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Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ~/i f/I CGt~ ~C~.TOWNSHIP~'7 f>O?Clf~ SEC . T LAN-R /~W
ADDRESS gDST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I•LHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
r
t
h
A 71~
j~l du~0 r
INDICATE NORTH ARROW
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off swito elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest ..,property line: Front, O Side, O Rear, 0 Ft.
Number of feet from well:
<E Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: Lenith: Number of Lines:_ Area Built: do?
Fill depth to top of pipe: G
Number of feet from nearest property line: Front, n,' Side, O Rear,O Pt
Number of feet from well: X21C. ``Zk r/
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:`
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969, ` BUREAU OF PLUMBING
MADIrSON, WI 53707
9RCONVENTIONAL ❑ALTERNATIVE State Me' LD. Numbers
(If assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound 4 -1
NAME OF PERMIT HOLDER, ADDRESS OF PERMIT HOLDER: INSPECTION EAT
Matthew Koester Rt. 2, Box 48, Somerset, WI 54025 g "J
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.
SE NE, Section 32, T31N-R19W, Town of Somerset
Name of Plumber: IMP/MPRSW No ___JEn a nty. Sanitary Permit Number:
Byron Bird, Jr. 3318. St. Croix 79183
SEPTIC TANK/HOLDING TANK:
NG COVER
V
MANUFACTURER: LIOUID CAPACITY. TANK 7~~
TANK OUTLET PERLEOPVERTY PRO WARNIIDE WNGEDLAEBEL UIPLLDIOCROVIINGDE VDEN TO FREH
V7 ~ YES ❑NO ❑YES NO
BEDDING: VENT DIA.: VENT MA7 HIGH WATE NUMBE OF ROAD B-
LINE j ) 2~I AIR INLET.
ALARM FEET FROM y({V/
❑YES NO ❑YES ❑NO NEAREST
DOSING CH MBER:
PR IDED. -IDED:
MANUFACTURER BEDDING. IL IOUID CAPACITY POMP MODEL 7FRCE TNM UHLH WARNING LABEL LOCKING COVER
❑SES ❑NO YE NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONER OF P OPEHTY LL BUILDING IV ENT TO FRESH
NE AIR INLET:
(DIFFERENCE BETWEEN FROM
PUMP ON AND OFF) ❑YES ❑ NEST_
SOIL ABSORPTION SYSTEM. Check the soil moisture at the de th of lowin UI ME T 1 ATE HIAL AND MARKING
or excavation, (If soil can be rolled into a wire, construction shall cease untiill the soil is dry enoug
h to continue.) CONVENTIONAL SYS7 EM:
WIDTH. LENGTH NO OF UISTH PIPE ,PACIN(, COVER INSIDE UTA =PITS ILIOUID
BED/TRENCH TRENCHES NrEHIAL: PIT DEPTH-
DIMENSIONS
GRAVEL DEPTH FILL DEPTH UIST H. PIPE UISTH PIPE R. PIPE MATERIAL NO DI H NUMBER OF PROPERTY WELL 74t DING: VENT TO FRESH
BELOW PIPES ABOVE COVER EL EV INLfI LEV NU _ C__1 PIPES FEET FROM LINE AIRINLETQ NEAREST-
MOUND SYSTEM: ---F--
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
❑YES ❑NO
PEHMANENrnHKEHS olssEHVanoNwELLs
ER rex7uRE M
SOIL COV _
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH 8ED DEPTH OVER TRENCH BED OFPTH OF TOPSOIL SODDED SFE UFD IMULCHED
CENTER EDGES
❑YES. ❑NO ❑YES ONO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
JWIDTH LENGTH NO. OF LATEHAL SPACING GRAVEL UE PTH HE LOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL . NO UISTH DISTR. PIPE DISTRIBUTION PIPE MATEHIAL & MARKING
ELEV.'. ELEV. DIA. ELEV. PIPESDIA
ELEVATION AND
DISTRIBUTION VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECT Ly COVER MATERIAL PLANS
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBS E R V ATION W ELLS. NUMBER OF LINEPROPERTY WELL. BUILDING:
FEET FROM
❑YES ❑NO ❑YES ❑NO N_EAREST
\ - _ 12-
A-_ -U,
t ~
-y)
i~
Sketch System on n co rity fiile for audit.
