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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS p H J-4
SUBDIVISION / CSM#
-s LOT
SECTION T_ 2 N-R Zo W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW 1
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I
~fo Ttc~4- Gvt/l S7• >rO ( r
=s T ~O&d I
b6 164 we
GNy '
y
0
3
n
~5c T s`~
INDICATE NORTH ARROW
i
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
s
r~
BENCHMARK: jf /w o
ALTERNATE BM'
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: a4r. ~S Liquid Capacity: cow
Setback from: Well ;05'0 01 House 9 Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: /L Length ~y Number of trenches
Distance & Direction to nearest prop. line: Z l
Setback from: well:- O/ House --70 Other
ELEVATIONS
A, tY'
Building Sewer ST Inlet. f'G. pZ ST outlet fS1.t
PC inlet PC bottom Pump Off
Header/Manifold f4./ Bottom of system ft, 3
Existing Grade Final grade ps' : L
DATE OF INSTALLATION: 6 lr l
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
labor and Heyman Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village ❑ Town o : State PI
DELTA CONSTRUCTION X
CST BM Elev.: Insp. BM Elev.: BM Description: fludson Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic jo Benchmark
Dosing
Aeration Bldg. Sewer
[Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet G •3~- 9,S7. -7`
Vent
ii to ntake ROAD Dt Inlet
TANK TO P/ L WELL BLDG. A
irl
Septic X50' ~c50~ y/S~ NA Dt Bottom
Dosing NA Header / Man. f of 1,
Aeration NA Dist. Pipe /0'n ql , 8
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand 13733
Model Number GPM
TDH Lift FLoss riction System Head TDH Ft
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 t)_ o / DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER Moe Number:
INFORMATION Type O `4-IQ a -76" OR UNIT
System:
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 g~ Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Hudson.17.29.20W, SE, NE, Lot 116, Sherman Road
b,1 I0,~X
J_ IP,3 1.0
C z~l. 7 s -
Plan revision required? ❑ Yes eNo
&Lt , , Use other side for additional information. ky" 1-1-f o f ' ~c~ Z fro
SBD-6710 (R 05/91) Date Ins ctor's Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: ;
SANITARY PERMIT APPLICATION safety and uillngWater Sn
Bureau o off 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 81/2 x 11 inches in size. !S--~- Cro )
• See reverse side for instructions for completing this application State Sanitary Permit Number
a,- r3 ((v
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 I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFOR TIO
Propert wner ame erty cation
S 1/4 1/4, S l T 2 , N& ,-Zp E (or)V
Property Owner's Mailing Address Lot Number Block Number
s~.
City, Sta Zip Code Phone Number Subd ion me or CSM Number
(Sk/ V /4"t
'1014 )
11. TYPE OF BUILDING: (check one) ❑ State Owned o Ityage Nearest Road
3 p vill
E] Public 1 or 2 Family Dwelling - No. of bedrooms Town of NPi
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo d 2d / a 'To
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. Z New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an
System System Tank OnlyExisting 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
1 1 m 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 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
V-410 ' 710tv .7 c , 2-0 Feet ?J;2-'f Feet
VII. TANK Ca
in gacit
gallons Total # of Prefab. Site Fiber- Plastic Exper
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App.
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the site sewage system shown on the attached plans.
PI er's Name: (Print) Plumb 's Signature: (N amp MR/MPRSW NO.: Business Phone Number:
tv r~ o r 2 - `.S"
PI is Address (Stree , ity, Sta 'p Code):
D Y' O Z
IX. COUNTY D PARTME T USE ONLY
❑ Disapproved Sa tary Permit Fee (includes Groundwater Date Issue Issuing Ag t Si ture (N Sta s)
Surcharge Fee) Approved ❑ Owner Given Initial 7/G~~/~
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety 8 Buildings Division, Owner, Plumber
I
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-
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.
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 appropria e 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 sui~ - ltted tc the county The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
arik(sl or other treatment tanks; building sewers; well,.- water mains/water ser„ce; stre erns ;ir a lakes; pump or siphon
(anks, c i 'tribution boxes, soil absorption systems; replacement system areas; a, (I the to _,t,o c f the building served;
B) ho? c rr~_,I 8,nd vertical elevation reference points; Q complete specificat.,v)o,, for purnos a ontrols; dose volume;
elevation differences; friction loss; pump performance curve; pump model and ~_ump rr:-,-iii f c'. rer, D) cross section
of the soil absorption system if required by the county; soil test data.o.n a 115 lorm; aai: ) jai sizirg information.
- - - - - - - - - - - - - - - - - - - - - - - - -
GROUNDWATER SURCHARGE
1983 Wisconsin Act 4,10 included the creation of surcharges (fees) for a number of regulated practices which can,
effect groundwater.
