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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER `yQ-~J4.P/ e_-_
ADDRESS 17J D
SUBDIVISION / CSM# er LOT
SECTIONT2C2 N-R / O W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
1
~ T
N
O '
av
o
3 J
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide
2 dimensions to center of septic tan}; manhole cover.
BENCHMARK:
ALTERNATE BM:
SEPTIC K / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: litJ~~ S Liquid Capacity:
Setback from: Well ~S House -35 Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location-
SOIL ABSORPTION SYSTEM'
11.1 Width: Length ✓ 3 ( Number of trenches /
Distance & Direction to nearest prop. line:
_~5~/
Setback from: well: House_L~5; Other
ELEVATIONS
Building Sewer >ST+InletST outlet
M°
PC inlet PC bottom Pump Off ll
Header/Manifold eA6 Bottom of system
G''rcl p c~
Existing Grader] Final grade Z
DATE OF INSTALLATION: 9- 9-Z
PLUMBER ON JOB: LICENSE NUMBER:
INSPECTOR:
3/93:jt
~ Safety and Buildings Division
~~■a.r■r. 4kANITARY PERMIT APPLICATION Bureau of Building Water Systemi
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- r
• See reverse side for instructions for completing this application State Sanitary Permit Number
'12 64,12 7 57
The information you provide may be used by other government agency programs ❑ Check it revision 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 >perty Location
~C 1/4 t5 erl/4, S T , N, R 1,1f _E (o
Property Owner's Ming d ss~ Lot Number Block Number
~C!
14
City State Zip Code Phone Number Subdivision Name or C M Number
I~
7/7 ( 1,6- V P/el,
t
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ City Nearest Ro
Public 1 or 2 Family Dwelling - No. of bedrooms 2 Vown of ,
III. BUILDING SE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo OC2 v //~18,-tc2o
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. ❑ New 2. <ystem eplacement 3_ ❑ Replacement of 4_ E] Reconnection of 5_ E] Repair of an
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
1 ❑ 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. PercAii to 6. System Elev. 7. Final Grade
Re fired (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (MMin.~inch) Elevation
3 /.~•lJ Feet _5.5 Feet
VII. TANK Capacity
in gallons Total # of Prefab. Site - "-Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer s Name Concrete Con- Steel lass Plastic A
New Existing strutted g PP'
Tanks Tanks
Septic Tank or Holding Tank 2 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATE-MENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signat No Stamps) ~J MP/MPRSW No.: Business Phone Number:
Pi timber's dress (Street, t , State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sara~tary Permit Fee (Includes Groundwater Date Issue Issuing Age t Signature (No s)
Approved E] '71X surcharge fee)
Owner Given Initial
Adverse Determination l DCJ /l
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6396 (R. 05/94) 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 bi~-, t enevved before rt-ie,x;)iration date, and at a time of renewal ar.y new criteria in the
~'~'isconsin 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 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.
WisconsinDepaftmentofIndustry, . PRIVATE SEWAGE SYSTEM • County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No,:
Permit Holder's Name: ❑ City E] Village Q Town of: State Plan o.:
FREDRICKSON, WAYNE
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: RICHMOND /00
k-j A9600102
TANK INFORMATION
ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark U~ a
Dosi ng
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet '
Verit
TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet
Septic NA Dt Bottom
Dosing NA Header/ Man. ~'0 ? 4 3,,, 7
Aeration NA Dist. Pipe
Holding Bot. System O J C~a Ga y'
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer
Demand ~ ~ r -1r: S 9 5 Y,;/
Model Number GPM
TDH Lift Lrictio System TDH Ft
Forcemain Lengt I Dia. f Dist. To Well
I
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS .3(. r / DIMENSIONS
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION Type Of &all? ( CHAMBER Model Number:
System: /S S >,16J c) , /k 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 00 Bed/ Trench Edges 11 4' 30 r' Topsoil E] Yes No El Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: RICHNOND.4.30.28W, NE, SE, CO RD A
Plan revision required? ❑ Yes lt~No
Use other side for additional information. a y yam, 6
SBD-6710 (R 05/91) Date a or's Signature Cert. No
Wisconsin Department of Industry, IL AND SITE EVALUATION odeO R T Page _ of
Labor and Human Relations
Divisign of Safety & Buildings in accord with ILHR 83.05, Wis. Adm.
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but 6/1,17 Gro f
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. / e
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY ATE
PROPERTY OWNER: PROPERTY LOCATION
GL~ r GGOVT. LOT 1/4 5 &-1/4,S T --7O,N,R
PROPER WNE MAILING ADDRESS LOT # BLOCK # SUED. NAME R CSMM r
CI TAT Z CODE PHONE NUMBER ❑CITY VIL GE OWN NEAREST
10
O~ - 'yo - - ~?'6 I A , y
New Construction Use [~Q Residential / Number of bedrooms [ ] Addition to existing building
~Q Replacement , J Public or commercial describe
Code derived daily flow ,-.l ~l/ gpd Njench,A2 Recommended design loading rate ed, gpd/ft2 trenchgpd/ft2
Absorption area required ZXZ bedft2 Maximum design loading rate %~bed, gpd/ft2 trenchgpd/ft2
Recommended infiltration surface elevation(sft (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable ft 1,4114- S =Suitable for system C VENTIONAL UND IN ROUND PRESSURE A RADE SYSTEM IWFILL
HOLDING ANK
U= Unsuitable fors stem S0 U 4S0 U S❑ U S❑ U El S U ❑ S 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 Trench
M:{ C (J/ /lam)
Ground 7
9 ev.
ft.
