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STC - 104
AS BUILT SANITARY SYSTEM REPORT sue.'
OWNER Kz N 5LLrA dt
ADDRESS
SUBDIVISION / CSM# HfSk 01t Court I" A4LOT ~ 13
SECTIONA_T a 1 N-RW , Town of TKOW
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Nom ' ~ 18x(~v
B' cp i
33 0'
5,IAN k " 800 gal Se IC. ~NkS
MPNtioks AKQ Olef-
~x~k (3a~Fles
N
Lu NOy LApt INDICATE NORTH ARROW
s.
Provide setback and elevation information on reverse of this form-
Provide 2 dimensions to center of septic tangy; manhole cover.
T
BENCHMARK: -~00 o~ I" Ate I Pose 'F, Lpv ' 00, 0
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: f, t5 Liquid Capacity: 1400 q~
Setback from: We1lOW .SUS House Other 17~
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length " Number of trenches
Distance & Direction to nearest prop. line: 7a
~ uU
Setback from: well: oVtj S House 1 T Other _47,
HeAee 83-09 - 83,09
Nv &.90 - &)-90
ELEVATIONS ^ ~uVeK $8.84
-X 87 50 l $~.IJ
Building Sewer ST Inlet. d- a7 (S ST outlet aN~ 84.$S COVeh Sa
PC inlet PC bottom _ Pump Off
Header/Manifold Bottom of system SRI 00
Existing Grade FF. 3o Final grade 8 ~ . 3U
DATE OF INSTALLATION: PLUMBER ON JOB:
LICENSE NUMBER: 3Y 0 Y
INSPECTOR:
3/93:jt
Vfi~ebnsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
,Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
w
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan o.:
SOHMIT. KEVIN & JikCKIE
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION E EVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosi ng
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet F 9'
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic >5 j' 7 NA Dt Bottom
Dosing NA Header / Man. IT, 56 Fs, O q'
Aeration NA Dist. Pipe g, g'' ~a,g5
Holding Bot. System /q 76,
'
PUMP/ SIPHON INFORMATION Final Grade 1~; 35-g6.30
T. 77
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
oss Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTI N SYSTEM
BED/TRENCH Width Length No. Of Trepches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS fib' ` / DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O l~'tF« Mode Number:
System: 7a I~ LSD' OR UNIT CHAMBER
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
Bed /Trench Center 3 (o Bed / Trench Edges 2 0 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: TROY.4.28.19W. Ski.. NE. LliNDY LANE
Plan revision required? ❑ Yes 1~ No /
Use other side for additional information. o % c® K~ a-7. 6
SBD-6710 (R 05/91) Date - ns a or's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
t
SANITARY PERMIT NUMBER:
Division
■ Safety o and Building Water System!
~GZI'r■Gi SANITARY PERMIT APPLICATION Bureau
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 1/2 x 11 inches in size. 4 d
• 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 if revision to previous application
(Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. umb r
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Nam Propert Location
1/4;UE 1/4, S T 4 N, R /f E (0 W
r erty Owner's ailing A dress Lot Number Block Number
Cit , tat Zip Code Phone Number Su ivisi or SM Nu ber
uJZ ( ) IvAld
It. TYPE F BUILDING: (check one) ❑ State Owned [I Llt)W 11 Nea est Roa
LQ
-'j I Public 1 or 2 Family Dwelling - No. of bedrooms ❑ Village -77
E] la Town OF
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) f
1 C] Apartment/ Condo A//-)
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
11J,Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12E] Seepage Trench 22E] In-Ground Pressure 42E] Pit Privy
13E] Seepage Pit 43E] Vault Privy
14E] 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
Re wired ((®;~f.) Proposed (q. ft.) (Gals/dsq. ft.) (Min./inch) EQleIvation
'T5 C) f ~ n Feet W 1o-1f~ Feet
VII. TANK Ca
in gallo city Total # of r Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existin strutted
Tanks Tanks
Septic Tank or Holding Tank 1;1 - bl~~ ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's N Print) Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
3 Lit'li
Plumber's Address (Street, City, State, ip ?d f):
IX. COUNTY / DE ARTMENT USE ONLY
❑ Disapproved Sa tary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signat re (No Stam)s)
*pproved Surcharge Fee) ❑ Owner Given Initial t
1 2 IV
Adverse Determination
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
a
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 ne,,v 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'-ransfer/ 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:
L 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 exist ng 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.
