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STC - 104
AS BUILT SANITARY SYSTEM REPORT J, RKU
DE c 3 196
OWNER
ST C140X
- N CCkf fiFTY
ADDRESS 7X (2 \,,,-N,.Z.GN-iNGQFPtCE A,
MEW
SUBDIVISION / CSM# A8/~&UE& 13a&42 LOT #
SECTION /S- T3/N-R16 W, Town of, f UU)!eAa &
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
/®®o c L s. 'T,
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50, LOT LjA(,9-
13rl
ON rOP se za7 -57,+Xe 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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rte' '
BENCHMARK : To n 31 LO T S LA Jr&
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity: /1000
Setback from: Well NoT /ni House ffor other-, 014, 16 S ~
Paillpe Man Model# Size
Float separation Gallons/cyc e:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length 5-7 Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: NoT ZAC House "7- iAf Other
ELEVATIONS
Building Sewer ST Inlet: ~5.6 9 ST outlet: 0,
PC inlet PC bottom ffA Pump Off
Header/Manifold jh 3' 7 G Bottom of system
'ToTT-
Existing Grade Final grade a_
DATE OF INSTALLATION-
PLUMBER ON JOB: )2,
LICENSE NUMBER: 31205
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION 284209
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
DIETHERT, TODD STAR PRAIRIE
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
/ r le--, / 4
TANK INFORMATION ELEVATION DATA A9600460 111-20126
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark d lp /
Dosing
Aeration - Bldg. Sewer
Holding st/)iIillt Inlet Af /psG
TANK SETBACK INFORMATION St/A Outlet S•~' /ps 3S/~
TANK TO P/ L WELL BLDG. Airl to ntake ROAD Dt Inlet
rl
Septic Z NA Dt Bottom
Dosing NA Header:
Aeration - -IVA Dist. Pipe g~ &S5 Holdin Bot. System 7 (07' Idl
oe?
PUMP / SIPHON INFORMATION Final Grade
,
Manufacturer Demand 01~s,7-
Model Num._ GPM
TDH [Forcain Lift Friction System TDH Ft
oss
Length Dia. H Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width ' I Length ! No. Of Aenches PI No. Of Pits Inside Dia. Liquid Depth
DIMENSION S DIMEN I N
SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEA
INFORMATION Type Of pa,,,, Qrj(r _ i , MBER Model Number:
System: -Er-,, { s >50 75 OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pip_e(s)~ x Hole Size x Hole Spacing Vent To Air Intake
Length 1'~L / Dia. Length Dia. Spacing
SOIL COVER X Pressure Systems Only xx Mound Or At-Grade S ms O
Depth Over Depth Over xx Depth Of rx Seeded /Sodded xx ched
Bed /Trench Center Bed /Trench Edges Topsoil E] Yes El No El Yes
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRAIRIE.15.31.18W, NW, SW, LOT 23, COUNTY ROAD CC
Plan revision required? ❑ Yes B-9,0-
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
f,^raiiirrs Safety and Buildings Division
v'~~■~R SANITARY PERMIT APPLICATION Bureau of Building Water System!
.O E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O.E. 201
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. C ro X
• 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 ❑ Check 1i revision t~ lous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Own r N me Property Location
T IV114 CU 1i4, S S T 3 , N, R 00 E (or(o
Property Owner's Mailing Address Lot Number Block Number
Ty 3
[City, State Zip Code Phone Number ivision Name or CSM Number
YPE F BUILDING: (check one) ❑ State Owned ❑ !ty Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms _3- E Towan OF C~
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo o3,p - //7F- g 0
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. p'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./inch) /o 2 Elevation
5-63 5- 70 l 1,6 4,e
VII. TANK Capacity /D Feet wr Feet
INFORMATION In gallons Total # of Prefab. Site Fiber- Ex er.
Gallons Tanks Manufacturer s Name Concrete Con- Steel Plastic p
New Existin strutted glass App.
Tanks Tanks
Septic Tank or Holding Tank
lax) -I I ~p i KJr ❑ ❑ 1:1 E] 1:1
Lift Pump Tank /Siphon Chamber 1❑~ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATE-MENT
1, the undersigned, assume responsibility for installation of the onsite sewage s stem shown on the attached plans.
