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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER -PA"
ADDRESS 1024 ~ 00 ti U` e
5`0L
SUSDIVTSION / CSMV LOT #
SECTION q~N-1,!~W, Town of QAA
ST CRO'IX COUNTY`, WISCONS%p
P VIEW
EK*W EVERYTHING WITHTP 100 FEET OF SYSTEM
}
U r g yvl 72-
V z
• n i K
3 y` Lo~E. ,r
INDICATE NORTH ARROW
Provid,w setback, and elevation information on reverse of this form.
Prlbvide 2 ,dimensions to center of septic tank manhole cover.
ok7Z
BENCHMARK : :rC c42 U ~ Y C fir ~y o ug, t s~ oC) r )IJ o Y 'A c ►~f
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Itil U.~s`C l"~h C, Liquid -Capacity: ) D d a
Setback from: Well 1 70 House Other
Pump: Manufacturers A Model# Size
Float seperation Gallons/cycle:
Alarm Location
.SOIL ABSORPTION SYSTEM
Width: ) ? Length-. 2 Number of trenches
Distance & Direction to nearest prop- lire: Z
Setback from: well: House Other
ELEVATIONS
Building Sewer ?8,P ST Inlet ; y8. v 4 ST outlet 1787
PC inlet- W PC bottom Pump Off
Header/Manifold Bottom of system- 9~ 7
Existing Grade Final grade
DATE OF INSTALLATION:
T'
PLUMBER ON JOB:
LICENSE NUMBER: twf S `3 3 7 6
INSPECTOR:
3/93:jt
r
Wi'consinDepartment of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations ST ON®T
Safety and Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI
SELISKT. RAYMOND & PATRICIA X
CST BM Elev.: Insp. BM Elev.: BM Description: WARREN Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
i
Septic Benchmark
Dosin
Aeration Bldg. Sewer S 1~S 97 97
How St/,( Inlet
940.s/
TANK SETBACK INFORMATION St/O outlet
TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet
rl
Septic -7 ' ~A NA Dt Bottom
Dosing A Headed 9
- S 7
Aeration NA Dist. Pipe ~ 2Z r CI5 ,P'/ /
Molding Bot. System '
S.v7' 9 y 95-
PUMP/ SIPHON INFORMATION Final Grade a/'
Manu rer and,~o ~L)t 9g, 2
Model Number GP
TDH Lift Fr' ' n System TDH Ft
Force I n Length Dia. I f Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width , Length , No. Of Trenches PIT No. Of Pits Inside Dia. i uid Depth
DIMENSIONS 1a % DIMEMSIGNS
SYSTEM TO P/ L BLDG WELL LAKE / STREAM _L anu acturer:
SETBACK
INFORMATION Type Of yt[.r~r^cn17, ,J 4-
System: C -,16) / >.so }l UNIT
DISTRIBUTION Mode Num er:
SYSTEM
Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing, -Vent To Air In e
Length Dia. Length 2i Dia. Spacing CO
SOIL COVER x Pressure Systems Only xx Mound Or At-Grad stem
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: WARREN.S.29.18/y, SE SW, 100TH AVE
Plan revision required? ❑ Yes No
Use other side for additional information. 67
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION
70ILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than a5~
8'fi x 11 inches in size. ❑ Check if revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROP~TY OWNER PROPERTY LOCATION
Trlc►w deli SF_Y45uj Y4,S S Taq,N,R lg ,ff(or)W
PROPER OWNER'S MAILING ADDRESS LOT # BLOCK #
) 1) 24 100 tH g u r n X
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
~o er~5 1 5462.3 7/S" 38)-S8;? X001 r.c,- 12-,cc- (
II. TYPE OF BUILDING: Check one CITY NEAREST ROAD
n( ( ) ❑ State Owned O VILLAGE 1~J Qr ~t;n / 0 0 T U
❑ Public 1211 or 2 Fam. Dwelling-# of bedrooms 21- PARGE1 TAX NUMBER( S)
111. BUILDING USE: (If building type is public, check all that apply) 0 4 2 , 4 21 - $ 0 ' t d 6
1 ❑ Apt/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 120 Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. % New 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 - 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 420 Pit Privy
13 ❑ Seepage Pit Pressure 430 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
-306 42q 4 3 a 0.7 M Feet 4 7, 3 Feet
VII. TANK CAPACITY # of Prefab. Site Fiber- Exper.
in allons Total Manufacturer's Name Con- Steel Plastic
INFORMATION New istin Gallons Tanks Concrete glass App.
Tanks Tanks structed
Septic Tank or Holdin Tank 1606 JD00 ) lt! tlSC2 Cc,ac- rc~l
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 Name (Print): Plumber's Signature: (No Stamps) MP/ R Business Phone Number:
Car- 1 P, 9etse 16 a r t/. 1 3378 1(71,c-
Plumber's )Address (Street, City, State, Zip Code):
/ Q S Gc l ti S uw &A L< _S4 -
IX. C LINTY/DEPARTMENT USE ONLY
❑ Disapproved San! ary Permit Fee (Includes Groundwater Date Issued Issuing Ag t Signature (No S p
Approved ❑ Owner Given initial Surcharge Fee)
Adverse Determination ~v 6 `7 9
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. Aspnitary permit is valid for two (2) years.