1
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33
33
FRESH Ii: INLETS AND ODSERVATIQN YI.PE
CROSS :SECTION
Approved Vent C'ap
Minimum 12" Above F)NA) (0 KAL
.
-final Gr~Sle---` - I Y3
~a ~ r>1 ~ i f
Above Pipe Cast Iron
_ vend r)4,e
VA3consin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of
r Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
RWEWERMAU Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION PROPER O
WNER: PROPERTY LOCATION R
GOVT. LOT 1/4 4,S 1T ,R r
PR RTY OWNER': MAILING ADDRESS LOT # BLO # SUBD 0 CS t1NTY
Cl STATE, ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE ®f0 S E RES D
( )
New Construction Use Residential ! Number of bedrooms [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow Zeno gpd Recommended design loading rate ed, gpd/ft2_trench, gpd/ft2
Absorption area required bed, ft2 ~ZrG trench, ft2 Maximum design loading rate _ , 7 bed, gpd/ft2__,j1 _trench, gpd/ft2
Recommended infiltration surface elevation(s) O ft (as referred to site plan benchmark)
Additional design / site considerations ~Z~ 42e
Parent material 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 s stem ®S ❑ U [ZS ❑ U OS ❑ U ZS ❑ U ❑ S !Z U ❑ S [&U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1XQ V1,4
Ground Z5--Z4 A4Z .5 ,r, 41a
elev.
ft. -
Depth to
limiting
factor
Remarks:
Boring #
Ground "Of A:3a
,
elev.
S~L ft.
Depth to
limiting
factor
Remarks:
CST Name:-Please Print Phone: --Zl? 91
Address: noa
Signature: Date: CST Number:
PROPERTY OWNER R;1 SOIL DESCRIPTION REPORT Page,
o'S~
PARCEL I.D. # k
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Pont. Color Gr. Sz. Sh. Bed Trench
~f
7 ~
Ground
.41
elev.
~g ft.
Depth to
limiting
factor
Remarks:
Boring #
v\M1
2:Z W /,Q
Ground 3
elev.
Depth to
limiting
factor
Remarks:
Boring #
7:. g
Ground
ele
ft.
Depth to
limiting
factor
> ~9y
Remarks:
Boring #
<
Ground
ele - -
ft. '
Depth to
limiting
factor
9;q
Remarks:
SBD-8330(8.05/92)
i~
3
\zlf
IJ -
33 '
T ( - OF)
SI•:I'I1C 1'ANI< 11^n1N}"1;~;1~'i'I: A(;121:i:n1l•:N'!
St. Croix (:aunty
A 4-
MAILING ADDRESS
PROPERTY ADDRESS S~o a L J n.c~ ~ (4,A e.,,_
(location of Septic sys e-ni) Obt;'U? irom dl c. i'I:r1lning Ocpt.
