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AS BUILT SANITARY SYSTEM REPORT'Al
OWNER
R g,
ADDRESS JG~-O ~C/DN~j G,J
. r
SUBDIVISION / CSM# LOT #
SECTION T30 N-R 11-W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
67
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INDICATE NORTH ARROW
z 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~~
.fit/fPAvZ57&Z0 AfetSi S'T'
Manufacturer: / Liquid Capacity: Q/~ /o~!'U
Setback from: Well 150 ' House Z Other
Pump: Manufacturer 20E~E~ Model# X31 Size /'2'
It 2-0
Float seperation Gallons/cycle: S
Alarm Location
W ARfl TE~rWiAPeGZ 9fEc . Cc . (VA,, f:;,t (tS cc~ t'S .
9-~ S 7 33
SOIL ABSORPTION SYSTEM
r f
Width: 5 Length O Number of trenches '
.Distance & Direction to nearest prop. line. CJ
i
Setback from: well: House ? 50 Other
o .
ELEVATIONS
Building Sewer ST Inlet. $9.63 ST outlet 7
PC inlet O b • S~' PC bottom $5. oT Pump Off 05
Header/Manifold 3 Bottom of system 6 l' -70
Existing Grade Final grade /d Z. LS
DATE OF INSTALLATION:.
PLUMBER ON JOB: 0 E) 6R C/Gl,T-
LI CENS E NUMBER: /k P R S 33 0
INSPECTOR: -TkZ Ai Ps D /j
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Wisconsin Department of 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 268696
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
WEGGE, MARILYN ST. JOSEPH
CST BM Elev.: Insp. BM Elev.: BM Description: ' Parcel Tax No.:
TANK INFORMATION ELEVATION DATA /6//{ TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark 70
pl LcJ ~ e f
Dosing
Aeration Bldg. Sewer
Holdi St/ Inlet
TANK SETBACK INFORMATION St/ FX Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake 77 /
Septic lei >/Sd NA Dt Bottom gS, U7 '
Dosing ) NA lioadep/ Man. 3~
Aerati n- A Dist. Pipe 2,371 6v,35~
VHolding Bot. System 1219 9q, 75~
V
' PUMP/ ORMATION 2 Final Grade
-g~/ G,a.m
ManufacturerQ~ emand
Model Number Z2Z 9pM
TDH Lift q, JXI Lriction 4, System., .0 TDH yq V Ft
oss Head
Forcemain Length A5_3 / Dia. y Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width , Length _ r No. Of T enches PIT No. Of Pits Inside Dia. Liquid Depth
A~ DIMENSIONS DIlEN 1 N
SYSTEM TO P/L BLDG WELL LAKE/STREAM L Manufacturer.
Ya~ SETBACK CH BER
Q' INFORMATION TypeO Mo thrnr~
Q System: a 1,13 11~ OR UNIT
DISTRIBUTION SYSTEM
the! jVlani Id . Distribution Pipe(s) x Hole Size I'll/ x Hole Spacing Vent To Air Intake
Length Dia- 4- Length 91 Dia. Spacing Y 6
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
t -,'COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: ST. JOSEPH.19. 30,.19W, W, NE, 145TH AV,/~N4E , - fti~ d
07 c = 5~(002~(9~/~al
Plan revision required? ❑ Yes No
Use other side for additional information. 1/01 /
SBD-6710 (R 05/91) Date .11 Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH `
SANITARY PERMIT NUMBER:
5;/7JE r9'fPZ5--SS : 1356. t 4 5 fll%- ,4 vim, • s c~ ► S
Safety and Buildings Division
riR 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, C,Pirx
than 81/2 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
a66C)"(41P 1'$0
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 S - D 3 7 S
Property ner Name Property Location
O~'t- A-) iF&GE_ ~1/4N~1A,S IF T ,N,R/ E(or W
Property Owner' ailin Address Lot Number Block Numbed
City, State ZCod g_ Phone Number Subdivision Name or CSM Number
C_ eA,4 OR I& _
it 11 Nearest Road
II. TYPE F BUILDING: (check one) ❑ State Owned L
Vil(age
Public or 2 Family Dwelling - No. of bedrooms 12f p Town OF 5T'
III. BUILDING USE: (If building type is public, check all that apply). Parcel Tax Number(s
oho -1a3
