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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER _aC d. / j / 0 f !
ADDRESS
SUBDIVISION / CSM LOT
SECTION_ 2 T,3, 1 " N-R W Town of r.
~s-ST. CROIX COUNTY, WISCONSIN
PLAN VIER
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
CA La l"= %0
/000
I
I boa
I ~ ~,-5x7S'
s I ~
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: S'f1J Gd STAKE ~L. /d4~D
ALTERNATE BM: 7dp f~ecfSL3 ~octitr~q,~o~ ~,2 ;t, 7
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: 111E rs Liquid Capacity: /0400
Setback from: Well ,!5'4f House. 2,0 ` Other
u turer Model# Size
Float seperation
A cation
SOIL ABSORPTION SYSTEM
Width: Length 7,51- Number of trenches
Distance & Direction to nearest prop. line:_ JV45r j 70 r
Setback from: well: House Other
ELEVATIONS
Building Sewer ST Inlet. 1,10,12_ ST outlet 119.
9
PC inlet PC bottom Pump Off /V,4
Header/Manifold 117,.3f Bottom of system_ //L,z~
Existing Grade Final grade
DATE OF INSTALLATION: - y' 9 S
PLUMBER ON JOB: - °
LICENSE NUMBER: fI/~RS'C!J
INSPECTOR:
3/93:jt
Wiscdnsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor 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 of: State PI .
WIEDERIN, RICHARD X
CST BM Elev.: Insp. BM Elev.:? BM Description: Parcel Tax No.:
/1~111/), 66 /Gtr. e 6a-e-r- p
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic e dw Benchmark'
Dosing ~I , .67
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic 7670 ,u7 NA Dt Bottom
Dosing NA Header- //,7
Aeratierr NA Dist. Pipe 7 //7, 13
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Num
TDH Lift Loss ea DH Ft
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width / Length No. Of renches No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMEN 1
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEAQU NG Ma
SETBACK
INFORMATION TypeO /e )'0,,;r' , i , ER Mo
System:- OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) ze x Hole Spacin Intake
Length _Zf Dia. u Length %a Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Gra ystems Only J
Depth Over Depth Over xx Depth Of xx Seeded / Sodded xx Mulched
Btd '/Trench Center Bed7Trench Edges - a Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Somerset.23.31.19W, SE, NE, Lot 4, Highway 35
t3~`P ~ ✓l ~~rd~ t '2 `~ct~' C c t_.i! (It!7~
Plan revision required? ❑ Yes (f' ITO
Use other side for additional information. s.._
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
F
i
I
i
it
SANITARY PERMIT APPLICATION
r~•~L■'■~7
In accord with ILHR 83.05, Wis. Adm. Code CON
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than a3~
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
%4 a/4, S T 31 , N, R Q E (or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
,30q U)Iu6cy ST' y A
R CSM NUMBER
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME,
O 7ek5er i 1(7/6-)2V7-3&2 3
II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
❑ State Owned VILLAGE L?/p S h4v 3 S
❑ Public ~9 1 or 2 Fam. Dwelling- # of bedrooms 3 PA CELTAX NUMBER(5)
111. BUILDING USE: (If building type is public, check all that apply) O _ O
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. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
(J a e ~o ~j G• s //9s7
Feet Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank 71 F-M
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): Plum s Signature: (No Stamps) /MP W Business Phone Number:
` s -64s/
Aft V/Af
00 SQ,#171rr_ 12 715- ) Plumber's Address (Street, City, State, Zip Cod b):
S ~So - - `
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Age Si ture (No mps
.
Approved ❑ Owner Given Initial f~D Surcharge Fee) s ?
Adverse Determination v J(
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:
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.
Vlll. 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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Labor arse! Human Relations
Division of Safety 8 Buildings in accord with ILHR 83.05~9
,Air~"~
COUNTY
Attach complete site plan on paper not less than 81/2 x 11 inches in si ~I musud , but. St. Croix
not limited to vertical and horizontal reference point (BM), direction an slopy"' . ARCEL I.D. # pending
dimensioned, north arrow, and location and distance to nearest road.
