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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER d r`
ADDRESS
SUBDIVISION / CSM#.../D~J~fB`i r GCSS. LOT #
SECTIONT N-R W, Town of
ST. CROIX COUNTY, WISC NSIN
L-
PLAN VIEW
SHOW EVER THING WITHIN 100 FEET OF SYSTEM
i
I it r
Z/.3r
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:e d L plc i /~o~
ALTERNATE BM:
SEPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: /(jam Liquid Capacity: A
Setback from: Well 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: 3
1/D
Setback from: well:_ ~ House,; Other
ELEVATIONS
Building Sewer ST Inlet . t~ 00~_ ST outlet y~ s-
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system -9
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wicronin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Didision
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village Q Town of: State PI o..
BERG, WAYNE g
CST BM Elev.: Insp. BM Elev.: BM Description: star Prairie Parcel Tax No.:
P r oy
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer g, (7
Holding St/Ht Inlet y5~ 9S, yY
TANK SETBACK INFORMATION St/ Ht Outlet RS, 03
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header / Man. 9, Ycf '
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
I Loss Friction System TDH Ft
TDH Lift
Forcemain Length Dia. If Dist.Towell
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION TypeO UNIT Moe Number:
System: OR
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over ll Depth Over 1~ 1 I xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Star Prairie.12.31.18W, SW, SE, Lot 3, 135th Street
7 /d~-0j
_I L,
f~ C5 f, Iq- S g. 7
Plan revision required? ❑ Yes ❑ No
L. .
Use other side for additional information. Fc/,~ kQx r
SBD-6710 (R 05/91) Date ` In `pettor's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
I
Safety and Buildings Division
"SANITARY PERMIT APPLICATION Bureau Building Water System
~r.■ ■ ■e~ 201 E-Washington Ave.
V'■■..■'■■'~
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 FrEj ty
than 8 112 x 11 inches in size. Sanitary Permit tuber
• See reverse side for instructions for completing this application 7 'J',
iv n to pre~~v1~QS application
The information you provide maybe used by other government agency programs tate Plan I.D. Number
[Privacy Law, s. 15.04 (1) (m)].
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATpleONocation 'YO E ( r)
Property Owner N me $7411 /4 S{ 1/4, S T 3 r N,
4l- ~ r Block Number
Lot Number
Property Owner's Maili g ddres
Phone Number S division Name or CSM Number Z47 - ~J l-" -I
Cit , ;State „ Zip Code
❑ City D Nearest Road
II. TYPE OF BUILDIN : (check one) ❑ State Owned ❑ villager e f~fo
Public TRI or 2 Family Dwelling - No. of bedrooms own OF
~ ~
I11. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo
2 E] Assembly Hall 6 E] Medical Facility/ Nursing Home 10 El Outdoor Recreational Facility 3 E] Campground 7 E] Merchandise: Sales/ Repairs 110 Restaurant/
Bar/ Dining
4 Mobile Home Park 12 E] Service Station / Car Wash
E] Church /School 8 ❑
5 El Hotel /Motel 9 E] Office/ Factory 13 E] Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) Repair of an
System New 2, E] Replacement 3_ E] Repl Tank Only acement of 4_ El Reconnection of 5.
A) 1. Existing System _____ExistingSystem
_
Date Issued
B) ❑ A Sanitary Permit was previously issued. Permit Number
V. TYPE OF SYSTEM: (Check only one) Other
Non-Pressurized Distribution Pressurized Distribution Experimental
❑
11 Seepage Bed 21 E] Mound 30 E] Specify Type 41 Holding Tank
22 In-Ground Pressure 42 ❑ Pit Privy
1 ❑ eepage Trench ❑ 43 E] Vault Privy
13 E] Seepage Pit
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. . Final Grade
Required (sq. ft.) Proposed (s q. ft.) (Gals/da /sq_ ft.) (Min./inch) Feet Elevation
Feet
4f 7 6~1 "?C-4:2 VII. TANK Capacity Prefab. Site Fiber Plastic Exper.
in gallons Total # of Manufacturer's Name Concrete Con- Steel glass App-
INFORMATION New Existin Gallons Tanks strutted
Tanks Tanks ~jf c ❑ ❑ El 11 1:1
Septic Tank or Holding Tank Oda / v`~ ❑ ❑ ❑ ❑ ❑ ❑
L.lfit Pump Tank /Siphon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
MP/MPRSW No.: Business Phone Number:
Plumb , Name: (Print) Plumber' ignature: (No Stamps)
Plum is Address (Street, City, State, Zip Code):
IX. COUNTY/ DEPARTMENT U5E ONLY
❑ Disapproved Sa itary Permit Fee (Includes Groundwater ate Issue Issuing Agent Signature (No Stamps)
Surcharge Fee)
Approved ❑ Owner Given Initial •{f/
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
NNW
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 tota, gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Cer,iplete 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 wi Lh 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.