1 E] 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. ❑ 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
11E] Seepage Bed 21 EWound 30E] Specify Type 41 ❑ Holding Tank
12E] Seepage Trench 22E] In-Ground Pressure 42 ❑ Pit Privy
13E] Seepage Pit 43 ❑ Vault Privy
14E] 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) Elevation
/ O 31 00 /.2- Feet Ol 7- Feet
VII. TANK Capacity gallonTotal # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer s Name Concrete Con- Steel glass Plastic App
New Exist in structed
Tanks Tanks
Septic Tank or Holding Tank ZDo 2od
lift Pump Tank /Siphon Chamber OOO &90 l ❑ ❑ ❑ 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) P I u m b e 's Sign ture: (No Stamps) PRSW No.: Business Phone Numbe
--Q0i3,ffP-T M30-7 7 •/g
Plumber's A5d``ess (Street, City, State, Zip Code,
s b ~vQ: ~ Civ J
IX. UNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing A nt Sign 7~-z
47 Approved E] Owner Given Initial Surcharge fee)
Adverse Determination
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 iristallation
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.
Vlll. 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.
SAFETY & BUILDINGS DIVISION
201 E. Washington Avenue
P.O. Bo: 7969
Madison, Wisconsin 63707
State of Wisconsin
September 27, 1996 201 East Washington Avenue
P. 0. Box 7969
Madison WI 53707
ULBRICHT & ASSOCIATES
ROBERT ULBRICHT
655 O'NEILL ROAD
HUDSON WI 54016
RE: PLAN S96-03751 FEE RECEIVED: 180.00
WEGGE, MARILYN
SW, NE, 19, 30, 19W
TOWN OF SAINT JOSEPH COUNTY OF ST CROIX
MOUND SYSTEM
The Department has reviewed the above-referenced submittal.
Conditional approval is hereby granted for the system plan submittal. A11
noted items must be corrected. The review and approval of the system is based
on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin
Administrative Code, and is contingent upon compliance with any stipulations
shown on the plans. This system has not been reviewed for the code
requirements set forth in chapter ILHR 82 or in chapters ILHR 50-64, Wisconsin
Administrative Code.
This plan submittal approval will expire two years from the approval date, or
if a sanitary permit is obtained, plan approval will expire on the day the
initial sanitary permit expires. The licensed plumber responsible for this
installation shall keep one set of plans with the Department's stamp of
approval at the construction site. The installer shall notify the appropriate
inspector when inspections can be made.
All permits required by the city, village, township or county shall be
obtained prior to installation.
Inquiries should be directed to me at the number listed below. Please refer
to the n number s above.
S' c y,
1~ I
Peter E. Pagel
Plan Reviewer
Section of Private Sewage
(608) 266-2889
8021R/ 1
SBD•6824 IR. 02M)
ULBRICHT & ASSOCIATES CO.
655 O'Neil Road - Hudson, WI 54016 Reg. Designers of Engineering Systems
715-386-8185 Private Sewage Consultants
PROJECT INDEX
DILHR PLAN ID # S96-03751 DATE Sept. 30, 1996
OWNER Marilyn Wegge PHONE 715-646-2432
ADDRESS 1628 Reidner Ln. Centur~a, Wis. 54824
LEGAL DESCRIPTION Part of a 120 acre farm property. (Wegge Family
trust). Tax parcel # 03G - 1035;, /0000 SW1/4, NE1/4, Sec.19,
T30N, R19W.
TOWN OF St. Joseph COUNTY St. Croix
CSTM Robert Ulbricht CSTM2482
LOCAL AUTHORITY/ SUPERVISION St. Croix County Zoning Dept.
PROJECT DESCRIPTION:
A replacement septic system. Existing
system consists of two (known) cesspool tanks (non-code conforming)
thot are overflowing.and sited in seaso>ially saturated soils.
