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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 5*,eVq 4. ().Of? -t
V, CL's eSJ
0
ADDRESS
SUBDIVISION / CSM# ~um Vir-A W l 1 s 'Phigc 3 LOT
SECTION o-t TZ9 N-R~W, Town of Hi4ysorii
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
4 1.100 5,01,
oQ
I I
No~~ : Se IL Cov0it sxkep (les
JS over, O~tie~ 4~
a
N
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
1
BENCHMARK: T-Row p►iQ AT SW Iq~ cor-we,
ALTERNATE BM•
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: WeQkS Liquid Capacity:
Setback from: WellGltK House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
-,SOIL ABSORPTION SYSTEM
Width: .Length S~ Number of trenches
Distance & Direction to nearest prop. line: QV Q R IJ~
Setback from: well : O1 t R S b House 38' Other
~i► y~, TLOT4 (A f~b~fi 105-10' ' ~ N n 1 bg s
Luw itIQNC,I, Fc log." T-NV 105.3`1
ELEVATIONS
Building Sewer ST Inlet, ST outlet
PC inlet ---y PC bottom Pump Off
Header/Manifold Bottom of system
0 •S Lola 1WW
Existing Grade Final grade- 1
l 0 $ . 415 Trrrr c~
loe.8o L ow'1R.NC1~
DATE OF INSTALLATION:
PLUMBER ON JOB: CA, U
LICENSE NUMBER: 3V
INSPECTOR:
I
3/93:jt
Wiscopsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations
INSPECTION REPORT ST. CROIX
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Qlcj N tCU9,.TOM HOMES, INC .
Pe96P
CST BM Elev.: [I City village ❑_TOwn of: State PI
Insp. BM Elev.: ~ BM Description: X Parcel Tax No.: HUDSON 0,7 - *9500289
TANK INFORMATION ELEVATION DATA 11 /S 9S'
TYPE MANUFACTURER C IT STATION BS HI FS ELEV.
i
Septic Benchmark
Dosing Z,_',',
Aeration Bldg. Sewer
Holding St/ Inlet d7 DD
TANK SETBACK INFORMATION St/W1 Outlet
Vent
TANK TO P / L WELL BLDG. Air Ito ntak ROAD Dt Inlet y/t
Ar e
Septic )16' 05 NA Dt Bottom V(
Dosing NA HeaderbMaa-
9,17 -Y, 02 o5, oS,I b
Aeration N Dist. Pipe 'Wol
Holding Bot. System
o,sb~ /o, ~dY2 0 .y
PUMP / SIPHON INFORMATION Final Grade
Manufactur Demand rr a A Cd er 9,
Model Number GP
TDH Lift Loss Ion System t
emain Length Dia. I- Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width i Length No. Of Trenches No. Of Pits Inside Dia. Liquid Depth
DIMENSION -7S aZ DIMEN I
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEAC anu acturer:
SETBACK
INFORMATION Type O ✓Ies-cr~U 3 AMBER Mode Num
System: ~a ? 1114- OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold ( Distribution Pipe(s) x ize x Hol acing Vent To Air Inta
Length Dia. Length Z Dia. Spacing Zai
SOIL COVER x Pressure Systems Only xx Mound Or At-Gr a Systems Only
Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched
Bed/Tr nchCenter Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON. 7.29.19Wi ~ SE, SE, BLUE JAY,,.,LANE
Plan revision required? Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspe or's Signa re Cert . No.
ADDITIONAL COMMENTS AND SKETCH '
SANITARY PERMIT NUMBER:
z
SANITARY PERMIT APPLICATION couNTY
In accord with ILHR 83.05, Wis. Adm. Code s , CA
STATE SANITARY PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than L '7 C?
8 x 11 Inches in size.
1:1 Check if revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PR NT ALL INFORMATION.
PROPERTY OWNER Mole-GrA A' r7 Y PROPERTY LOCATION
ft=- 0 S a T N, R 11 E (or) W
PROPERTY WNER'S MAILING 11 AE LOT # BLOCK #
c, 14e 54
CITY, STATE Z CODE PHON NUMBER SU DIVISIppN NAME OR C §M N MBER
1c oi ►(L ~1~)o>J
►S C.
~ rrib
11. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLA GE : NEAR W ROAD ja TOWN OF: ki ON u LQN
❑ Public 'I or 2 Fam. Dwelling-#~ of bedrooms ~ PARCELTAX NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply)
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 90 Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. W 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-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYST M E V. 7. FINAL GRADE
REO [RED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) MIS o f. N'~E~ ~TI
~ 4 .0ftt 1"0 1 c~ i et
00 50
LA
7 5 .