e ~Sa ~J~a ] -and spk {,'I i of smaller than 8 1/1 X 1 1 inches rn s -u k; its
e L: .nty- The plans must
iU'oIIovvir 7 PV j),3 i lfalNn iG scale or with complete loc.: io . ding tank(s), se t i c
tea i. lull ,Ing Se Wt'rs, JVeI~;, 11rai elt;
o c kes, auMp or siphon
n l oX `_t>1I r i,Un systems; reI) laCemer L i','•
d e u( ne bu lding served;
.c,~ f e (e powts• C, Cl'.-'n
e; f n CE t
nL+ol~ doge volume;
Ctl J 1 i. "Tlt (r( rf~r n InCe ( urve il aid -
r i D) cross section
Si r. to I ` )r c.
zing information.
GROUNDWATER SURCHARGE
1983 Vt'iscensin A( -t 41 inc!uded the creation of surcharges (fees) for a number oegu ated pr,ctire< which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contami cation investigations
and establishment of standards.
PLOT PLAN
PROJECT Wayne Berq ADDRESS 2203 135th St. New Richmond, WI 54017
S~ 1/4- i/4S 12 /T 31 N/R 18 W TOWN Star Prairie COUNTY ST. CROIX
• ~ 9/28/95 BEDROOM 3
MFRS BYRON BIRD JR. 3318 DATE
CONVENTIONAL XX IN-GR D PRESSURE CONVENTIONAL LIFT HOLDING TANK
1000 gal. LIFT TANK SIZE DOSE TANK SIZE
MOUND SEPTIC TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 643 BED SIZE 12 X 54
BENCHMARK V.R.P. Base of Siding ASSUME ELEVATION 100'
❑ BOREHOLE (DWELL *H.R.P. Same as Benchmark
VENT SYSTEM ELEVATION
12" GRADE
TYPAR COVERING
1„3 6'®3'
SEWER R K
12'
Line
O
5
12' 2 30'
ent
\ \ 10 o Slop
Primary\
.area \ 3
\ \ Alt.
Area
M
1 4
ST
45' 15'
Garage
Wi§consin Department of Industry, SOIL AND SITE EVALUATION REPORT Page - of
Labor and Human Relations
Division of Safety i£ 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
O _ 30
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
PROPERTY OWNER: PROPERTY LOCATION
W
a r GOVT. LOVE 1/4S4,S T"~F N,R Ag"E
PROPERTY OWNER':S MA NG ADDRESS LOT # BL=CK # SUBD. NAME OR CSM
O - Sv v~a~c
STATE ZIP CODE PHONE NUMBER CITY ❑VILLAGGE QWN NEAREST ROD ~c
f
[New Construction Use Residential / Number of bedrooms [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow ~Z5_0 gpd Recommended design loading rate 7 ed, gpd/ft2=trench, gpd/ft2
Absorption area required /56 33 bed, ft2 trench, ft2 Maximum design loading rate 7 bed, gpd/ft2 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
tU= table for system CONVENTIONAL MOUND IN GROUND PRESSURE AT-GRADE SYSTEM N FILL HOLDING TANK
suita ble fors stems ❑ U ~S ❑ U ®S ❑ U El ID'S ❑ U S 25U I ❑ S ,®'U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure Consistence Boundary Roots GPD/ft
Boring # Horizon P Texture
in. Munsell C lu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Ground
elev.
4ka ft.
Depth to
limiting
factor
%,42&
y
Remarks:
Boring #
Ground
elev.
ILA
Depth to
limiting
factor
4 Remarks:
CST Name:-Please Print Phone:
ddress:
CST Number:
Signature:
PROPERTY OWNER G SOIL DESCRIPTION REPORT Page
_bf, ,
PARCEL I.D. #
Borin # Horizon Depth Dominant Color Mottles Structure GPD/ft
9 Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
Ground
lev.
ft.
Depth to
limiting
factor
Remarks:
E?o rin~#
Ground
elev.
/ft.
Depth to
limiting
factor
3 ;7 Remarks:
Boring # /
Ground D /L ~7 d'am`1 -7 * D
elev.
Depth to
limiting
factor
Remarks:
Boring #
..........i.:::}4:ti:i
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
Soil Test Plot Plan
Project NameWayne Berg Byro ird Jr.
Address 2203 125th St
New Richmond, WI 54017 M #3479
Lot 3 Subdivision Johnson & Assoc. First Date 9/28/95
1 1 /4S12 T 31 N/R18 W Township Star Prairie
Boring ()Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft.Base of Siding
System Elevation * H R P Same as Benchmark
Property Line
0
5
12' 2 309
10 o Slop
Primary
Area 3
Alt.
