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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER *,n o E.
ADDRESS
~Q G U ti t N N
_ 13g fd ~.,M G~/,f ~ctaa
SUBDIVISION / CSM# LOT
SECTION N/w TN/k/ N-RW, Town of jK(
Gt S 1 t G
ST. CROIX COUNTY, WISCONSIN
A SHOW EVERYTHING W*H I
IN100 FEET OF SYSTEM
8M ~
36
o~se-
5~~~ INDICATE Pd0RTH AkRZ7
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: t O n i ~2 e-
ALTERNATE BM:
SEPTIC TANK / POMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Me t S t e rr1 Liquid Capacity: / 0 0 0
Setback from: Well N f - House Other
Pump: Manufacturer 20/%2 Model# 6 Size
Float seperation Gallons/cycle: 3 1 b
Alarm Location
SOIL ABSORPTION SYSTEM
Width: S~ Length 1 (10 Number of trenches
Distance, & Direction to nearest prop. line:
S0'
Setback from: well: House 111 Other
ELEVATIONS
Building Sewer ST Inlet. fly. gd ST outlet
PC i n e t PC bottom S- Pump Off
Header/Manifold (k-3 Bottom of system yl,
Existing Grade alt Final grade
DATE OF INSTALLATION: S^ S S~
PLUMBER ON JOB:
LICENSE NUMBER: 41/7/&
INSPECTOR: 112?'f rj Sa, 3/93:jt
9rli t /41`
woV
Wisconsin-Department of Industry, PRIVATE SEWAGE SYSTEM County:
Sabot and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
Permit Holder's Name: ❑ City ❑ Village ❑ Town o : State Plan o.:
MOE, RON X
CST BM Elev.: Insp. BM Elev.: BM Description: -9h River- Parcel Tax No.:
l1fJ , v ~~~t._
TANK INFORMATION ELEVATION DATA ps`"
TYPE / MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic C i ~r G; Benchmark
Dosing
i
Aeration Bldg. Sewer
Holdin St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
TANKTO P/L WELL BLDG. AirIto ntake ROAD Dt Inlet
Air
Septic >SD d s~ 4 NA Dt Bottom
Dosing NA Headers s s,
Aera n NA Dist. Pipe zo
F zL ,
Holdin Bot. System
PUMP /INFORMATION Final Grade
~D/
Manufacturer Demand .S, T
&/Zx,- O
Model Number GPM 'n t' 29 3,
TDH Lift Friction System TDH Ft
Loss flead
Forcemain Length Dia. 1~ Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length / No. Of T enches PIT No. Of Pits I Dia. Liquid De th
DIMENSION 5 /Q?~ T DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LE ING Manu .
SETBACK
INFORMATION Type O /law c HAMBER s ' 02 Moe Number:
System: Ca vr- a! yQ "SS OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) ~i ~ole Spacing o Air Int e
Length Dia. ~ Length L Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade S ms Only
Depth Over Depth Over xx Depth Of xx Seeded/Sodded xx Mulched
110-/-Trench Center Bfdtf-Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Rush River.11.28.17W, NW, NW, Lot 2r 50th Avenue
4L C~, GT .5. 17F
14L66- 1~40 a_~a 64-Y, c c r-7/. F - cr,
Plan revision required? ❑ Yes E:W6
Use other side for additional information. W5-----
SBD-6710 (R 05/91) Date Inspecton r'SSignatur Cert. No.
1
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
'I
;pry M
SANITARY PERMIT APPLICATION Safety and Buildings Division
Bureau of Building Building Water System
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 Count
than 8112 x 11 inches in size.
0 See reverse side for instructions for completing this application state SaarxPerfrtit Num er
""e~JJvious application
The information you provide may be used by other government agency programs ❑ Check it revision remvvisionnn to pr
tPrivacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Pro rty Owner Name P perty ocation
/Vo e- 1/4, S ( T , N, R E (or)b
Propert Owne 's Mailing Address Lot Number Block Number
City, State Zip Code Phone Number Subdivision Name or CSM Number
o 911`) 6 K1
11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road
~c.h n
E] Public or 2 Family Dwelling - No. of bedrooms 3 ❑Tow age
Vlln of )l?KS ~'vtr s U /T U
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo ` 06 16 00
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. t ew 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
11 ❑ See age Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 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 S. Perc. Rate 6. System Elev. 7. Final Grade
r / r v Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) G Elevation
Y c~ 1300 % V p 6.3 3 /Sz Feet 10&... Feet
VII. TANK Ca
in aacitllons Total # of Prefab. Site Fiber- Ex per.
INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existin strutted
Tanks Tanks
Septic Tank or Holding Tank /G UV M p Q or. otc, ri_ ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber f U j i f ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility or installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plum 's Signata(N amps) PRSW No.: Business Phone Number:
Jr, e- C
et .t
Plumber's Address (Str City, State, Zip Code)
Sao6 4V- //G c_ /.7 q 4/ & ej v t l /e kJ,j-
IX. COUNTY/ DEPARTMENT USE ONLY y-q 6 ,
❑ Disapproved S~adrpitary Permit Fee (Includes Groundwater Date Issue Issuing ent Sign re (N tamps)
Approved ❑ Owner Given Initial srI Surcharge fee) Adverse Determination l6rVC2 ao 07 / '
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
4
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.
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 an(.! specifications not smaller than 8 1/2 x 11 inches must be submitted t:) the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensi&r location of hcldinc tank(s), septic
tank(s) or other +_reatment tanks; building sewers; wells; water mains/water sErvice; strer n~<. ;Md lakes; pump or siphon
tanks; dint; r-Jution boxes; soil absorption systems; replacement system area,; an- the 1ocauof of the building served;
Et) horizontal and vertical elevation reference points; C) complete specifications for pumps ad ( ontrols; dose volume;
elevation differences; friction loss; hump performance curve; pump model and pump manufacturer, D) cross section
of the soil absorption system if required by the county, f_) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges ("ees) fora 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.
6 Ae N/w ~i t ~r
/1't dap a ~ 1 ''JwG !GG► '
,~'k hip He R
pet Lt,' .4-1 13Y st Ct A3
ti
, $ l ~ ° • ,tom. y
1offv
Fuoo
.n
.s' 60
v i
5 0-1
' S
s ~
N
5-6r6 gvN
,PNGE 6 01= b
K 7
EAD CAPACITY CURVE 3 7/86 t/a
H
MODEL "98" a s/8 {
e
25 ( 3 5/8
20 ZO. 5 + +
. 6 O
18~ L 4 3/16
15
4
0 10 1 1/2-11 1/2 NPT
2 5 S95°40072.
0
U.S. GALLONS 10 20 30 40 50 60 70 a0
LJTERS 80 160 240
0 FLOW PER MINUTE
TOTAL DYNAMIC HEADIFLOW PER MINUTE
EFFLUENT AND OEWATER1NG
CAPACnY 12
HEAD UNITS/MIN
FEET METERS GALS LTRS
5 1.52 72 273
10 3.05 61 231
15 4.57 45 170 3 5/ 16
20 6.10 25 95
Lock Valve 23'
CONSULT FACTORY FOR SPECIAL APPLICATIONS
• Electrical alternators, for duplex systems, are available and • Mercury float switches are available for controlling single and
supplied with an alarm. three phase systems.
• Mechanical alternators, for duplex systems, are available with or • Double piggyback mercury float switches are available for
without alarm switches. variable level long cycle controls.
SELECTION GUIDE
1. Integral float operated 2 pole mechanical switch, no external control required.
Standard all models - Weight 39 lbs. - 1/2 H.P. 2. Single piggyback mercury float switch or double piggyback mercury, float
98 Series Control Selection switch. Refer to FMO477.
Model Volts-Ph Mode Amps Simplex Duplex 3. Mechanical alternator 10-0072 or 10-0075.
M98 115 1 Auto 9.0 1 or 1 & 7 - 4. See FM071Z for correct model of Electrical Alternator, "E-Pak".
N98 115 1 Non 9.0 2 or 2 & 6 3 or 4 & 5 5. Mercury sensor float switch 10-0225 used as a control activator, specify
duplex (3) or (4) float system.
