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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
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ADDRESS zPIP z~-)
5
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SUBDIVISION / CSM# /V6. rT a71c LOT #
SECTION i T '~z V N-R Zd W, Town of Z/ rl
ST. CROIX COUNTY, WISCONSIN
I
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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_ INDICATE NORTH ARROW
Provide setback and elevation in ormation on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
III
BENCHMARK: j~c rn t ~t / j
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: 7~✓ I-) Liquid Capacity: ;;~~d
Setback from: WelIlej House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: S Length Ze/1 Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: 4),1rdr,//4Mouse 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: PLUMBER ON JOB: > G
LICENSE NUMBER: j~
INSPECTOR:
3/93:jt
Wiscpn'sio Department of Industry, PRIVATE SEWAGE SYSTEM County:
tabor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 284187
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
MULLEN, TIM HUDSON
CST BM Elev.: Insp. BM Elev.: s BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A960 44
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ~~5J Benchmark
Dosing--
Aeration Bldg. Sewer
Holding St/~d Inlet
Pr L.A
TANK SETBACK INFORMATION St/ Outlet f
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Man er Demand i
Model Number GPM
TDH Friction System TDH Ft
Loss ead
Forcemain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width / Length r No. Of Tenches PIT No. Of Pits Inside Di icluid Depth
DIMENSIONS S ev ✓ DIME I
LEA G rer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM
INFORMATION Type O r1~. Csn . t AMBER Mode Number:
OR UNIT
System: c ,s -2611J_ _ L' pIA-
DISTRIBUTION SYSTEM
Header / Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length ;-7-f Dia. Length 27 ! Dia. f ~ Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade S s
Depth Over Depth Over xx Depth Of r[E] Seeded / Sodded Bed /Trench Center Bed /Trench Edges Topsoil Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON. 2.29.20W, NE, SE, ADAM DRIVE
Z g~ CYd + Cyr' A' .
Plan revision required? ❑ Yes No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH ,
SANITARY PERMIT NUMBER:
. i
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7~
9
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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.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. , Croj~(
• See reverse side for instructions for completing this application State Sanitary Permit Number
AIs$N
The information you provide may be used by other government agency programs E] Check it r on to previous application
(Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
1 /45-Gc- 1/4, 51;2 T aq , N, R ge) E (o W)
Property Owner's Mailing Address Lot Number Block Number
City, State Zip Code Phone Number Subdivision Name or CSM Number ,-?l,J 1151,
1( 61f
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ Cityyage Nearest Road
❑ Vill
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)
1 ❑ Apartment/ Condo 0 Ze _l,( ( ; ^ led a d
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. I[ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an
System System Tank Only Existing System ExistingSystem
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) 164,76 9G•• Elevation `~j(1t
r'-1 c2 d 0 o c~ S ~E' 1,77F,G 0 Feet Feet
VII. TANK Ca
in gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete con steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank j~ d ~r? . Gpu+B / P ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans.
Plumber's Name: (Pr ) Plumber's Signature: (No Stamps) rMiMPRSW No.: Business Phone Number:
L/ 'tlr''a ~e S'e. ~ zcN1 a~ rte. ~ - 3I~ l
Plumber's Ad ress (Street, City, State, Zip ode):
Z 677." :5-C IX. COUNTY / DEPARTMENT USE ONLY
jApproved Disapproved Sanitary Permit Fee ( ncludesGroundwater ate Issue Issuing Agent Signature (No Stamps)
❑ / Surcharge Fee)
Owner Given Initial ~j ~ p
Adverse Determination ~--q~
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SRD-6398 (R. 05/94) DISTRIBUTION: original to Count y• One copy To: Safety & Ruildings 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 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 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 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 8 112 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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PROPERTY OWNER SOIL DESCR' ION REPORT
Page of
PARCEL LIM LO T~ Z-
Boring # Horizon Depth Dominant Color Mottles
In. Munsell Qu. Sz. Cont. Color Texture Structure Consistence Boundary Roots GVpjjt2
3 Gr. Sz. Sh. Bed ; Trench
Ground 3 -3 ,5
elev. y P_ J`/ Z S/✓ lw-,e s 5 , ,
2- f t OIL-)
75
Depth to
limiting
factor
7 in.
Remarks:
Boring #
_ G ~o yk y/a- s,~ ice, s~~fe s 3 f , s 61
~ z iog
7,5 .wrFI2 a_ 5 i 5
Ground Chi 7. S yR .S d S
elev. - -
/oo,._SD ft.