CITY/STATE
1'R<)I'1?12"i"1' I,OCA'I"iON .~1~ 1/4,-.X)- I/4, Section y ~8 t\'-:2 l q \N'
TOWN OF ST. CROIX COUNTY, Wl
SUBDIVISION LOT NUMBER ('I;12'1'[FiL;llSURVI;I' MA}' VOLUME 11'15, PAGE N7 , 1,OT \'UMI ER 3
improper use and maintenance of ),our septic system could result in its premature failure to handle
wastes. Proper maintenance consists of pumping out the septic tank ever' three years or sooner, it needed
by licensed septic tank pumper. What you put into the system can affect tits 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 it 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 properly owner agrees to submit to St. Croix %oning it ceriihication 1omi, signed by the owner
and by it mince plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal svstcm is in proper operuinl', condition and (2) after inspection and
pumpin)', (it nctcssary1), the septic tank is less than 1/3 full of ~ludgc and wane
I/We, the undersigned have read the above rcquirenrents and ;lgicc to maintain the private sewage
disposal "vStem in accordance with the standards set forth, herein, ati tics by the WV~ cousin i)N12
t'ciuficatum'tabu}', that your ~;cl)t1c has been maintained must be completed and whined tie the tit (rou:
( aunty ldviui}', t Micer )xlthur tU (avs ddf the three year cXprr;nnui d,rlc
`;It NlA) f<.eo-~- J
I)A11 V/aG/!6
`;t a i,n~ i ,unity /.d,nnu', t rltirr
~ ~,rvrinndrnt t rntei
I Itll t ainir, hail K„.+d
11u 1. ,n I Itl I t, I I,') {
• , a V V
r
'i'11to appIICtkt1071 rorrn 1,1; t•a 1>4; completed ill fu11. alid 151clned Ly tilt;
I owner.,(s) of, the property boi.ng dovelopod. Any inadaquueaQrs wi l .l
only result in clef iya of the pormit. f.rnitiance. Should th.it;
development be intcndcd f'(*)T• 1-esn l e by owner/Contractor, (Spoc;
house), then a second for shou.td b~~ r(:f-,,iined and completod when
t:ho property is :;old and s nbmitted to this office with the
appropriate doed recording.
1
owner of property.
Ke~
Location of praperty__S L,)1/4 _1J F 1/ 1, sect ion T-ate) N-R_1 _...w
Township 1 rt)✓ --~~-Ma ilingadd ress A
Address of is ite -4;2
Subdivision name 4. __!_St d e_ Lot no. ! 3 -
Other homes on property? yes No
Previous owner of property
Total size of
Total size of parcel - - -
Data parcel was created ~pc)
Are all corners and lot linen identifiable? _ Yes No
Is this property being developed for (spec houso)? _ Yes ~ No
Volume and, Page Number jy`7 as recorded with the Register
of Deadw.
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, is
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Cert:itied Survey Map, the certified survey Map
shall also be required.
PROPERTY OWNER CERTXFICATION
I (we) certify that all. statements on this form are true to the,
best of my (our) knowledge that z (we) am (are) the owner(:) 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) preF;ent.ly
own the proposed site for the sewage disposal systen or i (w(;,)
obtained nn casement., 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 pogint.01- of Ooi-d^: nr. Document. 11c).
~f
.'w g 14t 1.1 re of Applicant Co pllCant
of sl.gnatu c Datc of. Siljna urn
S .CR(
%
U
200.00'
I 1 ( UNPLaTTED LANDS No
y, ' 1
1 t oM
Lc)
zM - 8 14
1 M v i 02.01 ACRES t.
N8$• 4435'E
10
3 1 J 6 59.86' ~J+ le
O t _ Js • i
• a:l Lai ~J. , ,Lt,!~
_ n
o !
w l
- .l Y I iI + a N 10 A62CO.C-
• 113 O~4
W. a a 13 • y 84. 32'49'E
_ Q I6 ACRES VALLEY -
'A 584.32 49 H
a.'
o
TRUE BEARING 2 i° 1 17 '886 u114IAJ
W O ~JJ •00 ~.a /J I6S.00
ff-'~ e
- e~~~ I Q ! f / .0 Q i I3e'13 33 S• JJ 1
FRANCt'$ N OGDEN -8~2. I (n ff 9 ~)q.Qq' 19 9.E
r..-.aMT W
REGISTERED LAND SUR✓EYOR I t $S e-9 D 260.9g' fJTEMPORARY
UTLOT O CtL OE-SeC 1
C-0"' / TO Be AUTOMATICALLY vA-";
OCTOBER, THIS 7TH DAY OF 1
~NH9.37'w 2ao.98 / s9~eECCMes Aor'oN RoaD.