Soils in the replacement area are permiable (.4 GPD/ft2)
but seasonaLLY saturated at 18" as evidenced by mottling. The
site meets the " A plus 4 inch" rule for replacement sites. A
very long narrow (CURVED) mound using 18" sand fill is proposed.
The 1200 gal. precast septic tank (Midwestern Precast Inc.)
shall be provided with a Zabel filter to enhance the greatest
pretreatment and screening 9f the effluent before it is pumped
into the mound network..
Estimated daily~~stifdpw for this 4 bedroom home is
FF~600 gals.5
s S96-03751
ALL NON-CONFORMING
ape p TREATMENT TANKS SHALL
a a, y BE ABANDONED PROPERLY
FOR ILHR 83.03(2).
P9.1 PLOT PLAN VIEWS
Pg.2 SYSTEM CROSS SECTIONS & SYSTEM PLAN VIEW SPECS.
Pg.3 PIPE LATERAL LAYOUT
Pg.4 DOSING CHAMBER CROSS SECTION
Ulbricht 8 AssoClates
Pg. 5 PUMP PERFORMANCE SPECS private sewage Consultants
655 O'Neil Rd.
Hudson,/Wis. 016 a
w N \ M d kA
~ Z ~ ~ ~ v c m o ~ ~ ~
596-03'751
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S96-03'751
PLAN VIEW OF MOUQD Wit" 13ED
FORCE MMO A Fr-
I /oo Fr
K Fr= 1S g
-a I Fr- 1a3.4oy
kw Fr
w I' - 4CPk)r- FT
ya
BEV °F ADDah Tv l
«~TRAL Maki Fc,Lp DiSTR;(3uT101) PIPE uErWOR j<
9i9TR1r3uT100
LATERA15
END cAp 5
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Y z (BUG V=oRcE
MAW
LAST "OlE s NR 11 [3E
Nt✓t-r To END CAP VOID Vc)luMt FoR /00 Fr.
dF FoRcE MAW
113vERr ~ IEVAr~o~
~oD,zp
S96-03751
PERF'oRArED PIPE DET'Ai L
Q, HOF 10CATFD oX3
G OTrOM 5ti All BE
VAP A(5L5- Y E (ROhity 5PACeD.
Y DIST~Nce
iN .
yB rr Hole Di AK r= Te R
R
MANt FoLE)
y
X iN~tiES FoRcm MA~k) Z ~N.
of (lolE5 -
/ p i p E.. /3
PUMP CHAMBER CROSS SECTION' AND SPECIFICATIONS Pi41E -I OF 5
-VENT CAP
4"C.I. VENT PIPE
WEATHER PROOF APPROVED LOCKING
JUNCTION BOX MANHOLE COVER
25' FROM DOOR, l✓/fli,flA;1,06- 1AAt~
WIUDOW OR FRESH ~2"MIU.
AIR, INTAKE I
v.11 /On/ GRADE ( 4"MIFJ.
~f I
1 ~ I B" MI IJ.
