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JAN 2 4 ?g96
STC - 104
ST CROI, AS BUILT SANITARY SYSTEM REPORT COUNTY
ZONINGOFFICE 1+
OWNER-
ADDRESS.
ll5~/
-SUBDIVISION / CSM# LOT
SECT.ION_T N-R W, Town ofN
ST. CROIX COUNTY, WISCONSIN
/pu'Cz PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i4
I ~QVf K
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK •n ,~n n~ aiti o .~'1~
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: Length Number of trenches
Distance & Direction to nearest prop, line:
Setback from: well: ~ House Other
ELEVATIONS
Building Sewer LST Inlet, 1//'/~`,2 ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system_ 2S?//
Existing Grade Final grade 7
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:_ A
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor aod-Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
j GENERAL INFORMATION
Permit Holder's Name: ❑ City El Village a Town of: State PI
CST BM Elev.: Insp. BM Elev.: BM Description: x Parcel Tax No.:
Idd • ab / 6d. !56 ~ e a,5 k1zP-___ A9500427
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic et-/^P(~S cc-"toz Benchmark yf-
Dosing
Aeration Bldg. Sewer 7, Sf J/o?• O
Ho ng St/II, Inlet ,s3~ 1//•O
TANK SETBACK INFORMATION St/ Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic LSD NA Dt Bottom
yl AT-
Dosing NA Header
Aeration A Dist. Pipe ~j gel, Holding--- Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manu r Demand we-s7 , --X/,/
Model Number GPM 68'
r4S
TDH Lift Friction Syste Ft oss For ain Length Dia. Head
Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ~O2 ~7 % DIMEN I
_Manur
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEA acturer:
SETBACK
e r ModelNum er:
INFORMATION Type Of C
System: Q_rX,~, --8~, l OHANIT R
DISTRIBUTION SYSTEM
Header/Mani old << Distribution Pipe(s) ize ole Spacing Vent To Air ke
i
Length Dia. Length 5-K Dia. V/ Spacing
SOIL COVER x Pressure Systems Only xx Mound Or A rade Systems Only
Depth Over Depth Over xx Depth Of ~E] x Seeded / Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Troy-3-28.19W, NW, SE, Lot 4, Tower Road
Plan revision required? ❑ Yes Eff-No 4f tz- I
g
Use other side for additional information. /p2 Q /
SBD-6710 (R 05/91) Date Inspector's Signatur Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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IL R SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
STATE Z 714 ER2 #
-Attach complete plans (to the county copy only) for the system, on paper not less than 3
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 LL INFORMATION.
PROP TY WNE PROPERTY LOCATION
Vid '/ate " Y4, S , N, R ,E (or
PROPERTY OWNER'S MAILING ADDR LOT # BLOCK #
CITY ATE ` ZIP ODE PHONE NUMBER SUBDIVISION N AYE OR CSM NUMBE
s 3O AP
OWN OF~
11. TYPE OF BUILDING: (Check one) ❑ State Owned VILLLLAGE rEAREST ROAD
❑ Public ~ 1 or 2 Fam. Dwelling of bedrooms -
R
Ill. BUILDING USE: (If building type is public, check all that apply) ld0
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 1130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. X New 2. ❑ Replacement 3. ❑ Replacement of 4.0 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 Seepage Bed 21 ❑ Mound . 300 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 12. 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./' ch) ELEVATION
Feet Feet
VII. TANK CAPACITY Site
in gallons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
[Tanks Tanks structed
I
Septic Tank or Holdin Tank
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
1, the un ersigned, assume responsibility for instal latio f the onsit wage system shown on the attached plans.
P2ub er ' Nam (Pri Plum is Si re: o mp MP/MPRSW No.: Business Phone Number:
12
u ber' /t dre Street, C' , State 71 Code
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued. Issuing Agent Signature (No Stamps)
Approved El Owner Given Initial c`p O Surcharge Pee) p,
IN Adverse Determination t'
X.. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:.
SBD-6398 (formerly Plb-67) (R. 11/88) 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 renOWal 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 Fora:-, (:;;Rh 6399) to be
submitted to the county prior to instal!atiop.
5. Onsite sewage systems must be property maintdined. The septic tank(s) mist be puRtrp,:.>d by a licansed
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, Sfetx Ifuildirlgs_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 n,mber(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 !n ##1-7.
I!. Tank nfr F:---,aticn. Fill in the capacity of every new and/or tank, list tl e tu' zl li) L rumber of
tanks arid nanufarWrer's name. Indicat=j prefab or site c.o; siruaed and tank materi.rl~ (r,;r~: r to for all
septic, pimp/siphon and holding tanks "tor this system. Check eXpe r:tal approva c-+, h tanks received
experinn,>~t l product approval from DiLHR.