D98 230 1 Auto 4-5 1 or 1 & 7 - 6. Four (4) hole "J-Pak". junction box, for watertight connection or wired-in sim-
E98 230 1 Non 4.5 2 or 2 & 6 3 or 4 & 5 Alex or duplex operation, 10-0002.
7. Two (2) hole "J-Pak", for watertight connection or splice.
CAUTION
For information on additional Zoeller products refer to catalog on Combination Starter. FMO514; All installation of controls, protection devices and wiring should be done by
a quali-
Piggyback Mercury Switches, FM0477; Electrical Alternator, FMO486; Mechanical Alternator. fied licensed electrician. All electrical and safety codes should be followed inctud-
FM0495; Alarm Package, FM0513; Sump/Sewage Basins, FMO487; and Simplex Control Bm ing the most recent National Electric Code (NEC) and the Occupational Safety and
FM0732. Health Act (OSHA).
RESERVE POWERED DESIGN
For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump.
IiWL T0: P.O BOX 16347
Lorrisvlle, Manufacturers of...
Q Loue,KY 4o2s la 40216
C`/ 1 771-11 E/4' SH1P TO: isvill80 01d Hiders Lane 1~UAL/,7Y PUMPS ~~~E /939
Page Of
SEPTIC TANK & PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
i
4" CI VENT PIPE 12" MIN. ABOVE GRADE & WEATHERPROOF
?!25' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED
FRESH AIR INTAKE WITH CONDUIT MANHOLE COVE
P
FINISHED GRADE W/ ADLOCK &
WARNING LABS
„
4 CI RISER _
y 4" MIN.
18" IN. 6" MAX.
INLET
WATER TIGHT SEALS GAS-
TIGHTS ,
A SEAL e\k4PPROVED
JOINTS WITH
APPROVED - A LM APPROVED PIPE
PIPE 3' ON 3' ONTO
ONTO SOLID! ~ SOLID SOIL
C
SOIL PUMP OFF ELEV. FT. I OFF RISER EXI
D PERMITTED ON
IF TANK
MANUFACTURER
HAS APPROVAL
3" APPROVED BEDDING UNDER TANK
CONCRETE PAD
SPECIFICATIONS
SEPTIC / DOSE
TANK MANUFACTURER: /YJeC! hieSL~~'? NUMBER DOSES PER DAY :
TANK SIZES: SEPTIC r GAL. DOSE VOLUME INCLUDING
DOSE s"G GAL. FLOWBACK: 2s' GAL.
ALARM MANUFACTURER: CLe~r~esys. CAPACITIES: A = INCHES = 3ia GAL.
MODEL NUMBER:
~j
SWITCH TYPE: M cli r 4,vy B = 2 INCHES = 3 GAL.
PUMP MANUFACTURER:"Zd/e.e C = INCHES = J5 3 GAL.
MODEL NUMBER:
SWITCH TYPE: e 2 C k D = q INCHES = L53 GAL.