Area.
~ O
v~
M
1 4
V7
ST
45 15' Garage
C ~r
Scale 1/4" = 10 Ft. When Dimensions aren't stated
r STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER C
MAILING ADDRESS t? 4•~-!/<< ~i~ ~ r 9~j
PROPERTY ADDRESS 4Z oZ
location of septic system) lease obtain from the Planning Dept.
CITY/STATE
N-RW
PROPERTY LOCATION 114, 1/4, Section 'T
ST. CROIX COUNTY, WI
TOWN OF
f
t7 ~t ~t a 9~ ~ Ocr a ~ef i
SUBDIVISION ' ~e/`LOT NUMBER
CERTIFIED SURVEY MAP VOLUME 4/,PAGE LOT NUMBER_,.,_7"_
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, whicr 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)
and sand (2) after inspection and
the on-site wastewater disposal system is in pper than 1/3 full operating ludgecondition
pumping (if necessary), the septic tank is less
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 expiration da e.
SIGNED: C q
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road 11/93
Hudson, WI 54016
This application form is to be completed in full and signed b~ the
of-the property being developed. Any inadequacies will
owner(s)
only result in delays of the permit issuance. Should this
(spec
development be intended for resale by owner/contractor,
house) pthen 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 e, ✓e? r%*
,
Location of p..r~operty 1/4 1/4, Section./,4- T_SLN-R19"~ W
-
Township ailing addres
Address of site
Lot no_
Subdivision name
Other homes on property? Yes___,Z_No
Previous owner of property
Total size of property
Total size of parcel
Date parcel was created xro;>c
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes_No
Volume and Page Number 3&'e,7 as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which inclQCA 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 oof the
best of my (our) knowledge that I (we) am (are) the owner(s)
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.' 44, 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.
Signat re of p-NAW Co-Applicant
-9-1, _57-
Date of Signature Date of Signature
DOCUMENT-NO. ' WARRANTY DEED THIS SPACE RESERV fE_OROING DATA
STATE BAR OF WISCONSIN FORM 2-1982
45y56S
iVG; 873PAGE365 REGISTER'S OFFICE
ST. CROIX M, WI
James ii. Johnson and Glen E. Johnson, as tenants in Recd for Record
-
8:sd M
A., yAo
conveys and warrants to M ...B2Yg.-sIld_Malva -L. BeY.gt..........
C1 Deeds
husba)?d .end ProP~rty.,. _ with _ rights • of
survivorship,....
RETURN TO
the following described real estate in ...St.--Croix........................... County,
State of Wisconsin:
Tax Parcel No: Lot Three (3) of Johnson and Associate's First Addition to the Town of Star Prairie,
together with an Easement for ingress and egress over a private street, designated
as Outlot one (1), private street, in said subdivision.
This deed is executed for the purpose of fulfilling that certain Land Ccntract.
between the parties hereof dated Dec rber 24, 1981, recorded December 29, 1981,
at 8:30 a.m., in Volume "639", page 630, as Document No. 375118.
This is not homestead property.
(is) (is not)
Exception to warranties:
Dated this 1-0-th 13__x...
day of _..MaY.......... - - . - - . -
~r
(SEAL)
- (SEAL) ~
,lames-E._.J • Glen.E...Jcbnson-------------- - -
. --(SEAL) - - •(SEAL)
AUTHENTICATION ACSNOWLEDIGMSNT
Signature(s) STATE OF WISCONSIN 1
1 ss.
•
•---,_..ci49 County.
authenticated this day of........................... 19 Personally came before me this Lath.-day of
Y............... 1999--- t"e, above named
James H. Johnson-and-Glen
• -
TITLE: MEMBER STATE BAR OF WISCONSIN
. - -
(If not,
authorized by 708.08. Wis. State.) 5
to me nown to be the person yu executed the
foreg9 g instrument d,acknowledge -~e sa.-me.
I
THIS INSTRUMENT WAS DRAFTED BY Reinstra, Van Dyk & Needham, S.C.
Atth rrie.-- of-_ :~'r3-•------------------- y
y Tan L... Glaser -
New.Ri_cli xxA __k 1i•stXonsin•.__54011n0127_-__._ Notary Public .St-..Cmix------ 'elnty, S~
(Signatures may b, authenticated or acknowledged. Both My Commission is permanent. ([f not, r•expira?n ~ c
are not necessary.) date: 3-.3.1-91 .
•Namn of Deraotu+ signing in any opacity should be typed or printed below their si¢nacu res.
STATE BAR OF WISCONSIN
FORM Na. 2 - 1982 Stock No. 13002
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