VII. TANK CAPACITY Site
in alIons 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 Holding Tank _ (-Roo M- F] Q F]
Lift Pump Tank/Si hon Chamber
Vlll. 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 Sig ture: (No Stamp) MP/MPRSW No.: Business Phone Number:
Plu ber'a Addreos (Street; C' , State, Zip Code
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved SanT Permit Fee (Includes Groundwater a e Issued Issuing Agent Signature (No Stamps
Surcharge Fee) ~
Approved I El Owner Given Initial
Ill
Adverse Determination 1 /90
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.
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 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'/z 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)
I
R Q.L. 67 PLOTA 1-11) C" 10S S EC
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FRESH All; INLETS AND OBSERVATION'PI.PE
CROSS SECTION
Approved Vent Cap
Minimum 12" Above '30
F;na1~~,slemob ~v9.3u
~ 4" Cast Iron
Above Pipe Veiit Pipe
To Final Gradc-
Marsh flay Or ~Synthetic Covcri.ng
Min. 2" Aggr.c(j.',il `
Over Pipe
Distribut Tee
24;.
Pipe ._........_.I i
M) b - (OS. U Aggregate Pc3,: orated Pipe Belot.,
Ucncath Pipe --Coupling Terminating' P
cow (~`I S ~ _ . ` . iRot• tom. of system.
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Pie of `3
Labor and Human Relations
Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
5T. c~orx
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but PARCEL I.D. /
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE ,
PROPERTY LOCATION
/,fA/.p PROPERTY LOCATION
tiD D
PROPERTY OWNER:
GOVT. LOT (5 1/4 -'%F- 1/4,S 2 7 T 2 , N,R /J E (or) W
5
o GSA/.P.y y
CSM fl
If LOT ff BLOCK N SUED. NAME OR
PROPERTY OWNERS MAILING ADDRESS
33 ~2i8 f iD,uf~? a~
o ors $r ) s AiuMQi PD H1-0-3 (PtinsL 3
6 ~ ~B
CITY, STATE ZIP CODE PHONE NUMBER []CITY [1VILLAGE N NEAREST ROAD
gvG /~1N 5'5 /0/ (Grz) z2- 2-55'155 iju V-5o,j /3/ate ~.4 4,/
Vf'New Construction Use (,,-Residential I Number of bedrooms 3 [ ] Addition to existing building
Replacement [ ] Public or commercial describe
Code derived dally flow ioa gpd Recommended design loading rate - bed, gpdr112 trench, gpd/R2
Absorption area required 85 7 bed, 112 trench, 1112 Maximum design loading rate 7 bed, WM2 tr ench, gpoltt2
s-~ (as referred to site plan benchmark)
Recommended infiltration surface elevation s) 3 ft
Additional design/ site considerations efG4"AG' A04-d-'2 Lem a- AW,90 w 711CA) 40.5'
'n elevation, if i(able It
S
S ve,C~ CDT
wren Flood r~ ~
P tmaterial
S a Stritable for system Coy~ENrIoNAL MOUND IN-GROUND PRESSURE AT GRADE ? IN FILL HOLDING TAW
U- Unsuitable fors stem Q S [1U ❑ S 04 O U ❑ S 0 U ❑ S B tr
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Frizoni in Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed It3
-17 /D fit' 3 / Cd y/*~ fi Gy .fzs N
, s . 6
13 /7Y Y/y
Ground 46t ' y 7,S e / - CS &S elev.
107, z tt.
Depth to
limiting i
factor
Remarks:
Boring # Al /0 17~SL✓,~ 5 /7c • j'
2 2 11-3f /09 31f 5_1 2 f SY& 411 G
3 37,sYXI C'S D,s i•~
Ground
elev.
/0&, 92- ft.
Depth to
limiting
factGOr,
Remarks: /
CST Name:-Please Print ?2O B E (-T '4 LCie i' C-k 7-' Phone: 715_. 3 P6
ress: C¢5 s o' N~ i P U' so,J W /s 5016 /r- S- y csr-y 3- y~i
Date: CST Number:
Signature:
ORIGINAL for ThrstestSiteAPpR4
$ conventional septic system.
I _
PROPERTY OWNER SOIL DESCRIPTION REPORT Page? Of 3
PARCEL I.D. # GD 5 q U K C3 i 17 ` 1al s
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bond3y Roots GPD/ft
In. Munsell Qu. Sz. Cora Color Gr. Sz. Sh. Bed ranch
z W-11 /o re 31l - s/ 2~f sd~ ftfie es s C
Ground ;?.s ye G s O' GQ , 7 Zf
elev.
Depth to
limiting
facto
i
Remarks:
Boring # / 10-1-3 A0 ,,031/
z 3-30 2's yk s
3
Ground
elev.
!O y, /p ft.
