HomeMy WebLinkAbout030-2067-95-000
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER_ LT" ,4AO
L
ADDRESS
S'43 At
SUBDIVISION / CSMJ f►~/~ ~fjEL/~
LOT
SECTION-73,5" T l3jO N-R,1,6_W, Town of Sr,
r7bS ~iy
F'
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
w ESL
1 ' S x 38 ~/tLl~rG~ ~5~
EAU/ pRwc;
\J
70
V1
O
INDI CATL NORTH
Provide setback and elevation information on reverse of this fo►-m.
Provide 2 dimensions to center of septic tank manhole c_-,ovel
i r
BENCHMARK: n.0 //POA( CDT S rAA",9- 57,00 CORME9 E<< - ABU d
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: ZZ)926 ZC-S, Liquid Capacity: ~QQ
Setback from: Well House Zl' Other
PUMP! er Model#
Float seperation ons/cyc
Ala cation
SOIL ABSORPTION SYSTEM
Width: Length 38 ` Number of trenches
Distance & Direction to nearest prop. line: y~
Setback from: well:- 80' House 37 'Other
ELEVATIONS
Building Sewer G ST Inlet. 6, ST outlet 9
PC inlet PC bottom A Pump Off
Header/Manifold 9 7,Y3 Bottom of system r
Existinq Grade app, Final grade ~i
DATE=. Of INSTALLATION -
PLUMBER ON JOB: -
LICENSE NUMBER: 3j
INSPECTOR:
5/93: )L
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM Coun e,~ C'ROIX
+ Labor and Human Relations
Safety and Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
23
Permit Holder's Name: 3479
❑ City ❑ VillageX❑ Town of: State Plan ID No.:
BJELLAND, JOHN
CST BM Elev.: Insp. BM Elev.:, BM Description: Parcel Tax No.:
Sa-,r, J t c A9500177
TANK INFORMATION ELEVATION DAW'.'JO ~
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic
Benchmark
Dosing ~
Aeration Bldg. Sewer /7 2Z f,7 r
Holding St/Y Inlet
TANK SETBACK INFORMATION St/, PA Outlet
TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet
rl
Septic NA Dt Bottom
Dosing NA Header/dom.
Aeration NA Dist. Pipe
Holdi /
,[ag•` Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufa mand 4,,10 e '
Model Number PM
TDH Lift Lricti Srsttem TDH Ft
Forcemain L ngth Dia. Dist. To w
SOIL ABSORPTION SYSTEM
BED/TRENCH Width I Length r No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS J` DIMEN5M
SYSTEM TO P/ L BLDG WELL LAKE / STREAM I 'Manufacturer:
SETBACK
INFORMATION Type Of q~,,Gy~U R CH ER Moe um er:
System: >50 37 ('o > /0 R UNIT
DISTRIBUTION SYSTEM
Header X~~ Distribution Pipe(s) x Hole Size x Hole Spacing I Vent To Air Intake
Length Length 71,f_ Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems y
Depth Over Depth Over xx Depth Of xx S ed / Sodded xx Mulched
B)id'lTrench Center 9Fd /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: St. Joseph.35.30.20W, SE, SE, Lot 1, Highway 35
i
S~.(~ r ! new 1
23
Alan revi ion required? Yes INo _
Use other side for additional information. 1-7
SP-6710(R 05/91) 719 7
DInspector's Signature Cert No
f 5/d -
Safety and Buildings Division
~~■Lr■■7 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 8 112 x 11 inches in size. ~ • Crdl
• 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 reck it revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Num Pr
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION 02-33
Property Owner Name Property Location
E, /4 LC' 1/4, S357 T , N, R E (o W
Property wner's Mailing A ress _ Lot Number Block Number
-76-& rQQQ City, State Zip Code Phone Number Subdivision Name or CSM Number
5L A40L IYIV. 1'426 5' ( )
II. TYPE OF BUILD[ G: (check one) ❑ State Owned ❑ City Nearest Road
❑ Village
E] Public 1 or 2 Family Dwelling - No. of bedrooms Town OF G
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo d -"a 7 -.9-0
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. [X New 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 133 Y-7 9 Date Issued 4 ~ • xr
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11E] Seepage Bed 21 ❑ Mound 30E] Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22E] In-Ground Pressure 42E] Pit Privy
13 ❑ Seepage Pit 43E] Vault Privy
14E] 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
MA Feet / Feet TANK Ca acit Site VII. INFORMATION in gallons Total # of manufacturer's Name Prefab. Con- Steel
Fiber- Plastic Exper.
New Existing Gallons Tanks Concrete strutted glass App.
