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STC - 104
AS BUILT SANITARY SYSTEM REPORT i~ Yr1 ~~t°
C, ra,
OWNER
;x`~ r
ADDRESS
, r
SUBDIVISION / CSM# LOT #
SECTION N-R W, Town of_~ r~E
ST. CROIX COUNTY, WISCONSIN /5-0 ~otlr~~
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SY TEM
3G r.~L
/oy
b INDICATE NORTH ARROW
Provide setback and elev tion info mation on reverse of this form.
Provide 2 dimensions e r of septic tank manhole cover.
t
BENCHMARK: z
ALTERNATE BM: SEPTIC TANK, PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: ~ Liquid Capacity:_
Setback from: Well, House Other
Pump: Manufacturer, Model# Size
Float seperation Gallons/cycle:
Alarm Location -~i'.n,~s~
-:SOIL ABSORPTION SYSTEM
Width:-. 2 Length Number of trenches
Distance & Direction to nearest prop. line: /~L
Setback from: well: f _ House-/,, s Other
• ELEVATIONS
Building Sewer ST Inlet. /,7 7S ST outlet 7e
PC inlet 4 77, PC bottom Pump Off
Header/Manifold g Bottom of system
Existing Grade_ jJ Final grade /
DATE OF INSTALLATION: - 9
PLUMBER ON JOB:
LICENSE NUMBER: INSPECTOR: Ll/j1~C/
3/93:jt
Wisconsin Departmgntof Industry, PRIVATE SEWAGE SYSTEM County:
Labor andfluman Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Pef]Ng§~WEIUER, STEVE ❑ City ❑ Village 1k Town o : State Plan D No.:
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
/ 0 ' r
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic de'- y ova Benchmark / /00, 9 ' /000
Dosing X00
Aeration Bldg. Sewer '
/3,97' 94-93
Holding St/ Ht Inlet
8
94's
TANK SETBACK INFORMATION St/ Ht Outlet G' g~ yy'
Vent
TANK TO P/ L WELL BLDG. Airito ROAD Dt Inlet
Ar ntake ' 'f' j, 31
Septic & ' NA Dt Bottom w Z, ;Fb,'7'
Dosing NA Header / Man. , 05
Aeration NA Dist. Pipe 3, ly 41 q6. 6
Holding Bot. System y 6 < /
PUMP/ SIPHON INFORMATION Final Grade ' 160
Manufacturer Ar Demand
Model Number L GPM
TDH Lift Friction System TDHI7_2G Ft
Head
Forcemain Length '5~0 ` Dia. f Dist. To well
75
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ' 65 ' DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type Of CHAMBER Model Number:
System: ` 4 ' > 7,151 ' 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 ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION; ST. JOSEPH.03.29.19W, NW, NW, LOT 1, 61ST STREET
0 'jo.
Plan revision required? ❑ Yes Ej No [11 J& I
Use other side for additional information.
SBD-6710 (R 05/91) Date Ins ctor'449nature Cert. No.
ADDITIONAL COMMENTS AND SKETCH`
SANITARY PERMIT NUMBER:
I
t
Safety and Buildings Division
v^.~`R 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 81/2 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
-A 5l4TF
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 caner Name P operty L )cation
1/4 1/4, S T , N, R Y/(or)dO
Property Owner's Mailino Addres Lot Num er Block Number
Cit , tate Zip Code Phone Number Subdivision Name or CSM Number
11. TYPE BUILDING: (check one) ❑ State Owned ❑ ity Nearest Rojo
❑ vll age
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)
o so ~a o 9
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. M 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 ❑ 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
1 /1 -4q I /I Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (MinA ch) Elevation
e I Feet Feet
VII. TANK Ca
in alloacitns Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturer s Name concrete strutted con- steel glass Plastic App
New Existing
Tanks Tanks
Septic Tank or Holding Tank -6V I tom El El El El El
Lift Pump Tank /Siphon Chamber q~- - I El
VIII. RESPONSIBILITY STATEMENT
I, th undersigned, ssume responsibility for i allation•of nsite sewage system shown on the attached plans.
Plu ber' Name (P ) Plum is gnatur mps MP/MPRSW No.: Business Phone Number:
u ber's Address (Stree ity, Stat, Zip e):
IL A
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial t > /qb Surcharge Fee) ~Z
Adverse Determination Yr~'
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (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 be 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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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page _/1 of .5~
LaWrand Human 'Relations
.,Uivision'ofSafety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
` - COUNTY
Attach complete site plan on paper not less than an must include, but
not limited to vertical and horizontal reference pe4nt direction an o y ope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and dAiO to newest r d.