Reverse Side. SIGNATURE TITLEF
D I L H R S B D 6710 (R. 01/82)
rr.,
f onsin APPLICATION FOR SANITARY PERMIT
OUNTY
_ILHR (PLB 67) UNIFORM SANITARY PERMIT #
O DUSTRVELRBOR 6 HUR1R1-1 RELRTIonS 17 913
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNERL MAILING ADDRESS
e 6d I/K910-6 febr ~ r v 3 6a
PROPER LOCATION CITY:
V I LJ~A
in
114 E1/4,S oZ T I,N,R 14? ' E(or )TV CAM-
LOT NUMBER BLOCK NUMBER SUBDIVI ON NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED 03a -
A 1 or 2 Family Number of Bedrooms. ❑ Public (Specify):
THIS PERMIT IS FOR A:
New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
eepaye Bed ❑ Seepage Trench U Seepage Pit ❑ Holding Tank
System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued
❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
02 Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of P tuber (Print): Signatur r MP/MPRSW No.: Phone Number:
ae:~4 -Y
Plum d ress: Name of Designer: ~r
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: [Fee: Date: ❑ Disapproved
❑ Owner Given Initial
Approved Adverse Determination
Reason for Disa ro
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
r ,
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.) ;
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10., A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth c t e system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
APPLICATION FOR SANITARY PERMIT
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"), 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 1"~Q r \ t ~~'IC Y T 1~( I1 p~(~~U,~VI
Location of Property 34 Section` T 2 ` N-R W
Township Sm1r~P T
Mailing Address
~yvv_y~P_N ISy a,5
Address of Site
LOT- 5 LAC a7 5
Subdivision Name
Lot Number p
Previous Owner of Property ccyld, v LI 415"
Total Size of parcel 5 auy x
Date Parcel was Created Jude } lq
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume 1`1V' and Page Number 3\ 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 refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTV OWNER CERTIFICATION
1 (We) cehti.6y that att .statementb on this 6ohm ane true to the but o6 my (owc)
knowtedoe: that I (we) am (ane) the owneh (s) o4 the nnonentu dens nibed in thi.6
]FDOCUME.NT NO. WARRANTY DEED T"IS SPACE RESERVED FOR RECORDING DATA
STATE BAR OF WISCONSIN FORM 2--1982
614
K-915TERS OFFICE
....Roy R. Koester and Shirle A. Koester
hi s wi ST. aoix CO., WIS.
f e Fac'd. for Rewrd this 23rd
June _ $6
day of A.D
. 19
K
.
couve . s .and ~rarrants . to ..Ma . tthew
. J. oester and--**---- 8•30A • NL
Jeri......•...Biorl;j.gr c --a- j-o nt,..tenants.- and not
- as---tenants- .H-common belalu of DOW@
RETURN TO
Remington Law Offices
New Richmond, WI 54017
the following described real estate in St. CrO1X County.
State of Wisconsin:
Tax Parcel No:
Lot 1 of a Certified Survey Map recorded on June 18, 1986 as Doc. No.
413475 in Vol. 6 of Certified Survey Maps at pg. 1667 as recorded in
the office of the St. Croix County Register of Deeds. And also a parcel
of land located in part of the SEi of the NEI of Section 32, T31N, R19W,
Town of Somerset, St. Croix County, Wisconsin; further described as follows:
Commencing at the E} corner of said Section 32; thence NORTH along the
east line of said NEI, 401.70 feet; thence N87008135"W, 320.81 feet to
the point of beginning of this description; thence continuing N87008135"W,
253.31 feet to the SE corner of Certified Survey Map volume 6,'page 1667
as recorded in the office of the St. Croix County Register of Deeds;
thence N0001912511E, along the east line of said Certified Survey Map,
258.20 feet to the NE corner of said Certified Survey Map; thence S87008135"
253.31 feet; thence S00°19'25"W, 258.20 feet to the point of beginning.