CONDUIT--
~l v+n rti
11~
8.~ INLET PROVIDE I I
- AIRTIGHT SEAL I III V
I I
APPROVED JOINT A ,1h I~(D~ ~C I III APPROVED JOIMTS
W/ C. 1. PIPE lVtA I III W/C.I. PIPE
7-XTENDIIJG 3' 0~ I II ALARM EXTENDING
ONTO SOLID SOIL B ~O I I) ONTO SOLID SOIL
y01/ 3 3 / I i oN
v c iI
f-LEV.~~~ FL ' PUMP
1 ~ OFF
~6- D I.~
~nFl k O(: O , BLOCK
~ 1t v~ f
RISER EXIT PERMITTED OIJLL3 IF TANK MANUFACTURER HAS SUCH APPROVAL
SEPTIC E 5PECIFI•CATIOUS S96-03751
DOSE
TANKS MA►JUFACTURER: IJUMBER OF DOSES: ~ PER DAy
1oa
TAIJK SIZE: ~&-6-0 GALLLOMS DOSE VOLUME /p Z i
ALARM MANUFACTURER: 1-45V42- '414RL `Tl INCLUDING BACKFLOW: GALLONS
MODEL AIUMBER: APLy CAPACITIES: A= I(O INCHES OR y~ GALLONS
SWITCH TYPE: Afe5vePRK F/,q4r B= 2 INCHES OR 5-'o GALLONS
PUMP MAMUFACTURER: Z~~// C = ~-7 INCHES OR 2-18 GALLONS
MODEL NUMBER: 13-7 YZ ff -P D= /13 INCHES OR 332' GALLONS
5WITCH TYPE: p1J~SyQ~le ~ ~ / Fl-0 r NOTE: PUMP AND ALARM ARE TO BE
MINIMUM DISCHARGE RATE 35 GPM INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE..FEET -rAA)F S~C~S
T
+ MINIMUM NETWORK SUPPLY PRESSURE . . 2.5 FEET CCAC(A.. O4' J{ ~~L
+ ioa FEET OF FORCE MAIN X OS F 00FT.FRICTIONFACTOR.?" 0 ~ FEET G'UrIS Z"
= TOTAL D91JAMIC. HEAD FEET
2 , iI D
p 5
HEAD
11S
CAPACITY 32 110510 _
-
95
CURVE 30 100 -
28
90
29 85
I I
EFFLUENT 24 MODEL
and a 75MODEL 189
DEWATER/NG x 22 70 185
V 20 85%
Z 18 60
55
Fa- ~f-
ODEL
16 5o
183 MODEL
14 188
45
12 40_
35
10 MODEL
30 MODEL
137, 139.
SEWAGE and 195
° 2s
DEWATER/NG 9 29 MODEL
,5 MODEL 181
4 7
to - -
t W { 2 MODEL
5 S3, 55,
LL
! 57,59
0
BO GALLONS 10 20 30 40 SO 6,01 70 80 90 100 1,0
24
75 LITERS 0 80 ISO 240 320 400
22 FLOW PER MINUTE
70-
20 5 S96-03751
QC ,8 80_ - MODEL
4i 295
55
x 18
V SO
14 4S MODEL.
Z 4
29
12
JQ 35 MODEL
H 10 293
O 30 MODEL
284
MODEL
8 20- 282
i
4 15 _
10 MODEL Zffij Oi
2 _267,268
3280 Old Millers Lane
GALLONS 10 24 30 404 SO 801 70 80.1 90 1001110 120 130 140 ~SU 180 170 180 190 P.O. BOX 18347
'~-r--T-~~ Loulsvift, Kentucky 40216
LITERS 0 9O 180 240 320 400 480 Soo 940 720 (502) 778-2731
FLOW PER MINUTE
"137" Cast Iron Series
"139" Bronze Series HEAD CAPACITY
UNITS/MIN
Feet Meters Gal. Ltrs.
..a _ - 5 1.52 104 394
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.
Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must County 7
Include, but not limited to: vertical and horizontal reference point (BM), direction and s/'
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. #
03o • /o3~ • to •oa-O
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 p
14-111'.0,11
'"'11i01 vN we Govt. Lot s/,U 1/4 1/4,S Tjo N,R E (or )(0
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
I&zB 12ei9A-)e? L- .
City State Zip Code Phone Number E] Nearest Road
( -715 ~ y~/ - ~y3L city s [:1 Village Town ( [-f 5 ' vA
❑ N w Construction Use: L'J Residential / Number of bedrooms / Addition to existing building
Replacement ❑ Public or commercial - Describe:
Code derived daily flow CP p D gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/f12
Absorption area required bed, ft2 J! trench, ft2 Maximum design loading rate bed, gpd/ft2 ' S trench, gpd/ft2
Recommended Infiltration surface elevation(s) -56P- P 4 - 3 ft (as referred to site plan benchmark)
Additional design/site considerations 5,7r~ ~l E07-5 y
Parent material 5C.5 33 644's A S J WET i 5'r LT'S Flood plain elevation, if applicable N~ - ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade/ El System in Fill Holding Tank
U = Unsuitable for system El S C~ ❑ U E:] S O"~ ❑ S [B-6,
B u S 2~ El S
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2
in. Munsell Ou. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trench
Ell / 0-9 /oyk S'I L LfSbk As k cS , S
2- - 47 Kg :~Z
Ground J 2 S/ L 2.wt f % , S ~o
elev.
