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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS 1 1
SUBDIVISION / CSM# ~l J LOT #
SECTION f,, TgN-RW , Town o f
a,o
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FE T OF SY TEM
i
,
aat gS
DUs.~
Me
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK' ,o 1 AeJO D
ALTERNATE BM: c ~f~5'- /fJD.cS96
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
/~,g8~~ l
Manufacturer: 4tjrCS Liquid Capacity:
Setback from: Well House--,,- 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: 1 HouseTy- _ Other
ELEVATIONS
Building Sewer 9~'-~// ST Inlet. ST outlet
i
PC inlet PC bottom Pump Off
Header/Manifold 9_S7/l Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION: /
PLUMBER ON JOB:
,ir
LICENSE NUMBER:
INSPECTOR:
3/93:jt
i
Wiscoh;in Department of Industry, PRIVATE SEWAGE SYSTEM County:
Laborand Human Relations INSPECTION REPORT ST. C:ROIX
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No_:
PerRmltol lerRsrName: K ❑ City ❑ Village Town o : State Pla
MAR I
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
X00 , / a a
TANK INFORMATION LEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic, d a'?r Benchmark 105,111 /do
Dosing /0d49 /06
Aeration Bldg. Sewer 6,v q4.
Holding St/ Ht Inlet 7,0
TANK SETBACK INFORMATION St / Ht Outlet -7,,3 g S y
Verit
TANK TO P / L WELL BLDG. Air Ito ntake ROAD Dt Inlet
Air
Septic Say' }gJ ®";t' NA Dt Bottom
Dosing NA Header/ Man. Aeration NA Dist. Pipe 70
r- I Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade S (0 y
Manufacturer Demand
Model Number GPM
I Loss Friction System TDH Ft
TDH Lift
mead
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width/ / Lengt No. Of Tr riches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O / CHAMBER Mode Number:
System: ` ai / 3 $ P~CX~~ n 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 r Depth Over u 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.)
LOCATION: Richmond.6.30.18W, NE, SW, 95th Street
Plan revision required? ❑ Yes E:rNo _
Use other side for additional information.
SBD-6710 (R 05/91) Date 1 cto s signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH . '
SANITARY PERMIT NUMBER:
f
SANITARY PERMIT APPLICATION
v~~II~IIIR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
,6~tl v-
STATEY ER IT#
-Attach complete plans (to the county copy only) for the system, on paper not less than 3
8% x 11 inches in size. ❑ Check if revision to revious 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
Yk .5- %4, S T , N, R ,E 1
AIA- PROPERTY OWNER'S MAILING AD SS LOT # BLOCK #
CI . ,STATE ZIP CODE PHONE NUMBER SUBDI ISION NAME OR CSM NUMBER
D
CITY NEAREST ROAD
II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE
~QWN OF:
❑ Public VS'l 1 or 2 Fam. Dwelling-# of bedrooms AR
~
111. 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 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 5.0 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 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
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./' ch) ELEVATION
Feet Feet
VII. TANK CAPACITY Site
in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New lExisting Gallons Tanks Concrete structed glass App.
Tanks Tanks
Septic Tank or Holding Tank /low E El F F] El
Lift Pump Tank/Si hon Chamber F] R F] R
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installati of the onsite sewage system shown on the attached plans.
