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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
_,,yy~~'C~~ )G~ a
ADDRESS d'r
SUBDIVISION / CSMJ - LOT
SECTION- T,9F N-R_Z f W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
el,
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
F~ s
Z
4
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity:
Setback from: Well H use
D~' Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
:SOIL ABSORPTION SYSTEM
Width: a Y Length Number of trenches
e s
Distance & Direction to nearest prop, line:- ;;?e
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:
1121911-1-
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:-
3/9 3 j t
:
wiscortin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 268529
Permit Holder's Name: ❑ City ❑ Village 91 Town o : State Plan ID No.:
BISOGNO, DENNIS TROY
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
i i
TANK INFORMATION LEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic lf~
Benchmark y G b' 7G.3
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet 8c) 04
TANK SETBACK INFORMATION St/ Ht Outlet 3,Dy'
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic ,25 2 //0 NA Dt Bottom
Dosing NA Header / Man. /11 05~ 42 3.51 Aeration NA Dist. Pipe 7 3. 3 S'
Holding Bot. System ~6' d 1/0
'
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
oss Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ' //51 l __11 DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type Of CHAMBER -1"' Moe Number:
System: e >/O' y5' Q .1/ OR UNIT
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 Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Troy.16.28.19W, NW, SE, Southern Pacific
Plan revision required? ❑ Yes B/No
Use other side for additional information. 1,3 ! 6 2 $
SBD-6710 (R 05/91) Date Ins ctor's signature Cert. No.
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.
• 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 LD. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
Gl 114S,4!r 1/4, S l' ToX , N, f19 E (or)
Property Ow er's Mailing Addres Lot Number Block Number
re T . t C Y ro 6;;~ef
City, State Zip Code Phone Number Subdivision Name or CSM Number
/J 'r v :nl 2 ( > X v 577'
7`s a.rJ'
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cioty Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms 5- age
E] own OF !570w T/
K CLG/~r C.
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment / Condo a I'V6 - I n2 Q
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 online B, if applicable)
A) 1 _ .gLNew 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 ELSeepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pity r 43 ❑ Vault Privy
14 ❑ System-In-Fill y :6,a ;-vi,_
2~ Awl
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
d ® Feet 7~r ~Feet
VII. TANK Ca
galloacits Total # of Prefab Site
INFORMATION in Gallons Tanks Manufacturer's Name PConcrete Con- Steel Fiberglass- Plastic ExpeAppr.
New Ex'sting strutted
Tanks Tanks
Septic Tank or Holding Tank ,S Qr®tCJ~ 9 fC (.rd ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (N Stamps) IAP/VPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Induces Groundwater Date Issue Issuing Agent Signature (No Stamps)
❑ Approved ❑ Owner Given Initial surcharge fee)
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
INSTRUCTIONS
R
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.
5. 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-
Vl_ Absorption system information. Provide all information requested for numbers 1 through 7.
i
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 liar this system- Check experimental approval only if tanks received experimental product approval from
Dlt-HR.
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 P,ar,s and specific?tinns not smalle ti^an 8 1 /2 a 11 inches mus- be submitted to the county. The plans must
include the -roko,wing. A) plot. plan, drawn to scaie or vvilh complete dimer7siors, soc_ation of holding tank(s); septic
tank (s) c, ,weer F; t ne;~t tar : ; buiiciir n, a.F ;a e" _x: n te':r rriairis'w: ter service; stream s ar< lakes; pump or siphon
tanks; soil absorption systems- replacement system areas; and the location of the building served;
E?) horizo, ta" < r s rerti ai elevation reference ce inry ) ti:omplete spec-fica ions for pumps and cantrols; dose volume;
r-
la s; un'ip ' pi er,tormance- Curve' ')UFr1r) '~i(. -)dei and laump manufacturer; D) cross section
elevation di ffereiices- r(ction p
of the s6l absorption system, if required by the county; FF soil test data on a 111 5 form; and F) all sizing information-
GROUNDWATER SURCHARGE
I
1983 Wisconsin Act 410 included the creation. of surcharges (fees) or 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-
I
SANITARY PERMIT APPLICATION BureaSafety u of and BuBuilildings Division
ding Water 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 n -
than 8 112 x 11 inches in size. `-1271\
• 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 ew~on p re 1717 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
al 14114, 5 T , N, R E (or
Property Own s Mailing Address Lot Number Block Number
~ "tJ 6Y' ~ ~l ,r e
City, State Zip Code Phone Number Subdivision Name or CSM Number
a r yTi( ca:
11. TYPE F BUILDING: (check one) ❑ State Owned ❑ it Village Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
41416-
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. X New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5, ❑ Repair of an
------System ___System_____________TankOnly______________ Existing System _________ExestengSystem
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 ~~dstOElev. 7. Final Gr7
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 7~1a Elvati` B Feet TG Feet
VII. TANK Capacity al Ions Total # of r Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New ]Existing structed
Tanks Tanks
Septic Tank or Holding Tank s~ 2 r l / !s'r~ ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VI11. 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: (No Stamps) P/ PRSW No.: Business Phone Number:
1j11h1114Aft .SIGN" 7 ! -
Plumber's Address (Street, City, State, Zip ode):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Stary Permit Fee (includes Groundwater aIssuing A ent Sign ure (No Spr-MiAr
Surcharge Fee)
Approved ❑ Owner Given Initial Adverse Determination CJv
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety a 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, reccrnection, 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-
V11. Tank information. Fill in the capacity of every nevdor 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.