Depth to
limiting
factor
S55 Remarks:
Boring #
o- lo yk Z,wr sdk ds s 3 f
Z 2- y d' /o iP 9 tirL I-F-5h)tt d q ,.5r /f
3 51L 2f5hk dsA C S /vf
Ground o' / D f 51 elev
o- /o 44A 1 P scL z h r s
h ~h'I f ; ~T vie
Depth to
limiting
factor
,~OIn. Remarks:
CST Name (Please Print) Signature Telephone No.
VV ,9&-R 21/b& c-41 77 715-- 3f~Co ^ oOle
Address n~~e reT nr,,.. ►,e.
PROPERTY OWNER ~E✓~SE SOIL DESCRIPTION REPORT Z
Page of '3
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots G~pjft2
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Remarks:
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Boring #
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S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER 1i14R11-7 N 6- 6~-~
ADDRESS ~~Z ~~l~ L''~• FIRE NUMBER
CITY/STATE ZIP
cc D
PROPERTY LOC~TION: J~ 1/4 , /61/4 , SECTION I , T:- N-R f W
TOWN OF Tog Er , St. Croix County,
SUBDIVISION' 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 a 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 Co. Zoning Officer within
30 days of the three year expiration date.
SIGNED:
DATE:
St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
STC-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), thenia 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 propertys~i/4 N~1/4, Section fr , T `3'N-R ~fW
Township ST J d.S~
Mailing address',
Address of site 3~~ 7 S JLk 15
Subdivision name - - Lot no.
J
other homes on property? yes No
Previous-owner of property
Total size of parcel
Date parcel-was created
Are all corners and lot lines identifiable? Yes No
Is this property dieing developed for (spec house)? Yes No
Volume 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 & 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 t e office of the County Register o:
Deeds as Document No. 4~ 7- , and that I (we);presently
own the proposed site or the sewage disposal system or I (we)
obtained an easement, to run the aboire described property, for
44..yM ~ E'a
6 ,DQf.UMRN7 Q• WARR AM 0980 TNIA t►ACR UMjtV9D ►OR M000MM4 DATA
STATE BAR OF WISCONSIN * RIi ! J
SSGI5TERS OFfICt
ST. Ck01X CO., WIS.
A& 19th
widow seed, for NOW4 -
Aug. AAL-1987
r daY e:3o
F„ r
wave~pa W4 warrants to fail n-Me-gge .
T-1. f.
'
eswM. To
•..o.aoiy, '
~ - tbs. daaesl~ed red ststt M &t..Xroix
ad Wioeoada
Taa T,uesl No:
zY The Northeast Quarter of the Northeast Quarter (NE% of NEW,
Section Nineteen (19), Township~.Thirty (30) North, Range Nineteen
' 429) hest.
d 30 ' 03 l0 00
m
EEEI
This conveyance is given in satisfaction of that certain land
contract between the parties, dated December 29, 1983, and
recorded January 3, 1984 in Volume 679, page 612, Document
No. 390281.
This ...i-%..AQt........... bomeatead property.
(Ia) (b~ Sot)
Eweption to ww"antiss :
I! $7•
~.;1......
Elated this day of August
..s_.......... ! ...........(SEAL)
_ ...........----...(SEAL)
.r
• .Bs'na.::..G...ldeyr3e
(SEAL) ...........................................................(SEAL)
• •
fi
AUTRUNTICATION ACKNOW LBDGMZNT
Sigsstara(n) 3rnzt_G. wegge.--.__.._....__-__..-- s'rsTg of WISCONSIN
August N mp bef ~a
7 Pareonaft ca hk ----------------day of
t t it the abD.. names
~ltendrik I1. Vanai~ k....•---_ _
- _ .
2TnX: MMMZR STATZ $Alt OF WISCONSIN
. .
1709". Wis. Stst&) to we known to be the person wbo ezeouted the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFT[, arl
~ ~ Y ~
t.