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STC - 10 4 AS BUILT SANITARY SYSTEM REPORT
Jul N
1997
Iq 97
C.ZONINGOF'FICE
OWNERADDRESSQSUBDIVISION / CSM# LOT
SECTION~T_~,j N-R_Z,3~_W, Town of
ST. CROIX COUN Y, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i
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INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:. Z
P
ALTERNATE BM:
I
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity: /
Setback from: Well House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: /f Length 37 Number of trenches
Distance & Direction to nearest prop. liner
Setback from: well: gs_ House -Z~?" Other
ELEVATIONS
Building Sewer -9 ST Inlet: ST outlet:
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system k4
Existing Grade Final grade 5075
i
t
DATE OF INSTALLATION: - n
PLUMBER ON JOB: z.
LICENSE NUMBER: _T-D5:2
INSPECTOR: 7
LI
3/93 : jt
Wiscoi,sin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST . CROIX
Sanitary Permit No.:
Safety and Buildings Division (ATTACH TO PERMIT) 284196
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.,
EMERSON, BRUCE STAR PRAIRIE
Parcel Tax No.:
CST BM Elev.: Insp. BM Elev.: BM Description <
, ClJ `Ja-.tee
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
a l Benchmark /mod
Septic E Gad
Dosing
Aeration Bldg. Sewer (o- yL,
i
Holdin St/ Inlet 7 Z2
TANK SETBACK INFORMATION St/ Outlet 510
Ventto ROAD Dt Inlet
TANKTO P/L WELL BLDG. Air Intake
Dt Bottom
Septic
NNANA
Dosin
Headers Aeration Dist. Pipe
R . g Bot. System z 9/"
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand f C,1,
Model Nu GPM
TDH L' Friction m TDH Ft
Forcemain Length Dia. Dist.ToWell
SOIL ABSORPTION SYSTEM
BED / TRENCH No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
Width ~ Length c--°-
DIMEN 1 N DIMEN I Manufacturer:
SYSTEM TO P / L BLDG WELL LAKE/STREAM L IG~
SETBACK AMB a Num er.
INFORMATION Type O P OR UNIT ~
System:;.,, P, a
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
Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
Bed /Trench Center Bed /Trench Edges
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRAIRIE.24.31.18W, CTY CC
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
Date Inspector's Signature Cert. No.
SBD-6710 (R 05/91)
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
r, =i~'r'■n SANITARY PERMIT APPLICATION Buereaauu oand f of Bildi uildiinng Water gs ter
Bu System!
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 81/2 x 11 inches in size. ~X
• See reverse side for instructions for completing this application State Sanitary Permit umber
.2 P~1(
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 INFORMATION
Pro Owner Name Property L ation
1/4 1/4, S T ' , N, R V(or&[11
Xlpj Property Owner's Mailing Address Lot Number Block Number)
I tate Zip Code Phone Number Subdivision Nam pr CSM Number
e
l /
II. TYPE F BUILDING' (check one) ❑ State Owned E] City Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms F Town o ZZ 2zd
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)p q
1 ❑ Apartment/ Condo e..~s_ ! /
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. Ig 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 jo 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
Feet - Feet
VII. TANK Capacity
in gallons Total # Of Prefab. Site Fiber- Exper.
INFORMATION Tanks Manufacturers Name Concrete Con- Steel plastic
New Existing Gallons structed glass App-
Septic Tank or Holding Tank
21 ,Ir ❑ El 1:1 1:1 1:1 11
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the ndersigned, assume responsibility for inst ation i a onsite sewage system shown on the attached plans.
Plum r' am t) Plum is S at am s) MP/MPRSW No.: Business Phone Number:
Plumber'sAddress(St ree , ity,State Code):
IX. COUNTY/ PARTMENT USE ONLY e=l
E] Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing Ag t Signatu t O&V
Approved ❑ Owner Given Initial / Surcharge Fee)
Adverse Determination */2mo I O~
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 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_whenev_er .
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-
11. 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 bolding 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) fora 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
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 '
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)).