REQUIRED DISCHARGE RATE 1~.2~,GPM PUMP E ALARM WIRING AS PER ILHR 16.23 WAC
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE . . G FEET
+ MI
NIMUM NETWORK SUPPLY PRES RZ . . . . . . . . . . . . 2.5 FEET
410
FEET FORCEMAIN X FT/100 FT. FRICTION FACTOR FEET
TOTAL DYNAMIC HEAD = FEET
INTERNAL DIMENSIONS OF PUMP TANK: LENGTH ; WIDTH ; DIAMETER
LIQUID DEPTH
SIGNED: vim= LICENSE NUMBER: ry~ r GGKe_1o DATE: t5ps
1/88
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3
Labor and Human Relations
Division of Safety a Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 81/2,x 1'F inches in`siie PI st include, but
not limited to vertical and horizontal reference point ) direct;; n~ and % of'~kip , ale or PARCEL I.D. #
dimensioned, north arrow, and location and distan too,nearestt a
At3PLICANT INFORMATION-PLEASE PRI i~ L It~FORMATIOfh4t REVIEWED BY DATE
PROPERTY OWNER: \3v~-1~2 -RUB Y~tf PROP OCATION
d t,,) 1J 114 N W 1/4,S 1\ T 2-8 N,R 1 E
12 (006
PROPERTY OWNER':S MAILING ADDRESS BLOCK # SUED. NAME OR CSM #
CITY, STATE ZIP CODE PHO QVILLAGE WTOWN NEAREST ROAD
3Pri L~ww, ~v I S (loo Z (its) v S t~ `zt-wt Z S 0 I-4 1WL_
K New Construction Use Residential I Number of bedrooms 3 [ ] Add'ItiQn to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow LISD gpd Recommended design loading rate - bed, gpd/ft2 a 3 trench, gpd/ft2
Absorption area required bed, ft2 1 s Do trench, ft2 Maximum design loading rate o, 3 bed, gpdAt2 a • y trench, gpolft2
Recommended infiltration surface elevation(s) S P~ E 3 It (as referred to site plan benchmark)
Additional design /site considerations ~.tTC o MM E'vt 3 S ttt~~ww 11ZJ(5QCFe-'S- Ll e~j S' X t u u, Lo" G
Parent material s LL Flood plain elevation, if applicable N - A - ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM W FlLLHOLDING TANK
U= Unsuitable for stem M S ❑ U ®S ❑ U 0S ❑ U ~ S ❑ U ❑ S n U ❑ S Ulu
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Cor6swm Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed tench
] o_9 V'&tiv- 3I z - si z ~sbk v- a, s - o.s o. 6
<:x
2 q-t`t t12 316 - sit 2~sbh w~~~- ot,S - o.s o-b
Ground k-1 li V /y - S C S blz Wn `E _ G L.,.-) - 0-'4 D- 5
elev. O wt -Pi,_ - 0 3 o•
y
0A .-I ft, u S~=1Z 7-S `-L2Ylyr ~ S 'l -Pi,_ 0,
Depth to Cp S t b f S ^-u
limiting
factor I Fe)v I.v v o e-Lle S P /t ED LR c cL U G 1~4
w ~ 10 `112 S s
Remarks: P~SDU L 1~-~0 1'.1 ~ _'-r `T-z Bo~Z lh1 G F,
Boring #
1 0-8 lby~Z3I2 - SL~ Z`~Sb1-C ~^'t~~^ c~S U•So.~
Z Z 1%-V9 10-m- 316 - Sll Zs~h wt'E'►- arS - o.S o.~
3 Not -q y Z. S `'1 t.2 Y7 c s"O1z c w - o• y S
Ground
elev. ~I 70 $ Li k V/ S
w o. 6 ft.
Depth to
limiting
factor
7-704
Remarks:
TName.-Please Print Arthur L. We erer Phone' 715-425-0165
egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022
Signature: p Date: CST Number:
04 07N-21 Z5 M00576
PROPERTY OWNER SOIL DESCRIPTION REPORT Page 2-of 3
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Buxi3 / Roots GPD/ft
in. Munseil Qu. Sz. Cont. Color Gr. Sz. Sh. Bed rends
3 o-10 1,v`- Z. 31 Z -sf l Z Sb m 5h a, -s; - o. S 0- C
Z lu Zy t~~tt~~lb - sil Z~sbk ~-A 0..s - o.S 0.
Ground 3 Zq-Sri -1 • S ft v /y S 1 CS ~>z hn ` l,C,r," O . y 0_5
elev.
S ft. y u 70 -)•S `12 V/ - S j tJ rn ~'y. - 0-3 v•y
Depth to
limiting
factor
71 O''
Remarks:
Boring # o _ S t 1 2 Z~ Z b 1Z
b~t1Z31 -
3 Z -t9 1~111-1 VL I/6 - Sil 2~sbh
Ng-l-a -)Is 4 ti
Ground
elev. y ~iZ ~2 7.5 y 2 y/ _ s) O~nn
ft.
Depth to
limiting
factor
Remarks:
Boring #
..~x ) 0-9 10`12 312. ~ 51.1 ~~sbk
5 Z 9-2.1 l~ `11Z 3l~ S 11 Z `~S bk
- s) 1 ~s b1z
3 2 l -S>o • S y iZ L/ /V
Ground
elev. y S"--o 1.S Lip- U/y O~
14p ft.