Plumber' Nam (Print): Plumb is Si re: o'S s) MP/MPRSW No.: Business Phone Number:
1
PI tubers Address (Street, Ci% State, ZIP C
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanita ermit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination •G/~/
X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: V I/ I/
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 alicensed
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
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.11188)
r `
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i
C8'
~(i ar'~sio•~e/I
~'i'ouse
83
PAGE OF
CCrUSS 1 eqC Z. SyS~e r" to
Fresh Air Inlets And Observation Pipe
Approved Vent Cap
Minimum 12* Above
Final Grade
20- 42" Above Pipe _ 4' Cast Iron
To Final Grade Vent Pipe
Marsh Hay Or SyRAggregaie
MiODistribution
Pips Too
6" BePerforated Pips Below
- Co
oping Terminating At
Bolcom Of System
p~~PQse~ ~Inal grc,clc
71
SOIL FILL
DISTRiBUTI01.3 PIPE
APPROVED S49IETIC COVER
Op OR MARISN HAy9" OF STRAW
(o' OF 12 - ZI/Z AG GREGATE
DI5TRlR1JTI,3U PIPE TO BE AT LEAST IIJCHES BELOW ORIGIIJAL GRADE
AUL) AT LEAAST?O 11JCHES BUT KIC MORE THAN 42 IMC14ES BELOW FINAL GRACE
I" M"UM DEPTH OF EXCAVAT100 FKOM OKIGrdAL 6KAoF. WILL BE s2-/ IAICHES
MINIMUM gr=f rh OF EXCAVATION FROM 011KII61WAL (3RAQE WILL BE ~f INCHES
SIG►JEO:
LICLUSE DUMBER:
DATE: 2- ~5
oWs'nsinDepartmentofIndustry, SOIL AND SITE EVALUATION REPORT Page / of 3
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83. Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 81/2 x 11 i~ lude, but PARCEL I.D. # /
not limited to vertical and horizontal reference point (BM) n and %of slope;~c r I 0
dimensioned, north arrow, and location and distance to a roa R CG► " Cj
REVIEWED BY DATE
APPLICANT INFORMATION-PLEASE PRINT A FORMATION
PROPER OWNER: ` PROPERTY LQC ION l
,b ` t90VT. LOT: 1/4 S W 1/4,S, 6 T 3 c) N,R 1,9 f(or) W
D. NAME OR CSM #
_F9dPgRTY ER':S MAKING ADDRESS : K # SUB 0) 6
10 CITY, STAT ZIP CODE PHONE NUMB / VILLAGE QrOWN NEAREST ROhD
bi. New Construction Use [/4 Residential / Number of bedrooms [ ] Addition to existing building
( ] Replacement [ ] Public or commercial describe
Code derived daily flow }4 5 U gpd Recommended design loading rate , .5- bed, gpd/ft2 trench, gpolft2
Absorption area required !3to o! bed, ft2 9.~o trench, ft2_ Maximum design loading rate _L:5 _bed, gpd/ft2 trench, gpd/ft2
Recommended infiltration surface elevation(s) 9 ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material Gl [ A& Flood plain elevation, if applicable ft
S =Suitable fof System CONVENTIONAL MOUND INPROUND PRESSURE AT Da U SYSTEM ❑ S ~ UK
U = Unsuitable fors stem 144 13 U ®=S- ❑ U a
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
^ z D 3 - 5 1M a ,
4124- ✓ -7S D
Ground S
elev. s r
~i& (v s s
Depth to
limiting
factor
Remarks:
Boring #
--/a p 3/ C Z~nSD ,w c~ Z 5.
0-z 0 S - st3 C") z .3
Ground
222 O
Depth to
limiting
factor
Remarks:
CST Name:-Please Print Phone: z,4
Address: 0_0 IV4F,
Sgnature: _ Date: CST Ntxnber:
PROPERTYOWNER /cc 6 SOIL DESCRIPTION REPORT P,a'e
9-,2- Of
PARCEL LD. / r ~j I 9c)
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bour>aary Roots GPD/ft
in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. Bed ITrendl
MEW
Z ,.3
Ground . Z S .5 G~ l S rtJ ,
elev.~o i
r
Depth to z
limiting
`factor
/~ry
Remarks:
Boring #
C2 -3 /eq #Ise) Q)
Ground -y s ®S
elev. ~o `lQ S z ✓ 5 .
