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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
~ a
ADDRESS / Zgs/ef if 4~
SUBDIVISION / CSMJ LOT
SECTION _T N-V/W, Town o
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
11-111, AO A
f ~
ti e
L
_J e-
r
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tangy; manhole cover.
BENCHMARK' O
ALTERNATE BM:
SEPTIC TAN PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity:
Setback from: WellAo?~~ House a Other
t Pump: Manufacturer Model# Size
Float seperation Gallons/cycle :
Alarm Location
/ SOIL ABSORPTION SYSTEM
Width: Length Number of trenches
Distance & Direction to nearest prop. line: ZQ
Setback from: well: House Other
ELEVATIONS /
Building Sewer ST Inlet:
ST outlet
PC inlet PC bottom Pump Off
n
Header/Manifoldf-10";?6 Bottom of system
Existing Grade ' Q Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER: 1513/
INSPECTOR:
3/93:jt
i
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations
INSPECTION REPORT ST. CROIX
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Permit Holder's Name: ❑ City Village Town o : State Plan ID No.:
RYDER, ROBERT Star Prairie
CST BM Elev.: Insp. BM Elev.: BM Description: l Parcel Tax No.:
ads /rJ1~. ~P as
G61
TANK INFORMATION ELEVATION DATA V61196
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
i
Septic (~p S Cant', Benchmark
Dosing
Aeration Bldg. Sewer ("Os,
Holding St/ Inlet J , 97(01
TANK SETBACK INFORMATION Stq,4 Outlet 7~ 97.3
TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet
Ar I
Septic NA Dt Bottom
Dosing NA Headers 7' 970 '
la
Aeration Dist. Pipe 9(11,~y
r
Hold in Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand T
Model Number GPM
TDH Lift Ion System TDH Ft
_-ROss ead I 7 F
Forcemain Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width LengtFj~ i No. Of Trenches PIT No. Of Pits inside Dia. Liquid Depth
DIMENSIONS e „,1L DI N
u acturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM
INFORMATION Type Of W P CHA Mode Number:
System: S.C. 5.7J S~ Sd -//0, OR UNIT
DISTRIBUTION SYSTEM
Header / Mawifel Distribution Pipe(s) , r r7~: x Hole Spacin Air intake
Length Dia. Length ~ / Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Gr Sy s Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sod a xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoi ❑ Yes ❑ No No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Star Prairie.3.31.18W, Govt. 1, West Cedar Lane
Plan revision required? ❑ Yes No
Use other side for additional information. P 6 / pro S--
SBD-6710 (R 05/91) Date Inspector's Signa ure Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
o
i
y
SANITARY PERMIT APPLICATION BSale" an Bu I Idis
ureau of Building WaferlSystem!
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. S
• See reverse side for instructions for completing this application State Sanitary Permit Number
A05-1310
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)].
7-,4 o'r_" State Plan I.D. Number
1. APPLICATION INFORMATION - PLEAS PRINT ALL INFORMATION
Property Owner Name Property Location
r 1/4 1/4,S T ~ , N, R / (or W
Property Owner's Mailing Address Lot Nuplber Block Number
City, at Zip ode Phone Number Subdivision Name or CSM Number
11. YPE F BUILDING' (check one) ❑ State Owned City Nearest Road
Public 1 or 2 Family Dwelling- No. of bedrooms ° Vowa OF
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment / Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Ch ck 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 __stem 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
11Seepage 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
300 1-11216 Required (sq. ft.) Pr osed (sq. ft.) (Gals/ y/sq. ft.) (Min./inch) G~ Elevation
. J-149 e / Feet Feet
VII. TANK Capacity
in gallons Total # of Prefab. Site Fiber- ExPer.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel lass Plastic A
New Existin structed g PP'
Tanks Tanks
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑
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.
.RILLmber's Name: (Print)] Plumb Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
Vr 3_31t
Plu er's Address (Strpet State, Zip Cod
-1
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue issuing Agent Signature tamps)
roved Surcharge Fee)
pp roved Owner Given Initial
Adverse Determination D
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SOD-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 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 Perm i-L 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 lice used 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 thissanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax numLer(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, re .onnection, or repair.
V Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide ail 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 constructec, and tank material- Complete for all s,:ptic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks received experimenta 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 Robert Ryder ADDREss2361 West Cedar Lane New Richmond Wi 54017
1/4 1/4S 3 /T J N/R W TOWN Star Prairie COUNTYST. CROIX
rG~ n
MPRS BYRON BIRD JR. 3318 DATE 7/22/96 BEDROOM 2
CONVENTIONAL M IN-GRO D PRESSURE ONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 800 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 432 BED SIZE 18'X 24'
BENCHMARK V.R.P. Base of Siding ASSUME ELEVATION 100'
❑ BOREHOLE (DWELL *H.R.P. Same as Benchmark
VENT SYSTEM ELEVATION 96.8
12" GRADE
TYPAR COVERING
1 6' Q 3' 3'0 3'
d SEWER R K
12' 18'
Cedar Lake
100' of Lakeshore
T
5' 40'
3 Season
4' Porch
15' 28' *B. M. 16'
Well •
8' Building Sewer will
be insulated if the 18"
oN 30' cover is not
0 50' ST to be °Ia maintained o
c~ >25' from
T Well lope
r r
20' Garage
B-2 Driveway and
10' B-1 10' Parking Area
I
I
L15'
Well I I
15' -3 18' X 24' Bed
Property Line
West Cedar Lane
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. Adm. Code
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 Z, Y I Q
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
13 -q0 -ovo
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
r- Govt. Lot _ 1/4 1/4,S3 T N,R/~ E ( r) W
Z - IRVC& -
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
5 "f
city State Zip Code Phone Number Road
❑ City ❑ Village Town Nearest
❑ New Construction Use: Residential / Number of bedrooms Addition to existing building
Replacement ❑ Public or commercial Describe:
Code derived daily flow gpd ? Recommended design loading rate bed, gpd/ft2, trench, gpd/ft2
Absorption area required bed, ft2 ✓ 7.,5- trench ft2 Maximum design loading rate bed, gpd/fF rench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material L[JG> 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 S ❑ U XS ❑ U •S ❑ U )4S ❑ U ❑ S U ❑ S XU
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
l 1 I
AV) Y
Ground
eelleev.