Depth to
limiting
factor
y-~p5
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting-
factor
Remarks:
SBD-8330(8.05/92)
PLOT PLAN Page 3 of 3
SCALE 1"= 30 '
0..3 m~ To
`a'1 `tom sT.
~o
a
N
4 - S ~o~ 0
J
a
o ~
dIL 9 / \
too 8~ ag S
a.2
.+r s.V ~ti8_h - e--. 100.0 oN \~ul11G}{~
s.y
iV0`t~T;
v~ E \3 F ►91' L~~cs T -ZS" FIZ411 S LIST -2 t'n S.
W ALL • . S ~ ~ _
F TvV-j~ L_oT' LlN C-s R \C- r~-T-- L- (~A s7- S' FlUM S~4 3T&I f)~F1 S .
p CiLI-ZZS
~d- 9-L9-~~ (715 ) 425-N16q M00576
CST Signature Date Signed Telephone No. CST #
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
. couNrY
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but Y.
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.
A13PUCANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
f ;
PROPERTY OWNER: R.*~R-T Vi OE PROPERTY LOCATION
FZUI~ `h'1 0 ~-z GGVF4:OT-- tv W 1/4 NW 1/4,S 1 T 2-8 N,R 1-2 E
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM # '
l°l3 ~~N`fLf fV" - C'~-ci~os~o cs>7
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE MOWN NEAREST ROAD
Zpv~-bk-) 01 Gv I S V00 Z. 15) 67"3 ZZ USly 1;RL1
Ut'1Z S ~O =
pQ New Construction Use Residential / Number of bedrooms 3 Addition to existing building
[ ] Replacement [ ] Public or commercial describe
Code derived dally flow LISD gpd Recommended design loading rate - bed, gpddt2 a. 3 trench, gpolft2
Absorption area required bed, ft2 1 S uv trench, ft2 Ma)dmum design loading rate o• 3 bed, gpd/ft2 a , y trench, gpolft2
Recommended infiltration surface elevation(s) S Q'e- P~ E 3 It (as referred to site plant bemhmark)
Additional design/ s i t e considerations \ Z - I N - c Mh 0•,,b 3 S 1 LUJw T 2 , - - w c x + ~ - the. j S' x I I I un LWU G
Parent material s ~L Flood plain elevation, if applicable 1y • P\ , ft
S = Suitable for system CONVENTIONAL MOUND IN•GROUND PRESSURE AT-GRADE SYSTEM IN FIU. HOLDING TANK
U =Unsuitable for stem P9S ❑ U IRS ❑ U 0S ❑ U En ❑ U ❑ S ® U ❑ S oU
SOIL DESCRIPTION REPORT
P.
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPDIft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed rench i
} -9 W`tR 3IZ Si ` Z`FS1D1t W'- a S - o.S o.6
I
Z 9-t`l ~o~t1z-316 - siJ 2`Fsbh wt~~ ot,s - o.s o.b
Ground 3 1-1- SO . S `1Iz. Y,/Y- - S C s biz 1vt C t." - 0-11 o- S
elev. O w~ lout - 3 o• y
aiq •'7 It tf So ~ Z 7- S `-GfZ V/ y ~ S1
Depth to Co
>v S 10 ~I 6 / S
limiting
factor • t FE'~v I-v t QL s U /T D L cL U tt G
w~ 10 `1 Q 6 S t't err S .
Remarks: ' 0 t IuO S 4il~PLy $o\zl%yG 6
Boring #
1 0-b lb`-I~ 3tZ - S 1 Z Fsb1c m ~ti- C-- 5 o SIo.~
a. S o . S o.
Z Z 8-19 104f 316 - S11 z~'sMt 1n 'i P `
3 1-i -qty -T S ti 1Z V/ - S 1 cs~1~ y►t~~ cw - 6.y 0.5
GmW
elev. 70 S. `1R V/ S +n`~>^ - o• o.
VOL). 8 It.