TRANSM
S'
This i....s not homestead property. $ O
(is) (is not)
FEE
Exception to warranties:
Municipal zoning and ordinances, easements and restrictions of
record.
Dated this ? o June
day of 19.-86...
(SEAL) (SEAL)
• _....Roy R. Koester
......................(SEAL)
...........................(SEAL)
. Shirley A...-Koester
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) ._...Rgl!..Rr.. Koester and STATE OF WISCONSIN
Shirley A Koester, husband & wife ss.
authe... Ica...ted this June County.
n Q ..day of.. 19..8 6 Personally came before me this ................day of
t.t
19 the above named
s
K s.
DATE: 5-29-86
OWNER: MATT KOESTER
Location: Town of Somerset
Proposal: New home construction
Size of home: 24' X 52' plus 20' X 24' garac;e
Plat plan
258.20'
408.23' 721,84'
septic drainfield
I•f•/•1•p.1•
135'
35'
110'-- house
S
35'
Well
130'
Driveway
270.83'
192nd AYE.
1
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STC - 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
a
`J a
OWNER/BUYER Lja-E }Pier I~ueS4f_y-
ROUTE/BOX NUMBER 11i 'Box ~ p j Fire Number J/I
.CITY/STATE S~rme~Se.~ I LV~ ZIP
PROPERTY LOCATION:~H ;4, Section , T ~N, R_la-W,
Town ofine , 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 con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank pumper. What you pdt into
the system can affect the function of the septic tank as a treat-
ment 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 systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. o
I/WE, the undersigned, have read the above requirements and agree N
to maintain the private sewage disposal system in accordance with x
M
the standards set forth, herein, as set by the Wisconsin Depart- ro
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date.
f/
SIGNED
DATE -747
St. Croix County Zoning Office
P.O. Box 98,
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND. BOX HUMAN"R"-LATIONS PERCOLATION TESTS (11J) MADISON W 53707
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: OWNS /MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
1/ a /j3 N/R/ E co Sores erg lel
COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS:
-5f- Cro fer a2 X ~ e l,~ 4~o as
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence 3 WNew ❑Replace Ar
s 6
RATING: S= Site suitable for system U= Site unsuitable for system
Y
CON
7 XS STI❑u ONAL: M g. ❑U IN-GROUND PRESSURE: ISYSTEM-1N-FILLHOLDING TANK: RECOMM NED SYSTEM: ional~
V~_j I 9
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: /r 0
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 40as~/air -mac s
GG yw 4 o - is d^ l.7 s,~ ~a -3yL &-TV .5, e'--r
/.I W1 40r-,- 0, 19-V ewl
a a-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INOPPI<6 AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P- / • s- o/z _e a G
P- /i C t -3 '0
P-1< jr
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION ~I~• `6 0~
Coo +e~ sir' 6^C e'
rAPP
lyp for 9'e- ,
~„~3~X./~//! Tod osr-K/aw1~i'
ug~1► ..d0l0
- E
L
fro 4ok5
_ self _ , pi
"CTIONS I COMPLETING ~ 1 115 a S BD - 5595 ,
To be . :x'UratC your rep-oi t to
t , c w lc ~ on,
4 ,e.. ly i," .-,.his is i Oi" cornfnec cial project:
fi"o(' r:.'T,"vclal use
4, is t'
A SITE FOR A . : TANK ONLY !F ALL
l UL~ 'T BASED ON SL i `)ITPC)NF
tlons shat...; here `car ;vrEtin , c pt~ s ' completing the plot plan;
ram accurately locating your t: lrs£-t tions. Drawing to scale is preferred. A
{ i~ desired;
and vertical elevation reference point are dearly shown, ,and are. permanent;
Cornpi i boxes as to dates, names, addresses, flood plain data, percolation test exemp-
tiron, i- ";Ppr_;
the infc5rma Bch as flood plain, elevation) does not apply, place N.A. it) the app box;
1 Sian she form and place your current address and your certification number;
12. Make legible copies and distribute as reds€ired_ ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
