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AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS
/ k9
>
SUBDIVISION / CSM#~/~ LOT #
SECTION ~.S' T . / N-R W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN T OF SYSTEM Q-T
I a?G /
/8~ ova
ISM
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
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BENCHMARK:
o~
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity:
Setback from: Well House A,2,,5-- Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: ,/e Length_ _/g Number of trenches
Distance & Direction to nearest prop. line:_
Setback from: well: House_ Other
ELEVATIONS
Building Sewer 9l/ ST Inlet: 5~q/,~5 ST outlet: 91S??
PC inlet PC bottom Pump Off
Header/Manifold g7,/ Bottom of system ge,,y/
Existing Grade 1z5e,2k Final grade
DATE OF INSTALLATION: -
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and FiumanRelatiork INSPECTION REPORT ST. CROIX
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar PermitNo.:
16,651
Permit Holder's Name: ❑ City ❑ Village 71 Town o : State Plan ID No.:
GERMAIN, MIKE STAR PRAIRIE
CST BM Elev.: Insp. BM E ev.: , BM Description: Parcel Tax No.:
/a , G/J/ I~, S5 ,rn~
TANK INFORMATION ELEVATION DATA A9600356 ~b 2
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ~~s L!?C ~G Benchmark
Dosing,-- C, tau . k7D. 44 - -D, 60 U5 5/
Aeration Bldg. Sewer
Holdin St/,qf Inlet /
TANK SETBACK INFORMATION St/ I$f outlet
TANK TO P/ L WELL BLDG. Air to
Intake ROAD Dt Inlet
irl
r
Septic NA Dt Bottom
Dos' NA Homer / Man. 7
Aeration A Dist. Pipe 5S`
Holding---Bot. System 3110' 61 IP/'
.,-,-PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
A,,l~ Cc ; 5! ~S
Model um er .q GPM
TDH Lift Eric *on em DH Ft
Ss a
Forcemain Length Dia. Dist. Towels
SOIL ABSORPTION SYSTEM
BED/TRENCH width Length If No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN I N 6_1 DIME 1 N
manufacturer:
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHI
SETBACK Mode er.
INFORMATION Type O /I e,. CH BER
System: (!cnv E UNIT
DISTRIBUTION SYSTEM
Header / Memrfvfd--- Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length /,i, Dia. Length 6s/ Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems
Depth Over Depth Over /y xx Depth Of xx See odded xx
Topsoil Yes ❑ No ❑ Yes ❑ No
Bed /Trench Center L/(/ - Bed /Trench Edges Q - /,/V
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRAIRIE.15.31.18W, NW, SW, 112TH AVE
Plan revision required? ❑ Yes EjlTo
Use other side for additional information. D (o y
SBD-6710 (R 05/91) Date Inspector's Signa ure Cert. No
ADDITIONAL COMMENTS AND SKETCH
y e
SANITARY PERMIT NUMBER:
I
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Safety and Buildings Division
r^~~i~riR 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 -5-) e~~ / y
than 8 1/2 x 11 inches in size.
• See reverse.side for instructions for completing this application State Sanitary Permit Number
The information you provide may be used by other government agency programs El Check l revision'nto p6srevious application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Prope Owner Na a Property Location
114, 5-1,) S T2 , N, R V(or~
Property wner's Mailing d ess Lot Number Block Numt)//er
city, S ate Zip Code Phone Number Subdivisio Na a or M Numbe
( ) ~r
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cityy Nearest Road
❑ Village
E] Public 1 or 2 Family Dwellin - No. of bedrooms Town of ?Y"
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/Condo 0&5> 3-56
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 OnlyExisting System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 CKSeepage 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.hnch) Elevation
Feet IW, Feet
lQkA 64
VII. TANK Ca
in galloacitns Total # of Prefab. Site Fiber- Ex per.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New ExIsting strutted
Tanks Tanks
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for stallation of the onsite sewage system shown on the attached plans.
Plumber' Name: (Pr Plum is ' n ur No~ps) MP/MPRSW No.: Business Phone Number:
Plum er's Addresst reet, ity, State ip Code):
7~ 'd
IX. COUNTY/ EPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing Agent Signatur
Surcharge Fee)
q2k
Approved E] Owner Given Initial J
Adverse Determination O
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SHD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety $ Buildings Divr_ion, 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 nurr ber(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.