AS BUILT
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
Job Number
Name Date
DJA FOGERTY ~ '
Ucensed Perk Tester &
o 3233 got s s
F Road
ROSE ~W ONSiN 54023
phone 749.3656
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1
L SOIL AND SITE EVALUATION REPORT Page of 3
-Laabor and Human Relations Industry,
Division olSafety 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
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 REVIEWEDBY DATE
PROPERTY OWNER: / PROPERTY LOCATION
& C i HS 74 GOVT. LOT fE 1/4 N~ 1/4,S T AR ~a E (cdv
PROPERTY OWNER':S MAILING ADD ESS LOT # BLOCK # SUED. NAME OR CSM #
H'~, ll - /_qr"h /1iele'l 154,1
CITY, STA ZIP CODE PHONE NUMBER []CITY []VILLAGE ZTOWN NEAREST ROAD
~'f o g~ Uv/) 1"94 o~ ~x `i frivwh_
[/J New Construction Use[)] Residential/ Number of bedrooms 3 (J Addition to existing building
[ j Replacement [ j Public or commercial describe
Code derived daily flow ySo gpd Recommended design loading rate ed, gpd/ft2 , -P trench, gpd/ft2
Absorption area required 7z o bed, ft2 trench, ft2 Maximum design loading rate _,,Lbed, gpd/0, B trench, gpd/ft2
Recommended infiltration surface elevation(s) Z ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material 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 El s❑ U ❑ S O u ❑ S ❑ U O S 0 U ❑ S L ❑ S O U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BOu„dvy Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
74-
4•i}
Ground 3 3o-so _ 3
o s ~ / s
elev.
Depth to
limiting
factor
Remarks: # y° e-r
Boring #
Z ~2-1y /o
Ground
elev.
96.7 ft.
F.2,q,~ 01"7 s1 4s ® O
Depth to
limiting
factor
Remarks: _ v - war/ cam/
CST Name: Please Print Phone:
Address:
a/ v 7o b p ~ t~ c.~.L S' 0.2.3
Signature: Date: CST Number:
PROPE13TYOWNER L, f iil AIMI SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D. #
Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Bax>dary Roots Bed Trench
Ground Z 7 S - Y131
L rv zc r~ ss.. / I/~ -
elev.
~F • V ft.
y/. 79
Depth to -7
d
limiting
factor
Remarks:? .3 sue, ee
Boring #
v:y
L ti:
- -
o - z e-*.- /V-(
Ground / - .v ~ /
elev.
ps.7 ft.
Depth to
limiting
factor
Remarks:
Boring #
\'h 6-
) - -
VA/ S
4-S I
Ground Z 3 /o -
elev.
9L• v' ft.
91.7
s -7
Depth to
limiting
factor
Remarks:
Boring #
DAVE FO
ibeir
Ground
elev. 03233 288
is
ft. r6owtv H ad
WISC IN 5A 23
ROBE WS,
Phone 74 -3656.
Depth to
limiting
factor
Remarks:
I`
SBD-8330(8.05/92)
DAVE FOOMY PLUMBING
Licensed Perk Tester & Plumber
03233 #k3289
F Heights Road
R0BE~WISCONSIN 5402
Phone 749-36
3 8/ -i~.~6 360.
302
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ly
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S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
•
ADDRESS FIRE NUMBER I
CITY/STATE t' ZIPS
PROPERTY LOCATION: _1/4 A_r 1/4, SECTION 17 , T -z 9 N-R Z W
TOWN OF'' St. Croix County,
SUBDIVISION LOT NUMBER
v
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 a 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 Co. Zoning officer within
30 days of the three year expiration date. r
i
SIGNED: DATE:- /3
St. Croix co. Zoning Office.
911 4th St.
Hudson, WI 54016
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), thenta second form should be retained and completed when
the property' is sold and submitted to this office with the
appropriate deed recording.
-------------------------------------------------7----------------------
Owner of property
Location of ,property-z--r-1/4 x_1/4, Section 7 , TAN-R W
f
Township
Mailing address
Address of site
~ ~''~~~--~.-~-Q-~-✓ - / ! L
Subdivision name Lot no.
Other homes on property? yes V. No
Previous owner of property 44/~t/
Total size of parcel
r
Date parcel-was created 17
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes t,-INo
Volume r-1L.and Page Number 9 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 & 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.. 3 a G L Z 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 county Register of deeds as Document
No. ~~(o (62--
f
r -
Signatu 'of applicant Co-applicant
"Y 3--
Date of Signature Date of Signature
DOCUMENT NO. i! •TATE OAR OF WISCONSIN - FORM 2
ii WARRANTY DEED
• _ 8001[ 521 PAS [ 8{,/ THIS S►ACa 0159"90 /OR RECORDING DATA
326162
By This Deed..wife riaGISTERS OFFICE
r.i-st ar ST. CROIX CO.. W13.
RflC d for Record this_ lst_
Grantor conveys and warrants to.....` ,..7.R. -L?.rt...~. day ot_.MarCh------- &W. 19-75
P)"-ant -ar,:..an,4...wil 9.Z..j~.f. aZt.S 12:0 P.
M.