~ ) , REVIEWED BY DATE , 11 APPLICANT INFORMATION-PLEASE R IT ALL iioi0 li0N
c-
PROPER OWNER: P 30PERTY LOCATION
N LOT ! 114 1/4,S ? T N,R e(o&
ISS t # BLOCK # SUBD. NAME OR CSM #
PROP RTY OWNE ~AI NG -A\rD
CITY 171VIJLLAGE MOWN NEAREST ROA
CITY, TATE ZIP CODE P
1r% > 17Z /I
0
[A New Construction Use [_4 Residential ! Number of bedrooms ~ [ ] Addition to existing building
j ] Replacement ( ] Public or commercial describe
Code derived daily flower gpd Recommended design loading rate ed, gpd/ft2_trench, gpd/ft2
Absorption area required s/~Z bed, ft2 :5Z ~3 _ trench, ft2 Maximum design loading rate _bed, gpd/ft2_,~trench, gpd/ft2
Recommended infiltration surface elevation(s) W, / ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN 7FILLHOLDING TANK
U=UnsuitableCd7S ❑U WS ❑U ®S ❑U MS ❑U ❑S I~I❑S [09 U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. C nt. Color Gr. Sz. Sh. Bed Tiench
LJ
S
Ground 9', s - t 7
elev.
ft.
Depth to
limiting
factor
ypC
Remarks:
Boring #
,j/,n5e" -FIX-0 Al
Ground
elev.
"g ft.
Depth to
limiting
factor
> y~
Remarks:
CST Name:-Please Print Phone:
Address: Signature: Date: CST Number
PROPERTY OWNER SOIL DESCRIPTION REPORT Page,,,2,t
PARCEL I.D. # `
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends
gii.
Ground
elev.
ft. / o' t/ '41 Depth to S
limiting
factor
3,y- 17 1 ly
Remarks:
Boring #
7
Ground /
e g''
elev. Z//
Hot. - ~ 7
Depth to
limiting
factor
~®2
Remarks:
Boring #
/ Z"
3
Ground
elev. s /
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
h.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
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CERTIFIED-SURVEY MAP
Located in part of the NW114 of the NW1/4, Section 3, T29N, R19W
Town of St. Joseph, St. Croix County, Wisconsin.
TOWN OF ST. JOSEPH CERTIFICATE
I hereby certify that this Certified Survey Map is approved by
t St. Joseph To Board.
~0 - A -/-1 -9S
Jerk Date
OWNER'S CERTIFICATE OF DEDICATION
As owners,WE hereby certify that WE caused the land described on
this Certified Survey Map to be surveyed, divided, mapped and
dedicated as represented on the plat.WE also certify that this
plat is required by Chapter 18 of the St. Croix County Land Use
Regulations to be submitted to the following for approval or
objection: St. Croix County Planning and Development Committee
and the Town of St. Joseph.
WITNESS the hand and seal of said ownersthis day
of 19
In the presence of:
Witness S EN W. HENNING
State of Wisconsin ) SS `
County of St. Croix) NORMA J ENNING
Personally cape before me this day of 19-45., the
above named STEVEN W. HENNING to me known to be the
l+IORMA J. HENNING persons who
executed the foregoing instrument and acknowledged the Sam .
Notary Public 4~g,G 1A'•n' y^.s ..r,.• , • ,oV„
Wisconsin. •z„ ;r,r
My Commission expires
PATTI L. SATTLER 1
NOTARY PUSUC-MINNESOTA
MY COMMISSION EXPIRES 1.91.2000 ~
{ P,
, 04.
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER -
MAILING ADDRESS
PROPERTY ADDRESS s'
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION_ 1/4,~ 1/4, Section ~S T_C__N-R_W
TOWN OF f ~l ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIEDSURVEY MAP , VOLUME /0 , PAGER 107, 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, 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.
IZZ
owner of property -
i S
Location of property 1/4 1/4, Section 1.1 TAN-R )9 W
Township Mailing address
Address of site I Z' r
Subdivision name GS#L y-/0%167 Lot no.
other homes on property? Yes No
Previous owner of property
Total size of property
Total size of parcel sx~o~
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes --No
Volume and Page Number >:~Zg as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A I4ARRANTY 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. 9/ 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.
i
ranch nd.
Vo4i
igna re of Applicant Co-Applicant
Date of Signature Date of Signature
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PAGE OF
• PUMP CHAMBER CROSS SECTION AND 5PECIFICAT(ONS
V E NT CAP
y~ VENT PIPE
WEATHERPROOF _APPROVED LOCKING
JUMCTIOIJ BOX MANHOLE COVER WITH
Z5' FROM DOOR, WAAI~IING LABEL
WINDOW OR FRESH II"MIU.
AIR INTAKE
I
GRADE !
I B" Nl u.
CONDUIT--
IB"MIN.
