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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS
SUBDIVISION CSM# LOT
SECTION 17 TLN-R_&W, Town of
ST. CROIX CkMJN WISCONSIN
PLAN VIEW
OW EVERYTHING WITHIN 100 FEET OF SYSTEM
~Ila
I~
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:
ALTERNATE BM: 6~0 MC4-6~iz~
TIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity:
Setback from: Well %*o-*' 5 House )O Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width:/ Z Length Number of trenches
Distance & Direction to nearest prop. fine:
Setback from: well: > 150House_ Other
ELEVATIONS
Building Sewer 1175 ST Inlet; a ST outlet /
PC inlet PC bottom Pump Off
Header/Manifold z , ol- Bottom of system' l
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB: i
LICENSE NUMBER: 3 L
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Kuman Relations INSPECTION REPORT ST. CROIX
Sa;ety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
I' GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village a Town o : State Plan o.:
CHRISTENSEN, ARTHUR X
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
0 6 .E / U CJ r JC L/ ,a j .~4 I I A -9 2- _3 _2
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark ~/a boo
Dosing 5. ;z_
Aeration Bldg. Sewer r/ 7, 3-/'
Holding St/Ht Inlet G 56' Q7,o.-
TANK SETBACK INFORMATION St/Ht Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header/ Man. cl r' nfG , a
'
Aeration NA Dist. Pipe q S y' q("),:?
Holding Bot. System q,5 01 PUMP/ SIPHON INFORMATION Final Grade ('33, 97, 3'
Manufacturer Demand
Model Number GPM
TDH Lift Lrictio System TDH Ft
Head
Forcemain Leng Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia7__j Liquid Depth
DIMENSIONS /.2 r S- " DIMENSIONS
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manuacturer:
SETBACK
INFORMATION Type O CHAMBER Model Number:
System: 4-e. 8 J D .C/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 a6 -3,04 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Cylon.17.31.16W, NE, NW, Lagoon Road
Y
Plan revision required? ❑ Yes [TNo
Use other side for additional information. QS
11 SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
J(j SANITARY PERMIT APPLICATION
~ couNTY
va~InlR In accord with ILHR 83.05, Wis. Adm. Code
STATE S IT 1Pf PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than [T/v tf/1
8% 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.
PROPERTY OWNER PROPERTY LOCATION
, N, R E (or)
'/a '/e, s I_7 T t 9)
PROP R IT'S MAILING ADDRE LOT # BLOCK #
? . r`
CITY, STAT ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
K")IN 5,100 0, -69--s377
11. TYPE OF BUILDING: (Check one) 1:1 State Owned 0 VILLA GE NEAREST ROAD
o ts~- 2 c~
❑ Public ~1 or 2 Fam. Dwelling-# of bedrooms - PARCH L TAX NU ERO
111. BUILDING USE: (If building type is public, check all that apply) d .,~Ln _ S
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 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 in line A. Check line B if applicable)
A) 1.2SNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 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 L't~Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 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
L150 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
L15 0 q 3 C Z V Of Y. Feet Feet
VII. TANK CAPACITY Site
in ailons Total #of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank
Lift Pump Tank/Si hon 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' ig ure: (No Stam ) MP/MPRSW No.: Business Phone Number:
rta^- r~ l 7!
Plumb is Address (Street City, S6tate, Zip C e):
W1 bl IX. CO TY/DEPARTMENT USE ONLY
E] Disapproved Sani ry Permit Fee (Includes Groundwater Date issued issuing Agent Signat amps)
Surcharge Fee)
V oved El Owner Given Initial I VV 7-.2
Adverse Determination l~V
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(R.08/93) 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 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/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 & 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 in 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 in ##1-7.