TVIEWED BY DATE
APPLICANT INFORMATION-PLEASE PRINT ALL INFORM N'
PROPERTY OWNER: to PROP , TION
Richard Wiederin 0t/ 1/4,S 23 T 31 N,R 19 x (or) W
PROPERTY OWNERS MA!I_ING ADDRESS NAME OR CSM #
2159 60th. St. I a;4, ending
CITY, STATE ZIP CODE PHONE NUMBER []C GE MOWN NEAREST ROAD
Somerset, WI. 54025 (715)247-3062 Somerset St. HY. #35
[ New Construction Use[x] Residential /Number of bedrooms 3 [ J Addition to existing building
r ]Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate 5 bed, gpd/0 - 6 trench, gpdm2
Absorption area required 900 bed, 112 750 trench, ft2 Maximum design loading rate • 5 bed, gpdift2 - 6 trench, gpd/ft2
Recommended infiltration surface elevation(s) 115.55 ft (as referred to site plan benchmark)
Additional design/ site considerations for trenches 116.25 and following 3.5' below surface level
Parent material outwash Flood plain elevation, if applicable na It
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem S❑ U 43 S ❑ U as O U -10 S 01.1 ❑ S IOU ❑ S Is U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistenm Bmrr&y Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. -BW-ff rertdt
1 0-10 7.5yr3/4 none is Osg mvfr gw if .7 .8
2 10-21 7.5yr4/6 none is Osg mvfr 9w if .7 .8
Ground 3 21-58 7.5yr5/4 none f s Osg m vfr 9w na .5 .6
elev. 4 58-90 7.5yr4/6 none 1 fs Osg mvfr na na .5 .6
119.75 ft.
Depth to
limiting
factor
+90"
Remarks:
Boring #
1 0-13 7.5yr3/4 none 1 fs lmsbk mvfr gw if .5 .6
2 2 13-32 7.5yr4/6 none f s lmsbk mvfr gw if .5 .6
3 32-90 7.5yr5/4 none s Osg mvfr na na .7 .8
Ground
elev.
119.7l$
Depth to
limiting
factor
+90"
Remarks:
CST Name _Please Print Gary L. Steel Phone: 715-246-6200
Address: 1554 0th. Ave., New ichmond, 54017
Signature: Date: CST Number:
3-31-95 cstm 02298
PROPERTY OWNER Richard Wiederin SOIL DESCRIPTION REPORT Page 2 .of 3
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles I Texture Structure Consistence Bandary I Roots GPD/ft
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed ffrendi
v 3 j< 1 -10 7.5yr3/4 none 1s lmsbk mvfr gw if .5 j .6
a<:< 2 10-24 7.5yr4/6 none 1s lmsbk mvfr gw if .5 1 .6
Ground 3 24-84 7.5yr5/4 none f s Osg mvfr na na .5 i .6
elev. i
118.0f
Depth to
limiting
factor
+84"
Remarks:
Boring #
1 --10 7.5yr3/4 none is lmsbk mvfr gw if .5 .6
K'
4 2 0-16 7.5 r4 6 none is lmsbk mvfr if .5 .6
3 6-38 7.5yr4/6 none s Osg mvfr gw na .7 .8 i
Ground
11leV. 4 8-50 7.5yr4/4 none f s Osg mvfr gw na .5 .6
5 50-78 7.5yr4/6 none f s Osg mvfr na na .5 .6
Depth to
limiting
factor
+78"
Remarks:
Boring #
1 0-12 7.5yr3/4 none is lmsbk mvfr gw if .5 f.6
5' 2 12-34 7.5yr4/6 none is lmabk mvfr gw if .5 j.6
;aM;:z>>
3 34-76 7.5yr4/6 none f s Osg mvfr na na .5 .6
Ground
elev.
116.05
Deoth to
limiting
factor
+761,
Remarks:
Boring #
"
MEW"
X-X
Ground
elev. j
ft.
i
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel Richard Wiederin 1554 200th Ave.
CSTM2298 SE 4NE a S23-T31N-R19W New Richmond, WI 54017
MPRSW 3254 town of Somerset (715) 246-6200
t lot
N
1"=40'
BM.= top of SW lot stake at el. 100'
a ~ /~es2G S
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S M 812,1 -413
Gary L. Steel
3-31-95
s ~
FILED
APR 2 0 1995 ► 9
9 KATHLEEN H. WALSH
RegisterofDeeds >0
52`791+ SL Croix Co., WI
!f.