Depth to -
limiting
factor
In.
Remarks:
Horizon Depth Dominant Color Mottles Structure
Texture Consistence Boundary Roots GPD/ill
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Boring #
2 'e y~ Sam/ / f A& 4v' fit C:5- zf S
Ground ~L -~Fo 7'S 7 r V S J 'O .2 Q ~G 7' • 6
elev.
"
Depth to S
limiting s
factor
> 9-In.
Remarks:
Boring #
Ground
elev. ft.
Depth to
limiting
factor
in. /
Remarks:
SBOW-8330 (R. 08/95)
.I
•Wisconsin Department of Industry, SOIL AND SITE EVALUATION 2
Labor and Human Relations page of
Division of Safety and Buildings in accordanc ithis. I1-HR$4 is.
Attach complete alts plan on paper not less than 8 112 x 11 Inches i i Plan must
Include, but not limited to: vertical and horizontal reference point ( rection and , i p ST, C R C') I K
percent slope, scale or dimensions, north arrow, and location and quo nearest road = p D. #
APPLICANT INFORMATION - Please print all Infor n., sp ad by Date
Personal Information you provide may be used for secondary purposes (Privacy a 15. 1) (m)).
Properly Owner
Al /-+uP 21FIIA eoOT -D ,/S B10A',V5 o), 1/4 -4;L&r 1/4,S/Z T 2 / N,R a0 E (os
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
'Yo 9~7 w~//our ~~JXE ,P/~ • z- cs-wt !/W01 30!
city State Zip Code Phone Number Nearest Road
t~vl~So~ w/ SVOI& (715 El city ❑ village Gown
B "New Construction Use: Residential / Number of bedrooms 3 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow, y~ gpd Recommended design loading rate /'bed, gpd/fF ' trench, gpd/fl2
Absorption area required ad, ft2 lo-r trench, ft2 Maximum design loading rate / bed, gpd/f~ ' 5 trench, gpd/ft2
Recommended Infiltration surface elevation(s) 3 ft (as referred to site plan benchmark)
Additional design/site cod orations ~5Fti S ~Y ld-
Pare t material
1 / Flood plain elevation, if applicable ft
N
SAAIV V.
S = Suitable for system Conventional Mound ;FT In-GGrrou"essure rad^e/ System In Fill Holding U = unsuitable for system D-S El U ❑ S 13'S
L: U ❑ S It~'U ❑ S lia< ❑ S
E ~~t~Siv~ f~op~s SOIL DESCRIPTION REPORT E,~c~ss/vim S/~S
Boring # Horizon Depth Dominant Color Mottles Structure
in. Munsell Ou. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots GPD/ft2
Bed Trench
4-P1 1'4
S 3-f , s ; . L
Z -j-2 /e y s, 2 ,6.~1P cS z f S ' ,
Ground 3 -4 7 S ye / - S T sr//~ I
elev. a S . 5
/o a so ft. -fr /ofiE' S, s a~lC a S - , -t ;
k S
Depth to 5
limiting
factor
, 7 ;
Remarks:
Boring #
0-7 o 40- - 511 24. Zlrivoe-- 4,-,2 s 8 f s
Z Z -/~/o sue/ fs!>~ s -2 f . y;. s
3 tZz/ 2-4166_ , 5 61
Ground - 7,6 ► - s~ 2,"„ S~.E' ~•-F~ C' S f 5 ' ,
elev.
.s
Depth to
limiting
factor
g?f In. Remarks:
CST Name (Please Print) Signature Telephone No.
f'oBeRT- 24L.13R1'Gt-'7" 7i - 3Q6 -Q18S
Address Date CST Number
wbricht & Associates /D- S- 57<- G'STiv ~1Q2-
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FILED ,i
NOV27
1995 ►
~iof WAL
1
St Croix
Co., Wj 2
53675:
w
Om 0 0 0 0 0 0 O z
M Pi
Bearings are referenced to the
0 z y z z z z z N CA
Ln 0 w° N OOD D v O N N CO o C7 East line of the SE1/4 of Section N
o A of w- V1 o j o Ln o oD o in o in o m o 12, assumed to bear S01 18 02 E. R,
40 - Go A p °°l W0.01 °iln °N °N ju_ H
Z a kp N 0L OLn ON o - ON ON
,1 >E m - - - - - -
-1
V Tiy m
0 0 0 \
N N Z~
y C m A Vsi~ 7i
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JAY L Cp It !0
A >N m N pN ~.L N
z
oN m 1E \ C7
t p p ^ eD (l~ .G Z
CM ?
