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sTC - io4 AS BUILT SANITARY S YSTEM REPORT COUNTY -
OWNER ADDRESS SUBDIVISION / CSM9 - LOT
SECTION-JZ_T~30 N-R W, Town of -
ST. CROIX COUNTY, WIS ONSI /-Fs-
LAN VIEW
SHOW EV THING ITHIN 100 FEET OF SYSTEM
,EP ~s
7Z'
b2
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tangy: mant-1
17
BENCHMARK:
ALTERNATE BM:
y(
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity:
Setback from: Well House__-2K Other
Pump: Manufacturer Model
Size
Float seperation Gallons/cycle:
Alarm Location
:SOIL ABSORPTION SYSTEM
Width: Length_ Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: House_ Other
ELEVATIONS
Building Sewer_ g~S- ST Inlet: C
ST outlet
PC inlet PC bottom
Pump Off
Header/Manifold q Bottom of system
Existing Grade Final grade_2
DATE OF INSTALLATION:
PLUMBER ON JOB:
E
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin Department o Industry, PRIVATE SEWAGE SYSTEM County:
Labor+ind Human Relations INSPECTION REPORT STt CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 26
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
BOARDMAN, KEITH SOMERSET
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
2.3
TANK INFORMATION ELEVATION DATA 111.97 1096002.84 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic S ~cn~' c~Ur Benchmark ® S cJ
Dosi gion Bldg. Sewer Aerat
17-:3 9
Hol ' g St/yf inlet ~,60 Y5~
TANK SETBACK INFORMATION StIA Outlet 8./9 9021
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header Jdam.- rj/,AeratioNA Dist. Pipe D. SS~~
Ho Ing Bot. System i/, -5'
PUMP/ SIPHON INFORMATION Final Grade
sir? s r
Manufacturer Demand ("(,3, M tel Num GPM
TDH Li Friction S stem TDH Ft
L
oss
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 1.2 J' DIMEN I
LEAC Manufa
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION Type o /lK ,.C t/s .1n i CHAMBER Mode Num .
System: Axa fa ~7d OR UNIT'
DISTRIBUTION SYSTEM
Header AUUMORld- Distribution Pipe(s) Size x Hoes p o Air Intake
Length I Dia. Length, Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Gra ystems
Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx d
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No E] Yes ❑ No
I COMMENTS: (Include code discrepancies, persons present, etc.) ,
-140CATION: $OMERSET.,jll.1I1¢,.,30.19W, NW, NE, 160TH, AVE /
C/
r
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 '
s
SANITARY PERMIT NUMBER:
Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building Water Systems
`~~L■7R 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. i
• See reverse side for instructions for completing this application State Sanitary Permit Number
p~ 7
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. APPL ATION INFORMATION - PLEASE PRINT ALL INFORMATION
Prope Olyner Names P)ropert Location
_ 1") 0,1/ ~ 1/4, S T , N, R (or
PropeftyOwner's ai in ddr ss Lot Number Block Number
7
Cit , tae Zip Code Phone Number Subdivision Name or CSM Number
. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cityy Nearest Road
❑ Village
Public 1 or 2 Family Dwelling - No. of bedrooms Town of X',
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 F-1 Apartment/ Condo 03a-aoq~_ :?o
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. jX New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank OnlyExisting 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 [A 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) Elevation
Feet Feet
VII. TANK Capacity site all
Fibe INFORMATION in gallons Gallltons Ta ks manufacturer's Name Cone ette Con- Steel g ass Plastic Atppr.
New Existin strutted
Tanks Tanks
❑ ❑ ❑ ❑ ❑
Septic Tank or Holding Tank
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, th undersigned, assume responsibility f r i II ion t onsite sewage system shown on the attached plans.
Plu b s Na t)' Plu sSic e: Sta ps) MP/MPRSW No.: Business Phone Number:
r/ _P4 Plumber Addr (greet ity,State, Code):
IX. COUNTY/ DEPARTMENT USE O Y
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing Agent Si n m )
Surcharge fee) ~r
pproved ❑ Owner Given Initial O~ J _74-c
Adverse Determination p
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original n) County, One copy To: Safety & Buildings Divr ion, 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 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) fora 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
Labor and Human Relations Page -4 of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis.
