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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
,cl~~I
ADDRESS 4
c~,~ Trr`
SUBDIVISION / CSM#~~~r`G>~d2,~ LOT # 3,5
SECTION T/ N-R_4r W, Town of _5- r6, ,'e C-
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
41
s e~ G `r
l~
INDICATE NORTH RROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: JQ d~ / /
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: A7,k, e s T Liquid Capacity: Z;21--9,j
Setback from: Well House /S' l Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length 7 J Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: 3--C" House_ Other
ELEVATIONS
Building Sewer 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: 1
3/93:jt
-Wisconsin Department ofIndustry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
• (ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION yy 268584
Permit Holder's Name: TAR PI yRAI Town of: State Plan ID No.:
RICHARD STOUT
CST BM Elev.: Insp. BM Elev.: o BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9600290 f
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
i
Septic -C) Sf a! /77,,+ Benchmark
Dosing
Aeration Bldg. Sewer 0 A 260. 17
Holding-" St/$ Inlet agl
TANK SETBACK INFORMATION St/ Outlet (o, 'h~ 5cf 99,7-:5'
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom ,
Dosing NA Header/Man. n r~ i
Aeration NA Dist. Pipe 7 ad
Bot. System g3~
Holdirigf'
PUMP/ SIPHON INFORMATION Final Grade
ManufKturer Demand=1~ cC
Model Number GPM
TDH Lift Lriction Y _ _,DJH
ead
Forcemain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width i Length I No. Of Trenches PI No. Of Pits Insi ia. Liqui epth
DIMENSIONS
1
DIMENSIONS 5 5-
LEAC Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM MBER
r~'~ ti~~/ Jed -Model Number:
INFORMATION Type Of OR UNIT
System: r
DISTRIBUTION SYSTEM
Header / Manifold r Distribution Pipe(s) 7„c~! x Hole Size x Hole Spacing Vent To Air Intake
Length L- Dia. Length Dia. Spacin I//
SOIL COVER x Pressure Systems Only xx Mound Or At- e s Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded d
Bed /Trench Center Bed /Trench Edges Topsoil C] Yes [0] No E] Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etcj,-A5 r~k h
-r, ' ~ nC_ 363r(
LOCATION: STARQ PRAI IE.15. 1.1 W, E, SW, 212 AVE
L. 4 01)
Plan revision required? ❑ Yes 2-90
Use other side for additional information. 9G
SBD-6710(R 05/91) Date Inspector'sSignatur Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
Safety and Buildings Division
v~■~~r■r~ 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 Cou":!~ ('A.,-
than 8112 x 11 inches in size.
• See reverse side for instructions for completing this application state sanitary Permit Number
I? eo S, . -Sq
The information you provide may be used by other government agency programs W~eck if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
v et < 29 /J&1/4_5,,,,j 1/4, S T_,7l r N, R l gt (or)a
Property Owner's Mailing Address Lot Number Block Number
12 S-7 4 r<T'u ~ c o , ~ 3
City, State [Zip Code Phone Number Subdivision Name or CSM Number
0 G
e-,
rl o
46~ Z4 r
( t Lj,,., 00_4.1e]
Ill. TYPE F BUILDING: (check one) Q State Owned ❑ it~ Nearest Road
❑ VII age /Y G
Public 1 or 2 Family Dwelling - No. of bedrooms Town of TQ y r~
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo g -
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
S ❑ 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. 5' New 2. ❑ Replacement 3. ❑ Replacement of 4. Q Reconnection of 5. Q Repair of an
System System Tank OnlyExisting System _________Existing System
B) VA 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) Elevation'
45111 1 7 S G SG) , W. S1~' Feet 'Feet
VII. TANK Capacity
in gallons Total # of Prefab. Site Fiber- Ex er.
INFORMATION New Exist in Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
structed
Tanks Tanks
Septic Tank or Holding Tank r El ❑
Lift Pump Tank /Siphon Chamber El ❑ El ❑
VIII. RESPONSIBILITY STATE-MENT
I, the undersigned, assume responsibility for installation of the onsite se ge system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No S mps) MP PRSW No.: Number:
Business Phone
1
Plumber's Address (Street, City, State, Zip Code):
0,l
IX. COUNTY / DEPARTMENT USE ONLY
ncludes Groundwater ate ssue Issuing Agent Signature (No-Skamps)
❑ Disapproved Sanitary Permit Fe ,
r[J A roved Surcharge Fee)
Pp E] Owner Given Initial 7
Adverse Determination 1'1~a,4,14 1(4Kt,4J~
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 ne,,n( 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 most 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 8 112 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.