VII. Tank information. Fill in the capacity of every new and/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% 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, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
• PLOT PLAN
PROJECT Aurthur Christensen ADDRESS 2184 220th St. Deer Park Wi 54007
NE 1/4 NW 1/4S 17 /T 31 N/R 16 W TOWN Cylon COUNTY ST. CROIX
~
BEDROOM 3
MFRS BYRON BIRD 7R. 3318 7/18/95
DATE
CONVENTIONAL IN-GRO D PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 648 BED SIZE 12'X54'
BENCHMARK V.R.P. Top of Coner Stake ASSUME ELEVATION 100'
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
VENT SYSTEM ELEVATION 94.9
12" GRADE
tTY AR COVER ING
1 2 Q3'
ER K
2'
03
Bedroom
House
10 B-1 10
4
>20%
Slope
12' x 54' Bed -3
I I Rep A 0'
60'
2% '
Slope I I
Vent
B-2 15' 15' -5
300' 10 *B M >100' to P.L.
F Property Line
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page _ of
• Labor anq Human Relations
Qvision of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/rFCu2A"L I A t include, but
PARCEL I.D. #
le or
not limited to vertical and horizontal reference point (o
dimensioned, north arrow, and location and distance ;ro
APPLICANT INFORMATION-PLEASE PRINT ~b REVIEWED BY DAT E
PROPERTY OWNER: l ,O PER ATION
fOVT. LO 1//4,S T N,R j E
PROPERTY OWNER':S MAILING ADDRESS S' ~ tpT f. t SUBD. NAME OR CS #
50~ J!
F STATE r ZIP CODE PHONE VILLAGE WN NEAREST ROAD
C
=e lo,
KNew Construction Use >1 Residential / Number of bedrooms- -2 [ ] Addition to existing building
Replacement [ ] Public or commercial describe
Code derived daily flow , gpd Recommended design loading rate -bed, gpd/ft2. Ltrench, gpd1ft2
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate _,,2 bed, gpd/ft2. (y trench, gpd/ft2
Recommended infiltration surface elevation(s) rr~ A ` , ft (as referred to site plan benchmark)
Additional design / site jnsiderati ons
Parent material CJ Flood plain elevation, if applicable ft
S = Suitable for system C NVEWIONAL ND IN- ROUND PRESSURE AT-GRADE SYSTEM ILL HOLDING T NK
U= Unsuitable fors stem S0 U S❑ U ]Eks U ELS ❑ U ❑ S U ❑ S
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Gu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
:r> - Z
Ground
le .
Depth to
limiting
z
Remarks:
Boring # -a r;? -
Z-- ,,,5 tG S . 7
Ground
P~le .
Depth to
limiting
r ' Remarks:
CST Name:-Please Print 0 Phone: 6 0
!
Address:
Signature: f7 ate: CST Nu ber:
5
32" 9
PROPERTYOWNER 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. Cont. Color Gr. Sz. Sh. Bed Trench
4 4 0 -'2
Ground
ev
ft.
Depth to
limiting
fact r
Remarks:
Boring #
~4_. 2 ~ fez 5.6 n/
Ground
9 e ev.
Depth to
limiting
factoL
Z
57
Remarks:
Boring # / Z ~2 ~2 /
Y ~
Ground
I iv.~
/J Z ft.
Depth to
limiting
fact
'3--3 Remarks:
Boring #
4
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
` - Soil Test Plot Plan
Project Name Authur Christensen Byron Bird Jr.
Address 2184 220th St. 491=1=, 4~~.
Deer Park Wi 54007 C W#3479
Lot Subdivision Date 5/8/95
NE 1 /4 NW 1 /4S17 T 31 N/R16 W TownshipCylon
Boring ()Well PL Property Line ROIX
BM or VRP Assume Elevation 00 ft Top of Corner Stake ?
System Elevation 94.9 Same as ark
03
Bedroom
House
25'
c
0
B-1 30' B-4 20'
a
>20%
Slope
B-3
Pri A Rep A 0
60'
2% 30'
Slope
B-2 -5
t '
1300' >100' to P.L.
Prope Line
F
1 '
STC- 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
/
OWNERlw G7Y` / i-®l JPD C~. /'.t~
MAILING ADDRESS X021,
PROPERTY ADDRESS
I,~~''~~
(location/of septic system) Please obtain from the Planning Dept.
