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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER c
ADDRESS 1,744CI' ZqXI)
SUBDIVISION CSM# 6
~~c'✓V OT
L
SECTION (i _T~i N-R_ W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
mss' s f
7f ^r
A6 JX44DI A NORTH A ROW
L-
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:
ALTERNATE BM:
SEPTIC TAN / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity:
crzra
Setback from: Well v2 7 House / Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
-;SOIL ABSORPTION SYSTEM
Width: /4S Length Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: `ra House Other
ELEVATIONS
Building Sewer. 6• ST Inlet; .19Y. i03~ ST outlet ASS
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade y 7 Final grade
DATE OF INSTALLATION:"
PLUMBER ON JOB:
LICENSE NUMBER: INSPECTOR:
3/93:jt
Wiscorisin Department of Industry, PRIVATE SEWAGE SYSTEM 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
YEAGER, PATRICK & LINDA X
i
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
.
1 lee. 60 a t ' 61) TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ~le
S ~ ~ O Benchmark lee. 6~?'
Dosing
Aeration Bldg. Sewer 3y1
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet s gip'
Verit
TANK TO P/ L WELL BLDG. Airito ntake ROAD Dt Inlet
Ar
Septic 550 -2NA Dt Bottom
Dosing Headertbbml
Aeration NA Dist. Pipe ~U 7,U9~ S,~Q
Hotd-i ng Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Man cturer Demand
ohs So/' 9~ 02 '
Model Number PM
TDH Friction System TDH Ft
oss mead
orcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
DIMENSION BED/TRENCH width/~ Lengt r No. Of Trenches PIT No. Of Pits rde Dia. Li id Depth
DIMNI
SETBACK SYSTEM TO P/ L BLDG WELL -1/STREAM L Manufacturer.
INFORMATION Type O r CH BER Moe Number:
System: ~.tQt E, SS 75 UNIT
DISTRIBUTION SYSTEM 3< I a) C
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 A ade Sys Only
Depth Over Depth Over xx Depth xx Seeded/ Sodded xx
Bed/ Trench Center Bed/ Trench Edges Top ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Richmond.4.30.18W, N 1/2, SE 1/4, Lot 26, 174th Avenue
Plan revision required? ❑ Yes No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Sign ture Cert. No.
I
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
s
Safety and Buildings Division
~~■~r■r. SANITARY PERMIT APPLICATION Bureau of 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 8 1/2 x 11 inches in size. / ~i-•c
• See reverse side for instructions for completing this application State Sanitary Permit Number
The information you provide may be used by other government agency programs ❑ Check it revisi n to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Prope n Nem s rpperty Loc Ion
do .c 1 L i4, S T , NR/V1(q67
A 4 /V _,Je
Prop rty Owner's Mailing Address Lot N tuber Block Number
Ci Stat,~j Zip Code Phone Number Subdivision Name o CSM,#µfnber
GJ/~j!!!f'~~RG~ everl/a/~ e6cr G~
it)/ 1 N est Road
II. TYPE F BUILDING: (check one) ❑ State Owned °
L per
Public 1 or 2 Family Dwelling - No. of bedrooms ° town of
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ 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 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. ❑ New 2 Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an
------System ---System-------------- Tank Only Existing system Existing -----ystem
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
11 O$eepage 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
✓ `O 6 - Feet . j Feet
C aelt
VII. TANK in gallons Total # of Prefab Site
. Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank C.Q 2- ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VI11. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumb 'S Name: (Print) Plumb nature: (No S amps) MNo.: Business Phone Number:
rs Ad ress (Street, ity, State, Zip Code
yJ'J a -e
n T fd 6
IX. COUNTY/ DEPARTMEN USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
fAroved Surcharge fee)
pp ❑ Owner Given Initial
Adverse Determination A?lb 0
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SOD-6398 (R. 05/94) - DISTRIBUTION: Original to County, One copy To: Safety 8 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 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 maintai4d. 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.
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 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 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 1/2 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 contamination investigations
and establishment of standards.
LOT PLAN
PRO
JC T I AZD S S
A k5e 1/4/S of /T
,:;-e Nl W T N ^
COUNTY ,
rT~
MPRS Byron Bird Jr. 3318 DATE _
BEDROOM CLASS PERC_ CONV TIONAL>MV-GROUND PRESSURE
CONVENT ONAL LIFT__ MOUND- HOLDI TANK
SEPTIC TANK SIZE IFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA pERC RATE BED SIZE /~dX
11116, Benchmark V.R.P. Assume Elevation 100'
Location of Benchmark
171 Borehole Q Well Scale = Feet
0 Perc Hole System Elevation
Vent
12"
6 ode
TYPAR COVERING
t 2"
12" 3' 4 6' O 3' 3' O 3'
Sewer Rock
6" 12' 18,
G~
~v
n"
i
125 - - -
g _ vd
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page _ of
Labor and Human Relations
Division of Safety & Buildings in accord with I LH R 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 G ro ~
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. -q-0
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OW7ER: ` PROPERTY LOC ION ool
h lx r l C GOVT. LOT A[I 1/4,S T N,R .6 E (a®
PROPERTY OWNER':S MAILING ADDRESS LOT BLOCK # SUBD. NAME 0 CSM #
17 7/f 1--c._
CIT~YJ TATE ZIP CODE PHONE NUMBER _ ❑-ITY VILLAGE ;i0 NEAREST ROAD
r e LL1 ~i C ~fl9G e~ itlG' wl oZ ~L p
[ ] New Construction Use Residential / Number of bedrooms 2 [ ] Addition to existing building
j~Replacement [ ] Public or commercial describe
Code derived daily flow ~ gpd Recommended design loading rate • , 7 bed, gpd/ft2 • 5t trench, gpd/ft2
Absorption area required bed, ft2r4-3r trench, ft2 Maximum design loading rate _L;Z bed, gpd/ft2= trench, gpd/ft2
Recommended infiltration surface elevation(s)) 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 S ❑ U S ❑ U Q-S ❑ U Jas ❑ U ❑ S RU ❑ S RV
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Bound3y Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
6,e AA,
Ground
lev.