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3
Labor and Human Relations
Division of Safety A Buildings in accord with ILHR 83.05, Wis. Ad
COUNTY
sr, c R o I'x
Attach complete site plan on paper not less than 81/2 x 1 i inches in size. Pla ludo{ but
not limited to vertical and horizontal reference point (BM), direction and % of sc aor EL I.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATIO R DBY DATE
4 z--
PROPERTY OWNER: ~G ERTY IQCATION
Z'Ck.4R? 577-00 7-
. LOT 6( 7.; ; /4 5 60 T N,R E (o o
PROPERTY OWNER':S MAILING ADDRESS it }
1553 w.4 7-0 ~ej~5ff T.P.
aim 11a
CITY, STATE ZIP CODE PHONE NUMBER II G NEAREST ROAD
r~~ so.J '514
01(o (715)54'7-(o731 ~vy_ cc
(p4ew Construction Use [ 4-'Aesidenfial I Number of b6drooms 3 +0 4 [ j Addition to existing building
[ i Replacement [ ] Public or commercial describe
Code derived daily flow y °oc~ gpd Recommended design loading rate.,&/A-bed, gpolft2 ' 6 Trench, gpoltt2
Absorption area required N/ bed, 42 / trench, 42 Maximum design loading rate bed, gpd/ft2 ' trench,
Recommended infiltration surface elevation(s) SEA ft .3 4 (as referfed to site plan benchmark)
Additional design / site cons rations VSE` IV
La-v G- A ~ PoLo ' rke -vak5
Parent material vim' C-' (1~1 30veell 4,17 74- Rood plain elevation, R applicable R
S = Suitable for system COI IVOffIO L MOUND IN-GROUND PRESSURE AT-GRADE U SYSTEM-IN FILL HOLDMG TAW
U =Unsuitable for stem E91 C~ S 11 U fib ❑ U 21 11 a-5- 13 U O S
SOIL DESCRIPTION REPORT 1t11R= ,vo? ,PEcoHp~,v~Ef~
Boring # Horizon Depth Dominant Color Mottles Texture Structure Roots GPD/ft Consistence Bourd3y In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed
Tkench
e- b 3/Z 5 z f Sbk- n+~ fit S f , S
l - e ile 5S f
Ground 3 1--ics-ile n,•, -fie Ccv-
elev. _
looL?,? It. 5y 4V VrR
Depth to
limiting F
factor~
Remarks:
Boring #
z-F I
l b- lo y2 31i S K A,-FR . S.
i , G
5' h S Zf
Z /1-)7 /oy~ 3/ Si'~, Zfshe A41-F, S /f , S G
cw - - ~f l - S
Ground -3 X7'3 7,S Y12 31~ I If 5J4 ~ -F P-
elev. 37- 0 _75 Y R 3/ ~S f fl2 - S,
v
/DO, o_5 It.
Depth to
limiting
factor
>
Remarks:
T Name:-Please Print R C(3 a 12 T V L(3 R I'C k T- Phone. 715-- 38&_ 8 1 6
Address: _
Signature: U r c Date: CST Ntimber:
PROPERTYOWNER R1?-4VD 5400-7- SOIL DESCRIPTION REPORT Page Z Of
3
PARCEL I.D. 8 LOT A P ply ~l VET 8&;AJP
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Baxxlay Roots GPD/ft
In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed n
o- o %/R 3~- - 2 f s bK •~f P- s z f s
Z 9-/( /o `/ie 31S~ Z f Shy Lf(,. CS • S • G
Ground 3 ~(o /D Y ,vpE S . 0,5!j elev.
Depth to
limiting i
factor i
3
Remarks:
Boring #
El 1 / 1,9-/2- ioYR 3/z 5/ 44, -FA Z 11-2-.20 /o yX 3i3 511. 11Wf R, s u f , s
3 4o-27 jo Y)e 3l e-,,, -f P q s / of
Ground
elev. 7- D 7SYR31~1 "L4 S. d S •C ?
