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STC - 10 4
AS BUILT SANITARY SYSTEM REPORT
OWNER N--rr~w~
ADDRESS
SUBDIVISION / CSM# AYOT
SECTION_Z~~/ T~N-RW, Town of~
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
o
c
~'AN J
M
V7
INDIC TE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
4
4
l
BENCHMARK:
ALTERNATE BM: _ L
EPTIC TANI PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity: ~1:4//
Setback from: Well House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
:SOIL ABSORPTION SYSTEM
Width: ,/2 Length Number of trenches '
/ 045Distance & Direction to nearest prop, line:__Z 5
Setback from: well House Other
ELEVATIONS
Building Sewer, ST Inlet.
9 ST outlet ,
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system , gg
Existing Grade Q Final grade r~-
DATE OF INSTALLATION:
PLUMBER ON JOB: y ✓
LICENSE NUMBER:
INSPECTOR:
3/93:jt
WiscorSin Departmentof Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 262385
Permit Holder's Name: ❑ City ❑ Village ❑{Town of: State Plan ID No.:
BROWN, DON RICHMOND
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer Soc~ 9 ` 7-o3
Holding St/ Ht Inlet ~_0 V, ¢6. D
TANK SETBACK INFORMATION St/ Ht Outlet 3y' q , 7 F
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic >/o L,5-5 ' 3o' y~ NA Dt Bottom
Dosing NA Header/Man. Aeration NA Dist. Pipe 7,oa gS- /
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Loss Flea
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS Manufacturer:
SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHING
SETBACK CHAMBER Model Number:
INFORMATION TypeO
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 Center Bed /Trench Edges Topsoil ❑ Yes ❑ No [I Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: RICHMOND.4.30.16W, NE, SE, LOT 17 CARROLL ST
f`~ /t-~ 7~1.C2,(f"ld,, - ~.Q,(_,, ~-tC-''~.1, s'.•_,f 'Ab~1
Plan revision required? ❑ Yes ❑ No
c"
Use other side for additional information. F6_~_
1961'
SBD-6710(R 05/91) Date I p*tor'ssignature Cert No
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, W1 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less county i
than 8 112 x 11 inches in size. fi'p)
• See reverse side for instructions for completing this application State Sanitary Number
The information you provide may be used by other government agency programs E] Check it rev/vision 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 P pert LtyQf1On
4 va, S
N, R E (or
f T ,
-62
Property O tier's Mailing dress Lot umber Block Number
r
City, State Zip C e Phone Number S ybdivs on Name CS ,ember
I. TYPE F BUILDIN : (check one) ❑ State Owned !t~ N st Road
VII age
Public Agrl or 2 Family Dwelling - No. of bedrooms Town of . At~1ai~
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo
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.~ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. E] Repair of an
_____System 4ystem 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 `kSeepage 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: Perc. Rate 6. System Elev. 7. Final Grade
Re 'red (sq. ft.) Pro o d (sq. ft.) (Gals/day/sq. ft.) (Min./inch) EI io
Feet Feet
VII. TANK Capacity Site in gallons Total # of Prefab. Fiber- Plastic Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App.
New Existing structed
Tanks Tanks
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber' Name: (Print) Plumb ignature: (No tamps) MP/MPRSW No: Bu iness Phone Number:
Plumber's Address (S eet S te, Zip e
o ~
IX. C UNTY / DEPARTMENT USE ONLY
❑ Disapproved San tf7ry Permit Fee (Includes Groundwater ate Issued Issuing Agent ' Sig Nature (No am
Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination
X. CONDITION OF APPROVAL / REASONS FOR DISAPPRO AL: - ~f
11 Z Q,l~ Inc c,Q~` 4 P
SBD-6398 (R. 5/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSFRUCTIOMS t ,
~I
1 A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiratior date, and at a time of renewal any ,w trite; is 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) tra 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.
111. 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.