st - sto e over 10") BR Bedrock
cot) C,)I- (3 - 10") SS Sandstone
gl' ">t _ (Under 3") LS Limestone
s ,;I HGW High Groundvvater
cs ir: a Sand Perc Percolation Date
med s ilium Sarin{ W Well
fs - 3 end Bidg - Building
l~ _ L d > Greater Than
*5i _.r < L=-.,,s Than
_ Bn - Brown
~silsrr BI Black
si - Gy - Cray
ri sw' y Loam Y Yellow
Sandy Clay Loam R Red
S MY Clay Loam mot Mottles ~
Sandy Clay w - with
Silty Clay €ff few, fine, faint
*c; Clay cc - Common, coarse
pt Peat rnm Many, medium
M f luck d - distinct
p - prominent
HWL - High water level,
_;Oil t~,x.£zres surface vvrater
juaste disposal BNA Bench Mark
VRP Vertical Reference Point
. PLOT PLAN
PR6JECT_ e' ~e -,ADDRESS ~dX ~
1 /4/S,,V[T~.1 N/R ,~l W TOWN rs OUNTY a iX
MPRS Byron Bird Jr. 3318 DATE - -
BEDROOM '~LASS PERC CONVENIIONAL IN OUND PRESSURE
CONVENTI LIFI"_ MOUND HOLDING TANK
SEPTIC TANK SIZE LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREAT PERC RATE ABED SIZE
Benchmark V.R.P. Assume Elevation 100'
Location of Benchmark
* H.R.P._ G ors e/' "0; 4f
0 Borehole Q Well Scale . A~_Feet
O Perc Hole System Elevation
TYPAR COVERING
2"
121" 3' 6' 3' 3, 4 F2 3'
6" Sewer Rode
12' 18'
96 ~ to
~chC 4 L. i fL L
r
/v
Ae c,
r
~ao
of /a, es, r..
V /Qi^P~r
i
7 ~
Yvisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations ST. CROIX
Safety acrd Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary 6Permit No.:
8643
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
KOESTER, MATTHEW SOMERSET
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9600338
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet
rl
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O CHAMBER Model Number:
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 ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOQATTON: SOMERSET.32.31.19W, SE, NE, 37TH ST
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
SANITARY PERMIT NUMBER:
a
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, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less Counr. r
than 8 112 x 11 inches in size. J 0
• See reverse side for instructions for completing this application State Sanitary Permit Number
oYp Y6
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
APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
1/4 1/4, S T , N, R E (or
Property Owner's Mailing Address Lot umber Block Number
P_ ' f
City, State Zip Code Phone Number Sub iv io Name or CSM Number
Nearest R dot
II. W FE OF;BUILDING: (check one) ❑ State Owned ❑ itrage
Public 1 or 2 Family Dwelling - No. of bedrooms of T 51' _
Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo G~
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) JE~A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
114®.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: 96.
1 Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. Systen).Ug_v., 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) X07 EI at ion
~j Feet Feet
VII. TANK Capacity
in gallons Total # of site Fiber- Manufacturer's Name Prefab. Con- Steel Plastic Ap-
New Existin Gallons Tanks Concrete glass Appp.
strutted
Tanks Tanks
Septic Tank or Holding Tank ,r!r ❑ ❑ ❑ ❑ ❑
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's Name: (Print) Plum's S na re: (No Stamps) MP/MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code): /
IX. C UNTY / DEPARTMENT USE ONLY
❑ Disapproved Sa i ry Permit Fee (includes Groundwater ate Issue Issuing Age t Signa to
pproved E] Owner Given Initial C0 Surcharge fee)
Y
Adverse Determination
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/14) 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 y ne. criteria in the
Wisconsin Administrative Code wilt 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) t,, De 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.
Vl. 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.