Depth to
limiting
factor
•70,
Remarks:
CST Name.-Please Print Arthur L. We erer Phone: 715-425-0165
egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022
Signat<rre: Date: CST Number:
~4 137(4 -Z1S M00576
PROPERTY OWNER FLOE SOIL DESCRIPTION REPORT Page Z.of 3
PARCEL I.D. it
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed ranch
3 o-to ti~~2 3lZ - sil z s~ ~h a.s _ o.s o_ 6
2 lu Zy t%,y-j Ct. I si l Z~sbk ~-A fI^ a s - o.s o.b
Ground 3 Z~-Sb . S `t R V /y _ S 1 CS ~k >1n C L,,.,, 0,q O .S
elev.
` a•S ft, L/ 70 )-S `1lZ V/ S j ~ti, - o•3jo•y
Depth to
limiting
factor
Remarks:
Boring #
o-~ tibK1Z 3 l z - Si 1 Z-`E'sb1-c j
13
Z N9-1-1Z -)Is Hlz viy s1 Z ~sbk
Ground
elev. LZ 2 7,5 ~t 2 S// - S~ O
ft.
i
Depth to i
limiting
factor
i.
Remarks:
Boring # i
) 0-9 ~o~.R 31Z ~ s%~ ~~s~1z
5
Z 9-2.1 I~~IZ 31~ S11 Z`1'Sb~t _
s) 1 csblz !
3 Zl-Sb ~•Sy1z L/ /V
Ground
elev. y 5b.'~o ~,S'-t l2 U!y _ S~ OV,,
ti0D.-I ft.
Depth to i
limiting
factor i
y "~Dy
Remarks:
Boring #
i
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
PLOT PLAN Page 3 of 3
SCALE 1"= 30 '
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-L` (715 ? 4 .5-m 6s M00576
CST Signature Date Signed Telephone No. CST #
527344 CERTIFIED SURVEY MAP
LOCATED IN THE NW 1/4 OF THE NW 1 /4 OF SECTION 1 1, T28N, R 17W,
TOWN OF RUSH RIVER, ST. CROIX COUNTY, WISCONSIN.
NORTH LINE OF
POINT OF THE NW 1/4
BEGINNING UNPLA_TTED LANDS_
NW CORNER----- --N_ly4 CORNER
SECTION 11 S 89°53' 32" E 50TH AVENUE 2614.06' SECTION 1 1
T28N, R 17W . - - - - - - T28N, R 17W
co 190.00 cp
170.00' 20.00' 315.00' 2109.06'
I I S 89°53'
315.00'
- 0
I I I I o ~ --32PE
0 PROPOSED
I I c6 M o I DRIVEWAY
,.n o
I
LOT 1 NI
° HIGHWAY SETBACK LINE o V) I
C.S.M_ I zl
VOL. 9 I <I - - - - C6 I
PAGE 2458 of QI
DOC. _#480683 I w
LOT 2
<1 c) 03 0l LLJ
a ° 2.661 ACRES ° I
I 10-1 to 115,901 S.F. ~
I I of PO INCLUDING ROAD o <1
I I w RIGHT-OF-WAY d d l
I I ` 2.422 ACRES o
0 105,505 S.F.
I _ - - _ _ - - I EXCLUDING ROAD
RIGHT-OF-WAY
o
951
315.00'
FILED N 89°53' 32" W ,
Ol APR 0 3 1995 UNPLATTED LANDS
KATHLEEN H. WALSH - - - - - - - -
Register of Deeds
6 SL Croix Co., WI ,
a
W u; U, 4
Z
w
LEGEND,
ow~~ 4
~V) Ln
o u- a' 00
v ° COUNTY SURVEYOR'S MONUMENT,
uj ' BERNTSEN CAP, FOUND.
U-3:: Q
LU Zm
cn i = 0 1 " X 24" IRON PIPE WEIGHING
z F- = 1.68#/LINEAL FOOT, SET.
