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STC - 104
AS BUILT SANITARY SYSTEM REPORT
i
OWNER Gidt-
ADDRESS_ WW ri _
SUBDIVISION / CSMI~
LOT ~
SECTION / T N-R 7e&l
'--7-- --_[__W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
go
.5
1 40\-~
~JSr7 u,~ ~
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions
to cent-r ~f cnr-ao-a,.
f ,
BENCHMARK:. Q
ALTERNATE BM:
S C TANK / PUMP ;KW4ER / BOLDING TANK INFORMATION
Manufacturer: yujifsI lie Liquid Capacity:/")
Setback from: Well House
9 n~1 Other
Pump: Manufacturer~6G7 ICI Model#_ 0/
Size ,
Float seperation Gallons/cycle
Alarm Location
:SOIL ABSORPTION SYSTEM
Width: Length 2,: Number of trenches
Distance & Direction to nearest prop. line: k-1-
Setback from: well: 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: _J
INSPECTOR:
3/93:jt
_ SAN PERMIT UNTY
7) D1LHR _TRp►NSFER/ ENEWAL UNIFORM PERMIT
LJ 6 B 67-1~
PERMIT ENE L DATE: PERMIT TRANSFER DATE: ORIGINAL PER IT I UANCE DATE: STATE PLAN I.D. NUMBER:
/j
PR P TY CATION: CITY:
rQ n VILLAGE:
J '/4,S T ~d N,R ~l E (or) TOWN OF:
LOT N BERN BLOCK NUMBER: SUBDIVISIO NAME: NEAREST ROAD, LAK O LANDMARK:
C 'd
PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO:
NAM SIGNATURE: NAME. PH E U E
PHONE NUMBER: ADDR SS: ~ i
AD ES n
I, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this
propert .
PLU 'S SIGNATURE: PREVI US PLUMBE 'S N ME (IF CHANGED):
/s(([ 4 ~'G
PLU S ADDRESS: r PREVIO S P 'S ADDRES
MBER: PHONE NUMBER: MP PRSW NUMBEE PHONE ~NUM 3ER
M
3
SIGN TURE OF ISSUI G AGENT: DATE PPR V ED: DISTRIBUTION: Original - County
~j Copy - Bureau of Plumbing
• ~O Copy - Owner
DILHR-SBD- 9 ( /82) Copy - Plumber
msp. tsnn tlev.: BM Description: Parcel Tax No.:
/'0()
TANK INFORMATION ELEVATION DATA A9600263
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic O'.~) Benchmark l
Dosing IJ~ 1f J r.. d
Edi Bldg. Sewer St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet 7 ~3 ' pl. a
TANK TO P / L WELL BLDG. Air Ito ROAD Dt Inlet
Air Intake 7./ 7 1
Septic ® NA Dt Bottom * A), 33-
Dosing NA Header /Man. ~
/v , 7a
5-,69'
Aeration NA Dist. Pipe s; 82 /da s8~
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer q v
Demand r~:%~ . ~i rv t ' IOy,36
Model Number 3.9 ,71 ; GPM
l
TDH Lift 1 Loss I Head Friction System 'l TDH Ft
Forcemain Length ` Dia. s, Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ~2 75" DIMENSIONS
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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
than 8 112 x 11 inches in size. C z D /
• See reverse side for instructions for completing this application State Sanitary Permit Number
& g5_6-1)
The information you provide may be used by other government agency programs ❑ Check if revision to previous application
lPrivacy Law, s. 15.04 (1) (m)).
State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Prope O/w1n r Name - / Property Location
W ~ti4 1/4,S T Z , N, R j E (or)
Propert y Owne 's Mailing Address Lot Number Block Number
5K A/ 11-04 9 1 -
CO St Zip M Phone Number Subdivision Name or CSM Number fr
11. TYPE F BUILDING: (check one) ❑ State Owned ❑ cityy Nearest Road
1-1 ❑ Village C 044L v l4) A
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF
III. BUILDING USE: (If building type is public, check all that apply) arcel Tax Number(s)
1 ❑ Apartment / Condo 0- /0? 3 30V
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10E] 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. KNew 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 210 Mound 30E] Specify Type 41 ❑ Holding Tank
12E] Seepage Trench 22 ❑ In-Ground Pressure 42E] Pit Privy
13 ❑ Seepage Pit 43 ❑ 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
Required (s . ft.) Propos d (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
60-0 1 5? 5- S Feet /0(0 Feet
VII. TANK Capacity
gallons Total # Of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks
Septic Tank or Holding Tank Z~ 2019 ~s 67
El El El El El
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation oft onsite sewage system shown on the attached plans.