-
Grantee........, RaQister of Deed!
for a valuable consideration..n£...T.hirtear...thausa d....si.x-.hunter-ed........--.-.
..dQ11ar..a R[TURN TO
the following described real estate in........... t.....~5 ~1X County,
State of Wisconsin: That certain nareel of land or t.-act of
real estate .ocated i7 tea northeast quarter of the
Northwest quarter of Secti m 17, r. 29`;, R 19W, Town of Tax Key V 4udson, St. Sr^ix ^oun'yp '-iscer.sin, :nr,re fully descriced This is homestead
property.
as follcws: at a ooint on t~i= nortr. line of said Section 17, a distance of
2:55.4 feet east of t,e n,rt~iwest corner of s ip? °ecti on 17; thence sue South a
distance of feet; t'.-:ence S 120 ?C1 ra J:stanc, of 4)?,.K feet; thence S
25o 0111 a dist'.rce of 21[.2 feet; t aac S to 1:21 a distance of 194.5 feet
to the so,:th ling o° saAH n.•rtheast q.larter cf tl-,~ n-,rthwest quarter; th-°nce with
said so'.Ah, line iasterl7 a Jista^.ce of S!? -n-)rai or less, t7 t~e east line
of sail nortI-`tast quarter of the nort":west ^':arter; tw:'nc° northerly nlnnr sail
-ia=t line to t-- n-)-Vgv:3rter corn-°r -'f 3ai, 'ec+ion 17; thence west-r17 alOnP
the north lire or Sal' motion 17 t^ +v'? rni n, •r ~e -i^n' n t'-e ibo7? '!-scr-b?d
oa:-cel containing 17.3 acres, :nnre -r -ss.
TRANSFER
$-.1 40
FEE
Exception to warranties:
Executed at a3s>c_....... a.:,conr n................. this.. --2 . -A...h........ day of .:arc.•`......................... 19.1E....
SIGNED AND SEALED IN PRESENCE OF (SEAL)
'hilio L i s=rte
.s_..- - - -(SEAL)
Il ' s.^
1 1 (SPAL)
73 +
r
T
1: ~..5.._
„ . (SEAL)
~.tha' 7
Signatures of
_ - _ authentiwteJ this day If..... 19..__.....
Ti le Ntemhrr State Har of Wisconsin or Other Party
Au:hon:ed under Sec. '7t)606 viz.
STATE: OF WISCONSIN I
> ss.
- ~ day of •',.3.. _ , 19.
Personally came before me. this J 't t " _ ~
the above named..
to me known m he the pers n_S . who r.-rcured the L:n ng inurn•.rnt and .t, kr., wit !:;ed the same.
J _
THIS INSTRUMENT WAS DRAFTED BY leet e p/ r,,,,, l VV
- - . ...tiE, p TA k
s y • ^1X
_ y, Wis.
The use of witnesses is optional. ~ Notary Public. Count
1_q_77
Js V e o My commission (expires) (is)
✓1,
Names of persons signing in any capaciry 9lQl~:l V,.}twYor priw(,l he!,,w their signatures.
„II~I~~~~~~• VT.\'I'h: It.Ut III' \C 1~/'11\~I\ R'i>~~nm~in L~•^,~1 Esl:u•k r'nmpany
WARRANTY DEED F0101 No. - 1911 SLlwa:a.~,••, \\'L ( J'A' 31504,
w
GWIN & WERTHEMR, S.C.
HUGH H. OWN The Groin Building 7154884610
ROBERT A. WERTHEIMER 430 SECOND STREET FAX: 71540644M
HUGH F. (TWIN P.O. BOX 106
OF COUNSEL HUDSON, WISCONSIN 5016
April 21, 1995
Mr. Virgil Fedorenko
Delta Construction Co.
206 Second St.
Hudson, WI 54016
Re: Lot 115 and Lot 116, Park View Estates Fifth Addition
Dear Virgil:
Pursuant to the terms of a Vacant Land Offer to Purchase dated
March 30, 1994 and a Counter Offer dated February 1, 1995 for the
above lots and other lots, I have been authorized by my clients,
Darrel and Beverly Wert, to convey the following agreement.
The Werts hereby consent and give you permission to build on
Lot 115 and Lot 116 even though title has not yet changed from
their name. By copy of this letter to Tom Nelson, St. Croix County
Zoning Administrator, I am informing him of this agreement. It is
my understanding that based on the strength of this letter of
permission by the Werts, Mr. Nelson will allow you to pull a septic
permit on this lot and to proceed with the building of a home
thereon. Title to the property will be transferred from the Werts
to either you or your company or the eventual buyer at the final
closing on the property. I have assumed responsibility of
notifying Mr. Nelson of the names and particulars of the eventual
buyers so that the information can be put on the septic permit and
it can be correctly filed under the name of the eventual owner of
the property.
Very truly yours,
GWIN & ERTHEIMER, S.C.
ug H. win
HHG/en
cc: Darrel and Beverly Wert
Tom Nelson, Zoning Administrator
Jim Henry, Edina Realty