Depth to
Smiting
factor ,i
Remarks:
Boring #
10-Y IoW 311 - s/ fsh,C s Z* , y , s
Z y 1p /01~e y y S. / /-/Cs _ f s
Ground =
elev. y~ / D YiP S/ - . S S aQ~ • 7 '
it.
i
Depth to
limiting I
factor
I
Remarks:
Boring #
i
9
Ground
elev.
it.
Depth to
limiting
facto
Remarks:
can ooenio ne,n~\
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER ~~J1t vIJ~G'/ N
MAILING ADDRESS 740 7 ,~~~5a/✓ L c// S S7/
PROPERTY ADDRESS
(location of septic system) Please btain from the Planning Dept.
CITY/STATE ~64'/A/
PROPERTY LOCATION SE 1/4, 1/4, Section T a 9 N-R_ji_W
TOWN OF A up-so ST. CROIX COUNTY, WI
SUBDIVISION liar`' hlxd 4111-.5 -n t ed LOT NUMBER 5 /
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
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.
UWe, 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 dat
SIGNE
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11193
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), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property
Location of propertyef 1/4 56- 1/4, Section T gU N-R__Z.~_W
ss ~73 /N'S~t
Township Mailingaddre
LvGJ~
Address of site 1~7
Subdivision name ~"41 J ,yi//S 11*Vo Lot no.
Other homes on property? _Yes_>No
Previous owner of property Ham' 0,113ip-p L,/ KD
Total size of property - 30 A~~
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this prop,,erty being developed for (spec house)? Yes _X No
Volume /13b 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. _5-3332<3 , 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.
of Applicant C -App icant
t of Signature Date of Signature
f
THIS SPACE RESERVED FOR RECORDING DATA
' DOCUMENT No. j~ STATE BAR OF WISCONSIN FORM 1-1932II
WARRANTY DEED ~
1
3 23_= =-1- VOL 1_138AAGt-2
REGISTERS OFFICE
This .Deed, made between HumhiLd_Land._Co.LgnLatian...... ST CROIX CO., WI
Reed for Record
' ._A..M.inrxeso.ta.-Cox_garati.o-n
S E P 1 1996
, Grantor,
and..... Morgan.. Custom. .Homes-,-_1nc................................................... at 9:45 A.M
ReOtster Deeds
I~ , Grantee, I!
Witnesseth, That the said Grantor, for a valuable consideration...... j
` ..o_f.._one..doll.ar..or..wree-•--• _ I~. RETURN TO 0
RETURN
conveys to Grantee the following described real estate in
County, State of Wisconsin:
I, .v d
~i Lot 59, Humbird Hills Third Addition
Town of Hudson, St. Croix County, Wisconsin Tax Parcel No:
ii
~I
~J
I
i
I
I
I I
!
This is_ not homestead property.
II (is) (is not)
II Together with all and singular the hereditaments and appurtenances thereunto belonging;
i~ And........ Humbird_-Land-.Corpora.tiou
~I warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
I'
I
and will warrant and defend the same.
Dated this 31at................................. day of ...........August 1995.....
(SEAL) ..~~aM EAL)
! Humbird Land Corporation,
f I " * -By.:..... Austin.J.•--Bai,l,Lon, -Ats..President
! (SEAL) (SEAL)
*
AUTHENTICATION ACKNOWLEDGMENT
i
Signature(s) STATE OF WISCONSIN
i ss.
County.
St....GrQi x
II authenticated this ........day of........................... 19 Personally came before me this Rat........ day of
~I .......August 19-_9.5.. the above named
Auszl.n..J,...ba~ l~.Qn~._~xQ;dQn ..4f_..........
i
Humhi.rd..I.land..C4xPo:Z- Qn---•--............------.
TITLE: MEMBER STATE BAR OF WISCONSIN
II (If not,
authorized by § 706.06, Wis. Stats.)
to me kno to be the person who executed the
foregoing strument and ac " AAwlec~ the same.
~I THIS INSTRUMENT WAS DRAFTED BY pG
Humbird..Land..Corporation
! Brenda.. Poulin - ti1o ~qqR
1pr} 1ev
Notary Public St..-. Croix_.•_-•--
j (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, Ration
are not necessary.) mm
II date:-. 1d.O.V.emberr.:~ 19.6.....)
I! *Names of persons signing in any capacity should be typed or printed below their signatures.
WAnnANTY DEED STATR IlAlt OR WISCONSIN A'isconvin Lcaal D1ank.Co. Inc.
FORM No. 1 - 1982 milwankee Wis.
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LOT 59
W 2.30 ACRES
100,069 SOFT.
w w ~
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CUI
23.99' 265.16' "
_ IS v• S89° 20'47 "w 259.15'
JAY w LANE o
w N89°20'47"E 289.15'