x IIi
H,t ~ ~ t1~ 1111
r
~7-
'ZVI
s,
J
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%bOf/~5"a
A 9~73,6
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page \ of 3
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05 I e COUNTY
Ij ST-. C.CZ-o 1
Attach complete site plan on paper not less than 8 1/2 x 11 inches in P?an mu include,
e°
not limited to vertical and horizontal reference point (BM), direction o''of slppe~ alter PARCEL I.D.#
dimensioned, north arrow, and location and distance to nearest ro
APPLICANT INFORMATION-PLEASE PRINT ALL INFOR ,AfION EVIEWEOBY DATE
PROPERTY OWNER: PROPERTY LOCATION
6 Otto; v N,9, 1/ 1/4,S It T Z N,R 1 9 E( W
PROPERTY OWNER':S MAILING ADDRESS CK#1 NAME OR CSM #
I o fv . wt A-t 1Q1 g T. P ov fez sitt'f)t~►.) LI V Prod f17ON
CITY, STATE ZIP CODE PHONE NUMBER IL MOWN TEA REST ROAD
R.LUeTL. ~LLS, I,J I S bLZ (71S) LIU- g 1 61 O Y
DI New Construction Use.[X] Residential /Number of bedrooms Addition to existing buik1ing
Replacement Public or commercial describe
Code derived daily flow 60 o gpd Recommended design loading rate bed, 9pd/(r2 ±-_5 trench, gpd/tt2
Absorption area required 8 S$ bed, ft2 1 5 o trench, ft2 Matdmum design looming rate a • 1 bed, gpd/ft2 0. %trench, gpd/ft2
Recommended infiltration surface elevation(s) se Q~Gty a q r- 3 ft (as referred to site plan benchmark)
Additional design / site considerations %4- L k ft
Parent material sM1MtEwl outt S tfrhA y G%J*V -IW Flood plain elevation, 'If applicable N •A • ft
N~Suitable for system CONVeMONAL MOUND W-GRDUND PRESSURE AT-GRADE SYSTBA IN FILL HOLDING TANK
nsuitable for stem OS ❑ U ®S ❑ U ®S ❑ U ®S ❑ U ❑ S ®U ❑ S U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consisi>ence Bourifty Roots GPD/ft
Boring # Horizon in. Munsell QU. Sz. Cont Color Gr. Sz. Sh. Bed mn t
1 ) o_LO 10`1.tL 3lz - Sl 1 Zwt S)r rT CS o.S ~•6
n Z 1c~ -t9 loo -1Z 51 - Si I Z'PSbh W\ i~ CS - o•s o.
Ground 3 19-40 ,•S~~ 3ly - S1 _LM Sbk *Qj_ cw - o - S 13, 'a
elev. o.. y
q~3.5 ft. Lib-60 -)•s 'it?-' 31y S1 \ C S bh ~n V 4. CS o.S
Depth to S O-q Q, 7•S ytt y& - S lit- 3g Yvt ) - o. 0.8
limiting
factor
98
Remarks:
Boring #
J a_ 9 X QN-1 it- 31 a S l~ Zm s bh v`'~ `Fl• c S 0-S t"
z ; Z °l-Z~f ~O`i1z sly - S 1~ 2rrt 516k tvt -fl, CS - o . S C).