2. Your'sa.nitarypermit may be renewed before the expiration date, and at the 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/Re-ewa! Forrn 63t4)i to be
submitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The ,-:;.)tic tank(s;j r uat 1±e puriip Iy a iicensed
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code ac! ninistrator or the
State of Wisconsin, Safety & 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 cr 2 Fami:y Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacernenreco inection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested ir ##1-7.
VIE. Tank intcrmatici% Fill in thb; -apacity of ever, rew and!nr exi~-t n~:, t-lnk, 'ist -te tota` i ; nur,iper, of
tanks anri ni,arfutacturer oa.rre. Indicate r;refa. cr site constructed ar.0, tank 1).Iete f,,-,r all
septic, pump/siphon and holding tanks for this system. Check ex~;erirrrental 3pprova! r, k tank,; received
expEt+n~ ~aal product, approval from DIL.F.R.
Vlll Responsibility statement. installing plumber is to fH in name, iirense number with ai~proi-iate pr'Aix (e.g.
MID, etc.)„ address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Coe -1 -?t' plans and spe:-Jf cations not srsaller than 81/2 x 11 inches must hr subrr ' 'i.- co,.ri`y. The
plans rr st include the Ertl;(jwing: A) plot i:an, d?'a.vm to scale or rh ^c~r'+ipi. to cr rtt' 7, 7Cr:;: n of
hni, it;,g tank(s), septic or other ,eatniPnt tanks, hulldir-. , Nei l3; lk ~t vatf?r tiervice;
s redlvis and lakes, pumP or siphon tar!k +rstribution boxes, ; a')s vpfioi sy ;t,~?i"3 : f'*er":'';* systern
areas, r?(a i!h(iUCaiiOn o 4Sr building S°, a. t horizontal ~_k
C) complete specifications for pumps and contr of;,; dose volume; eievatior c lffere w7o,,r. f; ;+.',:ion Ecss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil ammirptior :system if
required by the county; E) soil test data on a 115 form; and F) all sizing information.
- - - - - - - - - - - - - - - - - - - -
GROUNDWATEM SURCHARGE
1983 Wiscor,sir: Act 410 included the creation of surcha•ges (fees) for a number :;r
regulated practices which can effect groundwater.
The dirvniis collected through these surchar es w ,irasi n;water contamination investigations and establishr w,L' of sing,(; rds-
SBD-6398 (R.11/88)
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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, 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 ro i
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. - 10 2 ] -50 - l 4 t3 . L142 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED
BY DATE
PROPERTY OWNER: PROPERTY LOCATION
Ka 111 n 7' i GOVT. LOT 5 F 1/4 SW 1/4,S 8 T 29 N,R I B Jr(or) W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
6 2 00 TN AV E N W W A
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE MtOWN NEAREST ROAD
o6er'T5 i 51o2 (715) 81-182s' rr I too ? AI
[-r New Construction Use [wj Residential / Number of bedrooms 2 [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 30t) gpd Recommended design loading rate 0.'7 bed, gpd/0b' (3 trench, gpd/ft2
Absorption area required 4 2 j bed, ft2 . '7 -5- trench, ft2 Maximum design loading rate Q " 7 bed, gpd/ft2 O trench, gpd/ft2
Recommended infiltration surface elevation(s) 94.0 ' ft (as referred to site plan benchmark)
Additional design / site considerations m5;7't. l l x 3G ` scg2t .t bcx
Parent material Flood plain elevation, if applicable IV A ft
S = Suitable for system CONVENTIONAL MOUND IN GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem IS S ❑ U ®S ❑ U 9S ❑ U 0S ❑ U El S 19u
❑ S l3U
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
0-0 I Q 4/-3
S a 2 f sbk, 45 I Uf b, 0.
Ytt4 mrka 0 msg rrr _ _ G .f.
Ground
elev
q7, t.
Depth to
limiting
factor g„
Remarks: ILS S,7C was 00k CE wLrn road ww~ bw 11 ~~ia e-►a~ is I c
Boring #
10: 0-10 1 o Ye- 4/3 S 1 1 Z f sb a S l u 0-s-
o G
2 ►6-1a0 71 YA4h - rnus 0b'"5 rn - 6.7 .01$
Ground
elev.
X13 ft.
Depth to
limiting
factor
too"
Remarks:
CST Name:-Plea e P wets t Phone:
pyk or '?I -42s- 2175-
Address:
1042 S n+a;~ S7.
Signature: ; Date: CST Number:
~GQ
I.- -&Wdd~ -3-3/4 1
PROPERTYOWNER ~Za-%inaA Se14, SOIL DESCRIPTION REPORT Page-?-of
PARCEL I.D.# b4Z 't p21 ' S0 -100
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Baxxby Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends
t ~8 Ip Y(L 4 a6 Ivf 0.5 0,4
atw ux`<kfssw 'L S -IA 7 S YR416 vn~l s D YnSq Wa1 b.7 L1,$
Ground
elev.
ft.