IIULET PROVIDE I
AIRTIGHT SEAL I i i I
! I I
APPROVED JOINT A I III APPROVED JORITS
I III W/- " PIPE
W/ PIPE
EXTENDING 3 tIALARM EXTENDIAl6 3'
I
ONTO SOLID SOIL
ONTO SOLID SOIL I I!
6
I I
I I ON
G 1
ELEV. FT. PUMP-~
OFF
r
D
CONCRETE BLOCK
RISER EXIT PERMITTED OIJLy IF TANK MAIJUFACTURER HAS SUCH APPROVAL
3" ~4PPr{ovEa BEDDIn+G ur~dcr TI!.~K
SEPTIC E SPECIFICATIOUS
DOSE
TAWKS MAUUFACTUREK: WMBER OF DOSES: PER DAy
TA WK SIZE: ` GA LOWS DOSE VOLUME
ALARM MAIJUFACTURER: ~.z - INCLUDING BACKFLOW: GALLONS
MODEL UUM6ER: CAPACITIES: A- 0JCHES OF, GALLONS
SWITCH TyPC: 1 / B=INCHES OR GALLOWS
PUMP MAOUFACTURER: G.INCHES OR GALLONS
MODEL NUMBER: D- INCHES OR may/ GALLONS
SWITCH TYPE: NOTE: PUMP AMD ALARM ARE TO BE
MINI MUM DISCHARGE RATE GPtA 'a INSTALLED OW SEPARATE CIRCUITS
S S
VERTICAL DIFFEKEMCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE..1 FEET
+ M`IUIIMUM NETWORK SUPPLY PRESSURE . . . . . . . . . FEET
+ <S FEET OF FORCE MAIN X F loo rT.FRICTIOU FACTOR.. FEET
TOTAL D9MAMIC H FAD = FEET
IUTERNAL DIMEWS1 L OF T : LF-W&TN iWIDTH iLIQUID DEPTH
SIGr~ED: _ LICENSE NUMBER: lDATEX-!;2s
Performance L i b i in ~ 2, ss i
Curves Pumps
METERS FEET
90
MODEL 3885
25 - 80 SIZE 3/a" Solids
WVSH
70
20- WE10H
60
W E07H
15 50
WE05H
40
NIL I
10 30 WE03
20 WE03L
5
10
0 0
0 10 20 30 40 50 60 70 80 90 100 110 120 GPM
t ' ~ t
0 10 20 30 m°/h
CAPACITY
U GOU LDS PUMPS, INC.
SBvECA FALLS NEW YCQK 1314 E
METERS FEET
120 MODEL 3885
35 110 WE15HH SIZE 3/4" Solids
i
100
30
90
25 80
70
20
60
O
r
50 WEOSHH
15
40
10 30
20
5
10
0 0
0 10 20 30 40 50 60 70 80 90 100 110 120 GPM
L i
0 10 20 30 ml/h
CAPACITY
• 1085 Goulds Pumps, Inc. Effective July. 1985
C38R'
ti 'ilk 1145PAGc-14
WARRANTY DEED
DOCUMENT NO. This space Reserved For Recording Data
REGISTER'S OFFICE
ST. CROIX CO., WI
Redd for Record
THIS DEED made between STEVEN W. HENNING and ,
O CT 2 0 X99,.
NORMA J. HENNING, husband and wife, Grantors and STEVEN
J. RIEMENSCHNEIDER and KELLY J. RIEMENSCHNEIDER, tit 9: 00 A. M
husband and wife as survivorship marital property Grantees, ~,aqALh*, Odd.,
Register of Deeds
Witnesseth, That the said Grantors, conveys to Grantees the / p cv
following described real estate in St. Croix County, State of
Wisconsin:
Part of NW-1/4 of NW-1/4 of Section 3-29-19 described as follows: Lot 1 of Certified
Survey Map filed April 19, 1995 in Volume " 10" . Page 2907.
TOGETHER WITH rights of ingress and egress as described in Access Easement dated
April 11, 1995, recorded April 19, 1995 in Volume 1118, Page 112, Document Number
527872
This is not homestead property.
TOGETHER WITH and SUBJECT TO reservations, restrictions, easements and rights-of-way
of record, if any.
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And Steven W. Henning and Norma J. Henning warrant that the title is good, indefeasible in
fee simple and free and clear of encumbrances, and will warrant and defend s e.
Dated this day of October, 1995.
(SEAL)
VEN W. HENNING
'-74 AAW-'~~ (SEAL)
N RMA J. NNING
STATE OF WISCONSIN )
ss.
ST. CROIX COUNTY )
Personally came before me this day of October, 1995, the above named Steven W.
Henning and Norma J. Henning, to me known to be the persons who executed the foregoing instrument
and acknowledged the same.