Plumber's nature: (No a s) MP/AN TM"ff1Qb.: Business Phone Number:
Plum is Name: (Print) 4
6q-t- C-bz X 379 ~~~-t~
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Saytary Permit Fee (includes Groundwater ate sue Iss ing Agent Signature (NO Stamps)
d
Approved E] Owner Given Initial / Surcharge Fee)
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Divwon, Owner, Plumber
INSTRUCTIONS .tf
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 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.
s
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63 7g
or and Department Industry,
Lab 3
' Labor and Human Relations SOIL AND SITE EVALUATION REPORT P8geOf
Divisidnvf Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8.1/2 x 11 inches in size. Plan must include, but .5"r- C R O/'
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D.
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY GATE
PROPERTY OWNER: PROPERTY LOCATION
JIM w A H Q E-0 [3 R O C-k GOVT. LOT SE 1 /4 S~F- 1/4,s 7 T 2-e AR E (or) W
PROPERTY OWNERS MAILING ADDRESS LOT # BLOCK # SU D NAMES OR CSM S ~
yD S•O. fO~K `
CITY, STATE ZIP CODE PHONE NUM~rBER QCITY OVILI AGE OWN NEAREST ROAD
h/vOSoa Gtr/•• ,51401 & (715) 3Kl - 18 5 _rR oy So. fog k 3)R .
[ New Construction Use [ Residential / Number of bedrooms
[ ]Addition to existing twilling
j ] Replacement [ J Public or commercial describe
Code derived daily flow gpd Recommended design loading rate • ~ bed, gpd$ • trench, gpd/ft2
Absorption area required V 5 9 bed, fit '750 trench, ft2 Maximum design loading rage • 7 bed, 91XW trench, 9;e-
Recommended infiltration surface elevation(s) S~ h 4 . 3 ft (as referred to site plan benchmado
Additional design / site considerations
parent material 5G5 73 PiY o T s, s y 01"cFR S/aw ;f / Flood plain elevation, if applicable ti4- R
,r,//,/ C ' "p-M /?A- I - F 7- j rsu -Suitable for system CONVENTIONAL. MOUND IN•GROUND PRESSURE AT-GRADE SYSr~i W FN L HOLDING T
= Unsuitable fors stem 01 ❑ U U r a-9- ❑ U aS O U 97S 11 U U ❑ S C
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture structure Roots GPD/ft
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed nEShdh
D- /0 V/P 3/2- - / 2 `F 5 k nom.-F R 05 t • 5 • G
I• G
6-1i A0Yk 14/14 s/ /f sd~ f e cs /f . s .
Ground Zen Z"3Z 7.syp yG 4-40
s, o, s ~,e Cs •fl
elev.
k ft
Depth to t
limiting
1WIDr
1
Remarks:
Boring #
. s . G
J-2- /-2.. 16 y~e 312-- Shk- /►a~. `F 9 C 5 I -F
El 30 /0 Ye 7-^ Y* ,w,-F,p C S
Ground ~O S~~v - • .s. d 1 S '(.e . 71 .
elev.
/01.7 fL
Depth to
limiting
factor et
> f6 I
Remarks:
CST Name:-Please Print Rof3ER T 'ULi3 f2 i c L, T' Phone:
713 - 3 696 - oo/(? S'
Address: 4 5 5 O' .v v ps 0'-j W/• S Y61(; C S%"! 2 41,0L.
Signature: f Date: CST Number.
.
