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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER_ ADDRESS
SUBDIVISION / CSM# LOT #
SECTION- ~7 W, Town of y
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHQW EVERYTHING WITHIN 100 FEET OF SYSTEM
yr.
~a
4-7
INDICATE NORT ROId j
Provide setback and elevation information o erse of this form.
Provide 2 dimensions to center of septic tank manhole coves.
f /
BENCHMARK: • ,(,p,~
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity:
Setback from: Well House ~2 -2 Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: 1W House ' Other
ELEVATIONS
Building Sewer ST Inlet. ST outlet
PC inlet PC bottom Pump Off
Header/Manifold_ 9y Z9 Bottom of system 2271
Existing Grade Final grade ge-9
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE S~IIIISTEV County:
Labor and Human Relations INSPECTION REPORT ST, CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI
MILLIRON, CHRIS X
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A 500041
TYPE MANUFACTURER CAPACITY STATION S HI FS ELEV.
Septic Benchmark ~Tlq(o !
Dosing g
Aeration Bldg. Sewer 2.71
Holding St/Ht Inlet 3-K al
TANK SETBACK INFORMATION St/ Ht Outlet
Verit
TANK TO P/ L WELL BLDG. AirIto ntake ROAD Dt Inlet
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe d Zd ~0
Holding Bot. System -7. f
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand -ld
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMEN I N
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type Of CHAMBER Moe Number:
System: 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.)
~r^ ~Q
LOCATION: Erin Prairie.7.30.17W, NE, SE, GG ky~ 6 Zeta( Plan revision required? ❑ Yes ❑ No
Use other side for additional information. I~-
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL CQMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION
COUNTY
In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITAELY PEOMI #
-Attach complete plans (to the county copy only) for the system, on paper not less than //~`''r'_
8% x 11 inches in size. ❑ Check if revision to 4vious 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
4~~161 A i&, 6 Z & % S T , N, R (or)
PROPERTY OWNER'S MAILIN ADDRESS LOT # BLOCK #
STAT ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
1
II. TYPE OF BUILDING: (Check One) ❑ State Owned VILLAGE NEAREST R?/ 13 CITY ?D
TOWN OF: j
Public M 1 or 2 Fam. Dwelling-# of bedrooms =Z PARCEL TAX NUMBER(S)
111. BUILDING USE: (If building type is public, check all that apply) ~D
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
40 Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
50 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. M 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 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-ln-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 ./'nch) ELEVATION
Feet Feet
VII. TANK CAPACITY Site
in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New istin Gallons Tanks Concrete structed glass App.
Tanks Tanks
Septic Tank or Holdin Tank
Lift Pump Tank/Si hon Chamber 171 F-I F-1 Ll El I L1
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumb is Name (Print): Plumber's ign re: ) MP/MPRSW No.: Business Phone Number:
lumber' Address (Street, City, State, Zip Cod
i
IX. COUNTY/DEPARTMENT USE ONLY
(No S
tamps)
❑ Disapproved S itary Permit Fee (Includes Groundwater Date Issued uing AgenMJJ
❑ Owner Given Initial Surcharge Fee)
XApproved
Adverse Determination J, A 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.
Ill. 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
i
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)
~ ~(l,F'/~, S~ sic 7, T.3a~✓ x~i7W
,kiJ , c,~/h~-d,~ ~S' ~D~~
vS~~~,~ ~~~~s /oa~~,~/
/7,~stil ~S`~'
1
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ia'
5'~ ,
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PAGE OF
CrC) Sec~lun O~ A e0 S stems
Y ~
Frech Air Inlets And Obcervatlon Pipe
Approved Vent Cap
Mlnimum 12" Above
Final Grade
20- 42' Above pipe _ 4' Coral Iron
To Final Grade Vent Pipe
Mash Hoy Or Synlhefk Covering
wtn 2" Aggregate
II Over Pipe
Olstrlbullon
Pipe 0 0 0 0 0 - Tee
i
6' Aggregate
Beneatn Plp• o Perforated Pipe solo.