Plumber's Name: (Print) Plumb Signature: (No Stam s) M W No.: Business Phone Number: l
Plum er's Address (Street, City, State, ip Code):
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing A ent Signatur (No St ps
Approved ❑ Owner Given Initial It . p~ Surcharge fee)
Adverse Determination ~O ~rD..,
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to Counly, 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 any nevi 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 exMing 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 isto 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.
Art~x 7i r-/015.
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Labor and d Human Department Relations Industry, SOIL AND SITE EVALUATION REPORT Page / p f 3
Labor a
Division of Safety A euitdings in accord with ILHR 83.05, Wis. Ad
~0 11 COUNTY QdL
Attach complete site plan on paper not less than 8 112 x 11 inches in size. PI nclude, bu sr. c R o I' K 111% - not limited to vertical and horizontal reference point
(BM), direction and % s 11 CEL I.D. /
dimensioned, north arrow, and location and distance to nearest road. scalar
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATI I DBY DATE
iD~ I. Jib
PROPERTY OWNER: k ~i'G !I A /?D STO v 7- 14 Sl~I~I e T 3/ N p
PROPERTY OWN R':S MAILING ADDRESS ' ' E
Sti
/ 3S3 W4 7-0 A-~Z= T.P. NA OR CSM! ,
CITY, STATE ZIP CODE PHONE NUMBER
OPOWR~
ST ROAD
H v Sow /S , 5 y01(v (;71!5) 5g1j - (07 73 l GE
R'h l t E- ~S'wy- c C
(ptfew Construction Use I'+) Residential / Number of b6drooms 3 +0 y
I I Replacement y o _ ( I Public or commercial describe I) Addition to existing buiklktg
Code derived daily flow 70 oel gpd Recomierided design loading rate 7 bed 2 2
9P kench,gpdM
Absorption area required bed, ry2. _75'-0 trench, R2 Maximum design loading rate ' 7 bed, gpd/ft2 g
Recommended infiltration surface elevations S~9 t0. •3 tretxh, llf2
R (as referred to site plan benchmark)
Additional design / site cons rations
Parent material ScS (11)
~3yrt?~'G -V 7- Flood plain elevation, If applicable tt
S = Suitable for system C VENTIONAL MOUND
~1 RoUNO PRESSURE AT X91 SYS NV t1LL Fp1 ON~;f TAW
U- Unsuitable for stem s❑ U G O U O U [j S O U ❑ U O S
SOIL DESCRIPTION REPORT 41I2= /"071 ,PE~oti/~~,vflLCf~
Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft
In. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh.iste Rood
Bed
/ 9-13 /o R z 2~sbK .ti►^ v~R 5 / . S -C-1
13 2-
13-3f IoYk,313 2, +s6,t Im fie a cu f .5
Ground y 60 7 ,Sye y
S _ S .7
elev. • g
/03.3 ft. U /D ,e S" s.-.609
S - ? S
Depth to
limiting
lac
7
Remarks:
Boring #
0-7 -0
Y/f
2-13 5 Z~f Y k IW-6e 6' 4j If .5 y 3a 7s y 9,~ ~E« / . ~ s
13 2-- _7-1Y 101le 313 -1 -Fme 1&1-6e 17--57 57
Ground C S Gfit~ C
elev.
Depth to
limiting
factor q
Remarks:
S Name:-Please Print P018 tR r
LQ R "C k T' Phone:
Address: 7~5= 3g~i - gs
'
S//' f4l
Signature: L Ulbricht /llt Y, V" priusts Sawaaa consultants Dale: CST
.
PROPERTYowin Pl?-44.eP SY007- SOIL DESCRIPTION REPORT Pagez of 3
PARCELI.13.1 LOT Z3 - /f1E~ t4~Nf,
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence 13=13y Roots GPD/ft
In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tmnch
ow O /o z 2f'S~k /!M v-,c
.
2 1.0-1P 31IAO dS~ S -7
Ground j 3 /D /,m
G~s c4J - • 7 g
elev.