This instrument drafted by Ed Flanum Job No. 9;95 S01~04132"W
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VOL. 10 PAGE 2908
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER jej C N-4)20 1 ~~c L V)
G S7- SUr~ s I U
MAILING ADDRESS 30q
(-a F/ I 15F
PROPERTY ADDRES S u S
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE D/ es E 7-
PROPERTY LOCATION sb ~ 1/4,DF NCI 1/4, Sccti(.4r ,?3 T31N N-R Iq W
TOWN OF _ solvl '!~es ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBF,R _
CERTIFIED SURVEY MAP Sa~9 , VOLUME" 100, PAGE a l( , LOT NUMI3ER~
Improper use and maintenance of your septic system could result in its premature failure to handle
wastes. Proper maintenance consists of pumr~ng out the septic tank every t-.ree years or sooner, if needed
by licensed septic tank pumper. What you put into the systen; 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 1-,,rant for a maximum of 60% of the cost
of replacement of a failing system, which was in operatior. ,nor o July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirem ;n' 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 ma*_er plumber, journeyman plumber, restricted rlu':;; - or a l,censcd r'umnper ver!f<y'rng 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 requiremews ~.nd 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 mus tie completed and returned to the St. Croix
willii„ 411 'd III, Iluc.
SIGNED: -
DATr:
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 raiC°; c°pe rt y
Locati n of property 1/4 nC 1/4, Secti,:)n 3 T N-RW
Township ~OMEiZS£T -Mailing address 3 DLL 16 1.j
ST
Sam o
Address of site 7 _
Subdivision name (2,-')n4,. /v O~ Lot no. L
other homes on property? Yes No
Previous owner of property _11/11S LA4,1
Total gize, df property Ae e, f
1
Total o of parcel
Date parcel was created d-
,i -
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes ✓ No
Volume' and Page Number_ as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING-.-----
A WA TI NTY, DEED which includes a DOCUMEN` F 'TMBER, VOLUME AND PAGE
NUMBER" D THE SEAL OF THE REGISTER OF EEDS. In addition, a
certified ' survey, if available, would bf- helpful so as. to avoid
410- I nyra+ or t 11- r ",v i -w i nt1 i-!- i ls"" tlr,~•~i f7"r.(•r. i ph i o ll
references to a certified survey map, I-Ile Cert:i.tied survey Map
shall "'als be required.
PROPERTY OWNER CERTIFICATION
I (we), certify that all statements on this farm are true to the
best of 'ty (our) knowledge that I (we) am (are) the owner (s) of the
property described in this information form, by virtue of a
warna.. ty deed recorded in the office of "f7he County Register of
Deeds. as Document No. 9 9Q to , ari,d that I (we) presently
own the proposed site-for ta sewage disposal system or I (we)
obtaifted 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.
aignaturel of Applicant Co-App:L_~_cant
"As- qs
Date of Signature Date of Signature
State Bar of Wisconsin Form 2 - 1982
W Y REGISTER`
S OFFICE
EII IE,
fq ST. CROIX Co., WI
tl Redd for Reconi
DOCUMENT NO.
APR 2 7 1995
at 11:30 Are
Dennis M. Neumann and Dawn. ~~lman
n} -
husband and wife,
conveys and warrants to Richard R. Wiederin and_Lisa_A~__ 'I
Wiederin, husband and_.wife,
THIS SPACE RESERVED FOR RECORDING DATA
ilk NAME AND RETURN ADDRESS
tom- i Chards -1 a i edf r i
wi ~to.>J strtet-
jj the following described real estate in St. Croix 30y
I'
County, State of Wisconsin: J~UYYIe(Se.} , W= 5 10 D,5
j
(Parcel Identification Number)
li II
I it
Part of SE1/4 of NE1/4 of Section 23-31-19 described as follows:
Lot 4 of Certified Survey Map filed April 20, 1995, in Vol. "10", Page 2908.
TOGETHER with an access easement described and recorded in Vol. 1118, Page 216.
. -J.. 4
This 1S not
homestead property.
(is not)
Ij Exception to warranties: Easements, restrictions and rights-of-way of record,
if any.
Dated this day of April 19 95,
~j
(SEAL) -1ZJ4 c<~ (e~'GQt,t.r (SEAL)
Dennis M. Neumann ,
(SEAL) LLL~ I~c~~~~ ~SEAL)
Dawn J. Neumann
*
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) _ Dennis M. Neumann, STATE OF WISCONSIN
- ss.
Dawn J. Neumann
lj _CZ_Gr01 _ County.
authenticated this day of April 19 95 Personally came before me this a day of
jj
/4 erCL 1915 the above named
* Kristina Ogland
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by §706.06, Wis. Stats.) to me known to be the person S who executed the
foregoing ins ment and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
AQ~p ~r/
Kris tins Ogland ate, r
* Gwv a v~ ea~
Attorne at Law Wis.
Count
; )e County
_no
Notar
(Signatures may be authenticated or acknowledged. Both are not i n is permanent. (If not, state expiration date:
necessary.) 19
li
I~
*Names of persons signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc.
FORM No. 2 - 1982 Milwaukee, Wis.