PLV1 PLAN
`PROJECT 111r + ADD4RESS ryry N
~~~~f
/"1/4 5~1/4/S I /T36 N/R ) ~W T COUNTY 'MPRS Byron Bird Jr. 3318 DATE BEDROOM CLASS PERC_ CONY JUND PRESSURE
CONVENTIONAL LIFT MOUND HOLDING TANK
SEPTIC TANK SIZE b 6 LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION ARE
PERC RATE . ~i BED SIZE l2-'>C ~L4
Benchmark V.R.P. Assum Elevation 100'
Location of Benchmark
* H.R.P. c
0 Borehole Q Well - Q Feet
0 Perc Hole System Elevation -
Uent
12"
Grade
TYPAR COVERING
n" _
12 3 4 6' O 3'
I 6. Sewer Rock
1.2'
r
d
01
3f
R
Soil Test Plot Plan
Project Name : l'etAf~ Byro ird Jr.
Address f
L T 3479
Lot,Subdivision ,11) ate
14'S6 S,T'4N/FW Township et4l
❑ Boring O Well PL Property Line County`
L BM or VRP ,.Assume Elevation 100 ft.
System Elevation *HRP-5R,~ rrA
0010
Scale 1/4 16 Ft. When dimensions aren't stated
JJ ' 0 it b 36-
25 QQ. /L
61 0
2
40 09' W
1-30
sc° 175. 23 490,23 16009 2.03 ' 247.27'
~ \61 1-Y ~ Pa Ba °yrR n$\h 0 East _ _Maroaret
j 0~ 116035 o°. \ / East 154.73
10
_ Oo
\~prO~ "0 4 9 2 0 i` GJ~'0Z 464.73° 90.00 0 60.00' '0o°87. 50' 90087.50' 90° S-
m u` S \0 J d ° °1 O
s0c'~o 0i 0~6 Dc~ 0 0i
PS
0 <1
U ,9 d 6, Q
CiJ lk~ 0/ o \1b c~j co I I 00 10 00 L 9 O 8 O
90 o _ -
L p - O
; Q -
eS, 12 ~ ~0
° B (V
4", DA
O 0J t cc00~ N
c / ~OeN18°52'V 0 to ; _270°00' 9,
s4023 16.17' 90 '00 $ ° . 0
\6 10 0,, 1W90.26 ' 0 95.00' 90.00' 9 87.50• 270°p0
n~C,~32 O East 375.26' West R o
O I 4° 87.50'90
$>7 .'E C+~rroll St. West
Wes 612.80 N22037'E
, .0 87. 80 o s00 105.00 105.00 105.00' 105.00' 105.00 90 /d,> 32.50 00
90 0
LO
C 34 , la
Q
U
A
' ri " / O
O O O O O O O
aas ~ o V)
19 18 17 16 15 14 1" 13 io
- u - - - - cn
o'Z6 'go 0 90p 0
150.00' ° 9° 105.00 105.00' 105.00' 105.00' 105.00' e 100.00' °
West 1016.00'
Unplatted lands COUNTY T REA`
STATE OF WISCONSIN) SS
or Valley View Addition to the Town of Richmond, County of St Croix and ST CROIX COUNTY )
I, Carl Dahlin, I
and Margaret Viebrock, Ronald J. and Betty Lou K. Fischer, and tax snles and no unpaid tax,:
inmencing at a point which is 34.24' West and 1569.00' North of the
ce Sown 255.nn'. thence West 1016.00, thence N1410,--'E x26.80'.
162.15, thence N81°02' E 241.30, thence N37042'E 201.40', thence N13°06'E 1 98.00;
'hence East 532. 90', South 230; 00' to~i,. poin' o` hr,ginr,in~t. C' ERT ! F I C~ ATE ~
-ind lying between the meander line and the water's ed-ge.''
,nd surveyed and the subdivision thereof made. -
Statutes and the subdivision regulations of the Town of Richmond ar I,
~fJ office, there are no unpaid to
Howard R. Kruse Surveyors
Reg-No. S-518 COMMON COUNCIL
Resolved that t
surveyed, divided, mapped and dedicated as represented on this plot. David R. and Marguerite C-
-litted to the following for approval or objection-. The Town of Richmond, I hereby certify th,
and the State Board of Health. of the City of r
1965.
TOWN BO/\RD RE
- Resolved thfit t'
I hereby -°trtify
~r
f the
' ~,nr r y n. F- i,rh
CONSENT OF CORPORATE MU
- T h o A rn -s f- v .t .