PROPERTY OWNER SOIL DESCRIPTION REPORT Page of 3
PARCEL I.D.0
Depth Dominant Color Mottles Texture Structure ConsisIence Bourd3y Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed mnch
3 o-~~ /o R Z/I e G~ ar c s. z •F s6,~ M,-f R S
G -ZO x 2-/z- sit ,~f,~ S ~T • Y • 5
Ground 0 -3 /b ye 3/ttl
S./. /~s6.f' ~►~~i' ~t -c• Y •S
/o-6 It. 13z 1-y3 /o y,f c, r, xzfL
Depth to 16 limiling
Remarks: /r'a& 44011;6W • 7~0 aiP/ 20.,,-" 132_ ~ 3.2 - 113 "
Boring # `o e- Z f Sh& M-fe aq
A /e t/le 34z S/ 2f Sit .571 . c
a i.1-32- -7 s ye y16 - = s/ z 444 5~,~ ~s
Ground
(oelev~G /O ! R o, S a~~ . 7 S
Depth to
limiling
law
Remarks:
Boring# d o-!/ 16,e 3lZ °j2G~,~~' s,~ ~70 5 fie
mac
k 4"
q,- 16) ye
erev.. l3,. o - 3 7.5 yR S .w►, C S • 7 1
~0 5 . Zo it
2G 1.- o /o yf s/G - S. O,S d:Q _ . 7
Depth to ;
limiting
factor
Remarks:
Boring #
I
I
i
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
y~ v
OWNER/BUYER Ay4c-e-w T. a d 15 a c a-ra L: I o r~ a r~
MAI wG ADDRESS 3 b J u_v, V i' w D r l e V N r Fa 1[s 4111 S y o;3 ,;l
P R O P E R T Y ADDRESS e d a r V i e w ~g ~A L j soh WT S g o I L
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE 4 A d S o r w T_
PROPERTY LOCATION 1/4, S 1/4, Section -7 T a N R!_W
TOWN OF TV o ~i ST. CROI K COUNTY, WI
SUBDIVISION C e 4 a r ~ 1~ e LOT NUMBER S
CERTIFIED SURVEY MAP 5-13 b7 VOLUME 10 ,PAGE a 45 LOT NUMBER S
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 a do date.
SIGNED:
DATE: 7 --5-1
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 A h jre-w ago( 'Sovc L arcs L . 1 o w ct n-
Location of property 5 E 1/4 SE 1/4, Section 7 ,TAN-R__L3 W
Township _Fr d Mailing address Su- h V ire w Dr,
Iyer Fa ~I s w'L 5y o aI
Address of site 41'7 cedar View EA ~udSon WL X4016
Subdivision name Ce A 0 or 1 d a e Lot no.
Other homes on property? Yes y No
Previous owner of property ray~c~s IV Tacjpes j" Sahara L_~acc~;x@s
Total size of property a cre S
Total size of parcel of . 3 S acres
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes No
Volume 17 and Page Number 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. S 1 ,_)7 17 , 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.
Signatur f Applicant Co-Applicant
7 - 31 Date of Signature Date of Signature
/U rv
STATE DAR OF WISCONSIN FORM 2 - 1982
WARRANTY DEED
DOCUMENT NO. VOL
- EG ASTE 'S E)FF&GE d
Francis N. Jacques, Jr. and Sandra L. Jacques, Redd for Rowrd
husband and wife holding as survivorship
marital property APR 25 1996
1:30 P
conveys and warrants to Andrew T. Yonan and Barbara L.
Yonan, husband and wife holding as survivorshi ^.l•;,;w~. c. -3y
marital property
THIS SPACE RESERVED FOR RECORDING DATA
~ NAME AND RETURN ADDRESS
the following described real estate in St. Croix County, pyld~}
State of Wisconsin:
Ii
PARCEL IDENTIFICATION NUMBER I.
I~
Part of the S 1/2 of the SE 1/4 of Section 7-28-19 descr_:_bed as
i
follows: Lot 8 of Certified Survey Map filed November 22, 1994,
in Vol. "10", page 2845, Doc. No. 523676.
r
TRACNZ ER
E
i
I
This is not homestead property.
%X (is not)
Exceptiontowarranties: Easements, restrictions and rights-of-way of record,
if any.
Dated this 23rd day of April A.D., 19 9 6
i
(SEAL) ► ` - Q.C (SEAL)
~Fancis Nac-sJr(SEAL) (SEAL) II
Sandra L. `J cqifig~s
I~
AUTHENTICATION ACKNOWLEDGMENT
of Francis N. Jacque-s, Jr, State of Wisconsin,
Signal ~I
,I -
ss.
an s)andra L. Jacques
- County.
r ~.r ;2 3 rr7 i- ,ilr April 19 96 Personally came before me this day of