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Lbor siffDepartment of industry, PRIVATE SEWAGE SYSTEM County:
Safety Labor and and Human
Buildiumanngs Relations Divisioon INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary 6Permit No.:
8579
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
JOHNSON, MICHAEL STANTON
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9600347
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
TANK TO P/ L WELL BLDG. A
irIto ntake ROAD Dt Inlet
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
1 1,
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 TypeO 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.)
LOCATION: STANTON.31.31.17W, NE, SW, 144TH 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 z :
SANITARY PERMIT NUMBER:
0`~~""~ 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 County
than 8 112 x 11 inches in size. 1
• See reverse side for instructions for completing this application state Sanit ry Permit Number
The information you provide may be used b other government agency to 9-5-17 Y by programs
(Privacy Law, s. 15.04 (1) (m)]. ❑ Check if revision to previous application
State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property wner Name Property Location
/4 /4, S T 3(, N, R E (or
Property Owner's Mailing Address Lot Number Block Number
I;z / _43747 j
City, State Zip Code Phone Number Subdivision Name or CSM Nujnber rQ oW✓1
G (7i aY6 -Y3~s " n
11. TYPE F BUILDING: (check one) ❑ State Owned ❑ Nearest Roa74_7
E] e
Public 1 or 2 Family Dwelling - No. of bedrooms j
vowan OF
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo 03G '-v9dG 1 /v
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 _____ExistingSystem
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 S. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) rte- Elevation '
~J I17Feet Feet
VII. TANK Capacity
in gallons Total # of r Prefab. Site Fiber- Ex er.
INFORMATION New Exist in Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
structed
Tanks Tanks
Septic Tank or Holding Tank kb 0 ! n ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ 1:1 1:1 ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans..
I=Mb
e~ Name//: (Print) r'ss ignature: o St mps) MP/MPRSW No.: Business Phone Number:
Plumber's Address (Street, C , State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sa' tary Permit Fee (Includes Groundwater Date Issue Issuing Agent Signature (No Stamps)
Approved Surcharge Fee) y
❑ Owner Given Initial ~ n
Adverse Determination 19
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: original to Couniy, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS '
r.
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-
11. 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) 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 _L of
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83. 5, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must include, but St.
. .
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # Gp r++ . no
dimensioned, north arrow, and location and distance to nearest road. 00 a
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVI D BY DATE
PROPERTY OWNER: PROPERTY LOCATION
12hk Z06%-SO" GOVT. LOT Of- 1/4 SW 1/4,S3 T 3 AR 17 E (or) W
PROPERTY OWNER':S MAILIN~ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
I.S o'l jqq T 5+. Q1 own up. o f
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE ®fOWN NEARES,~ROAD VM O"
[ ] New Construction Use [ ] Residential / Number of bedrooms [ ] Addition to existing building
[ ] Replacement [ ] Public or commercial describe
Code derived daily flow Iq SO gpd Recommended design loading rate . 7 ed, gpd/ft2~trench, gpd/ft2
Absorption area required q3 bed, ft2 SWS trench, ft2 Maximum design loading rate gibed, gpd/ft2~trench, gpd/ft2
Recommended infiltration surface elevation(s) 5 "ll or r 5 ft (as referred to site plan benchmark)
Additional design / site considerations dewrl
Parent materi< wa k v% rear Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN-GBOU ❑D U ESSURE AT-GRADE S DEE 211 SYSTEM S RD IN FILL HOLDING DING®TAbNK
U = Unsuitable fors stem P'S ❑ U S ❑ U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
a la-12 o R 3 a b rn Fie C, w I F .5
, Q
Ground ] -T t S M L. C".) IV F .7
elev.
90
ft. y Y R 9/y .7 i
Depth to
limiting
rI
fac or
Remarks:
Boring #
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Grou
elev. Depth o-
limiting
factor
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Remarks:
CS e:-Please Print Phone:
r -.-4
_U 15 Addres
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X7 1. r CA
Si ature: Date: CST Number:
-a -9b
i
PROPERTY OWNER SOIL DESCRIPTION REPORT Page - of
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 Tmr&
.vt'~•-v Cvti
•kh4x:vv:w'iY
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
}4??