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 ~n
than 8 112 x 11 inches in size. Cr-19/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 it revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan LD. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Property L cation
1/4~o/ 1/4, S 0 T IF/ , N, R (or) 49
Property Owner's Mailing Address Lot Number Block Number
City, State Zip Code Phone Number Subdivision Name or CSM Number
II. TYPE OF BUILDING: (check one) ❑ State Owned E] City Nearest Road
E] Public 1 or 2 Family Dwelling - No. of bedrooms ❑ Town OF r Irk A!~,kAO CM
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo 039-- /l
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. r"ew 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 ❑ 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) Q7 ~10 Elevation
4"'10 C~Q® l0't~ 94 • J Feet 161 , Feet
VII. TANK Capacity
in gallons Total # of Prefab. Site Fiber- Ex er.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel Plastic p
New Existing strutted glass App.
Tanks Tanks
Septic Tank or Holding Tank j~Q / r~ 1;G 7` N ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se ge system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: o tamps) P/ PRSWNo.: BusinessPhone Number:
rf rr r3 I91 ~t ~{t G~ c f ~ :3~Pr ~ o?
Plumber's Address (Street, City, Statue, Zip Code): 40,
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includescroundwater ate Issue Issuing A en re St s)
Approved ❑ Owner Given Initial xr1 Surcharge Fee)
Adverse Determination ~YYY(!!p eta
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to Courtly. One copy To: Safety & Buildings Division, Owner, Plumber
L
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 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 into be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
111. 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
Walon of Safety A Buildings in accord with ILHR 83.05, WifF 1
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan n' not limited to ver
tical and horizontal reference point (84, direction and 1% or slop ARCEdimensioned, north arrow, aril location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT
ALL INFORMATION REVIEE DATE
PROPERTY OWNER: PROP OCATIO*c.,uN i v
/'G /I /4 STOUT GOVT. L X4 1'1;S 3~ ,N,R E
PROPERTY OWNER':S MAILING ADDRESS
/ 333 14 W,4 7-0 lF~rff LOT # 'PC MM I CITY, STATE ZIP CODE PHONE NUMBER LADE NEAREST ROAD
~U So0 lc~/S. Syo1( (,5)54r~1-L731 PRhtRtF 11c0y. cc
(i,.tfew Construction Ose
) 4'Aesidential /Number of bedrooms 3 +o q Addition to existing twiklhtg
] ] Replacement ( ] Public or commercial describe
Code derived daily flow ' Zo ov 9Pd Recommended design loading rate • bed gpdM2 •8 trench, gIxM2
Absorption area required bed, 112 76;o trench, R2 Maximum design loading rate ' bed, gpdffl g trench, gpd412
Recommended Infiltration surface elevation(s) Sty t~1.3 R (as referred to site plan benchmark)
Additional design / site oons rations
Parent material 5C-5.09 v/p,C~ ~ /,U /'EC Fitxxi plain elevation, N applicable R
S =Suitable for System WNVENTQ U L ❑U IN.G D PRESSURE AT GRADE SYS IN FILL HOLDNG TANK
U- Unsuitable for stem us O U [ ❑ U Cl"p U 0S
SOIL DESCRIPTION REPORT /t'//e = ,vat' ~PE~oHI~FN~Ef~
Poring # Horizon Depth Dominant Color Mottles Texture Structure Consistence 9wifty Roots GPD/ft
In. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. Bed
Tbxh
o-g /axle 3/3 s /'W s s Zf .7 .g
2 g- ye) /o Ws c's . 7 .8
Ground 0 D ~ooe W °G
S• 0 s ~ i - .7 g
elev.
99 y.~" rt.
Depth to
limiting
factor
-
7
/v -
Remarks:
Poring #
0-/0 /0Yif 3/ - /s / ~ls as zf 7 .
2- V- 2oloyle
Ground 210-39 71 5 y A CS S d , . 7 g
elev.
101-50
Depth to
limiting
7 facGtor .
~a~-- Remarks:
ST Name:-Please Print R CJ 8 ~ Q T 21 L R R IBC T' Phone. 7/JC-, 3 a(D - ~ ~ S 5
Address: C~ 11 -1V / q6l
t^sT~1 1 yd'.~
Signature: c c / Date: CST Number:
i ba.st• Ceases rlnnitultanm
PROPFFMOVIER Rr?-44,PD 5-(vo7T SOIL DESCRIPTION REPORT Pr Z
PARCELI.D.0 LOT 33 ,E /vEre 89!itJP
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourdary Roots GPD/ft
In. Munseli Qu. Sz. Cont Color Gr. Sz. Sh. Bed
2- jV XO 31 it,"" 15;
Ground to yeAv
S, a S
elev. GC • ? g
Depth to
limiting
factor/ n
1-21
,
Remarks:
Boring #
. o-/o lo YRL - S/ /,wf~ cs Z,,,,~ .7
z azo,oy~ 3/ 4,
?44P e
Ground 3 - p /O S. O S - - 7
elegy
/0/•ISD It.