Depth to
limiting
factor
> )o4
Remarks:
Boring # Q_ 4 I D 2 S; ~ rn~ r a 5 I v 0. s 0. G
. -I0Z 7. S Y2A G w Yha~ S G 1M1+5 ! 0` 1 016
4 '
I
Ground
elev.
I ft.
Depth to
limiting
factor
►o2
Remarks:
Boring # 0, lv
Y+,e~ s - _ D 019
5 " 2 A ~106 7 5 rz 414,
Ground
elev.
q t3,?ft.
Depth to
limiting
factor „
Remarks:
Boring #
};2 v
>•sxks45.wz
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
PL 6F PLAN P13oJ3
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SG►~Gw ~=40~
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Q5
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER !1't L. I S/C
MAILING ADDRESS -2 7 ~8 l/C6~nE~~ S ~a 2
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE p~
PROPERTY LOCATION S 1/4,~ 1/4, Section U T,0'1_1 N-R W
TOWN OF _ WA k ST. CROIX COUNTY, WI
SUBDIVISION ~I LOT NUMBER.
t
CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER
P 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
K as a treatment stage in the waste disposal system.
43 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 completed and r turned to the St. Croix
County Zoning Officer within 30 days of the three year ex
SIGNED:
tu
DATE: lC f 6
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(:), 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.
5 -
L fS
Owner of property y~ Tl (C
Location of property;-L 1/45181 1/4, Section T2 2_N-R Ii?' W
Township Mailing address
Address of site D -2 ~d d& ,6C-2 -Ly (.J-C YL 23
P Subdivision name A114- Lot no.
Other homes on property? Yes V1 No
~Y Previous owner of property Cler
Total size of property '202) /1 C'yC'CS
N Total size of parcel
Date parcel was created J
O
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes No
Volume 77r and Page Number (81 as recorded with the Register
E~ of Deeds.
Z
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
O A WARRANTY DEED which includes a DOCUMENT. NUMBER, VOLUME AND PAGE
lJ 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. Y2 5x7 ,F~ , and that I (we) presently
own the proposed site or 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.
Signa re of Applicant Co-Applicant
Date o Signature Date of Signature
roc 995E~3
oocurKE-NT No. WARRANTY DEED
THIS ePACL RCSLRV[D IOR RCCOROINO DATA
STATE BAR OF WISCONSIN FORM •'^q
495'785
__.Rohe_rt L. Mello _ and Lucille C_. Mello. ns his wife REOX 8 FFl
and in her awn right............................... ST.CR (XX,1M
Reed tof Record
MA
conveys and warrants to ]~~._gcl(j--Nt---,----$__44-
Real i ck; ,__husband.and-vi fa,.-as..sur-vJ-_vorshipL_maxi~al._.._._.. at 3:00 '
I rdatlt
RETURN TO
the following described real estate in .__.________..st,._Croix
State of Wi-consin: County,
Tax Parcel No: .
iag~S4 Sec. 7;
SWk Sec. 8; and that part of the N Sec. 17 lying Northerly of the hiway,
except: Beginning at the South quarter corner of Sec. 8; thence South 00 9,
19" West 55.09 feet to the centerline of 100th Avenue; thence Southwesterly
864.61 feat along said centerline along the arc of a 6043.88 foot radius curve
concave to the Northwest whose chord bears South 74°57'45" West 863.87 feet;
thence North 00°39'19" East 1042.52 feet; thence North 89046135" East 831.77
feet to the East line of the Sik of Sec. 8: thence South 00°39'19" West 766.54
feet along said East line to the point of beginning;
a -
All in T29N-R18W.
a .
This 4 •nOt--------- homestead
property.
Xtik (is not)
Exception to warranties: Existing highways, easements and rights of way of
record.
Dated this
day of
t - ---(SEAL)
- - ..-----..(SEAL)
r
l~lln_
• Robert_.L. _
(SEAL)
- . Lucille C - Mello
AUTHENTICATION s
ACHNOWLBDOMBNT
STATE OF WISCONSIN
-
91s__ CXPU--Coun
authenticated this --------may ~ ty-
it _ . Personally came before me this Soh day of
MSrch---------------- 19.93 the above named
• RDbert•L-_Malltl-and_ uc lp.r..._Mel tn,-
TITLE: l[EYBEB STATE BAR OF WISCONSIN
- : ..............ltdy7~>~rfe ° -
(If not,
zised by ?08.OE~ Wis. Stab)
bath rson4___________ Who executed the
t4LFj4AP.
to .*oknow
THIS INSTRUMENT WAS DRAFTlD BY
ledg8 the name.
Attnrnsav fle,riA 7 L•..r~___ Jf~' /I/L.[>r -