Depth to
limiting
fact
Remarks:
Boring #
X::.:4 -g /ms s k _ 5
Ground VIA I
J~v
Depth to
limiting
fact
f~
q Remarks:
CST Name: Please Print O-- l Phone:
Address:
Signature: ~ f Date: ` 4/1.✓ CST Number:
R: 7
!7 S~276
PROPERTYOWNER+~d ✓~A/h OIL DESCRIPTION REPORT Pageof '
PARCEL LD. # • r
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Cu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Ground
Depth to
limiting
fac
-3
Remarks:
Boring #
71
Ground
le
~ f
Depth to
limiting
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
J
Soil Test Plot Plan
Project Name Wayne Fredrickson Byron Bird Jr.
Address 1730 Co. Rd. A
New Richmond Wi 54017 CSTM #3479
Lot 2 Subdivision Viebrock Date 5/12/96
1 /4 1/4S4 T 30 N/R18 W Township Richmond
Boring ()Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft.Base of Siding
System Elevation 92.15 * H R P Same as Benchmark
Property Line 180'
10'
60' *B.M.
33'
Driveway Garage 4'
56' B-3 36' B-2 15'
3 i
Bedroom 16 ° 3% 20'
n House 18' 3' Slo T 36'
Is .4 0 0' 6- B-1
a
Y 24'
6'
Well t~
10' CD
180' P.L.
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
'T
MAILING ADDRESS f 7 455d
PROPERTY ADDRESS /y~. A~ •'~~z L~r ~~o/
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION D? (!~F_ 1/4, 1/4, Section T_,F,~9 N-R / .,5-r- W
TOWN OF G~ ` G/7/ice ®b~ ST. CROIX COUNTY, WI
SUBDIVISION ~iv9c y r- G~ /LOT NUMBER v2
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, W1 54016 11/93
a
Thi's applicatio~rm is to be completed in 1 and signed by the
owner(s) of the operty being developed. Wly 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 X150`2
Location of property ~~~C~ 1/4 SE' 1/4, Section
Township Mailing address
Address of site
r
Subdivision name i ~n~ ,vCr U1C~-' c Lot no.
Other homes on property? es_, <,No
Previous owner of property 104 f'z"~i!~ `^o
Total size of property ea /x
Total size of parcel /gyp l
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes _t No
Volume 44577 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. 5;7 2Z , 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 Applicant Co-Applicant
Date of Signature Date of Signature
DOCUMENT NO. I WARRANTY DEED
STATE OF WISCONSIN-FORNI 1
THIS SPACE RESERVED FOR RECORDING DATA
THIS INDENTURE, Made this. 1:71h
day of DeCertlber i r -
A. 1)., 19 69 between Marvin Viebrock and Margaret Viebrock-,
his wife,
. .
December
_ _ -
_
p IeS.-of the first partand 1;00 _1'
Wayne H. Fredrickson and Victoria_Fre-dricksan_,_his -wif
as joint tenants, /
parti es _ of the second part, RETURN TO
W i t n e s s e t It, That the said partA es -of the first part, for and in consideration
the sumof_ On.e_DoItar..and.. other. good and..val.uab.l.e .cons.1-der-atio
to . _them in hard paid by the said partl_e$ ..of the second part, the receipt whereat r h+rcby
confessed and acknowledged, have __.given, granted, bargained, sold, remised, released, aliened, conveyed and confirin d, and by these plea ❑ts
do____ give, grant, bargain, sell, reutise, release, alien, convey and confirm unto the said parti es... of the second part,_the ilp-irs and a> igns
forever, Cro
I~ forever, the following described real estate situated in the County of__ _St. _ _t.-. _._._i_..x ....and State of Wisconsin, to wit:
Lot 2 VIEBROCKtS RIVER VALLEY VIEW ADDITION of the Town of Richmond, located in
North Half of the Southeast Quarter of-Section 4, Township 30, North of Range 18,
West, in St. Croix County, Wisconsin.
G
p
I~
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t
i
I I
(IF NECESSARY, CONTINUE DESCRIPTION ON REVERSE SIDE)
Together with all and singular the hereditanrents and appurtenances thereunto belonging or in any wise appertaining; and all the estate
right, title, interest, claim or demand whatsoever, of the said part--l es of the first part, either in law or equity, either in possession or expectancy
of, in and to the above bargained premises, and their hereditanrents and appurtenances.
To Have and To Hold the said premises as above described with the hereditanrents and appurtenances, unto the said part l es of the
second part, and to_thelr hcirs:uul assigns Ft)RI:A'E lt.
And the s,id -Marvin V i ebroek and Margaret. V 1 ebrock,.--h.i_s
for themselves, their _ heirs, executors and administrators, tlo covenant,
it - },rurl, bargain, and agn•r• to :uul
with the said part I es of the second p;ut,.-. their . _ heirs and assigns, that at the time of the enscaling and delivery of these pn,cnts
they are well seized of the premises ahove described, as of a good, sure, perfect, absolute and indefeasible estate of inheritance
in the law, in fee simple, and that the same are free and clear from all incumbrances whatever-.... -
- -
and that the above bargained premises in the quiet and peaceable possession of the said parti.e$._of the second part, tbeiirirs and
against it]] and every person or persons lawfully claiming the whole or any part thereof, -_they _-.will forever WARRAN"r AND )FIA:A'D.
Lt Witness Whereof, the said p,art.IeS._of the first part ba-Ne.._hcreunto set their... hand. S .-and cal. S, this 17th
day ,f_.Qecember A. D., 1969__
i
,'D AND SEALED IN PRESENCE OF z, SI?A1.)
Marv% Viebro ✓
i _ Henry kC, Oakey , ar..garet__Vicbrock__....