Wisconsin Department of Industry, SOIL AND SITE EVALUATION
Labor,and Human Relations Page of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County l
include, but not limited to: vertical and horizontal reference point (BM), direction and c~
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION - Please print all information. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
26~~:E Y- Govt. Lot- 1/4G7;7 114,S T N,R / E ( ~V~
Property Owner's Mailing dress Lot # Block# Subd. Name or M#
.11Z /7 C rte, , i1
Ci to Zip C e Phone Number rest R d
❑ City Village own N
&:_04 2
1f A!0
❑ New Construction Use: Residential/ Number of bedrooms Addition to existing building
replacement ❑ Public or commercial - Describe:
Code derived daily flow jgpd Recommended design loading rate bed, gpd/ft2- _~_trench, gpd/ft2
Absorption area required 65~ bed, ft2~rench, ft2 Maximum design loading rate :_bed, gpd/ft2___!&_trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material Flood plain elevation, if applicable N 1i~J ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill HoldingTa k
U = Unsuitable for system XS ❑ U As El U S❑ U S❑ U ❑ S U ❑ S U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Ground
~7/,o
limiting
Remarks: E
Boring #
Ground
Dep to
limiting
fa r
In. Remarks:
CST Name (Please Print) nature Telephone No.
Zel,
Address Date CST Number
SOIL DESCRIPTION REPORT
PROPERTY OWNER Page of
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
D a L's
Ground I
r
Depth to
limiting ;
f
in.
° S Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # ;
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBDW-8330 (R. 08/95)
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER l
MAILING ADDRESS ? ILA ' 1
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE ^
PROPERTY LOCATION C 1/4, 5 C- 1/4, Section TM N-R - W
TOWN OF ~ ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP , VOL~~ 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 ye a piration date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
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 he-permit issuance.. Should this
development be;intended for 'resale by owner/contractor, (spec
house);_ythen 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
Location of roperty ✓I E 1/4 56- 1/4, Section ,T N-R .W
Township t Mailing address
Address of site 2
Subdivision name Lot no.
Other homes on property? Yes__Y_No
Previous owner of property
Total size of property i~~ X Imo
Total size of parcel
Date parcel was created
Are all corners and.lot lines identifiable?
Is this property being developed for. (spec house) ? Yes •_N0
Volume and Page Number,as-recorded with the Register
of Deeds
-L'--
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
i certified survey, if available, would be helpful so as to avoid
delays' of the` reviewing process. If the deed description
references toy 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 i office of the County Register, of
Deeds as Document No. '+5,` and that I (we) presently
own the proposed site or°the ewage 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 off`oe of the County,;-`.Register of Deeds as Document No.
a it
gnature of pplicant Co-Applicant
Date of Signature Date of Signature
DOCUMENT NO.- STATE BAR OF WISCONSIN-FORM 3
K QUIT CLAIM DEED
VOL 545 PAU.,F310 THIS SPACE RESERVED FOR RECOROING DATA
BY THIS DEED, Diane L. Brow_n_ REGISTERS OFFICE
ST. CROIX CO., WIS.
i
- - - y- Grantor Recd. for Record this 1 th
quit-claims to Dona Td _H. Brown Y of ov. A.D. i 92
i
i, Act ___.._._9:30 A., ht
Grantee_.-.+, for a valuable consideration
- ' St. Croix Register of s
the fotlowin¢ described real estate in County, State of Wisconsin:
T RET AN TO
l i
I
Tax Key a
f
' This is - -homestead property.
Lot 17, Viebrock'S River Valley View Addition to the
Town of Richmond. a
4
FEE
F. XE'11APT
{
f L
I c
Hudson, Wisconsin this 8th dap of November 19~~2.
f Executed at
l `SIGNED AND SEALED IN PRESENCE OF ,S(~ZL'YLC aC ~L'~~ (SEAL)
Diane L. Brown j
'I
(SEAT.) !I
t
(SEAL)
3
t r
„ signatures of _ Diane L. Brown
I
day of November 76
authenticated this Sth
Title: Member State Har of Wisconsin gXj@$t3p{jtg=
74447{94DRX}@4F3CJ~~X~3~@C
{t
a
STATE OF WISCONSIN
County. } -s-
Personally came before me, this _ -day of 19-
the above named
to me known to be the person- who executed the foregoing instrument and acknowledged the same.
+ . ~
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