<003
mw
z r-
0 , ~
~2 _
~F Z
U) of 03
a °z SCALE IN FEET
0' 50 100' 200' 300'
OWNER & SUBDIVIDER
W. RONALD AND BONNIE MOE
1934 CTY. RD. "N"
BALDWIN, WI 54002
THIS INSTRUMENT DRAFTED BY JAMES D. FILKINS PAGE 1 OF 2
VOL. 10 PAGE 2902
STC- 105
SEPTIC TANK MAINTENANCE AGREEMENT
/ St. Croix County
OWNER/BUYER g° _ Odd C r d yo C.
MAILING ADDRESS I~"~~ _~`C~Ir~ trM lar 4:~ydoz
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE &)l
PROPERTY LOCATION ~IGI 1/4, 1/4, Section j T .2 0 N-R_. 177_W
TOWN OF u4~V ..t t ST. CROIx COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIEDSURVEY MAP, VOLUME 10, PAGE, LOT NUMBER Z
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 date.
SIGNED:",, t
DATE: t c 577- -
St. Croix County Zoning Office
Government Center
1101 Cann ichael Road
Hudson, AVI 54016 11/93
• n S T C - 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.
Owner of property j Ka-A\"C r Mg. 61 GAS -ik Location of propertyl/4
g~j 1/4, Section )),TN-R__Ll_W
Township 9 uh JZJ gjf.t Mailing address H3'f Ca NA A/
IM 'Y4C3
Address of site / 5 U t y~
Subdivision name may( `2 a9 Lot no. a
Other homes on property? Yes No
Previous owner of property ~r -t PVIXM14P Mae
Total size of property
Total size of parcel
Date parcel was created y13
Are all corners and lot lines identifiable? ✓ Yes No
Is this property being developed for (spec house) ? Yes No
Volume /0 and Page Number ,;~Ojoj 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.
. 73 yY
44d~ A~
Signature of Applicant Co-Applicant
Date of SiQnature na+ o ~f c; n„~+,,,
i
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVED FOR RECORDING DATA
WARRANTY DEED REGISTER'S OFFICE
2 OIX CO., WI
VOL 1116RArF504 forRecord
f:J 0~n ~A {3a'YLt~ Mine .1995
at 4:15 PM
to it- Register of DeedB
conved warrants n,
ys ener P a er`~v~~ tM, YV1c~
Sur u~~rs arc'
RETURN TO QOM J~'~
!)oI~e.r~'f- R. w Ka.~haR~t~e rf~
the following described real estate in i County, CZt (dLUi'f Loo ~Z100~
State of Wisconsin:
Tax Parcel No:
P4. NW "T z6 PJ
w
,-ow.y\ ol~m d~ e6 W\
(~cco `1 3~ 9 V"~.c, ' 5;7 3L1'~
V,, .10 '2-
E~EMP-~This 1-~ Y\c homestead property.
(is) (is not)
Exception to Warranties:
Dated this 1 day of htP~ , 19_J 1_.
IV Y - (SEAL) (SEAL)
2~ael\k Mee
K (SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
I
Signature(s) STATE OF WISCONSIN
ss.
:S+. 0.'T"'~ County.
authenticated this day of , 19 Personally came before me this th day of
P~ 193 the above named
W ld yyivt 0.n S.
Tel o E
TITLE: MEMBER STATE BAR OF WISCONSIN ,sesesv0eeoee~seee
(If not, SC Me known to be the person 5 who executed the
authorized by § 706.06, Wis. Stats.) a°°°a°°oaeo,oo,ing i ume tan kno ed the
yt THIS INSTRUMENT WAS DRAFTED BY
1 1~ ?®p~ ~~Q ell ~4 00o
e°>f'1out1 O
Z :4e,-"
`Y
Otar\gpublic 5 C{o X- County, Wis.
(Signatures may be authenticated or acknowf$dge oap ttf a(obmmi%R i permanent. (If not, state expiration
are not necessary.) ~•v~ faf csoaav0" ®~y v? ry ublic-State of Wisconsin 19 )
of
of persons signing in any capacity should be typed or printed below their signatures. SB2 NTF 0021
WARRANTY DEED STATE BAR OF WISCONSIN Nelco Tax Forms, P.O. Box 10208, Green Bay, WI 54307-0208 ,
Form No 2 - 1982