• PLOT PLAN
PROJECT_ ei.) ADDRESS
11411X- 1 /4/S,,z/T,jt N/R,7W TOWN rs OU NTY G•-a iX
MPRS Byron Bird Jr. 3318 DATE - 62(1
BEDROOM3LASS PERC / CONVENTIONAL IN OUND PRESSURE
CONVENTION LIFT MOUND HOLDING TANK
SEPTIC TANK SIZE /o LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA ! PERC RATE 3BED SIZE
Benchmark V.R.P. Assume Elevation 100'
Location of Benchmark VokA~- zi
91
* H.R.P. r a~
GD h er
Cl Borehole Q Well Scale 0 Feet
O Perc Hole System Elevation-
TYPAR COVERING
nN
12" 3' 4' 6' 3' 3' 4 4' 3'
1 6" Sewer Rods 24
12' 18' '
to jGhC 4 2-,
d
Ion n!/ 6~►'
( 00
pn~
f' P-1
.3 64 ,o y b P3 0?5
Refleae, 7
by
6 ~
7
ti
1s
~J fln 'T~ • ~i~,Q2
i0
~ , i ~ ~ hod
i
611
wtsOnsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
St - C' i!5
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan siakictude;-°
r t
not limited to vertical and horizontal reference point (BM), direction and % of ale ECEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. 3 2. - D 1? 6 '7
/ ~~Ca Cti `s ED BY DATE
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION
PROPERTY OWNER: MOPE C TI N
1'r ~~W K O e VT. LOT ,5 ;>n N Z4.1 T 31 N,R I' E (or)(b 16 % PROPERTY OWNER':S MAILING ADDRESS L BL @. R C,
119 65 3-7 t
CITY, STATE ZIP CODE PHONE NUMBER NEAREST ROAD
Y~' S'•',
[ ] New Construction Use Residential / Number of bedrooms .3 [ j Addition to existing building
l ] Replacement [ ] Public or commercial describe
Code derived daily flow x}50 gpd Recommended design loading rate bed, gpd/ft2 . 9 trench, gpd/ft2
Absorption area required 64 3 bed, ft2 S 1#2 •5 trench, ft2 Maximum design loading rate . 7 bed, gpd/ft2 g trench, gpd/112
Recommended infiltration surface elevation(s) q$. lid ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material nY.,lP6 C 6 -Yrt0,,w.:1Ct CA Flood plain elevation, if applicable It
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon in. Munsell Clu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench
3~ J L Hof rFl- F
rn r C- g ell F. 5 • ~o
Ground 3 111-3D 7.51I, 1Ls O -s m i. \j F. 7 , g
elev.
ft. y 30.4 7-SYK "Ib ~ ~.d c~-s M t-- - • 7 "R
Depth to
limiting
factor
~O
Remarks: ~ J it. A. Clet
tl
Boring #
4.v n..
cc) M kA
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
CST e:-Please Prioli.• r p Phone:
.V0 hv\A
ddress;1 to O a~ S a►+' ` r• : r S C
Sign tune: Date: CST Number:
s- 9V o
PROPERTY OWNER SOIL DESCRIPTION REPORT Page _Qf~ ,
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourxk3y Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
.\+'.~\-:-1M
.~•.::;tivtivti...•i
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
yi5
In'
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
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INDUS ISION
DvEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDWGS
NDUSTRYY, , DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 76
HUMAN RELATIONS
N, WI 53707
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: OWNS /MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
~ % /T3 N/R/ E (o So~► eg
COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS*
Sr- cro -r ter x" 02 ~X 5~' 5& 'Pt
~S
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: Comm ER IAL DE CRIPTION: I PROFILE NS: 1PERCOLATION TESTS:
Residence New ❑Re lace 11
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSU E: S STEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
S❑ U S❑ U S❑ U ❑ S 2U I ❑ S U 1o /t5 404- COAVZI,
00,
If Percolation Tests are NOT required DESIGN RATE: If
f
any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: loodplain, indicate Floodplain elevation:
a
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN. ELEVATION OBSERVED ES IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
AV '
B , y G-3 it.< 7yG 0-Ia2 d'
3
pp
B-
B G ~7 -ice c. Adg~P a: 1.0 4*- lG CJs S
Gyc L
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER IItOPW-& AFTERSWELLING INTERVAL-MIN. PERIOD t PERT D P PER INCH
P- ,5 ~.e oZ
P. c
P-
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION ~Ia• `d•
G~
~S ' Ga~^i+c~ bar ,n-C
'
)f- #k/ Corn rr ~a
e3m 14/11 0ct/,0 4,,r F/lz~ T~ '.5- a
~~5 2E-iv , v o
1~I /00 Q ,(~orc.r, q TN
h~. 13191
p `Poky L!; erg n
well VD
I U~ 2yr -v x ax,
~1'3 1
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently serving
the residence located at: Sec. ,?,;.2, T ~IN, R__Zj W, Town of St. Croix
County, Wisconsin. Upon inspection, I certify that I have found the tank and
baffles to be in good condition, and it appears to be functioning properly.
