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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER,_'/ ,oo
ADDRESS_9~j)
SUBDIVISION / CSM# LOT #
SECTION ~T_?/ N-RW, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTE
for-~.s
5
P
V.
JNDICATE NORTH ARR W
S
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer:S Liquid Capacity: /
e-J
Setback from: Well House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
-:SOIL ABSORPTION SYSTEM
Width: 1,2 Length Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well:_ Housed Other
ELEVATIONS
Building Sewer ST Inlet. ST outlet
PC inlet PC bottom Pump Off
Header/Manifold ?27 Bottom of system 9,272
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
I
3/93:jt
I'
Wisconsin Department Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT `"T' ^
Safety and Buildings Division A. • 4&%i~W.L
j~•
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Permit Holder's Name: ❑ City ❑ Village Town of: State PI
POPP, LORREL E.
CST BM Elev.: Insp. BM Elev.: BM Description: FRAIERiH Parcel Tax No.:
,~j , 60' iea , ~v ' Q s l--,e-
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark Xe) 60 Dosing- ,--Iice . 4 71,
Aeration Bldg. Sewer 6) '
Hold' St Inlet dr /6~11,
TANK SETBACK INFORMATION St/ Outlet r X8'902
ent
TANK TO P/ L WELL BLDG. Avir
Ito ntake ROAD Dt Inlet
Septic >So G NA Dt. Bottom
Dosing - NA Header /AdM. 70
Aeration NA Dist. Pipe ~0, q/ 3 (0~ '
Holdin Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand "Op
Mode -Numb GPM
TDH Friction stem T H Ft
F cemain Length Dia. Dist. To Wei
SOIL ABSORPTION SYSTEM
DIMENRENICH Width Length i No. Of Trenches PIT No. Of Pits Inside Dia. uid Depth
DIMEN~I
SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHI -Manufacturer:
SETBACK
INFORMATION TypeO t?t- - ~ CHAR
System:nl DIA0- 3f a Mode Num a
ORd~NIT
DISTRIBUTION SYSTEM
Header / Manifold y Distribution Pipe(s~ x Hole Size x Hole Spacin Vent To Air Intake
Length Dia Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or rade Syste I
Depth Over Depth Over xx Dept xx Seeded/ Sodded xx
Bed /Trench Center Bed /Trench Edges TOPI-
Oil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRAIRIE.28.31.18, S .y NW
Yr
~I
Plan revision required? ❑ Yes 13-90
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION Bureaux Bulilding WaterlSystems
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 8 112 x 11 inches in size. "I V
• See reverse side for instructions for completing this application State Sanitary Perml Number
ff9//S3
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
Propert Owner Name Property Location
114 1/4,
S T__7 , N, R 4'(or9
Pro y Owner's Maildre of Num er Block Num
City tate Zip Code k/ Number Subdivis Name SM Number joT
Lj I / ( _ ~
/ p
II. TYPE F BUILDING: (check one) ❑ State Owned o City Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms 0 rowan O [jil Ill. 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. I( 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 j2f 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. 'nch) Elevation/
Feet y Feet
VII. TANK Capacity
INFORMATION in gallons Total # of 's Name Prefab. Fiber- Plastic Exper.
Gallons Tanks Manufacturer Concrete Con- Steel glass App.
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank - El 11 El 1:1 1:1
Lift Pump Tank /Siphon Chamber El ❑ ❑ 1 ❑ 0
VIII. RESPONSIBILITY STATEMENT
1, the ndersigned, assume responsibility for i allation of the onsite sewage system shown on the attached plans.
;P1U e " Nam : (P tPlumb is Si at p
s) MP/MPRSW No.: Business Phone Number:
' _ -Q
)Ar
Plumber's Address (S et, City State, Zi ode):
J
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sa ary Per Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
Approved ❑ V Surcharge Fee) -
Owner Given Initial CZ/ Ov
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SOD-6398 (R. 05194) 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 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.