Tanks Tanks
Septic Tank or Holding Tank DQ 1,9 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIIF. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plum Z, Signature: (No St s) M PRSW No.' Business Phone Number:
L"Ae ScAmr- r ~ ~6GS
Plumber's Address (Street, City, State, Ip Code):
&
IX. C UNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Indudes Groundwater ate issuecli Issuing Age t Si nature (N Sta s)
A roved Surcharge Fee)
pp E] Owner Given Initial
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
581)-6398 (R. 015/94) DISTRIBUTION: original to Counl y, one copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1 . A sanitary permit is valid for two (2) years.
2. Your sanitary permit maybe 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 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 i.f required by-the cou-nty 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.
• 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 8 112 x 11 inches in size.
• 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 eck it revision to previous application
[Privacy Law, s. 15.04 (1) (m)). State Plan I D. um er
(.;APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
+ !
1/4 SLC 1/4,S Tad ,,N,R E(o6-w-.,y
C _*A1 4 NQ _57
Property Owner's Mailing A dress Lot Number Block Number
oo C 0_ I AA
City, State Zip Code Phone Number Subdivision Name or CSM Number
Sr, P-4UL 5-5-/0 _T ( A - S c e/J427 CAE-5
II. TYPE OF BUILDI G: (check one) ❑ State Owned ❑ ut~r Nearest Road
❑ Vel age
❑ Public 1 or 2 Family Dwelling - No. of bedrooms -Town OF 577, GSA s
III. BUILDING USE: (If building type is public, check all that apply) Panel Tax Number(s)
1 ❑ Apartment/ Condo 0-340 -110 a - 96
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. [)g New 2. ❑ Replacement 3. [:],Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
------System System Tank Onlyy_____________ Existing System Existing System
B) A Sanitary Permit was previously issued. Permit N6 mber.2 -43Y7? Date Issued 6.2.2
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 ~j 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
/1 Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
151 / Feet /d Feet TANK Ca aclt
VII. FORMATION in gallons Total # of Manufacturer's Name Prefab. CoSite n- Steel Fiber- Plastic Exper
New ExIsttn Gallons Tanks concrete glass App.
strutted
Tanks Tanks
Septic Tank or-Holding Tank ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage s stem shown on the attached plans.
Plumber's Name: (Print) Plum C Signature: (No Sta s) M PRSW No.' Business Phone Number:
4 03~ 7/ i
Plumber's Address (Street, City, State, ip ode):
1X. C LINTY / DEPARTMENT USE ONLY I
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing Age Ft Si nature (N Stamps)
Surcharge Fee)
Approved ~
E] Owner Given Initial 4~ A-
Adverse Determination r f w
X. CONDITIONS OF APPRO~ 'AL REASONS. FOR DISAPPRPVAL.
SHD-6398(R.015/94} ISAtlauT10N: OriginaftoCounty;.onecopyTo: Safety 8AuildingsDivision,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 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 and specifications not smaller than 8 112 x 11 inches must be submitted to the county. The plans must
include the following; A) plot plan, drawn to scalp 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) 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.
36 /~PP~av~,n co~~-2
D?A/~c! ~ o Roc K ~o ~
/~ECo/yrN'7~lO~a EL, y~ 3Y VAL''
goo ~Qt
,Lev
3
4
4-
C
1317 iop sE LOT
ca S TA /Iris EL . 106" 0
/.86 ACA4ES
8r1
G
U2~9cv/N~ fv2 : b'-.zo- 96 ~aP~4 ~ lay : _
KE4WEU.,) ACIPEY O'la 6:,y c1fE4v r~.
~yo~ S
u~so~ Zvi` - _5-Y,014 ERS, E T 40.
/y~,21'c'v 3xos
SANITARY PERMIT APPLICATION COUNTY
- r~elLlnlln In accord with ILHR 83.05, Wis. Adm. Code S
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than El ~33 1`[7frIvious 8'/ x 11 inches in size. Check if revision to 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
'/4 E t/4, S 35 T 3Q, N, R ;to E (or)
_MW
C A/ PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
0.0,0,0 ACloy
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
SST. S -
Li I
VILLAGE : NEAREST ROAD
II. TYPE OF BUILDING: (Check one) El State Owned ED
. r, - T, -
❑ Public ~ 1 or 2 Fam. Dwelling-# of bedrooms ~ 'PARCEL TAX NUMBER(S)
Ill. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo O
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 80 Mobile Home Park 120 Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ® New 2.E] 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
i
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
600 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals%day/sq. ft.) (Min./inch) p ELEVATION
~ . 7 7,311 Feet 0. Feet
VII. TANK CAPACITY Prefab. Site Fiber- Exper.
in allons Total # of Manufacturer's Name Con- Steel Plastic
INFORMATION New istin Gallons Tanks Concrete glass App.
Tanks Tanks structed
Septic Tank or Holdin Tank
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.