S
_ o• S o" ~
3 Z~-31 Z- SYR 3 Ly - S -Z`F s bk mui -wy it. CLQ
Ground _ Q'q o.S
elev.
fl 3) - Sy -I_SyQ Sly _ S Zc'Thw yo \.),6 as
Depth to S S4_00 ~•S 17R Vl6 - S~ GH 0%) - o•~ o•g
limiting
factor6
7 ~6 y
Remarks:
T Name:-Please Print Arthur L. Ice erer Phone. 715-425-0165
Ad:
egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022
Signature: d . Date: CST Number:
s G ~(-30Z7 6D 1-3D -95 M00576
PROPERTY OWNER B`t ZC-tN Z SOIL DESCRIPTION REPORT Page Z- of 3 "
PARCEL I.D. #
Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourdary Roots .GPD/ft
in. Munsell Ou. Sz. Cont color Gr. Sz. Sh. Bed Trench
I::^~ MHO
£E 3 0-Io vO-ttz 31-L - s11 ZMSbk wti`~h GS o.S o.b
Z to-,3z V)47- S /V - S 1 1 Z sbh >n ~t^ c-S - n• s u. 6
'Zi -14 b.s
Ground 3 3Z_S3 -)•S y(z 31y 1 C S~1t ~•,-i`Fk Cs
elev.
0 Z- S ft. S3 CIb -)•S Lim V/6 - S o S g I - o . i o • 6
Depth to Ct)N NS c o vn U S i
limiting
factor i
7 O'~ s
I
Remarks:
Boring # •
0--7 tiU1-1 VL 31z - st ZVKSbk 0 S - o•5 o. L
> 1`>' Z 1-7-6 10`4R sit/ - S I z`fSbk vn Ft, C S O, S o-6
3 Z6-S3 ~.SyR sty s l ~ esbrr yn eS _ 0.4 o.S
Ground O ' i o• 8
elev, L/ 53-99 7 -S ` rz Y/4 SILGI. 0 S9 yn j
q$l. f t.
i
Depth to
limiting
factor
q
g9
?
Remarks:
Boring # i
I o 9 ~o`1R 3tZ - 5t` ZmSb4 `n cs _ o•S io.~
4 Y
5 Z q-37 1 O`I2 S l - S i t Sbh wt 'Fti c g _ p. S i u. 6
S':aa'C:E:«
Ground S,-1 ti VA ~ S ftCv. 0 303 Ivt ~ _ o.-) o. g
elev.
~1S.Dft.
t
Depth to
limiting
factor I
i
Remarks:
Boring #
i
Lam. • s:.::.:
I
Ground
elev. i
ft.
Depth to
limiting
factor
Remarks:
SBD•8330(R.05/92)
PLOT PLAN Page 3 of 3
SCALE 1"= 90 '
0
0
r
T
X1'1- qno, as ' uN,
_ Z << l R.o>v PIPS
3 Z - L'2 ~
V'- q'1 S o So 8:Z ZL qZl
F~lZeR1.11~j$ S, r1.41l s 8.3 e. 1.11.1 \S1 h"l. X12 ~kJ C4}lsr
s b~
Sb%
g•V It"~o
EL Rbly 6.1
x-993 S
NOTE: House to be at least 25' from trenches.
Well to be at least 50' from trenches.
1RO~ 1~1PE
Zo\ ~
~ROh3 Pt pE
NOTE TO INSTALLER:
Place trenches 60'r7deep at the upslope edge.
Place maximum 42" cover over the distribution pipes.
Determine trench elevations at the,time of construction.
,p 9~-3oz _ 60
~d - 9S (715 ) 425-0765 M00576
CST Signature Date Signed Telephone No. CST #
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page \ of 3
Lbbor and Human Relations
Division of Safety 8 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 ST- C--kZo 1 X
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. 8
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
C. M- B4 E' ?Mx 17~1J \ S S Q-VtQ L Z 681fF. EffF N w 1/4 Sle 114,S It T Z N,R 19 E( w
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK X SUBD. NAME OR CSM /
LO fV . n''t A11u g T. 60 - GLpUL31Z SlRfiO►J t! RDpCRON
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE MOWN NEAREST ROAD
R L U U V L , PtLL5, wL S OLZ. (7157 LIES- 4 I L I O Y
[)(J New Construction Use. M Residential/ Number of bedrooms [ J AddihQn b e4sting building
J Replacement [ J Public or commeraal describe
Code derived daily flow boo gpd Recommended design loading rate bed, gp(i'ft2 8 trends, gpdi'ft2
AbsorpdDn area required 8 S$ bed, ft2 -1 s o trench, ft2 Wotn tm design loading rate a • 1 bed, gg$ 0.9 trends, 9pdjft2
Recommended infiltration surface elevation(s) SE ptKge 14 o r- 3 It (as referred to site plan benchmark)
Additional design / site considerations k < < n .
