft -ed In. Munsell Qu. Sz. Coat Color Gr. Sz. Sh.
B Trench 77, Z 6-
2- e 7,YYe y/(Q , S . 4 , S ~ ~S • ? ~
oQ . 7
Ground ICU /o Sly C•S . 6.
elev.
yp. ss tt. ~
Depth to
limiting
facto I
1
> j
Remarks:
Boring # 9.P9Uf~~
o-, /10 ,e .31z sY/, 17 .00
E z 11r- ;s -s ye .7
,
I
Ground
elev.
`1y ft.
Depth to
limiting I
factor
Remarks:
Boring # *wy l f,P yv Ds -
7-1~ 75 YiP yl~ Gds o,s ,2 (IT
Ground O /0 /t? Sl4
elev
92.4 ft.
1
Depth to i
limiting '
actor
I
3
Remarks:
Boring #
i
131
i
Ground `
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86.82'
hi
S44°I0b0"E ~-..I
S 7g 27'41 "E
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A T
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAW NG ADDRESS 7// 1-86/tl , et) f
PROPERTY ADDRESS ?f
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE ~"-1 GtSo/y Gc~
PROPERTY LOCATION 1/4, 1/4, Section z 7 , T. j N-R_yj_W
TOWN OF 7`t 41 A cQ A) ST. CROIX COUNTY, WI
SUBDIVISION j n j6le i) is c 5 ~~te`~ /TUB rev l~ , 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 piratio te.
SIGNED:
DATE: 2 - I (0 '96
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 bkC k V, ik~Q1671-l/C-- 1 C 7EN ~F
Location of property S E` 1/45&' 1/4, section 27 , T gLN-R~-W
Township Mailing address -7t1 Q,
Address of site 73-9 6a166e-f'- ZAfV6
Subdivision name us~B/~P~1 'Allee S Lot no. 47
Other homes on property? Yes_ c No nn
Previous owner of property 14u4r l!~r,0.
Total size of property 14 at
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? _ C Yes No
Is this property being developed for (spec house) ? Yes __X No
Volume / and Page Number P16 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. 4 -A-7a 31 , 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.
ignatur of Applic t Co-Applica
Date o Si nature Date of Signature
(13 rin
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STATE BAR OF R'ISCONSIN FOP.}[
DOCUt,1EN 1 "0 WARRANTY DEED
` .
-146
n I I FA'c 537269
IV 11 11r
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Humbird_.Land.Co.rpcr3t'on,_..
This Deed, made between DEC 7 19 A Minnesota Corporation
Grantor. I
- 10.15 A
1'1
I
nn-I Dale R. Ostendorf.and Kri.stlne-J, Osterdor
- - - s
Husband _ and-Wife
I ~ I
Grantee.
ll wi.tilesSefh, That the said (;raptor, for a valuable considrrat.+n
.I - lpL'VR
,.,,n•;rys to Crantee the following described real estate in
j~ C j
State of Wisconsin: -
I
!I; Lot 47, Huwnbi rd Hills Third Addition,
Croix County, Wisconsin Tax Parcel No:.......
I
Town of Hudson, St-
1. 1
tI I
III I
II T A Ek
i~
.I
II I
If I
I
This S_. nOt........... homestead property-
(is) (is not)
ular the hereditaments and appurtenances thereunto belonging;
I Together with all and sing
-
AuLI_ Humb,l rd•.-Land._._orpora.....
l ~rarrantn that the title is good, indefeasible in tee simple and tree and clear of encumbrances °zc
Easements, restrictions, and Rights of way of record, if any
Ea ~
1995
and will warrnnt and defend the same. November
I
28th.. day of
at'
Humbird Land Corp
poled this t n
SEAL) (SEAL)
( By'-
II - - Austin J. B lllon, Its President
-.(SEAL)
(SEAL)
ACKNOWLEDGMENT
I AUTHENTICATION
STATE OF SXKIX4199YA
Signature(s) MINNESOTA ss. I
Rain5ey-------------------------- County.
i authenticated this .....--.day of 19 rersonally came before me this .......28t -day o
Naveclher__---•---• 19.9-5. the above Hama
i Aslstin J_._..~a)J.lan,._Eres.)de.nt..of-----------------
!iambi rd_ Land-
TITLE: D11 F61BFR STATE BAR OF WISCONSIN
I - .
r,:w- - ~ it
to be the person -~~0 eecnteLl the t
([f not, - - r
authorized by § 706.06. Wis. Stat_s.) to me k> n
foregoing instrument and aeknii Tedge the sine
ce...
.
fit. ;j ,
THIS IN ;TRVL•tFNT WAS OR i
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