Plumber's Name (Print): PI is Signature: (No Sta s) M PRSW No.. Business Phone Number:
0_0& 7o ;egLm. e.;:;, 1 %Z
~j Q6_') - ~M-6451
Plumber's Address (Street, City, State, Zip Co e):
S ,
IX. COUNTY/DEPA MENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includeg roue water a e issue ing Agent Si nature (No Stamps)
A
A pproved ❑ Owner Given Initial 0 % ~S
Adverse Determination V
61 VV-
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:
x. I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
Il. 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% 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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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3_
L:.'`aoraRd 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 St. Croix
not limited to vertical and horizontal reference point e i % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and dist Ntt 030-2067-90
APPLICANT INFORMATION-PLEASE kv, AL INF RM REVIEWED BY DATE
PROPERTY OWNER: OPERTY LOCATION
John & Barbara B ' elland ° VT. LOT SE 1/4SE 1/4,S 35 T 3C ,N,R 20 N(or) W
PROPERTY OWNER':S MA!i_ING ADDRESS T # BLOCK # SUBD. NAME OR CSM #
756 Goodrich Ave. 4 `pa Riverview Acres
CITY, STATE ZIP C00 ,,PHONE NU CITY []VILLAGE EFOWN NEAREST ROAD
St. Paul, MN. 55105 Stjbj Z 2R4 95 : St. Joseph St. Hy. #35
[xJ New Construction Use Residential / Num s4 [ )Addition to existing building
( ( Replacement ( Public or commercial describe
Code derived daily now 600 gpd Recommended design loading rate .7 bed, gpd/ft2 .8 trench, gpd/ft2
Absorption area required 858 bed, ft2 750 trench, ft2 Maximum design loading rate . 7 bed, gpd/ft2 .8 trench, gpd/ft2
Recommended infiltration surface elevation(s) 97.34 ft (as referred to site plan benchmark)
Additional design / site considerations na
Parent material river terrace Flood plain elevation, if applicable na ft
S = Suitable for system I CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable for svstem IMS 1:1 U 193S ❑ U I taS ❑ U I ig S ❑ U I ❑ S fR U ❑ S )e U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft _
in. Munsell Qu. Sz. Cont Color ( Gr. Sz. Sh. I Bed (Trench
>....1...... 1 0-10 10 r 3/3 none 1 2msbk mfr gw 2f .5 .6
2 10-30 10yr 3/4 none cos Osg ml gw na .7 .8
Ground 3 30-80 10 r 3/4 none cos Osg ml na na .7 .8
elev.
ion-
Depth to
limiting
factor
+80,
Remarks:
Boring #
1 0-10 10yr 3/3 none 1 2msbk mfr gw 2f .5 .6
2 10-8 10 r 4/4 none cos Os ml na na .7.8
Ground
elev. 9
Depth to
limiting j
factor
+80" j
Remarks:
CST Name:-Please Print Gary L. Steel Phone. 715-246-6200
Address: 1554 20 h Ave., Ne. Richmond, Wi. 54017
Signature: Date: CST Number:
4-25-95 cstm 02298
PROPERTYOWNER J. & B. Bjelland SOIL DESCRIPTION REPORT Page,- -of_ 3
PARCEL I.D.930-2067-90
Boring # Horizon Depth DominantColor Mottles (Texture ( Structure Consistence Bounb3y (Roots GPD%ft
in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. Bed iTrerxh
1 0-8 10 r 3/3 none 1 2;nsbk mfr gw 2f .5; .6
3
- 2 8-33 10yr 3/6 none is ~lscoat mvfr gw if .51 .6
Ground 3 3-80 10 r 4/4 none cos Osg ml na na .71 .8
elev.
100.841.
Depth to
limiting
factor
+80"
Remarks:
Boring #
1 k-10 10 r 3/3 none 1 2msbk mfr w 2f .5 .6
Osg w
4 2 10-31 10yr 3/6 none is cl coat-"-- mvfr w na .5 .6
3 31-80 10yr 4/4 none cos Os ml na na.7 .8
Ground
elev.
100.9t.
Depth to
limiting
factor
+80" T-1
Remarks:
Boring #
1 0-7 10 r 3/3 none 1 2fpl mfr w 2f .2 .3
Osg w/
52 7-42 10 r 2/2 none is cl coat mvfr w na .7 .8
:::Y:4v~<:;::i:::::
3 42-84 10yr 4/4 none cos Osg ml na na.7 .8
Ground
elev.
100.7t.
I
Depth to
limiting
factor
+84"
Remarks:
Boring #
Ground
elev.
ft. i
Depth to
limiting {
factor i
Remarks:
SBD-8330(R.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel John & Barbara Bj elland 1554 200th Ave.