Parent material SM"(E&41- OULM S "*M*, `7 Q\X-J ~3N Flood plain elevation, if applicable N •A • ft
S = Suitable for system CONVEdTIONAI MOUND 7T~ PRESSURE AT-GRADE SYSTEM IN FlLL HOLDING TAW
U=Unsutable for system JoS ❑U 21 S ❑U U ®S ❑U [IS ®U [IS 19U
SOIL DESCRIPTION REPORT
Boring# Horizon Depth Dominant Color Mottles Texture Structure Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed iench
l O_LO lo`1R 3 t2 S1, Z.M Soh O.S 6
1o-t9 loo tiR s1 - Si l Z T-5bh tin 'fit- CS - o-S o.
Ground 3 19-40 -)-S112 31 - S~ .-Lyn shk *%-A- ew - o• S o. b
elev.
983.5 ft t-Iti-613 -)-s `1R 31y S \ c s bh \,n V CS a-4 a.S
Depth to S Lift V& - S q G, o gg wr 1 - o• o. g
limiting
factor
a
Remarks:
Boring #
4-9 10-ttz3lz stl Zmsbh "~~h cS o.So.`
El Z °l-Zy \pyR sly - S11 Zion SM, WI ~L: CS o . S o. f•
3 1-4-31 Z-slilz 3Ly - S1 2.?-361,c muil►►a - o•S 0,6
Ground'
elev.SyR 3/y - rl lcsbk \nU' o.y `o.S
S 4-°tq ?•S 1.19- VIG SIGH o s9 o•g
Depth to
limiting
factor
7 X14.''.,
Remarks:
T Name.--Please Print Phone:
Arthur L. We erer 71.5-425-0165
egerer Soil Testing,& Design Service-P.O. Box, 74 River Falls,WI 54022
Sgnature: Date: CST Number:
d G y-302 - loo J-3D -9-5 M00576
PROPERTY OWNER B`t t:-!- - 3 C*Q t-TZ- SOIL DESCRIPTION REPORT Page Z of 3
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Car. Sz. Sh. Bed Trend
1 Z`~sbh m'Fh cS
Z I.o-3Z V111-17 s/y s1 '0-T 11.6
Ground ..3 32-53 ~•S y12. 3/y S ~ \ C S~k M~l^ as - o •S
elev. S O S g) ° ' g
q„. s ft. S3 =90 .S Y2 y/b
k
Depth to CON S Flo o w► U S
limiting
f~tof~i
Remarks:
Boring # m`Fh C S
O-1 -1 R 3l Z S t Zw1 Sbk o•S o. 1,
Lf Y Z -Z.6 1O~R Sly Z`Fsbk VVI ~l, e S - o•S o.6
3 zb-S3 ~.Sytz sly - S 1 1 eSbk vn v~~ es ~,y o•S
Ground
elev. L/ S3-901 -1 .S `1R y/6 SF1.61. O S9 yn) i
ft.
Depth to '
limiting,
factor
Remarks:
Boring # c
0 t0'~(R I z - 51 Z vn S b h wl S
♦ 1+{y
2 q-37 10`12 s l - s I f Z sbh cS - d S G- L
3~-9>J S`1tz v/b S ~[Ga O 3~y Ivt - o.~ 0.8
Ground
elev. i
q'1S.Oft.
Depth to
limiting
factor
701
Remarks:
Boring #
.r
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
PLOT PLAN Page 3 of 3
• SCALE 1"= q0 '
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0
r
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~--B'►1- tL.ti`A7. X176.3 ~ erg
tM1 em &JT - sPir~~ 1` ABou~ GRouu.D ►N pP
C,- R-t S Tt, gZZ
4~lZE~ZI-tl~~ _ _ z S rt q-►~ s s.3 ~rL. )w \~1 h 1. \1Z Ek/ CE{lT
5o%
• S.
mss.