VII!. Responsibility statement. Installing plumber is to fill in name; license number with aoprop,i~ite prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complc...e plans and specifications not smaller than 8'/z 11 inches rr,utc,t be :ubmitted thr, '_.0Unta: The
plans mr;: t o.,~iude the following: -V, plot nlan, drawn to scale ,,r vilh con lei i ton of
holds y : septic tanka(s) or other trealrrent tacks; bui d7r3 1 !_:s: welivv ti: v ,.er Service;
strean!s and laces; pump or siphon tanks, distribution boxes sos; so,piior~ ~,ysie!n ,e, .,,,:,r„ent system
areas, w--d the location of thrbui!ding served, 3) horizontal and vertica+ e ley id or. r~te-nr~a- I mints;
C) complete specifications for pumps and controls; dose volume, e!evatior! c 'terences; fri,Ai:)n 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. '
- - - - - - - - - -
GROUNDWATEIR SURCHARGE
1983 'vVisconsin Act 410 inc!udi,-.d the creation >f surcharges (fees) for a nkjrw)y,e el
regulated prlac`ces which carr -ff ct groundwater.
s
The mop-Ls col ected'hrc iJgh tt~se surchar(fr } are -js(d for monitorin
water contanination tm Fstigatior,s and>establishr~ren° of standards.
SBD-6398 (R.11/88)
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'Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor-and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper IT, not less than 8 1/2 x 11, inch St. Croix
Zpe, must include, but PARCEL I.D. #
not limited to vertical and horizontal reference point (BM), direotibrt.,~ scale or pending
dimensioned, north arrow, and location and distance to nearest road.- ti APPLICANT INFORMATION-PLEASE PRINT ALL INFORAVVIREVIEWED BY DATE
PROPERTY OWNER: rFROPERTY LOCATION
Richard Stout .LOT 1!4 SE 1l4,S3 T 28 N,R 19 f(or) W
PROPERTY OWNER':S MAKING ADDRESS BLOCK # SUBD. NAME OR CSM #
1353 Awatukee Trl. ' °na csm
CITY, STATE ZIP CODE NUMBERf, CITY ❑VILLAGE )TOWN NEARES R
OAD
~Yny `Z S'
Hudson, WI. 54016 Troy Tower Rd. 0
[x] New Construction Use [xJ Residential / Number of bedrooms 3 Addition to existing building
j J Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate • 7 bed, gpd/ft2 - 8 trench, gpolft2
Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate -7 bed, gpd/ft2 -8 trench, gpd/ft2
Recommended infiltration surface elevation(s) 93.58 ft (as referred to site plan benchmark)
Additional design / site considerations na
Parent material stream terrace Flood plain elevation, if applicable na It
S = Suitable for system CONVENTIONAL MOUND IPRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem ® S ❑ U F) S ❑ U S ❑ U
I t3 S ❑ U ❑ S 0 ❑ S 13U
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 Trt &
€'.„••1••• 1 0-24 10 r2 2 none 1 2msbk mfr w 2f .5 .6
2 24-3 10yr5/3 none scl 2msbk mfr gw if .4 .5
Ground 3 3 8 - 8 7.5 r4 6 none is os mvfr na na .7 .8
elev.
95.88 ft.
Depth to
limiting
factor
+84,
Remarks:
Boring #
1 0-22 10 r2/2 none 1 2msbk mfr 2f .5' .6
A' 2 "Y 2 22-36 10yr5/3 none scl 2msbk mfr gw if .4.5
:Y•X.M`::..iy ti
3 36-84 7.5yr4/6 none is osg mvfr na na .7.8
Ground
elev.
97.55 ft,
Depth to
limiting
"'%4
Remarks:
CST Name _Please Print Phone:
Gar L. Steel 715-246-6200
Address: 1554 200th Ave. New Ri 10- cstM02298
Signature: Date: CST Number:
PROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Pagd, 2 of.->3
PARCEL I.D. # pending
Boring # Horizon Depth DominantColor Mottles Texture I Structure Consistence Bounclay Roots GPD%ft
in. Munsell Cu. Sz. Cont. Color Gr. Sz. Sh. Bed iTrench
3 1 0-24 10yr2/2 none 1 2msbk mfr gw 2f .5;.6
v....... 2 24-38 10yr5/3 none scl 2msbk mfr gw if . 4 .5
Ground 3 38-90 7.5yr4/6 none 1s osg mvfr na na .7 j .8
elev.
96.75 ft.
Depth to
limiting
Remarks:
Boring #
1 0-22 10 r2/2 none 1 2asbn mfr gw 2f .5;.6
2 22-39 10yr5/3 none scl 2msbk mfr gw if A .5
3 39-88 7.5yr4/6 none is osg mfr na na .7.8
Ground
elev.
