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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER t7xu H: ~r
ADDRESS
SUBDIVISION / CSM# LOT #
SECTION -s T,--2? N-R ' W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 F ET OF SYSTEM
cJ~~~ ~uS£ SB --7 ~ ~
4 -16,
f
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: /ffO
ALTERNATE BM•
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: UUfcyt'S Liquid Capacity:-
Setback from: Well f 7~ 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: House Other
ELEVATIONS
Building Sewer ~'9L~' ST Inlet; 9~ 6c~_ ST outlet 97
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER: INSPECTOR: 'JUn;
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Ht Man Relations
Safety and Buildings Division INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Permit Holder's Name: ❑ City ❑ Village O Town of: State Pla
HENNING, STEVE A
CST BM Elev.: Insp. BM Elev.: BM Description: ST. -JOSEPH 0~4"-009-30-000
/ Parcel Tax o.
p )
TANK INFORMATION ELEVATION DATA S/
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark 7-3 Ard,10
Dosing / lodrq-:~-
Aeration Bldg. Sewers 77,
Holdi. St/f't Inlet 3 (p ?df
TANK SETBACK INFORMATION St/ t Outlet 7~--
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing N Header=tw-- S/ 23
Aeration NA D)st. Pipe 7 5$ S '
Ho f:Bot- System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number M
TDH Lift Friction Ft
Forcemain Length Dia. Dist. To Well
SOIL ABS ON SYSTEM
BED/TRENCH Width / Length / No. Of Trenches PIT No. Of Pits Inside D' iq th
DIMEN 1 N e2 $ DIMEN I
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEA anufacturer:
SETBACK
INFORMATION Type O e CH~ ER Model Number:
System: C'oia- 71663?' >/G) OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold /~Distribution Pipe(s) / x _Hole Size x Hole Spaci ent To Air take
Length (o Dia. 7 Length 79 Dia. ~ Spacing CO
SOIL COVER x Pressure Systems Only xx Mound Or At-Grode ystem
Depth Over Depth Over xx Dep_ xx Seeded/Sodded xx Mulched
Bed /Trench Center Bed / Trench Edges Topsoil ❑ Yes ❑ ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)` LOCATION: -ST. JOSEPH
33 . 2 9 . 9.4 5A , W , NW CO. RD~ E
~~6c
U
Plan revision required? ❑ Yes D-40" Z2
/
Use other side for additional information. S /7
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
f
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
aµSANITARY PERMIT APPLICATION
~'=LriR COUNTY
In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than a O0 D J
8% x 11 inches in size. ❑ Check if revision to previous 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
dk) t/4 t/4, S , N, R )(or
PROPERTY OWNER'S MAILING RESS LOT # BLOCK #
CITY, ATE ZIP CODE PHONE NUMBER SUBDIVISI N NAME OR CSM NUMBER
I
II. TYPE OF BUILDING: (Check one) El State Owned VILLAGE NEAREST ROAD
FV TOWN OF:
❑ Public IC
J 1 or 2 Fam. Dwelling-# of bedrooms E_ PARCEL TAX NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply) /00?so coo
1 ❑ Apt/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 in line A. Check line B if applicable)
A) 1. ® New 2. ❑ Replacement 3. ❑ Replacement of 4.E] 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 19 Seepage Bed 21 ❑ Mound 30 ❑ SpecityType 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
1 Z-40 &Z REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./'rich) ELEVATION
Feet Feet
VII. TANK CAPACITY Site
in gallons Total # of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed F-1 F1 F] 1 F]
Septic Tank or Holding Tank /14WLF_ 1S,91) 14-JERS"
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumb 's Name (Print): Plu er' Si at ~(N(~ps) MP/MPRSW No.: Business Phone Number:
Plum er's A dress (Street,-City, State, Zip Code):
J
IX. COUNTY DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued, Issuing Ag t Si ture (No am
.4Approved ❑ Owner Given Initial 141k Q Surcharge Fee)
AdversermtiX. CONDITIONS OF APPROVAL/REASO S FOR DIS APPROVAL: .Ld~l2 Gr2'r~u^~,'►.~°~ 07~l~c(~G~c.(,L,Df7
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.