CITY/STATE JQ 4r- gel V11 z
PROPERTY LOCATION 04~/4, Section TN-R_7Zz_W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION 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
i
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 expiration date.
~L--
SIGNED:
CSC
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
S T C - 100
f ,
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.
----d------------------------
----------------------+------------------14A
Owner of property P ! 1&, r- lQ ( 5 - 1k Location of property-a-1/4~~ 1/4, Section T N-R W
Township/. d YA Mailing address -q!i --;.W yF
& ~e- aoj 4- Ads' t~-
Address of site 5 41 prCi2
Subdivision name Lot no.
Other homes on property? Yes__K~No
Previous owner of property MM -e-
Total size of property
Total size of parcel
s
Date parcel was created'/
Are all corners.and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes __Z No
Volume 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. _Z~V~ , and that I (we) presently
own the proposed site for the ewage 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.
gna ure of Applicant Co-Applicant
71,-R lcll~~
Date of Signature Date of Signature
3-1W0 6~3 9 - _
This Indenture, Made this 23rd day of , in the year
of our Lord, one thousand nine hundred and---...seventy.. two between. Dennis F. Emrick and.. E-1iza-
{
beth_ A. Emriek. husband and wife,_ and said Elizabeth A. Emrick in her individual
-
' ri ht
z Part-_ies__of the first part, ~
i
and...--Arthur N. Christensen and Violet M. Christensen,
of - - Deer Park, Wisconsin
husband and wife, as joint tenants, parties of the second part.
I'
Witnesseth, That the said part-_-ies --of the first part, for and in consideration of the sum of
Thirt four Thousand $34 000.00
j y o ---h ----.)_..------------------------------------------Dollars,
them
to--.....-__..--.-___--..in hand paid by the said parties of the second part, the receipt whereof is hereby confessed and i
acknowledged, ha Ve...._-given, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and by
ii these presents do------------ give, grant, bargain, sell, remise, release, alien, convey and confirm unto the said parties of
~i the second part, as joint tenants, the following described real estate, situated in the County of.....-.- --t. Croix
..-and State of Wisconsin, to-wit:
I Parcel No. 1
ii
I
East Half of Northwest Quarter (Ez of NA) of Section Seventeen (17), Township
Thirty-one (31) North, of Range Sixteen (16) West, St. Croix County, Wisconsin,
except those lands and rights sold to the Village of Deer Park and described as:
A parcel of land, being the West 310 feet of the North 590 feet of the Southeast
Quarter of Northwest Quarter (SE -14 of NW-14) of said Section Seventeen (17), to-
gether with an easement for overflow 20 feet wide from said parcel Southeasterly
1i to the Willow River, and the West 50 feet of the Northeast Quarter of the North-
west Quarter (NE -4 of NW-14) of said Section Sixteen (16) for roadway purposes.
Parcel No. 2
is
North Half of Northeast Quarter (N -j of NE u) of Section Seventeen (17), Township
II Thirty-one (31) North, of Range Sixteen (16) West, St. Croix County, Wisconsin,
I subject to easements of record.
I
!
This deed is given in fulfillment of a land contract between the above parties
dated December 31, 1970 as to the real estate described under Parcel No. 1, and
i' in fulfillment of a land contract between the above parties dated September ,
1970 as to the real estate described under Parcel No. 2.
j
j
ii
'That the said party of the second part, Arthur N. Christensen,is also known as
j Arthur Norman Christensen, and the said party of the second part, Violet M. Christ-
ensen, is also known as Violet May Christensen.
i
ii
FEE
I EZX-1 .i,. T
I'
Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise apper-
I~ taining; and all the estate, right, title, interest, claim or demand whatsoever, of the said part.-ies.._of the first part,
i ;
either in law or equity, either in possession or expectancy of, in and to the above bargained premises, and their heredita-
I
ments and appurtenances.
To have and to hold the said premises as above described, with the hereditaments and appurtenances, unto the
it
said parties of the second part, as joint tenants.
li BOOK 405 PA-CE16
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