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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
a
ADDRESS Gwx k
SUBDIVISION / CSM'
LOT
SECTION
_TN_R W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i
5-
,~~,'Je~~ V BD MA 2 6 1991
~~CEt
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center nr a
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: _ Liquid Capacity: p
Setback from: Well-. House Other
Pump: Manufacturer Model Size
Float seperation Gallons/cycle
Alarm Location
:SOIL ABSORPTION SYSTEM
Width: Len th l
g Number of trenches
Distance & Direction to nearest prop. line:
~ V
Setback from: well:__,E_ House Other
ELEVATIONS
Building Sewer Tn Z ST Inlet._
ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:-
3/9 3 j t
Wiscdnsin DepaIrtment of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and 14-;man Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
268611
Permit Holder's Name: ❑ Cit E] Village Town of: State Plan ID No.:
CONSTANT, STEVE STAR PRAIRIE
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
CO" J
TANK INFORMATION ELEVATION DATA A9600309
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark i '
Dosing - /.U
Aeration Bldg. Sewer 9p p3'
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet y~ 3
TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet
rl
Septic NA Dt Bottom
-99
Dosing NA Header/Man. 7' 9a-25
Aeration NA Dist. Pipe 11,5, Qs -
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade o r S.g
Manufacturer emand
Model Number GPM
TDH Lift Loss System TDH Ft
Head
Forcemain Lengt Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION ' '74 DIMENSIONS
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type O~ 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 -q.c f' Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRAIRIE.10.31.18W, SW, NE, OLD MILL RD
Plan revision required? ❑ Yes [21No
Use other side for additional information. 3 Q r~i 6
SBD-6710 (R 05/91) Date sp cto ' Signature Cert No
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
I
I
I
Safety and Buildings Division
"~GE rin 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 8112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Per it Number
o~(V g (a t l
The information you provide may be used by other government agency programs ❑ Check it revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFO
Propert Owner N e Location
4 1/4, S T , N, R , (or6//
Prope y O 1 ~rla n Addr ss Lot Number Block Num r
Cit tate f 100 Zip Code Phone Number Subdivision Name or CSM Num r
11 , A~~4 I ( oy~ . TYPE OF BUILDING: (check one) E] State Owned El City Nearest Roa <~4e A~
❑ Village /
❑ Public 1 or 2 Family Dwelling - No. of bedrooms 01 Town 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: (Check only one box on line A. Check box on line B, if applicable)
A) 1. pq New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
------System System Tank Only----_------ Existing System -__-____-Existing System
-
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
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 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./i ch) Elevation
5 Feet Feet
VII. TANK Capacity in alIo 5 Total # of Prefab. Site Fiber- Exper.
Con- Steel glass Plastic Appistin
INFORMATION New g E x Gallons Tanks Manufacturer's Name Concrete strutted
Tanks Tanks
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility f installatio the onsite sewage system shown on the attached plans.
Plumb 's Na : (P nA) Plum er's i at o S mp T P/MPRSW No.: Business Phone Number:
Plu ber' IAddress (Strr-e~et, ity, State ip Code .
C
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sarlflary Permit Fee (In(ludes Groundwater Date Issue I ing Agent Signature (No Stamps)
ttt~lll~J Surcharge Fee)
Approved ❑ Owner Given Initial
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBO-6398 (R. 05/94) DISTRIBUTION: Original to Cnunty, One copy To: Safety & Ruildings Divi ion, Owner, Plumlyer
INSTRUCTIONS '
1. A sanitary permit is valid for two (2) years.
2_ Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the
county prior to 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) 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.
. 677 72
.
7
Tae
78
h
F Z \
Y '91
\
,ate
Am (VQ
~usti
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 1/4 1/4,S T N,R )~(or '
P wner's Mai mg Lot # Bloc Subd. Name or C M#
Ci ip Code Phone Number Nearest Ro d 11'WkXA4Q I 711J~,r_7 =/7 I AA;_
J a ( / ) ❑ City villa Town
t4 New Construction Use: EZ Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow : L _a gpd Recommended design loading rate bed, gpd/ft2_,j/trench, gpd/ft2
Absorption area required bed, ft2_,750 trennc~h, ft2 Maximum design loading rate _bed, gpd/fi2 c~ trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design/site considerations A
Parent material L~f ,11 &zeq 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 S❑ U [F] S ❑ u CZS ❑ u ❑ S Rfu ❑ S 19 u
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2
g Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Con . Color Gr. Sz. Sh. Bed ,Trench
Yi (9-9 '61
Ground /
elev.
ft.
Depth to
limiting
factor
yq in.
Remarks:
Boring #
GZ -f
now
Ground s _
elev.
q5__~ft.