/oo • Y~ ft. '
Depth to
limiting i
factor y i
i
Remarks:
Boring #
/ o-Q /o /,2 s 6 k /,M-rp s 2 f -S
/o Vg 31y 4~0- c5 c f • S
c ~ • `f • 5
Ground S YR 3/ 5/ /fsh~ ,w4 -FP w
elev. it.
f7,5 YR 81f vfl 51 L 74S6,e 4M-fk 4 5 • S •G
7 s VA 11-114 S D s a 5
Depth to
limiting I
factor
Remarks:
Boring # i
i
Ground
elev.
ft.
Depth to
limiting
factor
S -
13I /0°•/P~
I3Z 100-05-
B 4 Boa, y~
L. 0 T
~3 5
/0 7 •
c~ 2 ~ o
0
lo,
f-
- 113 136
43 of
4t
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix C unty
OWNER/BUYER
MAILING ADDRESS P.O 3 ~I -
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION N 1/4, S U~ 1/4, Section, T-2j_N-R__S_W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION U-1n LOT NUMBER
CERTIFIED SURVEY MAP , VOLUM4.jq9, PAGE0)9, LOT NUMBER J
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 ate.
SIGNED: '
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, W1 54016 11/93
• S T C - 100
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner/ contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
owner of property
Location of propeerty~W -1/4 uJ 1/4, Section _ZS_,T L_N-R 1'~ W
Township J, 1i~l A Mailing address PG . 1 3'70
Address of site 113 I& ox
Subdivision name Lot no.
Other homes on proper y? Yes~_No
Previous owner of property
Total size of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes No
Volume IaQq and Page Number oj~L 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. cj 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.
L0 91V3
Sig Nature f Applicant Co-Applicant
241
234 228 '
LOT 43 OT 42 LOT .41 300 534.
LOT 40 LOT 2 39
~ LOT
T
909 0 907 906 905 89
M . h
48-1
LOT
8 89
SST- - _ER N
OT 38
904 LOT 2
\ o
N 893
2 3 4
LOT 37 .3,39.84'
d
845 846 0 8417 3a9.21 903 LOT 30
a to
N 894
310.62'
N 5
d
N 849 I LOT 36 26'..47'
200 ' ~ . 208' • 22 1 .
254'24 378.63 902 LOT 31
263. 24
I co 895
a LOT 2 CY in
LOT 3 = 6, N
N
10, _ PAGE N 2937
d 6 LOT 3 5
2
54, 6D •G 269 '•D M 8 50 i 8 9F
901 898
92.:18 ' LOT
81' 351. '
1125/-6x4 5 66
,-LOT 3 3 p_
851 LOT 34 f
N 7 a
900 a 899
399.
-
431'~a\ .852 ' - AVE'
2 70 0
2ee.gp ,
SUE
R-
~ SE
Z14 - S w 114
0 9 I 13 _ 14 N 15
vat ff99PAa1 4 %
549143 STATE BAR OF WISC NSIDEED M 1 - 1982
WARRANTY
DOCUMENT NO.
- REGISTERS OFFICE
This Deed, made between ST. CROIX CO., WI
Ric-bard f1 Stout Reed for Record
SEP 6 1996
Grantor,
and Mi r•haPl -J Qnrmai n and Mi r-hal 1,e M Ge-ma i.n, at 8'30 A M
hiishand And w.i fA T. tl...,.-K J.4k.
Regis1wr of Deeds
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration
Richard O Stout
conveys to Grantee the following described real estate in St. Croix THIS SPACE RESERVED FOR RECORDING DATA
County, State of Wisconsin: NAME AND RETURN ADDRESS
Lot 5, Plat of Apple River Bend, Town of
Star Prairie, St. Croix County, Wisconsi . P-Q• 8w*,V'q
d3~ f I I -SCE
PARCEL IDENTIFICATION NUMBER
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TRAINSFER
6
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This is not
homestead property
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And Richard O. Stout
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements, restrictions, rights-of-way and covenants of record,
if any.
j
and will warrant and defend the same.
.
Dated this 30 day of August 1199 ~
(SEAL) (SEAL)
I I
* Richard O. Stout
(SEAL) (SEAL)
* * ii
AUTHENTICATION ACKNOWLEDGMENT
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State of Wisconsin, r
Signature(s) SS.
St. Croix County. ill
y
Personallv came before me this _ly 3 day of