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Wistonsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of
Lttbor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 1 size. Plan must include, but
not limited to vertical and horizontal reference i °C of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and i t e to nearest ro
APPLICANT INFORMATION-PLEA INT,rI?NFORMATI; REVIEWED BY DATE
PROPERTY OWNE r JROPERTY LOCATION
OVT. LOT 1/4 114,S T_ N,R (orkf
PRO ERN OWNER':S MAILING ADD LOT # BLOC # SUB NAMES R CSM #
CITY, STATE ZIP OD ONE NW R Z CITY VILE E OWN NEAREST ROA9,
E
Pq New Construction Use IN Residential I Number of bedrooms [ ] Addition to existing building
( ] Replacement [ ] Public or commercial describe
Code derived daily Flow ,-,~D gpd Recommended design loading rate ed, gpd/ft21,F_trench, gpd/ft2
Absorption area required S1 bed, ft2 trench, ft2 Maximum design loading rate ~-bed, gpd/ft2_, ~trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material hr ye .5,,Za Flood plain elevation, if applicable ft
S =Suitable for system CONVENTIONAL MOUND IN GROUND PRESSURE AT-GRADE SYSTEM IN ALL BLS DING
U= Unsuitable for s stem S❑ U [H S❑ U [O S ❑ U [ZS OU ~ S 0 U
SOIL DESCRIPTION REPORT
Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
0-17 42
.-.:f:..........
441 ~7
Ground A, Y'
elev.
'eft.
Depth to
limiting
factor
L
Remarks:
Boring #
~a• 4M1••-
Ground
elev.
Depth to
limiting
factor
Remarks:
CST Name:-Please Print Phone: C
Address:
46Z 14
Date: CST Number:
Signature:
PROPERTY OWNER SOIL DESCRIPTION REPORT Page,,-? of '
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cqnt Color Gr. Sz. Sh. Bed Trench
ZL dl
Ground s~ r
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring # J
7 _
Ground
elev.
q ft.
Depth to
limiting
factor
Remarks:
Boring #
iC
4:: i • .4` : : ? ? :iii
q ell
Ground _
elev.
ft.
Depth to
limiting
factor
i~
Remarks:
Boring #
K*?{ •r,}::ti•}:::. iii:
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
Ali
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNERIBUYER
MAILING ADDRESS
PROPERTY ADDRESS
(location of eptic syste ) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION 114, WILI 1/4, Sectioq, ~ T,,Z~_N-R _W
TOWN OF , s,
z__ oe, ST. CROIX COUNTY, WI
SUBDIVISION o c,M 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.
1/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 c iration ate.
SIGNED: , .Q c- Q
DATE: , W
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.
------------------------,,-n~---/~---------------------------------------
Owner of property Location of property,_:i/,fd 1/41/4, Section, -)2 ,T /JAN-R-a K~T
Township A fir Mailing address
Address of site '7
Subdivision name -S 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? ~~;I- Yes No
Is this property being developed for (spec house) ? Yes No
Volume and Page Numbers 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. 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.
Sicgnatu pplicant Co-Applicant:
Date of Signature Date of Signature
State Bar of Wi,consin Form 2 1982
539232 WARRANTY DEED
~i ,,L 11t~0 257
DOCUMENT NO
-_Dan McCulloch, a/k/a Daniel ~ItCulloch, _ FEB 5 1996
-
9:30 A.
contevs and warrants to Lorrel E. Popp and Ruth M_-Popp - ~
husband and wife, - -
TM~S SPACE RESERVED FOR RECORDING DATA
%AWE "0 RETURN AOt PESS
the following described real estate in - St. Croix f G p,,X 7~-~
County. State of Wisconsin:
f;~j/r~
(Parcel Identification Number)
Lot 25, Red Pine Estates in the Town of Star Prairie.
~ TR
This is not homestead property.
Rte[ (is not)
Exception to warranties: Easements, ;restrictions and rignts-of-way of record, if any.
Dated this _ day of nary -.1996
C ✓ 4`
(SEAL) (SEAL)
• Dan McCulloch, a/k/a Daniel McCulloch
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF
ss.
County.
authenticated this day of '19-- Persoaai:% came before me this S day of
la a a zy 19_96 the above named
Dan `•ScCulloch, a/k/a Daniel McCulloch
TITLE: :MEMBER STATE BAR OF WISCONSIN
--not. - QCQA/~RYAN-
(If authorized by §706.06. Wis. Slats.) to me moo s to be the , N6 Idm TA
foregoing., ment and a the samasnumy 31. 2000
THIS INSTRUMENT WAS GRAFTED BY
t~jwl~