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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
rADDRESS 7
SUBDIVISION CSM
LOT
SECTION_ /b T__,70 N_R_'Z~ W, Town of
an
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i
l 5`D sc~~l
I /
,s
SS
00
INDICATE P ORTH ARROh'
Provide setback and elevation information on reverse of th s form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK'
ALTERNATE BM'
SEPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer' - Liquid Capacity:
Setback from: Well-. House other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: y/,2 Length Number of trenches
Distance & Direction to nearest prop. line:„ /j~--
Setback from: well:,/~L House= Other
I
ELEVATIONS
Building Sewer ST Inlet:/~ S ST outlet =
i
PC inlet PC bottom Pump Off
Header/Manifold 2,: a9 Bottom of system p
Existing-Grade Final grade
DATE OF INSTALLATION: - -
PLUMBER ON JOB: a
LICENSE NUMBER: INSPECTOR: ~j
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor.and Human Relations
Safety and Buittlings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
233403
PeRMYOWKR
INa ❑ Cit ❑ Village Town of: State Plan ID No.:
SYomerset
CST BM Elev.: / Insp. BM Elev.: 7BM'Description: Parcel Tax N
TANK INFORMATION ELEVATION DATA 5 S
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic (L)W_5 Benchmark O.w /Ov, 0
Dosing '
Aeration Bldg. Sewer -
H St//Hl` Inlet
g
TANK SETBACK INFORMATION St/H,(Outlet Vent TANK TO P / L WELL BLDG. Air Ito ntake ROAD Dt Inlet
Septic NA Dt Bottom
Dosing Header+ 7 0 9,3 Q9
Aeration ___N A ~ Dist. Pipe -7,7J' ~V-96
ding Bot. System 'K/
PUMP/ SIPHON INFORMATION Final Grade
Manuffiij: urer Demand 3 G/ 9Z OZ'
Model Number i:EP,M E~~ c9 j. O$ /D. 5l~
! TDH Lift Lriction system - TD7H Ft
Forc in Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length ✓ No. Of Trenches PIT No. Of Pits Inside Dia. Li h
DIMENSIONS DIWENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING M cturer:
SETBACK
INFORMATION -Type O ~7c~ r CHA Model
System: OR UNIT
DISTRIBUTION SYSTEM
Header / Distribution Pipe(s)/ x Hole Size x Hole Spaci Vent To Air Intake
Length Dia. Length 2: Dia. Spacing Ce
SOIL COVER x Pressure Systems Only xx Mound Or At-Grad stems Only
Depth Over Depth Over o xx Depth Of xx Seeded / Sodded xx Mulched
Bed/ Trench Center 3 - Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) -S
LOCATION: Somerset. 10.30.19W,~NE, NE, 170th Ay
v
Plan revision required? ❑ Yes 9-60, /
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
i
SANITARY PERMIT APPLICATION
' In accord with ILHR 83.05, Wis. Adm. Code couNTY
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ r~ mod
8% x 11 inches in size. check if revision to pre ous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPE TY OWNER PROPERTY LOCATION
% X '/4, S T__?,o , N, R /gr (or
PROPERTY OWNER'S MAIL N DDRESS LOT # BLOCK #
CI STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
0 CITY
VILLAGE : NEAREST ROB
1(,71-5- II. TYPE OF BUILDING: (Check one) El State Owned E3
❑ Public ® 1 or 2 Fam. Dwelling- # of bedrooms `S PARCEL TAX NUMBER(S)
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
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. 0 Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 51-1 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 El Mound 30 El Specify Type 41 El 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./i ch) ELEVATION
Feet Feet
5!~11 9e 15) 1
VII. TANK CAPACITY Site
in allons Total of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank o
Lift Pump Tank/Si hon Chamber E] 1 0 E]
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installati of the onsite sewage system shown on the attached plans.
Plumbe s Name (Print): Plumber Si at Nd ps) MP/MPRSW No.: Business Phone Number:
,
07 l -9
1 20
72 5 -
lumbers Address (Street, City, State, Zip ode): JJZ
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitalao ermit Fee (Includes Groundwater ate Issued I Issuing Agent Signature (No Stapal
rO Approved ❑ Owner Given Initial Surcharge Fee)/~~
TTj Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
i
INSTRUCTIONS ,
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit maybe 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/Renewah 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 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)
` 47
acs"'
~/EQ
~f B/ti
G/ ~yO
a
aa'
,t36 ~ `/as.~ i
ti1f~~
r
PAGE OF
CrUSS Sec~Iun p~ 1~1 ~e0 SySTe~
~ A
(~15/~li RCr Fresh Air Inlels And Observation Pipe
1 Approved Vent Cop
Minimum 12" Above
Final Grode
20- 42" Above Pipe _ 4" Cast Iron
To Final Grod• Vent Pipe
Marsh Hay Or SyntMlk Covering
i win. 2" Aggregate
Over Pipe
Olstribullon
Pipe 0 0 0 0 0 - Too
6" Aggregate a Perforated Pipe Below
Beneath Pipe
o -Coupling Terminating At
Bottom Of System
PruPose~ ~tnk~ qre ccVc
"LieJeJ ton
SOIL FILL
D1STRIBUTIOU PIPE
APPROVED S~ItlTMETIC COVER
2" OF l►6Cry. R F0.AT6. a e OR MAR'SN mk`j OF STRAW
0 8
e (o OF 12-Zi~2 AGGREGATE ~f .