8•V
0
lTt 89114 11 ° B 1
~L963 S
NOTE: House to be at least 25' from trenches.
Well to be at least 50' from trenches. ayy
1"tRo~ ptP~
Z.'1 Z, 04' X1.1 ~ 9`i°~_SO• oiv
~ ~ ~ROt~1 Pt PE
NOTE TO INSTALLER:
Place trenches 60" deep at the upslope edge.
Place maximum 42" cover over the distribution pipes.
Determine trench elevations at the.time of construction.
fit!-3o2_6d
(715 ) 425-01 64 14005 66
CST Signature Date Signed Telephone No. CST #
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNERBUYER
MAII_JNG ADDRESS /2 ~t' ;t PL S T ' l= 4 `ls .l _ .
PROPERTY ADDRESS .s_el__f ,y per, d ~ lell
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE t- - e
PROPERTY LOCATION 1/4, 1/4, Section Ti~ F' N-R'7 W
TOWN OF a 5 , ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIEDSURVEY MAP _,VOLUME _ S 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 1984, 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 rton date.
77
SIGNED:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
STC - 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.
-----------+a-----------------------------------------------...-------
owner of property ,o i LZ -T d ;S'a 9'~Jd
Location of property.,k)GJ„_..1/4S so:5-1/4, section ,T~,FN-R w
5
Township Mailing address 8~ dos y-
'1Ls:%_L~L~ fry
Address of site 7"', er Aee
Subdivision name Lot no. 620
Other homes on property? Yes No
Previous owner of property .42ysJ,I s S~
Total size of property Gl yfl.yvai~
Total size of parcel ,z awe s
Date parcel was created /`y6
Are all corners and lot lines identifiable? >C Yes No
Is this property being developed for (spec house) ? Yes ~ k No
Volume 1/i and Page Numbers as recorded with the Register
of Deeds.
-------------------------------------------------------------r--
ZNCLUDN 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. 4-.9,1r~:5:7 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.
re of Applicant-- o pplic nt
T1A'to of Ci r~»a+•„re+ n..~.., ..r e+s _r.__°-
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435.93' . '
• 181.96
' . .......:...............................2
S 01003' 36" E 350.00' 01°03' 36"
o : Z Ira ~~,:1;
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DOCUMENT No. STATE BAR OF WISCONSIN FORM 1 -19SZrlr THIS SPACE RESERVED FOR RECORDING DATA
WARRANTY DEED
r I
-538573
II G Ii ~ rr !Sts i~ L7s,~ tq~ i~
11 1 PAn, 5) 72,
VV t_ _ {mil
This Deed, made between __Demis_R,___REhu],z_______________________ 1 JAI 15 1996
1:20 P."
1:20
- - -
Grantorn
- - - - -
and Dennys- Bisogno- and. Lori -Dopkns-_Bisogno, -
husband_and-wife,- -as- marital -survivorship-_property_-_-__-__-
I~ ,
E~
Grantee, n
Witnesseth That the said Grantor, for a valuable consideration______ f,a iold
D_ennis_R.-_Schultz-
A 7y~ D~ ^7
y
conveys to Grantee the following described real estate in _ _ St.._.CrQZX___ _ PO BOX 16/
i LIRZiver N O 1•~. a
Fall WI 54022
County, State of Wisconsin:
Lot Sixty (60), Glover Station Fourth Addition,
Tag Parcel No-
Town of Troy, St. Croix County, 6Iisconsin.
Subject to driveway easement shared with Lot Fifty-nine (59)
as shown on said plat.
i
TRAM 5FR
t FEE
Owners of Lot 59 and Lot 60 mutually share any expenses in the
f maintenance of the driveway easement as shown on the recorded
plat of Glover Station Fourth Addition.
i
i
This is._not------------- homestead property.
i (is) (is not) i,
I
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And---- Dennis_.R__Schultz-----------------------------
w arrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except nR1nCpa7
E{
j and zoning ordinances, easements for public utilities, and building restrictions,
of record,
and will warrant and defend the same. i
Dated this - - day of - - ------r 1995
i
(SEAL) (SEAL)
Dennis R. Schultz
------------(SEAL) (SEAL)
I;
is
1
l AUTHENTICATION ACKNOWLEDGMENT
STATE OF WISCONSIN
Signature(s)
ss. , L
L ,
Stx. =ix-------------County. 11
authenticated this ________day of___________________________ 19 P_ersonally came before me this day of