Coupling Terminating At
Bollom Of System
Prupo c ti Pmcd grcac'< -
~~cJr.~ iorl \ \ /
SOIL FILL
DISTRIBUTIOF.1 PIPE
APPROVED $4NTUETIC COVER
2"oFAGGREGATE ~MATERIAt- oR 9" OF STRAW
OR /'JARSN HAy
!v' of "'2 AGGREGATE"8
ELEV. of FEET,
ps, K--
DIS7-RIgJTIOU PIPE TO BE. AT
L S
AIJU AT LEASTZO WCHES BUTI.IOMORE THAM 42EAICHES BE OW FIIUAL GRADE
MAXIMUM ®EQrli OF EXCRVAT100 FXom OKI&WAL 69A0F. WILL BE 1UCHES
MINIMUM OEf OF EAC4VATION MOM 01K141"AL GRAVE WILL BE INCHES
SIGAIED :
LICENSE IJUMBER:
A DATE:5~
VViscons"eFrartrhent of Industry, SOIL AND S I T E E V N REPORT
Labor and Human Relations Page Division of Safety & Buildings
Of
in accord with I
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 i in size- P-fF~n-must inclUde,'-but
not limited to vertical and horizontal reference point (BM), ion and °Io of sfope, scale or - PARCEL I.D.
#
dimensioned, north arrow, and location and distance to nei~estf road. -
APPLICANT INFORMATION-PLEASE PRINT ALLRMIITION REVIEWED BY DATE
F
PROPERTY OWNER: ""MOPERTY LOCATION
J., GOVT LOT - 1/4 - 1/4,S T N,R (Oro
PROPERTY OWNER':S MAILING ADDRESS ~K # SUBD.,NAME OR CSM #
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY IL GE MOWN NEAREST ROAD
NJ New Construction Use [XJ Residential / Number of bedrooms ~
L ] Replacement [ ] Public or commercial describe [ ]Addition to existing building
Code derived daily flow _ gpd Recommended design loading rate _bed, gpd/ft2 2
_`~trench, gpd/ft
Absorption area required f~ bed, ft2 - S- trench, ft2 Maximum design loading rate bed, /ftl 2
Recommended infiltration surface elevation(s) q~ g~ ark) trench, gpd/ft
ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material J,R Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U=Unsuitable fors stem ®S [3U 2S ❑U ®S ❑U ~S ❑U [Is ~U ❑S 0
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft
`.in in. Munsell Qu. Sz. Cont. Color Texture Consistence Bound3y Roots
Gr. Sz. Sh. Bed Tre &
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground _ S
elev. 15
Depth to
limiting
factor
,xr
Remarks:
CST Name: Please Print Phone:
14 ~V
Address:
Signature:
Date: CST Number:
3
PROPERTY OWNER SOIL DESCRIPTION REPORT Pagof 3
PARCEL I.D. #
Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon Texture Gr. Sz. Sh. Consistence Boundary Roots
in. Munsell Qu. Sz. Cont Color Bed Trends
01.......,r..,
1': /
Ground
elev.
ft•
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
R 7
L
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
L! ~ ;C7oc°,i,~ s
/ -y0 sc,,.t~ y
C.ST~o d~yy
G'G
\ NNN to 6
Y
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
,St. Croix County
OVVNER/BUYER z C dal
MAILING ADDRESS
PROPERTY ADDRESS
(location septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION
1/4, ` 1/4, Section T_N_R! 7 W
TOWN OF
ST. CROIX COUNTY WI
SUBDIVISION ~UU /V '
LOT NUMBER /li~A'4~57
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 se tic
as a treatment stage in the waste disposal system. P tank
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 verifyin that 1
the on-site wastewater disposal system is in proper operating condition and (2
) g ( )
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. after inspection and
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,4nust be County Zoning Officer within 30 days of the three year, eexpiration date. eted and returned to the St. Croix
n
SIGNED:
DATE: 3 - Z 7
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016
11/93
y S T C - loo
This application form is to be completed in full and signed owner(s) of the property being developed. An inade uaci b
only result Y Y the
development ben delays of the permit issuance. Shout s will
intended for resale b Should this
house), then a second form should be r tainedr and completed when
the property is sold and submitted to this office with
appropriate- deed recording the
of propertyC~/1r,.5 ~
owner Location of propertyfi-F--l/4_5E 1/4
Township Q; Section N_RW
Mailing address
Address of site
Subdivision name O/UJ
Other homes on Lot no. ~V~
property? Yes No
Previous owner of property
Total size of property /1r~E~7z~ Si S -0
Total size of parcel,
Date parcel was created
Are all corners and lot lines identifiable?