MEV. OF22 Z FEET
i
DI-S-rRItj+JTIOW PIPE TO BE AT LEAST -:;z;_ INCHES BELOW ORIGIMAL GRADE
AQU AT LEAST20 WCHES BUT AIO MORE THAM 42 MICHES BELOW FINAL GRADE.
/'MAXIMUM ®EQTH OF EXERVAT100 FROM 0KI& NAL 6KADE WILL BE - - IAICHEs
MINIMUM ®EPm OF EACAVATIOW FROM. OlikI(,INAL GRAPE WILL BE INCHES
SIGMED:
LIC-OUSE UUMBE"R: -
DAT E :
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page --L of
Labdr 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
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.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPE OWNER: PROPERTY LOCATION
GOVT. LOT - 1/4 114,S T N,R Z~Z Z(or&
PROPERTY OWNER':S MAI~(IV ADDRESS LOT~f BLOCK# SUBD. N ME OR CSM #
v 1
CITY STATE 1 ZIP CODE PHONE NUMBER ❑ ITY ❑VILLAGE OWN NEAREST ROAD
[ ] New Construction Usej~4 Residential/ Number of bedrooms J? [ J Addition to existing building
LA Replacement [ ] Public or commercial describe
Code derived daily flow er gpd Recommended design loading rate bed, gpd/ft2 j~_trench, gpd/ft2
Absorption area required ,9,n0 bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2_,~trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material IG 4-2/ 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 E] U MS ❑ U ®S ❑ U [US ❑ U ❑ S 0, ❑ S ICU
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. Bed Trench
Ground _
elev.
ft. _
Depth to
limiting
fact
Remarks:
Boring #
'EM
Ground
elev.
ft.
Depth to
limiting
fact
~L
Remarks:
CST Name. Please Print Phone:
Address:
Signature: Date: CST Number:
PROPEUYOWNER ~~fi cx rYA) SOIL DESCRIPTION REPORT Page,-.Z oi
PARCEL I.D. #
Depth Dominant Color Mottles Texture Structure Consistence Bounday Roots GPD/ft
Boring # Horizon in. Munsell Ou. Sz. Co t. Color Gr. Sz. Sh. Bed Twich
p, mu
04 JY14"
el) 2,ev-
4
Ground
elev.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
zv,- iy~'`~) x .U~y sic /1~, r~o~l,~i~4J
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNERIBUYER
MAILING ADDRESS
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION -,~LC_ 114,11/C 1/4, Section Z,,~)T __Z4::) N-R-)-~?_W
'SOWN OF s~F,esF 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.
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: ECG, G2~~
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
Location of property AIZ _1/4AIZ 1/4, Section T_N-RW
Township Mailing address l ?
Address of site ry„o~H~
Subdivision name Lot no.
other homes on property? Yes__,* No
Previous owner of property
Total size of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for or (spec house) ? _ Yes --No
I
Volume///f and Page Number 7% a,-, 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 decd 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.
S.iynature of Applicant Co Applicant
Date of Signature Date of Signature
(YTATa OF WISCONSIN) F1 1104d by "a C111n a.a 1ud'1.g1 C.` -96 No, S-P, Pl.rrlnty DN4-9hvrt Forty. Soe. 236.31. W St•ty
Fors Na f
'VOA"111~~a~F27~
~{{,,jB ~ri~YttfltXpr Made by tntma Belisle and Edmond Belisle, her
+t husbands
County, Wisconsin, hereby conveys
of St. Croix Bockrzan, his wife, as
grantors
and warrants to John H. Bookman and Norma A.
point tenants,
St Croix County, Wisconsin, for re
grantees ,of Bother valuable consideration receipt of which.is
the- gt Croix County, State of Wisconsin:
e
the sum of l
the following ac o an In
Northeast Quarter of the
(30), North of
Commencing at the Northwest corie0~ °Township Thirty
ter Section Ten ( ,
Rarge Ninet North line o said
said
Northeast Quar (19) West thence East on the
line of said
'
I en
h parallel with the West h Forty 560 feeet, thence Soul
Forty 364 feet, thence West Parallel with the Northto place of of said , thence Forty to the Y!
beginning.
This is to include the well locate~Sotheretobove described Forty
with the right of ingress and eg e
Grantors agree to pay all of the 1953 Taxes on the real estate
hereby conveyed.
i ~
I
head s and seals this ~
yn alttntoo MILCUOtt the said grantor x ha ire hereunto set the it
71CK _ day of ,day r~~~'r''~ ✓ ___._---!Seal)
Signed and Sealed in Presence of Emma Belisle'*
1 / ems)
- Edmond Belisle
w-Ifi-------'."_
I
Henr C ke
Ivah L. Krause
state of tatoconoin, ss. I
County.
btay , A. D., 19 53 .
~
Personally came before me, this 7~ day of
Emma Belisle and Edmond Belisle her husban ,
the above named
nt and acknow/ed ed the same.
to me known to be the person s who executed the foregoing inst
Henry C. Oa key
_ County, Wis.
Notary Public,
o• D„
19:rS`
My commission expires L
y.r.w•uw a..sd-u~-s*a.urw
I ~-C14;9-WIf. 4k.1~ KMW~Y.R ~D'M•••'~'
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