v A/11- /1/111%
Depth to
limiting
factor
Remarks:
Boring #
C~d ,7
53 M
Ground
Gele~v. e'
Depth to
limiting
factor
Remarks:
Boring #
~ ~s
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-6330(R.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel e-Me
C.S.T. 2298 New Richmond, WI 54017
MPRSW-3254 (715) 246-6200
ly~% s w s - f3o~~/0)
~i✓ i4 10Z~
odd dV7 Po's
0
TI *j
/ S k~ \ y9 10
q4'
~-eV
~.3 l080 M
SIC
ho Jr C OWLvtu2
~ - 'g
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNERBUYER / "l A-/?A_ 4~)- 7L 1171? 1/ 4 /7~ASTR~~n
MAILING ADDRESS 30 i L S7 : ei4S T (.c) o S A S
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE _50 M p_ P, S 7' l~ i 5 ~
PROPERTY LOCATION _ 1/A J LJ 1/4, Section , T_Z Q_N-R_IJE~_W
TOWN OF R1 C l-F MpNt> ToL.) w on p 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
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.
SIGNED: ~ ' - ~Za-ry,
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
STC - loo
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.
Ownerof property MARK jl~, 1- M.AA)" Z--
Location ~?6r+1
of property J 1/, S W 1/4, Section (T 30 N-R_18 W
Township R "CivMoA! D Mailing address 365 /.f 116W 5/- ':'61
177 f JAJ S 4e Oa 5
Address of site L 1Z2 Subdivision name Lot no.
Other homes on property? Yes _X_No
Previous owner of property f+A RR,/ O LDS ouxc,
Total size of property 9. 5 AcRes
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 X_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. 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.
A '~A' ~
Signature of Applicant Co-Ap lica t
*SgLOtDate of ure Date of Signature
• THIS SFA-A RESERVED FOR RECORDING DATA
' OOLMENT NO WARRANTY DEED
STATE BAR OF WISCONSIN FORM 2-1982.
515470 MSE162 • - - ; - DICE
07'
'a. 4'C1X C0'WM
Harr 0: Oldenburg and Georgianna M Oldenburg.----
Harry APR 18 1994
-
8:30 M
conveys and warrants to Repstrom-and- Mary-- L.-
Rens.><rom,.-husband.-and-vife.>_-as marital -property ..with....... i
t
right-.of-.su-;yiv9xskt.ip._
-
11 RETURN TO
~I
- .
the following described real estate in St.-.Croix .................County, -
state of Wisconsin: Tax Parcel No:
1
All that part of North Half of Southwest Quarter (N} of SW}) of Section Six (6),
i
Township Thirty (30) North, Range Eighteen (18) West, lying Southerly of the Railroad i
I Right of Way.
i
;I
1
I
This is IIOt homestead property.
(is) (is not)
Exception to warranties:
5 April I9 94
day of
Dated this
(SEAL)
i (SEAL) -
ii . Harry 0. Oldenburg
!i - - (SEAL)
(SEAL) E~ ~/~nw... . .
i Georgianna M. Oldenburg
;I
AUTUBNTICATION ACKNOWLEDGMENT
i
Harry 0. Oldenburp,_and STATE OF WISCONSIN
Signature(s) ss.
County.
Geor ianna M. Oldenburg..................
~J'day f _ 19-_94 Personally came before me this
anthenti C April day of
th
19 the above named
%
Hendrik W._Van_Dyk_.---------•-----•--•----------------
1i TITLE: MEMBER STATE BAR OF WISCONSIN
- -
(If not-
~i authorized by 4 706.06, Wis. Stats.) to me known to be the person who executed the
I foregoing instrument and acknowledge the same.
i
lil THIS INSTRUMENT WAS DRAFTED BY - -
REINSTRA, VAN DYR NEEDHAM, S.C.
ZOT°S:"RriiSwIe's~
Notarv Public - - - . County, Wt's.
_ New_ Richmond WI--540-
NIV Commission is permanent. (If not, state expiration
! (Signatures may be authenticated or acknowledged. Both I9 )
date: - + ,
are not necessary.)
"Wass of persons sigmas is any capacity should be typed or printed below their si¢natures. - - - I.