Depth to
limiting
fact
Remarks:
Boring #
1777
Ground V
elev.
Depth to
limiting
factor
Remarks:
CST Name:-Please Prin Phone:
o r! , '026 • ?6 ~
Address:
~N r Q~
G ~
Signature: Date: CST Number:
PROPERTYOWNER c SOIL DESCRIPTION REPORT Page _ol
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 Tmrch
gl..
117
Ground
elev.
Depth to
limiting
fact
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
wr,
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
Soil Test Plot Plan
Project Name Byron Bird Jr.
Address /7y7W~
C TM #3479
Lot Subdivision ie.L✓r.~c/~~/ Date
I~'3r 1 /4S_4T N/R /,VII Township
iC .vzc
❑ Boring O Well PL Property Line County
BM or VRP Assume Elevation 100 ft.
System Elevation 7,cl- ~Z * H R P ~
3
IA f
X
JT
6 1
Scale 1/4" = 10 Ft. When Dimensions aren't stated
r
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER ~4, ~ 4 -,C✓'
'7
MAILING ADDRESS
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION U4, 1/4, Section, 0 N-R ~,e W
TOWN OF 1( r c s 2 d«~ ST. CROIX COUNTY, WI
SUBDIVLSION i ~s1 ro c r l/a EW O~ LOT NUMBER
CERTIFIED SURVEY MAPu~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.
I/We, the undersigned have read lfffft ove 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.
SIGNED: /
DATE: l D l c~ 00 Q'yr
St. Croix County Zoning Office '
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
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
' old and submitted to this office with the
the property is s
appropriate deed recording.
Owner of property 4".
Location of property 1/ 5 4, Section ,TFz5> N-R / o W
Township , cl o Mailing address 174,50 /Z,~i
~/i t % ovu r S moo,
Address of site
Subdivision name no . l
Other homes on property? Yes No
Previous owner of property
Total size of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable?_Yes No
Is this property being developed for (spec house)? Yes 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 avail-ab4:e, 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.' , 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.
Signature of ppli nt Co-Applicant
Date of Signature Date of Signature
DOCUMENT No. WARRANTY DEED THIS SPACE 015E>.ED FOR RECORDING DATA
STATE BAR OF WISCONSIN FORM 2-1982
~ 424904
;
NIL 77CParlE t94 REGISTERS OFFICI
ST. C?OtX CO., WI&
Da;: id A. Hallberg and Myrna L. Hallberg, his Rsc d. 4,0r Recced M 24th,
-
i wlfe., as... din(:...terfarits
Y of--la-a1 A.D. 1987
t 11:30 A
conveys and warrants to ..-Patrick ...G....Yeager...and..Llndr~..K...
- rileir M ~se11~
.•--Yeager, --husbanc'.•and-. wi-fe-,--.a-s survivor-ship..........
....mar-ital--_proper.ty
_
•
FZ{c 4~~r rnal~nlc of Naa l~dlruid
RETURN T01 09 E 2rd St 8cc C
1
I~ .
NEw Eddrcnd, W 54017
the following described real estate in St• CrO1X ._--County,
State of Wisconsin:
i'
Tax Parcel No:
Lot Twenty-six (26) of Viebrock's River Valley View Addition to
the Town of Richmond.
This deed is executed solely for the purpose of fulfilling that certain
land contract between the parties hereof dated February 27, 1987,
recorded March 2, 1987, in Volume "770", page 297, as Document No.
~j 422869.
MANS 0
wow
FEE
This .1S homestead property.
(is) (is not)
Exception to warranties:
Dated this . Z.4..... day of -April 19-- -87.
1 ,
yr)
- (SEAL) -------(SEAL)
David A. Hallberg Myrna L. Hallberg
- - - - - - -
- ----(SEAL) - .....-.(SEAL)
AUTHENTICATION ACSNOWLSDGMSNT
Signature(s) STATE OF WISCONSIN
ss
._..St..___CrQl}L----------- County-
authenticated this day of___________________________ 19...... Personally came before me this __-z y----___-day of
Apr-iL_._---- 19---- 87 the above named
David-_A-._Eallherg__and-_ ivrna..I._.....___
• Hall.herg-------------------------------------------------•-------•-•-
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by $ 706.06. Wis. Stats.) -
to me known to be t erson S-____--_- who a cuted the
foreAi g i rume a ackn ledge,
THIS INSTRUMENT WAS DRAFTED SY
Rei_-lstra Van Dyk & Needhatit';
r e ' .M....
•
Atton s at Law-- • iC l2. '-tI- t-O
y o-1.------. -
Nec~-•Rict rl(~nd•r Wiseonsi 31T=0121173rotary Public ._S.t...-CrOiX-------- County, Wis.
(Signatures may be authenticated or ackn6wlt A o Sy Commission is permanent. (If not, state expiration
are not necessary.) L _ q0
0, a. date. - 3
-Names or persons signing in any capacity should be~lypxd~r-y Tinted b-qQ their signa[ures.
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