Depth to
limiting
factor
~in. Remar s:
CST Name (Ple se rint) Signature „ Telephone No.
'
y
Address Date CST Number
7
PROPERTY OWNER z SOIL DESCRIPTION REPORT Page of
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
.41 Z,
- ~ b
_
Grounds t--?6- Sv AC I
Depth to
limiting
factor
Remarks:
Boring #
L /
j
Ground 9K YV/v - _
elev.
Depth to
limiting
factor
Zn.
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 #
l
- -
Ground - -
e ev
ft.
Depth to
limiting
factor
,>A/- in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBDW-8330 (R. 08/95)
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
11 St. Croix County
1 I
OWNER/BUYER 5~ T t~ v p n t~Gi e h P 1 n n S'7" G2 YI T
MAILING ADDRESS 11&(o m t I 1 PA, (Y lLt- tt r' mr9nd,Wj, 5
A(al7
PROPERTY ADDRESS I/ l /I /f It
/ t
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE 9 c A m o AA.
PROPERTY LOCAii TION &V 1/4, kE 1/4, Section W
TOWN OF S ' a r Ariairlto ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP , VOLUME, PAGE , LOTNUMBER
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 treaunent 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 (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: /-z E22 St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
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 .341.0E _RaAel C.C2 S+a r,
Location of propertyAIW 114_1/4, Section 10 J31 N-R I8 W
Township S-ckd' PNk;rt`e Mailingaddressilte(d CIA. ol~'l~
i ' Sq 7
Address of site at'uhniand'eCt i, 6-y0(7
Subdivision name Lot no.
i
other homes on property? -Yes ~ No
Previous owner of property ShelJOA t~c4s5e'l/
Total size of property 57.77
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? _L_ Yes No
Is this property being developed for (spec house) ? -Yes _I~No
volume g 7 7 and Page Number 204 as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCLIME'NT NUMBL••IZ, VOLUME AND PAGE
NUMBED. AND THL: SEAI, OF THE REGISTER OF D1iEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the decd description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
_ Cpr'f-i-C'a Sceyej ma iS UIfXEr~n~~~-
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. L~q 3() 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.
LO.A
ant.
'cant Cc`-A lic
signature of Al>>li [~P
5x3
4F - ___L J_ f __'L_.. - -
S gnaturc DaLe 0 Date of Signature
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1 1982 ! TN's srAcs Ressavco row Rscoao'NO owri. «
WARRANTY DEED
40930 10". f
yo. ~VP"cE 224
REGISTER'S OFFICE
-_p This ?deed, made between Sheldon P.. Russell ST. CROIX CO., Wl ~
Recd for Record
Grantor, pt SL15 2 ls~o M
and---- StQYgn..D...CQn-stallt..and..Rubed._.R...ConsuiLt_,..hu_sban.d.... ' A•.A
and-,wife.as...susvivcrs-hip._alsrit-al.._Property--• ( QI C~ .JrX.
Reytstero#Oe~dt
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration......
_ = - i
RETURN TO
conveys to Grantee the following described real estate in ._..St._.CXRiX...._...._.. ( Northwest Federal i
County, State of Wisconsin: P. O. BOX 160
INew Richmond, WI 54017
Northwest Quarter of Northeast Quarter and the Southwest a: Parcfl No:..______
Quarter of Northeast Quartet except a parcel o escribed
as follows: Commencing at the North Quarter corner then
S 0°21'33"E 1693.70 feet to the Point of Beginning; thence
S 89°50'05" E 550.02 feet; thence S 0°21'33" E 968.04 feet;
thence N 89°50'05" W 550.02 feet; thence N 0°21'33" W 968.04
feet to the Point of Beginning. All in Section 10, Township
31 North, Rsnge 18 West.
TRANSFEA
S". 40
r
-M
This &0.BRt--------- homestead property.
(is not)
i` Together with all and singular the hereditaments and appurtenances thereunto belonging;
` And........... gK4111 iC.. tle1 dQ?~._ _.._Kussell
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements, covenants and restrictions of record, if any,
and will warrant and defend the same.
Dated this . day of Ju 1 .9-0....
•-----•-----------•-----------•-----------------------•------•-------(SEAL) - (SEAL)
Sheldon P. Russell
•
......................(SEAL) •-----.(SEAL)
s
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
as.
_St---Croix................... County.
authenticated this day of ..........................119 Personally came before me this . day of
July 19-.90-- the above named
Sheldon--P-Russell--------------- 1'kgGiL j.'t-
i
-
TITLE: MEMBER STATE BAR OF WISCONSIN
=
(If not,
authorized by 1706.06. Wis. State.)
to me known to be the person lxrwho ei;q;utM