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and
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 er Property Location
Govt. Lot J 114 1/4,S T ,N,R ~FIf or&
Pro arty Owner's Mailing Address Lot # Bloc Subd. Nayhe or CSM#
City Stat Zip Code Phone Number El Nearest Road
( City illage Town
JR New Construction Use: C2 Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow gpd Recommended design loading rate y2 bad, gpd/ft2_1-y-trench, gpd/ft2
Absorption area required 1y3 bed, ft2,,_trench, ft2 Maximum design loading rate ~7 bed, gpd/ft2__z_9_trench, gpd/ft2
Recommended infiltration surface elevation(s) (as referred to site plan benchmark)
Z45-1- 9"S ld,, _1Ld
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 Fill Holding Tank
U = Unsuitable for system [0 S ❑ U VLS ❑ U Os ❑ U ® S ❑ U ❑ S 9 U ❑ S J M U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
Bed ,Trench
in. Munsell Qu. Sz. Pont. Color Gr. Sz. Sh.
9--_2 el M .41
Ground
~elev ;
eft. ~ rys
Depth to
limiting
factor ;
Z/,ALin.
Remarks:
Boring # /
3
-14 -
Ground
elev.
~~ft•
Depth to
limiting
factor
yi/o in. Remarks:
(/T Tele
CST Name ( ea Print) Signature Phone No.
Address Date CST Number
SOIL DESCRIPTION REPORT
PROPERTY OWNER Page of
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Structure 2
g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Trench
L
A Z.
L
Ground
elev.
Depth to
limiting
factor
in.
Remarks:
Boring #
Jose
Ground
elev.
Depth to
limiting
factor
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Co . Color Gr. Sz. Sh. Bed , Trench
Boring #
Ground
elev.
Depth to
limiting
factor
, ~in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
If ctor
in. Remarks:
SBDW-8330 (R. 08/95)
bit ltjk
"fo.'t,
Sir
)
STC-105
SEPT C TANK MAINTENANCE AGREEMENT
St. Croix County
O WNER/BUYER
MAILING ADDRESS
PROPERTY ADDRESS
1117 - d
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION _ 114,-446 1/4, Section _ T- .2L_N-R__4Q_W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
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.
Tlie 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 (I)
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
1 101 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.
Owner of property
Location of property l/4_1/4 , Section `rN-R~ W
Township s„y Mail ' ng addresses
~'w . ' J-
Address of site
Subdivision name 71- _ Lot no.
Other homes on property? Yes No
Previous owner of property
Total size of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? _Yes /Nco
Volume and Page Number as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBLIZ, 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.j 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 a!; Document No.
Signature of Applicant Co-Applicant:
Datc of Signature Date of Signature
H S L't~ M1S K A; ✓ S.
A
g ~ { 4' Y,fr dA E ♦ h~ ~ a - r - 'ti o, S Y y ~ 2, '~,r,'k t y t
~ k
n.a ~ 4 „i $nY p r?i S a~+~j,'Si :4 I~'t,': y~.n, ~+}7a ~ed'e.?liau.l...~u{u:......w~ .rd:~6ta~r
~Ctt1%Uh.7i NT NO. STATE BAR OF WISCONSIN-FORM 3 Ij
1 1'~~Jg QUIT CLAIM DEED
BOOP, U-1- PA•'E THIS SPACE RESERVED FOR RECORDING DATA
t
'oix C0., %Vis.
zlin --H, >car dm _n~ n le_ m n_ T. CR
13 en n
BY THIS DEED,
_ R-c'd for Record this- lth
Grantor
_ Af).~.9.74
- ._e
cf;
isen ,y rf I :
_James ,r ~o;Drdmar.
quit-claims A
- - -
Grantee for a valuable consideration - F.Ogv ler of Deeds
-
St the following described real estate, in CrOSx County, State of Wisconsin
- -
RETTU URN TO
Lots One (1), Two (2), Three (3), hour (4),
Fi v e 5 (G), Seven (7), ~ I:i,,ht (8),
'
Slx
liin r
Ten (10), Eleven (11) and Twelve (12) , r ix I ey
„r-. - of Ii ~Tdon, This ic:. homestead property.
Block ''Iit', of the Plat, of the Viii unt-in
.t. Crcix County, L'+isconsin.