Depth to
Nmitlng
factor(]
8~
Remarks:
Boring #
/ a-iz /o YR 313 - ,e ds ~5 3 f .77 Z !2 - 3 /o le 3141 ~S /M d15 CS y , -7
.
Ground 0 73 S, O $ - 7 ~
ellev~
Depth to
limiling
factor If
Remarks:
Boring #
Ground
elev.
it.
Depth to
limiting
factor
El::r7-
w r
_I
1
p o
U~
O ~ o
~ C
To
n C ~o
rd •
0
70
O $ K kA
G
R~ m m 1 W
c ~
1
i 1.39 AC. EXC.
S88°48'45"W 265.47' I q
L U ► 60,679 SO. F
LOT 36i I N85014137"w
1.95 AC. M
85,084 SO. FT. ° Qi LOT 31 ,
lO
U) N p 1.73 AC. 8
I ro 75,367 SO. FT. I C) L 1
I to
N U
i N°~
S89°50'06"E 346.56' O
i VIA
N88°43'44"E 335.06'
LOT 35 9000' 245.06' -
~ i
1.91 AC. 8
N
83,046 SO. FT. M \ 0
N LOTS
I
,
N32
LOT
S89056'04"E 351.59' ~VA 2.04 AC.
10& 88,727 SO. FT.
g 33 A ; , I
1.74 AC. 3 v / 1
LO T 34 75, 617 SO. FT. • ' / \
i 33' 33'
Q.y • /
2.2 7 AC.
' 98,972 SO. FT. g
M
•$"2 i~
~ ~ 4000
\ 246'50
1 i
408.50 LOT
122.00 S?6° 58'46%%
OT /6
`O 15
OT 14 r
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER e. tl l SGT. T -
MAILING ADDRESS 13 W ~ /,c /fi -e-- /7_4,cn, k
PROPERTY ADDRESS / /-/a 140L° -
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
Uk'6c•i~l~
PROPERTY LOCATION 114,-'5A-) 1/4, Section T 5V N-R__ZrW
TOWN OF SraV- l~~w r~X, Erb ST. CROIX COUNTY, WI
SUBDIVISIONS P 1_f._ ZV-QI( LOT NUMBER J3
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 year expiration date.
SIGNED:
DATE: zz ~Z~P
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 /I,'~~u
Location of propertya~E_1/4 ,5 xd 1/4, Section 1.5-T, / N-R ! W
Township Mailing address i3
Address o f s ite / J j Iv 4 UG',~"",r~ gyp
n`
Subdivision name Al 'Bg 1,, Lot no. ,
Other homes on property? Yes_~_No
Previous owner of property ACR/d
Total size of property 1.7V Total size of parcel
Date parcel was created 2 j e
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? _kYes No
Volume 1 I/ and Page Number / Q' 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. SY7a D`/ , 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.
J Z
e
Signature of Applicant Co-Applicant
/_d- / PZ
D to of Signature Date of Signature
STATE BAR OF WISCONSIN FORA! 2 - 1982
WARRANTY DFED
DOCUMENT NO.
ST. C-all i
C_
rl,A
David L. Green and Christine Joyce Green,
_-a7k7a ristine J. Green,-iu- sBaanc7 aria
JUL 23 11996
ELI 1:20 AM ~
conveys and warrants to Kiclard-0 Sr--fit
I
- j THIS SPACE RESERVED r^,7 RECORDING DATA
I
NAME AND RETURN ADDRESS
/O
the following described real estate in $t • CroiX County, I `4 tom-
K e
State of Wisconsin: LA
Lots 8, 9, 14 and 15, Plat of Apple River Bend, I I n
Town of Star Prairie, St. Croix County, Wiscons•p; ~ u -C)i)
and Lot 33, Plat of Apple River Bend First I ~I
Addition, Town of Star Prairie, St. Croix County
PARCEL IDENTIFICATION NUMBER II
Wisconsin. Ij
I,
'i
II
~ I
I ~I
II .I
This deed is given' in partial fulfillment of that certain Land Contract
between the parties hereto recorded March 8, 1994, in Vol. 1068, Page 114, II
as Doc. No. 513887, in the office of the Register of Deeds for St. Croix II
II County, Wisconsin.'
-homestead property.