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 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 arid/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.11/88)
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PAGE OF
CrUSS Sec~lon o~ 4~e0 Sy5~e~1
Fresh Air Inlets And Observation Pipe
Approved Vent Cap
Minimum 12" Above
Final Grod•
20- 42" Above Pipe _ 4" Cost Iron
To Final Grade Vent Pipe
IAarsb Hay Or SyntMtk Covering
yin. 2" Aggregate
Over Pipe -
Olstrlbutlon
Pipe 0 0 0 0 0 - Too
Aggregate
Sense l b Pipe 0 Perforated Pipe Below
Be -
-Coupling Terminating At
Bolcom Of System
PruPoSe~ 1'tnkl gr~.~1c
5-1Icv..~ ton
SOIL FILL
DISTRIBUTIOF.I PIPE
APPROVED $4W'(NETiC COVER
2T F- OR AMA RIKI op, 9" OF STRAW
RSN NA'3
e
C~'0F12-Zt/Z AGGREGATE
V-LEV OF-222FEF-T.
DISTRIF3UT10M PIPE TO BE AT LEAST INCHES BELOW ORIGIUAL GRADE
AMU AT LEAST20 INCHES BUT UO MORE THAM HZ lUr-HES 6ELOW FILIAL GRADE
MAXIMUM DEPTH OF F-XCRVAT100 FRoM OK1&vVgt 6KADF- WILL BE _2Y=2 INCHES
1AIt11MUM 94'" OF EACAVATION MOM 01KI6114AL RaVf- WILL BE y2 Z INCHES
1
SIGUED:
LICEUSE UWABER: -
DATE:'
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
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but - y ~~'v Z
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARC L I.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
GOVT. LOT Vpj 1/4 1/4,S T N,R /(o r(
PROPE TY OWNE ':S ILING SS LOT # LOCK # SUBD. NAME OR CSM #
CITY, 7 ATE ZIP CODE PHONE NUMBER ❑CITY VIL GE WO N NEAREST ROAD
VJ New Construction Use Residential / Number of bedrooms [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow D gpd Recommended design loading rate ~Zbed, gpd/ft2_Lj _trench, gpd/ft2
Absorption area required bed, ft2 s'G trench, ft2 Maximum design loading rate bed, gpd/ft2 , 8 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 ZS ❑U ®S ❑U ❑S ®U ❑S OU
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon in. Munsell Qu. Sz. nt Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Tmr&
:::a` / s
Ground / - f
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
-
Ze 5f~I-Fll X4~ r s
Ground s s~'
elev.
2V ft.
Depth to
limiting ,
factor
> 99
Remarks:
CST Name:-Please Print , Phone:
Address: S
Signature: j Date: CST Number:
l
PROPERTY OWNER SOIL DESCRIPTION REPORT Paged of
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Motlles Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed d Tre Tmnch
Ground
elev.
ft.
Depth to
limiting
factor
I,
Remarks:
Boring #
rl _7 LX
•.Ground••••.
elev.
ft.
Depth to
limiting
factor
> y/
Remarks:
Boring #
r as,
Car
Ground
elev.
ft.
Depth to
limiting
factor
> 9/
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
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43 -
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CERTIFIED SURVEY MAP
Located in part of the NW1y4 of the NW1/4, Section 3, T29N, R19W
Town of St. Joseph, St. Croix County, Wisconsin.
OWNER'S CERTIFICATE OF DEDICATION
As owner, I hereby certify that I caused the land described on
this Certified Survey Map to be surveyed, divided, mapped and
dedicated as represented on the plat. I also certify that this
plat is required by Chapter 18 of the St. Croix County Land Use
Regulations to be submitted to,the following for approval or
objection: St. Croix County Planning and Development Committee
and the Town of St. Joseph.
WITNESS the hand and seal of said owner this day
of 19
In the presence of:
Witness James Durning
State of Wisconsin ) SS
County of St. Croix)
Personally came before me this day of 19 , the
above named James Durning to me known to be the persons who
executed the foregoing instrument and acknowledged the same.