97.4 ft.
Depth to
limiting
factor
+88"
Remarks:
Boring #
1 0-22 10yr2/2 none 1 2msbk mfr gw 2f .5 .6
5 2 22-30 10yr5/3 none scl 2msbk mfr gw 2f .4 '.5
3 30-84 7.5yr4/6 none is osg mfr na m .7 .8
Ground
elev.
95.4 ft.
Depth to
iiri7iting
factor
+84"
F--
RBoring #
,}}:•i:{{•;ti•}::•' is
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel Richard Stout 1554 200th Ave.
CSTM2298 NW4SE4 S3-T28N-R19w New Richmond, WI 54017
MPRSW 3254 town of Troy (715) 246-6200
lot #37-csm
1 1"=40'
BM.= top of red tel. ped. C el..100
P~\
0 11 L)0'
tr`y' ~C.S IQ
30
Gary L. Steel
10-19-95
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS C Vim.,
1,2 an el!)
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE -
PROPERTY LOCATION W 1/4, ' b F.1/4, Section T~_N-RW
TOWN OF _ -{~r•~~ ST. CROTX COUNTY, WI
SUBDIVISION Cf~I Ati •r~( 1 1 , LOT NUMBER
CERTIFIED SURVEY MAPS!; 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 expiration 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 i
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 j
the property is sold and submitted to this office with the ij
appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - " - - T - - - - " - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of property AZU66
Location of property 41W 1/4tif _1/4, Section a _,Tl _N-R_Z2_W
Township zhrc7V Mail ifig address ,aao eraX&%.a
Address of site
subdivision name Lot no.
Other homes on property? Yes No
Previous owner of property
Total size of property . Ar-,&!1L5 Ji ~n7
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable?! _Yes No
Is this property being developed for (spec house)? Yes No
Volume and Page Number le-?- as 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 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. 117~-?Z L27 , 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 ofAjYp 1ca Fo-Applicant
1
bAtp of Sib ti-atil-r- nAttn nf girinatiirP
s SLEDS .
NOV 2 9 12
KATLEEN H.Wp1.SH
Reg H islef of Deeds
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i DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACER ESE RVED FOR RECORDING DATA
WARRANTY DEED
537127 4; ,..1152PACE 182 ! f,;~_( iSTER's OFFICE
T. CROIX CO., WI
Rood for Record
Richard 0 Stout and T SP. steut, ; DEC 5 1995
hus and and wi f--ta survivor- h r l
s ~iaria~ -at 2:15 P. M
properi-17 I J*
jj ,~,~~A~
conveys and warrants to 'j 1'~a'` •v~+1. t-11j,
Registar of Deeds
La Cass e
f 'y J*
RnF ~TURN TO /
/~~v
/353 ,e.
the following described real estate in St rrn; sr County, l ai~ ~ s0~i&
State of Wisconsin: Sect. 3, T 28N, Range 19.
Tax Parcel No:
Lot 4 of CSM recorded November 29, 1995, in
the St. Croix County Register of Deed's Office as
Document No. 536865 in Vol. 11, page 3016.
Above described lot being part of the NWJ of the SEJ of Section 3,
Township 28 North, Range 19 West, Town of Troy, St. Croix County,
Wisconsin.
This i s not homestead property.
(is) (is not)
Exception to Warranties: easements, restrictions and rights-of-way, of
record.
Dated this 1.Rt- day of De Mher- '1995
(SEAL) (SEAL)
Richard t)_ St--nut- (SEAL) Janet Pat;421b11; (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
ss.
St . Croix County.
authenticated this day of 19 Personally came before me this- day of
nPCPmb -r 1199-9 above named
Richard O Stout and Janet P Stout
TITLE: MEMBER STATE BAR OF WISCONSIN
,(If not, me known to be the n G who executed the
authorized by § 706.06, Wis. Stats.)a g to trument an ck I dge the same.
THIS INSTRUMENT WAS DRAFTED BY
Janet P. Stout r~~
t355 Awarukee.Tr. OTA y
kudson Wi 54016 ► ^N0tar •P tic County, Wis.
(Signatures may be authenticated or acknowledge B PLDLf~~i gmrsssion is permanent. (If not, state expiration
are not necessary.) J' -f- IQ- q 1 19 )
•~.,,~1 Wisco
'Names of persons signing in any capacity should be typed or printed below their signatures. SB2 NTF 0021
WARRANTY DEED STATE BAR OF WISCONSIN Nelco Tax Forms, P.O. Box 10208, Green Bay, WI 54307-0208
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