This s not
(is not)
Exception to warranties: Easements, restrictions and rights-of-way of record, if any. .I
it
i
96
Dated this 3 _ day of T4 A.D., 19
(SEAL) L~^ JG ^ ca~,c« aS!N ,_A~ (SEAL)
v a ~I
• David L. Green Christine Joyce Green
a c a ristine J. Green I
(SEAL) - (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
na,ure(s) State of N4'isconsin,
Sig lib
~I
St Croix _ County i
authenticated' this da)• of 19_- pel )trali) came ln•fole file this day of
19 _96-, dw ahove named
_David L Gre Land-Christine Joy. '
- -
_ Greener a/k/a Christine- J_ -Green, _
- - --L-
I I I I F MEMBER STATE BAR OF WISCONSIN F, husband _and wife,
(If not NaT. - - - II
t t.i, A7AA nR Vlk c„« 1 .4A. kno,cn to Ix thr t•etsl,n$ wh *rxrc,urd thr foil goinK
i
l.abor.enand Human Relations tions
Wisconsin sfry, SOIL AND SITE EVALUATION REPORT Page / of 3
OFlslon or safety A Buildings in accord with ILHR 83.05, Wis. Ad 1 _ J
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan mu 1 de but4 ' C R 0 1' K
not limited to vertical and horizontal reference point (BM), direction and 9'e of slop a or
dimensioned, north arrow, and location and distance to nearest road.00
',E~: ARCEL . . 13 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION L ~ ^ WE DATE
PROPERTY OWNER: -
/'G lr,9 A?D ST'o v T PROP OCATIO1tcm +TY
GOVT. L 70tf 5 W-v 's, 3I N,R IP E W
PROPERTY OWN R':S MAILING ADDRESS
/ 3 3 1 W,4 7-0 3 M ME` M /
CITY, STATE ZIP CODE PHONE NUMBER ITY ILLAGE (PrOWN /E NEAR SROA
tf'v so,) w/s, 5yol(a
(715)54q-Co731
sr PRAIRIE- //,wY. Cc
(i,} ew Construction Use (r-} Residential /Number of b6drooms .3 +o y Addition to existing building
Replacement Public or commercial describe
Code derived daily flow y°ov 9Pd Recommended design loading rate • 7 bed 2 , 8 2
, gpd/ft trench, gPdlft
Absorption area required ff bed, 112 Zj 49 trench, ft2 Maximum design loading rate bed, gpd/ft2 ' $ trench, gpdM2
Recommended Infiltration surface elevation(s) SEA t~4 .3 ft (as referred to site plan benchmark)
Additional design / site cons rations
Parent material SCS 11 vWe ? iN /'Ec
Flood plain elevation, if applicable It
S =Suitable for system coNVfNta U I MOUND o U IN-OROUNOp U ESSURE ATt DES U SYSTEM_ IN U L HOLDING TANK
U = Unsuitable fors stem Irk l4< [~-S' ~ 9-s E] O S
SOIL DESCRIPTION REPORT ,vv7 ,0,6e,-A IEAlp4%,49
Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft
In. Munseli Qu. Sz. ConL Color Texture Gr. Sz. Sh.iste Roots
/o S Bed
Y/e 13 1,w s S zf ,7 .8
z g- yo /o y,~ 3/~ /s /,rrr ds cs _ 7 8
Ground 0 D
S . $ i 8
elev. /o Ve !OC cl
y9. y.~ rt.
Depth to
limiting
factor
Remarks:
Boring #
o- ~o /0 yie 313 /s / ~s as z f 17-
2, o- zo /0
y/P 31zl' 7 .8-
3
_?9 7
S Ve yC'S S d GS 7 g
Ground
elev..Z 0 it. Depth to
limiting
factor /r •
Remarks:
ST Name:-Please Print 8
RCS R r 21La1'C k T' Phone: 71S.,3UC75
Address: '
_ c %Co CST 1
Signature: r c /
Private sewage Consultants Dale: CST Number:
are r%111,1_11 DJ
PRoPEryo"ER P;G:44,PD 5400T SOIL DESCRIPTION REPORT p Z 3
age - of
PARCEL I.D.# GoT 33 PlVaP B AD
Boring # Horizon Depth Dominant Color Mottles Texture Structure Roots GPD/tt
In. Munselt Qu. Sz. ConL Color Gr. Sz. Sh. Bed Thench
0-1o /,o Of 3 s a's Z 7. g
Z 3141 1
Ground
elev.
is/j ft.
Depth to
limiting
WIT it
Remarks:
Boring #
z /0.20 /o y/' 3/ fe t-/y cs Zf- . s
2 4 Y, e
Ground 3 . k /,o
el Af
10/19 it, Depth to
Wiling
factor
Remarks:
Boring # C
0-/z. io y2 31
3 - ~S ,P dS 5 3 IF .7
. S
Z ~2- 3 10 YAP 3 CS r • -7
-
Ground -L44L
el_ev~
Depth to
limiting
factor ,t
Remarks:
Boring #
Ground
elev.
It.
Depth to
limiting
factor
. r'
r
w r
n `
O o
O ~
o ~
n m o0
-ro
o \
N ~
70
N
O $ ,c o
7d z ~ rn G m
C~ r
b
~ 7-1
o
1