Notary Public, Wisconsin.
My Commission expires
TOWN OF ST. JOSEPH CERTIFICATE
I hereby certify that this Certified Survey Map is approved by
the St. Joseph Town Board.
Clerk Date
SHEET 2 of 2 SHEETS
THIS INSTRUMENT DRAFTED BY ED FLANUM JOB NO. 94-54
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER TIJr~ i✓.L/~~~
MAILING ADDRESS /S/,/ FT)i ;5S o
PROPERTY ADDRESS it .1" (a I Sf
Dn
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE UhSOItJ ~'~C~
PROPERTY LOCATION 1/4, ~/4, Section T~N-R~W
'OWN OF 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 expiratio date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
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`<?~ /4/X;>-J b
Location of property N~1/4 1/4, Section ~3 , Tp` N-R_Z W
Township Mailing address (!~>6 4W ZSN ;E!,-)
Address of site (0
Subdivision name Lot no.
Other homes on property? Yes No
Previous owner of propert
Total size of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? a!~__Yes No
Is this property being developed for (spec house)? Yes 6~< No
and Page Number,_:_:_A:3 D~'as recorded with the Register
Volume~
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.
Signature of Ap cant Co-Applicant
Date of Sianattirp natP of gicrnatiirP
WARRANTY DEED
Docutz" NO. p.~. ,...e..s .es ,.rordi,, Mt.
GSTER'S OF SCE
524239 VOL 1105W,457
ST. CROIX CO., W1
;iac'd fir ttacord
THIS DEW made between JAMES J. DURNING, Grantor ED C 19 1994
and STEVEN W. Zffe KG and NORMA J. HENNING, - 9:45 - q.M
husband and wife as survivorship marital property, Grantees,
Witneweth, That the said Grantor, conveys to Grantees the d Deeds
following described rral estate in St. Croix County, State of
Wisconsin:
North-1/2 of Northwest-1/4 of Section 3-29-19, except and subject to the terms and
- 3 Fr
conditions contained in the conveyances of the following described parcels: T.
L-
(a) The North 83 feet of said N 1/2 of the NW-1/4 as described in a Warranty Deed
dated February 10, 1916 and recorded February 19, 1916 in Volume 149, Page 335 in
the office of the Register of Deeds for St. Croix County, Wisconsin. p'
(b) A triangular strip of land lying south of and parallel with the strip of land
described in (a) above, being that part of the N-1/2 of the NW-1/4, and outer land, z.
described as follows: Beginning at a point on West line of said Section 3, 83 feet South
of the Northwest corner thereof; thence East 80 chains, more or less, to a point on the
East line of said Section, 83 fort South of the Northeast corner thereof; thence South on
the East line of said Section, 76.6 feet; thence westerly 80 chains, more or less, to place
of beginning. Said strip of land hereby conveyed being 1 rule long, 76.6 feet wide on
East end and pinning to a point on West end, as described in a Warranty Deed dated =.k
February 18, 1918 and recorded February 20, 1918 ir, Volume 161, Page 288 in the
Office of the Register of Deeds for St. Croix County, Wisconsin-
TOGETHER WITH and SUBJECT TO reservations, restrictions, easements and rights-of--way
of record, if any.
This is not homestead property.
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And James J. Durning warrants that the title is good, indefeasible in fee simple and free and
clear of encumbrances, and will warrant and defend same.
Dated this 8th day of December, 1994.
(SEAL)
JAMES J.
ATE OF WISCONSIN )
ss. V
r ST. CROIX COUNTY )
personally came before me this 8th day of December, 1994, the above named James J. Durning,
to me known to be the person who executed the foregoing instrument and se1-now!edge,the same.
N: r
Barry C. Lundeen N y 13
Notary Public, State of Wi3+C~pin
My Commission Is Permaneitt.4
THIS INSTRUMENT DRAFTED BY: RETURN TO: -
Barry C. Lundeen
MUDGE, PORTER & LUNDEEN, S.C.
110 Second Street
Post Office Box 802
Hudson, Wisconsin 54016