Prope Owner Property Location
Govt. Lot 1/4 1/4,S T N,R(or 1y
Property Owner's Mailing Address Lot # Bloc Subd Name or SM#
Ci Stag Zip Code Phone Number ❑ City ❑ Village LA Town Nearest Road
❑ New Construction Use: Residential / Number of bedrooms Addition to existing building
® Replacement ❑ Public or commercial - Describe:
Code derived daily flow ~G gpd Recommended design loading rate bed, gpd/ft2_,trench, gpd/ft2
Absorption area required _4;~_Z? bed, ft2 trench, ft2 Maximum design loading rate ~7 bed, gpd/ft2_1S__trench, gpd/ft2
Recommended infiltration surface elevation(s) / ft (as referred to site plan benchmark)
Additional design/site//considerations
Parent material /,.m - / 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 121 S ❑ U XS ❑ u ® S ❑ U ❑ S ® U ❑ S ® U
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
Ground , 17
elev.
.S -
215--ft. WWI ZS-"
Depth to
limiting
factor
z,2Y in.
Remarks:
Boring # -
a
'2 -2
2s /
Ground
elev.
ft.
Depth to
limiting
factor
7-kin. Remarks:
CST Name (Ple se P int) c Signature Telephone No.
- -
Address Date CST Number
C_ X -3
>
P SOIL DESCRIPTION REPORT
PROPERTY OWNER Page of
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots Mft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
5
'41 Z,
Ground
lev.
Depth to
limiting
factor
Z&_in.
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)
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 property 1/4 Olt} 1/4, Section,--a/ ,T_,ULN-R_/Z_W
Township ' Mailing address
Address of site A,, I
Subdivision name Lot no.
Other homes on property? 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 _!aL and Page Numberl~_ - 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. '7 , 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.
.
Signature of Applicant Co-Applicant
_71~ ' S /J
Dat of Signature Date of Signature
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNERBUYER
MAILING ADDRESS
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION Iy 1/4, 1/4, Section, T_N-R_ff_W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION 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 year expirati n date.
SIGNED: 4au~
DATE: 0 y- I el ~l ~v
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
f DOCUMENT NO. WARRAN"263 DEED it TWS SIA-~C RESERVED :OR RECORDING DATA
STATE BAP. Of WISCONSIN FORTH 2-1982
49US? ISTER' FFICE
REG
Sal. C" CO., % _
Alice L. Emerson, a single person _ Reed for Record
. - - . _ JAN 2 0 1993
. . 1.
eY 8:30 A.M
. - a Bruce V .
- - - - - - - `i
conveys and warrants to Emerson
5
Pkj~sW
-
,s
.
- -
. RCTURN TO
. .
the following described real estate in .St-.--Croix County,
State of Wisconsin:
I Tax Parcel No-------------••---••-•-•--.....
I,
The North Half of the Northwest Quarter (I1# of NW}), Section Twenty-four (24);
the Southeast Quarter of the Southwest Quarter (SE} of SW}), Section Twelve (12),'
ALL in Township Thirty-one (31) North, Range Eighteen (18) West.
This conveyance is given in satisfaction of that certain Land Contract between ~I
the parties, dated February 19, 1980 and recorded February 22, 1980 in I~
Volume "608", pag3 449 as Document No. 362870.
FEE)
This -----.--is homestead property.
(is) (is not)
Exception to warranties:
1993_
Dated this .12th. day of . January
l~j J~^v`~~ t 1ha2G'YL/ (SEAL)
(SEAL)
`lice. L,...EmQrBOtl... •
s -------(SEAL) .
•
ACKNOWLEDGMENT
Signature(s) - STATE OF WISCONSIN
as.
St. Croix
- ---County.
authenticated this day of___________________________ 19_____ Personally came before me this '-....day of
----January 19-91.- the above named
-Alite._L._Eme.raon......
t------•----•-------
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by 786.06, Wis. States) e
pest{! a..E 111 1), eXecuted the
me known to be the
foregoing t trum:;nt and &tc`1T ,rsrle sa11`. ,
THIS INSTRUMENT WAS DR 4FrED BY