CSTM2298 SE4 SE4 S35-T30N-R20w New Richmond, WI 54017
MPRSW 3254 town of St. Joseph (715) 246-6200
t 174 Riverview Acres
N
1"=40'
BM.= top of se lot stake at el. 100'
0
-5
77, Z3
1 ze
c
XGa L . Steel
-25-95
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER(1 ffac4 j 1~LfE ~.i L L L /fr iii 1~
MAILING ADDRESS n ' .5 I G S
PROPERTY ADDRESS y- HL/,&So r1 W, SLR X40I
(location of septic system) Please obtain rom the Planni g Dept.
CITY/STATE
PROPERTY LOCATION 1/4, 1/4, Section T 3L _NCR , W
TOWN OF J c c,) ~1 ST. CROIX COUNTY, WI
SUBDIVISION t t1 6' N iL F\ C y'f-S 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 maintains u "l be co pleted and returned to the St. Croix
County Zoning Officer within 30 days of the three year k"biration ate.
,e
SIGNED:
DATE:
j~
l
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 b owner/contractor, (s
y pec
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 ~I" ~ V) u n c fS ark u ra ~ i F / 16 h C~
Location of property 1/4 1/4, Section 3,-,7 _,T_,3C) N-(RHO _W
Township SeTy~ Mailing address JjL- Y'i C° A Uf'.
US
Address of site _ 7y 4`1 &c"vc%itu- Arr,s. MiGld6%n ff S(". -,fC)/
Subdivision name ki re ~ Lot no. ~
Other homes on property? Yes_~(-_No (6 a ra y e
Previous owner of property ~Dc t) 1-'s Sc, 1) Li l s t1.3 c~
Total size of property d'11
Total size of parcel oZ • 9 /
Date parcel was created _ / q a' N
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? _ Yes No.Sa £
Volume I( y5 and Page Number 5_1 as recorded with the Register 447-1%h3
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. S ~1 '5-6 ~ , 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 o ice of the Cou egister of Deeds as Document No.
i
(_Xv, / 72 X"(/ -e Ila-
Sig ature of p 1' ant Co-Applicant
%SJ
Date o Si nature D to of ignature
'j ~ vo~ltly~racE~1~
DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
ISTATE BAR OF WISCONSIN FORM 2-1982 521506 : ; T-- a `s C1N:7FK; ,
it
ST. CROIX CO., WI ~ j
Reed fbr f:emrd
Dennis__W,..5chulsta....and..Pamela......Schulstad,-_--_-__-•-----__-- SEP 1994
husband and wifet
8:30 A.
_U' .
conveys and warrants to d Register of DeSa
Barbara- -A...B.3a11and-,_.husband-and.waif-e................................
as:.sur. i.rorship..maxi-tal-_propar.ty...........................................
.
RETURN TO
II
the following described real estate in St. Croix County,
of Wisconsin: ~
Tax Parcel No:
See attached description.
Ii
I
i
I
I
I
i
, 1882
Description for Dennis Schulstad February 11,
A parcel of land located in the SE 1/4 of Section 35, 30 N, B 20 ,
To', n of St. do:~eph, t. Croix County, ',Iiscon,-Jn, further described as
f011c s:
Commencing at the SE corner of said Section 35; thence I"I 510-041-30"
( true bearing ) 1667.08 feet to the point of beginning of this description:
thence N 850-38'-40" L, 265.20 feet; thence IT 1710-231-20" 140.00 feet
along the i esterly line of a proposed To,.,,-,n road; thence 14 3111-041-40"
y,
61.74 feet along said z:,esterly R/ti line; thence S 66°-38'-34" 4:, 194.50
feet; thence S 480-391-40" 16, 200.00 feet to the point of beginning.
Above described parcel contains 213 of an acre and is to be sold to an
adjoining owner.
Allen 0. Igyhagen B.L.S. 1407
S & N Land Surveying
108 Walnut St.
Hudson, Wi.
44V
• S a N LAND SURVEYING*
HUDSON , WISCONSIN 54016
(715) 386-2007
Name DENNIS SCHULSTAD
Address 4009 E. 49 STREET
MINNEAPOLIS, MINN. 55417
Description (SEE ATTACHED SHEET)
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265. 20
N 850 38' 40" E
1667.08'
N '.51004'30 W
COUNTY MONUMENT
*SOUTHEAST CORNER
State of Wisconsin SECTION 35, T30N, R20W
O IRON STAKES DRIVEN
County of ST. caotx ) as. SCALE OF MAP - I INCH _ So Feet 0 IRON STAKES FOUND
It AIIEN C. NYNASEN , registered Wisconsin Land Surveyor,do hereby certify that
on APRIL 9 19 62 , 1 surveyed the above described and mapped property according to
the official records and that the accompanying map is a correctly dimensioned representation to scale of the boundaries,that
all buildings and improvements lie wholly within the bound<q>lie4;,,,and that no encroachments by adjoining owners appear
4:~
from said survey.
rr ' J yJ e~l~'o
Map No. 92 -02 ~r. 'P.CE. FI ~
C-1. E
Drawn By - Barry Palmer
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