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
::::w;:s
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspect d the septic tank presently serving
the residence located at: V4, _l,
Sec. T_a\ N, R 1 -)_W, Town of 5 rQ 0 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 X No (if no, skip next
line.
Approximate volume or length of time: gallons _ minutes
Capacity: 1000
Construction: Prefab Concrete 7. Steel Other
Manufacturer (if known):
Age of Tank ( i f known) :
617e~,~
(Sign ure (Name) Please Pi~i~ht
®pfarOr n
(Title) (Li ense Number)
7-----),2 - q6
(Dat)
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 f r inspection opening over
outlet baffle) .
Name Signature
MP/MP-1-
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STC-15
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
COWNE . cnS
r
MAILING ADDRESS ) / tl(' ~ c~" UP (A " c L-u S X61
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE Ma') 12\-c,LyoanJ `
PROPERTY LOCATION &f,_ 1/4, _'~(A) 1/4, Section T v? N-R_L~_W
TOWN OF Src1, 0n ST. CROIX COUNTY, WI
SUBDIVISION LS o1yx~ LOT NUMBERaZ
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 oper tion 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 11 of sludge and scum.
[/We, the undersigned have read the above requi ments 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 mu be comet and returned to the St. Croix
County Zoning Officer within 30 days of the three year a it date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
I!
• i
STC - loo
This application form is to be completed in full and signed by the
owner(s) of the property being dev loped. 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.
,,n 1 ~
Owner of property 1 r ► i Cha~\ J J
Location of property
Township ~n►~ Mailin address ) -6,3\ J yq vT
P ~ K~ m I~
Address of site / s/-
Subdivision name ~c AM, Lot no. Q\
Other homes on property? Ye __~~(_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 `tea and Page Number S3-1 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 statement 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. 3 --a, , 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.
Sign tune of plicant Co-Applicant
Date of Signature Date of Signature
_jOCUMENT NO. WARRANTY DEI®D
STATE OF WISCONSIN-FORM 9
3 2 3 0 3 2 em 513 PA U 532 THIS SPACE RESERVED FOR RECORDING DATA
THIS INDENTURE Made b .nY... WAYNE G. COLEMAN and REGISTERS OFFICE
ERMA J. COLtMP'N, is wife, ST. CROIX CO.. WIS.
grantor-.S. of....... St..... Croly..................................... ounty, Wisconsin, Recd for Record th1S__ 18th
hereby conveys and warrants to._MZCHAEI...Il__..SIIHI1iS N... nd day of ___,9u._1_Y_____A.D. 19-14
COM.TANCE...J......JOHNEQN..... hushana..and_ fe.,_...as at----- 11.1.5 M.
j-ai.nt.. tonantws•••--•••••-••-••••••••••••••--•••-••--••••-••••.•-................................................ _
- -
..grantee..$ of Register of Deeds
-..S.t.t... CZ:.Q1 ;;...•-••••••--•-•••-•.........-••••-••-•-•County, Wisconsin for the sum of - -
t~1f~ T1 7~~]y~
...YI~Q.r..._`. 4±llc+fi-__g.Q.Q . i!. al Mab.le.... RETURN TO
.
.
the following tract of land in.......... --t.---- Crr.Q1Z ......................................County,
Wisconsin :
Lot 21, Hook's Second Addition to Township of Stanton.
3 aR
FEE
In Witness Whereof' the said grantor ...5. ha...Ve.. hereunto set..i-.... t.heir.......... hand-%. and seal _._S_ this
18th----------- day of July .......••••-----::-'c.: A. D., 1!)--74
~ J
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(SEAL)
SIGNED AND SEALED IN PRESENCE OF Wayne~G. Coleman
-mac jyL*Lti ;::?1L)
!tit .
..Erma JU Coleman
(SEAL)