1976• I ! 1d
" REVISED TH15 16 TM DAY OF 1 III ti 1 187 50'
q;f
N89'37`N
NOVEMBER, 1976 1 1 W 73.48 2 TARE OF AN G_ °'T• I H
i~ t I NC N89'37'W ES •1. A'l 55.15'30" 21 i
Js F 2.35 ACRES
n - 0' 1 O B '1 43*3C 50
1.3
-
Go'' 2 C'.43 .36 56°
is ~\yootys~~,y l 70 L - 9° D'l 11'41' 3'" JJS 'm
TRAl:C:g.H; t I ".G2A 1784' F •B' _
~iDEll.:'. 1 1 I.~ 204.41'30• I.n
N89.37'N ~9 G•187.13'48-
22
Lg.1, ~0 "O W. 4.29 ACRES
n bZ \e ; ,-5~ 558.52 .y
q~ S,q.CI f5 ~O
r:
LEGEND:
BS✓C.J CCUr.EP Mrril;ME:T 2•rRC'I PIPE NEIGH1'IG 365
L
- aY 'EAL 'Cti,T, M,1"i•: 3ERNTSEt4 C:.P. (A
pCq*
_ 5JS 3: 6 I" PIPE c:% LINE
ra 2 , EXISTI•;G 2' PIPE REIG~':NG ! 61L5S/ L!%EAL rCCT rF~
a 1 C EX15Ti•.G I" PIPE NEIG-•1'iG 168 LSS✓LINEAL FCCT.
r % c 3 0 Z• Pr=E hEiGHING 3 65 LBS ✓ L' :EAL FCUT SET
ALL CTHER LCT COPNEQS ST;.KED W1-, ;'X 24,
L4Cy c!?E
'NEIGHING 169 LBS : LINEAL CC4T
i• i
CATION SKFTCi
Ck
NOTE:
x ALL DISTANCES, LENGTHS AND WIDTHS ARE MEaS,;RED TO NE I4SE T
HE NEAREST ONE HUNCEREDTH CF A FOOT, ALL ANGULAR 728 F
i' MEASUREMENTS HAVE BEEN MADE TO THE NEAREST TWENTY
IS 6
+t SECONDS AND COMPUTED TO THE VALUES S40WN
t:
ALL BEARINGS ARE TRUE FROM SOLAR 08SERVATIONS /
4 v MACE AT SITE.
OUTLOT 2 IS DEDICATED TO TH
FUTURE PUBLIC ROAD CCNTA NE oURUC FOR
0
542924 WARRANTY DEED ~Ol~'7 1
Document Number VOL 1175PAGE147
RED V, OFFICE
o CROIX OTC'., W9
Reed for Recaed
Return Address F
APR 3 0 199G
` 11:00 A.
Rag= G1 Dess-3
Parcel I.D. Number:
A & R, Inc., a corporation, conveys and warrants to Kevin Schmit and Jacqueline K. Schmit, husband
and wife, the following described real estate in St. Croix County, State of Wisconsin:
Lot 13, High Ridge Court First Addition in Town of Troy, St. Croix County, Wisconsin.
This is not homestead property.
Exception to warranties: Easements, restrictions and rights-of-way of record, if any.
Dated this day of QRx-,~, , 1996.
A & R~, Inc.
(SEAL) By (SEAL)
Y
Harley Rla qresiden't-
ACKNOWLEDGMENT
STATE OF WISCONSIN ) TRANS 7-'9
ss FEE
COUNTY )
Personally came before me this day of 1996, the above named Harley
Roen as President of A & R, Inc., a corporate, to me known to be the person(s) who executed
the foregoing instrument and acknowledge the same.
Notary Public County, WI
My commission expires
Alice Joy Connors
THIS INSTRUMENT WAS DRAFTED BY: Notary Public
Attorney Kristina Ogland State of Wisconsin
Hudson, WI 54016