This lwhichd was to give to be prepared confirm a recorded made August 9, 1950, the evidence
EXEI,AVT
D'. 25th ~nril Z4.
N~-j4lsdid±4~!ia W.:.~s___ • I~
Executed at this day of
4 (SEAL)
SIGNED AND SEALED IN PRESENCE OF '
n~imin H F3o rr m n
(SEAL)
III (SEAL)
i
~I (SEAL) j I
l
~I
i
- - - -
Signatures of BenlIfl_~.Tl H.OyY r mn___-- -
- - A n I91. ~I
authenticated this__- 25th day of ri 1
_Edwnr L I( I~ Fps _
ji Title: Member State Bar of Wisconsin or Other Party
Authorized under Sec. 706.06 viz.
f
Ii STATE OF WISCONSIN Ij
I
ss.
• County.
day of 1`F_
Personally came before me, this - - 'i
u
, ~,y. ~ tr ye. x `*r
'~cr .-.r yi. A.. t.;..:....2. a _o. . y,..x.t..y.....«,.,a.., r w..
Nv. 8-9. 1L4rr=t7 D-d--tih.., t Bonn tOTATr OF WISCONMNI Pobllabed b7'aa ('lalm 2V-* A t''~thw:s
(tom 2736.16, Wia t?tatube) Porm No. 9 ~
0.r l! a..
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(!~l~t~~ ~211>slb ltl'k'. Ilizideby Benjamin H. Boardrrran, a single man
grantor , of ')t. Croix County, Wisconsin, hereby conveys M
andwarrantsto Frank Keith Boardman and Benjamin James Boardman, ~,3 I.
r
tow,,.nts in common
grantee s , of ~t , Cron x. County, Wisconsin, for
thesumof Crw, Dolt,-, and other valu-bie consideration
the following trcct of land in at . Croix County, State of Wisconsin:
is
R: .
Thb ~~Icst half cr' Ile Murt-herl.st, C?uarter (~J~1 of NE;.) and the
Ncrthwest Ouartcr (U,'' of Cecticn Thirteen (13), Township
Thirty (30) Ncrt.tr, of l'an,Te Ninetcen (1O) est .
Th1 leca i i v;:rr ccrrrct tr : descripti cn in that certain s
~ ,
1e.,E.-l t~;;twc._.n tJw 196 and recorded
JI-runry 1.96x; n 1,10 G1 Deeds cn pages 8,3 and ~4,
Document No.
i
!-:::GISTERS OFFICE
ST. CROIX CO.. WIS. FEE
J!_
Pecc'd fox Record this- 2-4th-
I
1.
day rri---~'° y------ A.D.19-74 EXETVIPT
.4 6:30 A
ke: f ter of h~ea i3
U
e.
Cif
,may
~.,1 i;,tbtslt~i+ r tlCr:r," t'.. _.x 1 'r nto7 E_t'• hcreunto 1"11 hared aryl seal e
Us 7?4,
I
Sif r.ed end alai in Frrscuce of
_
_ {
_ _ - _ L
'~ti
"40" Description.
A parcel of land located in the Northwest quarter of the Northeast quarter of Section 13, Township 30 North,
Range 19 West, Town of Somerset, St. Croix County, Wisconsin, described as follows:
Commencing at the Northeast corer of Section 13; thence South 89 degrees 35 minutes 05 seconds West
1323.75 feet along the North line of said Section 13 to the Point of Beginning, (bearings referenced to the North
line of Section 13, assumed to be South 89 degrees 35 minutes 05 seconds West); thence South 00 degrees 09 min-
utes 19 seconds West 1317.63 feet along the East line of the Northwest quarter of the Northeast quarter to the
South line of said Northwest quarter of the Northeast quarter, thence South 89 degrees 28 minutes 47 seconds West
1326.03 feet along said South line to the West line of said quarter section; thence North 00 degrees 15 minutes 12
seconds East 1320.08 feet along said West line to the North line of said Section 11; thence North 89 degrees 35
minutes 05 seconds East 1323.75 feet along said North line to the Point of Beginning, containing 1,747,218 square
feet (40.111 acres) more or less.
- - - - - - - - - - N 89'35'05'E 1323.75' - - - - - - - - - -
160 TH AVENUE
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