I -
Depth to
limiting ;
fYto
Remarks:
Boring #
Ground
ew.,
ft.
Dptf1 to
limiting
f
/)r in. Remarks:
CST Name (Pleas rint) Sig Telephone No.
r 7lS- ' 761
Addresa~ Date CST Number
~~GG//
SOIL DESCRIPTION REPORT
PROPERTY OWNER - Page of
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots G~ptft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
i O
Ground
v~ ft.
Depth to
limiting ;
f o
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
SBDW-8330 (R. 08/95)
Soil Test Plot Plan
Project Name Robert Ryder Byron -Bird Jr.
Address 2361 West Cedar Lane
New Richmond Wi 54017 CS FP '01
#3479
Lot Subdivision Date 7/22/96
1 /4 1/4S3 T,5l N/R f Y W Township Star Prairie
Boring ()Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Base of Siding
System Elevation 96.8 * H R P Same as Benchmark
Cedar Lake
100' of Lakeshore
T
5'
/40o
3 Season
4' Porch
15' 28' KB. 16'
ell
rn
50' %
lope
r r
Garage CD
B-2 Driveway and
10' 0% Slope Parking Area
20' B-1 10'
15'
15' -3
Property Line
West Cedar Lane
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OVYNERBUYER V kA
~ ~T~r T `/may
MAILING ADDRESS. l mil,ac %x/
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITYlSTATE xA
60Ovt/P;r'
PROPERTY LOCATION 1/4, 114, Section T_2 ZI W
TOWN OF /"~1 C ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIF'I'I VOLU 7~AGE L.~/LOT NUMBER
ED SURVEY MAP. ME ~
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 tanks 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
plun*,'Cr, restricted,plumber or a licensed pumper verifying. that (1)
and by a mater plumber, journeyman
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 trust be completed and returned to the St. Croix
County Zoning Otcer within 30.days of the three y e piration
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, W1 54016'. ` - 11193
This application form is to be..completed in full and signed by the
owner(s) of the' property bein4~developed. Any inadequacies will
only result in delays of ~he he..'.: permit issuance. Should tiAs
development be ."intended for ;resale by owner/contractor, (spec
house),, then a",'second form should be'retained and completed when
the property s' sold and-'.submitted to this office with the
appropriate deed recording.
-
41 &1
owner of proper t
y .
Location of prope fyr t /4 '1/4, Section ,T.. 4Z.N-R W
Township % Mailing address
7L Z,
Address of site "
Subdivision name Lot no.
other homes on property? Yes-No 1
Previous owner of property
I
r
Total, size of property
Total size of parcel
Date parcel was created
Are all corners and.lot`line's , identifiable? _Yes No
Is this property being developed for (spec house)? Yes 'No
as-recorded with the Register
63
Volume and Page Number
• -c r
of Deeds.
------------------T-------i~-
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 o f a •
warranty; deed recorded i of ice of the County Register of
and that I (we) p r
Deeds as Document No. , resently
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.
Sig ature o App 'cant Co-Applicant
-7 Z r/
Date of Signature Date of Signature
DOCUMENT NO. VIARi 1WTY DEED
STATE OF WISCONSIN-FORM 9
I ? TIM SPACE RESERVED FOR RECORDING DATA
THIS INDENTURE:, Made by Sherman K. Stromen and
Isabelle-_~tromen, his wife_ ST. c.i o;x ca,. wl,>.
grantor of St. Croix
County. Wi~ccinsin, hereby conveys an4t warrants d• r` OvPril>e 1- _ _ r,. Li. 1
to Robert- R._ der an Audrey J, Ryder _8-30At Pt4.
husband and wife as Oint tenants
t :,isl r
- -
gra°+ RETURN TO
of County, Wi nsi , for the sum of
_ one- doll _ and-other andother good and va ua~ile
consideration
the following tract of land in Croix County, State of Wisconsin;
A parcel of land in Gov. Lot 1 in Section 3, Township 31 N,
Range 18 W, St. Croix County, Wisconsin, described as follows:
Commencing at the meander corner on the South line of GOV.
Lot l; thence West on said line for 339.5 feet to the place
of beginning; thence continuing West on said South line for
214 feet; thence North 15012' East for 147.3 feet to the
Westerly side of an old road; thence South 50008' East for
218 feet to the place of beginning.
1
1111 ~I ~ S:' - r,
FEE
IN WITNESS WHEREOF, the said grantor s ha Ve'hereunto set their_ hand S and seals-- this---3rd
day o(_ October A. D., 19 69
.
~7
SIGIyED'AND SEALED IN PR N O ' ~;~//~Gtsr.e (SEAL)
Sherman-K,t _ _Stromen_._
e F ho ns (SEAL)
- - -Isabelle
tromen
(SEAL)
J.A. Gres -
(SEAL)
RTATF nr? 1LVTCrnAT0m?