01-4 It. 36 - o S. D S -
Depth to
Ilmitlng
factor
Remarks:
Boring #
Z 7-16 e 31-3 S -fS6~ ~rfe <S • 5 .
3 o s //0 1 ~s .7 .
Ground
elev. - /O S ~~'X .S . d S G~iQ 2 Z 1. g
/03,5-fl.
Depth to n 7 s S S
Imitlng
facto
Remarks:
Boring #
. D-// /o Y/e /-,41 sh r iwr v ie C s 3 .7 S
2- /a Yle -7
. $
o le o s cs - .7
Ground
/elev.
0& t.
Depth to
limiting
factor
~L
Remarks:
Boring #
Ground
elev.
ft.
Depth to
Wiling
factor
W rn G c
W LA) a (OD 1 =m p >
? v Ln v' N L dam
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER l0Q 0 ~ /1-- Thy g-R 77
MAILING ADDRESS x_'1,35 g77'f1 ST. , "C on/ W, Yyat y
PROPERTY ADDRESS 11411 2 /2.' A-yi5- A&&2 ~r'C~~otiio L~y * - "
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE Mew alot `CiF1'7,0Af"_) W.; .5-y0/?
PROPERTY LOCATION NlU 1/4, 57W 1/4, Section 16', T __U / N-R_Jg _W
TOWN OF 5rA& PST. CROIX COUNTY, WI
SUBDIVISIONAPne &oek I~ /VFW LOT NUMBER
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 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 ye per ion da
SIGNED
DA
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 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 /ODD D«Tff eR T
Location of property_AL4e) 1/4 5W 1/4, Section T_VN-R_Zg _W
Township SzA& P-AALIPA Mailing address /y3S- y~7-//Si-
Address of site [y„Q / 7// le- aAoo
subdivision name ~/1~ L,67-7 ffuLot no. ~3
Other homes on property? Yes__,K_No
Previous owner of property te OcA 12 Zoc-t
Total size of property
Total size of parcel / 7/ Ar e.S
Date parcel was created A12 j1 /,ay G
Are all corners and lot lines identifiable? k Yes No
Is this property being developed for (spec house) ? Yes No
Volume 00/ and Page Number 9.~ 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. 5y(FFJ 6 , 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 ure of Applicant Co-Applicant
Date of Signature Date of Signature
► Jct9A2[ STATE BAR OF WISCONSI,: FORM I - 1982
54992G WARRANTY DEED
DOCUMENT NO. U~l~ ~ AMSTERIS OFFICE
°y UUU 96
ST. CROIX 00., WI
This Deed, made between Richard O. Stout f~cakcF#toot0 Y
` SEP Z 4 1996
Grantor, at 2:40 P. M
and Todd J. Diethert•yf~,•,~
j Replatwof Deeds
Grantee,
Witnesseth, That the said Grantor, for a valuable
,
Richard O. Stout 3i 3p
conveys to Grantee the following described real estate :It St- Croix THIS SPACE RESERVED FOR RECORDING DATA
County, State of Wisconsin: NAME ANO RETURN ADDRESS
Lot 23, Apple River Bend First Addition, jp,~Fr S(bl(r
Town of Star Prairie, St. Croix County, ti357S (ataXrMtC-:6-M-
Wisconsin. LjnS,
~ }IN~SO N =1-
r Stfo ►6
PARCEL IDENTIFICATION NUMBER yy
F _
_f
t
s hA ER
t
This is not homestead property.
(is) (is not)
A
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 ~.ny.
and will warrant and defend the same.
Dated this 21st dayof September 1~6
' yC7C (SEAL) (SEAL)
Richard O. Stout
(SEAL) "(SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Wisconsin,
SS, k
St. Croix stn
authenticated this day of , 19 Personally aunt befre ine this 21st day of
September , l9 96 , the about named
Richard O. Stout
_ TITLE: MEMBER STATE BAR OF WiSC ONS
(if not, A
authorized by 9706.06, Wis. Stars.) t to me known to be the person who executed the foregoing
~1►0
C _ instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED By
Janet P. Stout ti• pU$L~
1353 Awatukee Tr- t-1 I)VI At JO )A- J