AL1_ i RAC- \ G rn q
- " West line of the NEB of the SEk, `b~~ed~ed 4szyi L.
N01°12' 36"W 660.22\ ° ohs p~~•....• +''p
589.35' 18-.87'
x 608.22' 52.06
I-2-0 N3004715211 E N
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
I w~ A- MOLL
OWNER/BUYER Vt
MAII.ING ADDRESS _7=_1~0 1 A IV . `A N 5~311~
PROPERTY ADDRESS C-S M HCh LA 0,r-,A AA& 2'-tcnl
(location of septic system) Pease obtain from the Planning Dept.
t
CITY/STATE 1A LACA n
PROPERTY LOCATION _ 1/4, _ 1/4, Section f a , T _.a ~N-R oZi> W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER J. CS\
_
CERTIFIEDSURVEY MAP VOLUME L I , PAGE 8501.Q+ LOT NUMBER ,5 _7
i
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: c'
DATE: C7 _ ~p
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
i
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 L`
Location of property L~L 1/4 _:~,E--1/4, Section (jL-,T o N-R -~D W
Township Mailing address ►1U``
Address of site
c~,~vc~,cM
Subdivision name f~ a ~-Il of - Lot no. a csrn
Other homes on property? Yes 1/ No
Previous owner of property h $ N Lc, 1, s~~pp 1 r~-~-
Total size of property (..8 4 Total size of parcel o-.cv-s
Date parcel was created [ [ - ~t - 9 5
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? yes No
Volume 11 and Page Number 3 OiC) 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. 53 lp-7 S 3 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.
J ~~-l S 3
Signature of Applicant Co-Applicant
/v 9-~6 rcD, . ~-9c.o
Date of Signature Date of Signature
_ STAI E N to "'F N>>C lti`+l\ JR~I -
11?l~~r.~~ A-
'
B & N Land Develoate_ntj Niscon in Linitud APR 8 ;996
- - -
L>_ability CanpanYi-- - - - 8:00 ~A.'•
- Renee
L ~ll~n and
- - TirTathx_ - -
cortce)> and warrai t> to _
Mul lec z_-husband - and- wi e t
-
- - TH.S SPACE RESCRAO rCq RE~O:+O~nG CA'A
..•A. tr Ah ~ t
- -
the foil-mg dzscritxd real estate in _--st-croix
State of Wisconsin
=.RCEL ;CEN?iE:CAT~CN NUMoER
Part of 131/2 of NEi/4 of SEi/4 of Section 12, Tc;.? shiF 2° North, Bane 20 West,
St. Croix county, Wisr. resin, described as fo11 Lot 2 of Certified Sul-vey
Map filed November 27, 1995, in Vol. !!11", P'~c I Doc. 536753-
map
This is not homestead prom ,y. l
)OM (-isnca; oi_way of record, if any.
Exception to v,arranties Fasements, restrictions and right--
' March
Dated this daT of tyi 'vOf 1 a
B& N v o ent, a Wisconsin Limited Li i - (SEAL)
B -
-------tsEaU y Denni.3 jorrtstad
-
Thomis K. Nie - - - - (sE,4L)
(SEAL)
ACKNOWLEDGMENT
AUTHENTICATION Statc of Wisconsin,
Dennis M. B'ornstad 55. 11
Signature(s) . /
coon;
ihom~ts K. day of
i~ar_h % Pen :an-< before mr this
the alx;e named
.e i this
authentic
-SIQ
_ - - r -
K_r, srina Ogland i - -
R 5T-1T L BAR OF A'15~ i1"S"' = - -
i I 1 LE S1Eb1Bt R
executed the me u!„3
s vti
7
allih.0(._.3 by §70f, .l.f, v:>. State • }e ~T~ ,;j J~ '~F ~ >,.ne
Of l~:+z'.'~ f
P 18~ f
tr,yT VI AS . ~)RA= ~D BY
TH!5 INS fRuti. df/~•..,..++••
1~L.4~' y`} C`
,4. 1,e 01
Kristina Ozland
- -