Last time serviced
Did flow back occur from absorption system? Yes No (if no, skip next
line.
Approximate volume or length of time: /Ct9 gallons --25 minutes
Capacity: 1/011-yo
Construction: Prefab Concrete Steel Other
Manufacturer (if known):
Age of Tank (if known) :
_ ~/~f? Lam..
(Signature (Name) Please r t
(Title) (License Number)
(Date)
Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or
licensed disposer (NR 113 Wisconsin Administrative Code) ,
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
-
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank condition, I
certify that the tank, to the best of my knowledge, will conform to the
requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over
outlet baffle).
Name Signature
✓ MP/MPRS~
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
DYER ~ ~~E?~7
MAILING ADDRESS 6 x)it 7~5 d
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION J 1/4, A,1 1/4, Section ~ c T N-R_~W
TOWN OF S0'-/zV sz 7~ ST. CROI K COUNTY, WI
SUBDIVISION , LOT NUMBER
CERTIFIED SURVEY MAP k//-S(/ , VOLUME G,, PAGE%f~~, 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
r 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 v 1/4~C"-:'.1/4, Section IT ' / N-R~2 -W
Township _Mailing address ILI,
Address of site
Subdivision name c- {J/rrjLot no. Z
Other homes on property? Yes ~C 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 No
Volume and Page Number -3c// 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. /Z/,<l: , 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.
ignature Applicant Co- ppli ant
Date of Signature Date of Signature
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.Y DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
STATE BAR OF WISCONSIN FORM 2-1982
REt WERS OFFICE
Roy R. Koester and Shirley A. Koester ST. CROIX CO., WIS.
his wife Recd. for Record this 23rd
June
. daY _A.D. 19 6
8:30A M,
conveys and .varrants to ..-.Matthew J. Koester and
.-..Jeri-._A.....Bjp) 1%: t;nd._as...jo nt.._tenants__.and. not-
as tenants-ip-eommorl....
,,.f D*W#
RETURN TO
Remington Law Offices
New._Richmond, WI 54017
the following described real estate in St. Croix County,
State of Wisconsin:
Tax Parcel No:
Lot 1 of a Certified Survey Map recorded on June 18, 1986 as Doc. No.
413475 in Vol. 6 of Certified Survey Maps at pg. 1667 as recorded in
the office of the St. Croix County Register of Deeds. And also a parcel
of land located in part of the SEI of the NE} of Section 32, T31N, R19W,
Town of Somerset, St. Croix County, Wisconsin; further described as follows:
Commencing at the E} corner of said Section 32; thence NORTH along the
east line of said NE}, 401.70 feet; thence N87008'35"W, 320.81 feet to
the point of beginning of this description; thence continuing N8700813511W,
253.31 feet to the SE corner of Certified Survey map volume 6,'page 1667
as recorded in the office of the St. Croix County Register of Deeds;
thence N00019125"E, along the east line of said Certified Survey Map,
258.20 feet to the NE corner of said Certified Survey Map; thence 687008135113
253.31 feet; thence S00019125"W, 258.20 feet to the point of beginning.
WIANSFM
4.~
This is not $
homestead property.
ls> cis not) F.EFi
Exception to warranties:
Municipal zoning and ordinances, easements and restrictions of
record.
Dated this aV day of ..June.•--•---- 19._86...
. (SEAL) f I. ✓
{ (SEAL)
Roy R. Koester
_ ..........................(SEAL) .............(SEAL)
Shirley A. Koester
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) Apy._R... Koester and STATE OF WISCONSIN
le.................. A Kester, husband . &..wife ss.
......................................County.
authenticated this Q..day of....... June $6
18.._... Personally came before me this ................day of