Is this property being developed f (s
Volume (spec house) ? Yes __No
and Page Number as recorded with
--2~7 of Deeds. h the Register
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS R, VOLUME AND PAGE
certified survey, if available, would be helpful so asdtolavo'd
delays of the reviewin
references to g process. If the deed description
a Certified Survey Maps the Certified Survey Map
shall also t required.
PROPERTY OWNER CERTIFICATION
I (We) certify that all statements on this form are true to the
best of my (our) knowledge that I
property described in this (We) am (are) the owner(s) of the
warrant information form, by virtue of a
Deeds as D ed e No.ed in p Office of the Count
own the proposed Y Register of
site for the sewa e' pand that I (wm presently
obtained an easement, to run the above described p ropert , I for e
construction of said system (we)
t and the same has been duly recordedpin
of the Count
(.B y Register of Deeds as Document No.
Signature of Applicant
Co- pplica. t
Date of Sicrnaturp
TlatP cif Rirrnati~rP
' 526891 v L ~ j f 5 78
DOCUMENT NO. WARRANTY DEED
This Space Reserved For Recording Data
REGISTER'S OFFICE
ST. CROIX Co., WI
THIS DEED made between RAYMOND G. SISLO and Reed for Record
ANNETTE M. SISLO, husband and wife, Grantors and CHRIS R. MAR 2 1 1996
MILLIRON and LINDA G. MILLIRON, husband and wife as
survivorship marital property and Grantees, at 11:00 A. M
K• ,.-A. I. JJ.-
Witnesseth, That the said Grantors, conveys to Grantees the Re9later of Deeds
following described real estate in St. Croix County, State of
Wisconsin:
The Northeast 1/4 of the Southeast 1/4 of Section 7, Township 30 North, Range 17
West; EXCEPT the North 4 rods thereof, and EXCEPT all that portion lying within Lot
1 of the Certified Survey Map recorded in Volume 71of Certified Survey Maps on
Page 1965 as Document Number 437245.
The East 4 rods of the Northwest 1/4 of the Southeast 1/4 of Section 7, Township 30
North, Range 17 West; EXCEPT all that portion lying within Lot 1 of the Certified
Survey Map recorded in Volume "7" of Certified Survey Maps on Page 1965 as
Document Number 437245.
S EBB
This is not homestead property.
TOGETHER WITH and SUBJECT TO reservations, restrictions, easements and rights-of-wa
of record, if any. y
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And Raymond G. Sislo and Annette M. Sislo warrant that the title is good, indefeasible in fee
simple and free and clear of encumbrances, and will warrant and defend same.
Dated this 20th day of March, 1995.
R G. SISLO (SEAL)
i
ANNETTE M. SISLO (SEAL)
STATE OF WISCONSIN )
ss.
ST. CROIX COUNTY )
Personally came before me this 20th day of March, 1995, the above-named RQnyo
ed G-,,,Sislo
and Annette M. Sislo, to me known to be the persons who executed the fore
acknowledged the same. gtrurtl~d
`co
Notary Public, State of Wisconiif,/;'~ ..Q•T~
My Commission
FApk:69: l
THIS INSTRUMENT DRAFTED BY: RETURN TO:
Barry C. Lundeen
MUDGE, PORTER, LUNDEEN & SEGUIN, S.C.
110 Second Street
Post Office Box 802
Hudson, Wisconsin 54016
_ .
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E 1 /4 COR.
SEC. 7
- - r
1056 426/543
14 SE 114 ► NE 114 SE 114
I
I
1066 105A
106A 807/390 _
807/390
426/543
807/390
564.45
105C
9 06
16 2ND ST.
I
LOT 1
'n r
_ vol. _7,_ pg._ 1965
C.S.M_
r
07B
1086
310/264
807/390 & 470
810/264
I
811/309
564.27'
114 -SE 114 i SE1/4-SE 114
I
I
107A 108
807/390 807/390
0
U
J
A VE.
SE COR.
SEC. 7