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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ~T01~~ IJ~ CCJ/S '7~ ~lJtipE/~54~✓
S~•/~ ADDRESS ~0 C /y
syo~~
UDSOO 60).
SUBDIVISION / CSM# CIC+RU ~ LOT # ICS
SECTION 5 T 15 N-R I T W, Town of T ~d y
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
ORIGINAL
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:
Tor of ALUA-c. 000,f ALTERNATE BM:
SEPTIC TANK / DUMP ^Q71BER / K
Manufacturer: kiEWf 440iy4IIR- Liquid Capacity: ?p741
Setback from: Well 77!~ House /d Other
Pump: Manufacturer / Modelty~ Size
Float se eration '
p / Gallons/cycle: /
Alarm Location /
SOIL ABSORPTION SYSTEM
Width: Length fF62 Number of trenches
Distance & Direction to nearest prop. line: 70 zvz , S7
Setback from: well: gy House 1/0 Other
ELEVATIONS
Building Sewer ST Inlet. /oG .30 ' ST outlet 1,06. ,/2
PC inlet PC bottom-_.-' Pump Off TAB
S ~I Header/Manifold Bottom of system
4
Existdgx= Final grade
IV4A~D/~ 4dUa S
DATE OF INSTALLATION: ! 5
15T T Nkl /0,f,61
PLUMBER ON JOB: LICENSE NUMBER: 330 M PF S
INSPECTOR:-
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Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
tabor and Human Relations INSPECTION REPORT ST. CROIX
-Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Perff9`T`6 V§e: JOHN & AMY GUNDER City ❑ Village ~TOwn of: state Pla
CST BM Elev.: Insp. BM Elev.: BM Description: Troy
Parcel Tax No.:
r
too
7/00, TANK INFORMATION 61 U
ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ~ ~ aO.J 6 0 Benchmark /0c)"'
Aeration Bldg. Sewer
Holding St/P Inlet 5 a, io6-mss
17, /off, 3
TANK SETBACK INFORMATION St/* Outlet 5. S- / 6 6 39
7y i3
TANK TO P/ L WELL BLDG. Air Ventto ROAD Dt Inlet
Air Intake
Septic ;'a5"' 125-1 to >,;2 NA Dt ttom
Dosing NA Header /Man. n' y$q(1 1v3,iIV3
Aeration NA Dist. Pipe ff./" l a 3.1
Holding Bot. System 5'.9sl /a a, 9a
PUMP/ SIPHON INFORMATION Final Grade 5:3 c/ o
Id 5 .
Manufacturer Demand 5joa '`k / V, q ' 10 S.q 7
~
n E tilts ,D 107,8`1
Model Number GPM .4~1e-,/ y, ' io U„ S~
TDH Lift Lricti stem TDH Ft
Forcemain JJL th Dia. ~isT~oweu
SOIL ABSORPTION SYSTEM
BED/TRENCH Width / Length / r No.~f Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ~d f~ <y' DIMENSIONS
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION TypeO / Moe Number:
System: ?,dj /S ~U ~l A CHAMBER OR UNIT
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 I Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes El No ❑ Yes El
No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Troy,5.28.19W, SW, SW, Lot 10, Highway FF
kilt, too
~ X 9 6 96 O .6t ca.- ° 3 - 5X~ 3
Plan revision required? ❑ Yes ❑ No
Use other side for additional 1/7Wq'71 /jl k]
SBD-6710 (R 05/91) Date sped 's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH a
SANITARY PERMIT NUMBER:
i
SANITARY PERMIT APPLICATION COUNTY
v'~~IIInlfirfi In accord with ILHR 83.05, Wis. Adm. Code 6;r. C,ebi7(
STATE SANITA PERM'I`T#
-Attach complete plans (to the county copy only) for the system, on paper not less than a G1~30
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 , n
JO K) QETG~f 7 o/ ; ! 10 y A~ (T Ul/l/ SD~J ~UJ 1/o $.W '/a, S ,:5' T N, R I~ E (o W
PROPERTY OWNER'S MAILING ADDRESS LOT #/D BLOCK #
p Rte. F~
CITY, STATE ZIP CODE PHONE NUMBER L SUBDIVISION NAME OR CSM NUMBER_
vOSva a// SY016 yso y~~ c/ /M`w
IL TYPE OF BUILDING, (Check one) 1:1 State Owned CITLAGEY : NEAREST ROAD N OF:
❑ Public L 1 or 2 Fam. Dwelling-# of bedrooms PAR EL TAX NUMBER(S)
Ill. 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 O X,PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. New 2. El Replacement 3.E1 Replacement of 4. El Reconnection of 5. El 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 4 J? 046,V~s ✓3
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
-75-0 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
39 fi~r_ • 9 ~ Feet Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New isting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank 00 l0 S
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installati n of the o ite sewa a system own on the attached plans.
Plumber's Name (Print): Plumber's Si amp MFIMPRSW No.: Business Phone Number:
~B EQT' 41_8r1,aT" 655" D ' N.e,/ 41- 3307 7is 3?6 0e
Plumber's Address (Street, City, State, Zip Code):
xa' Iv I.2- oso,~ GU ~S. S ~'6i
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater LDate ssu Iss ing Agent Signature (No Stamps
Approved El Owner Given initial C,({rcharge Fee)
-3// /IJ7,7 A-
Adverse Determination I' 15 0 v'~
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.
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 otheir-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 srircharges-are.used for monitoring groundwater, ground- ' . ,
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
Al
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L~Cr~ESTiVG~ Q-- Aoprov.d v..t c.o
Minimum 12" Above
Final Grade
-4r- 1j'--1x11_rhif7- f~~~~--
/oso'
Above Pipe _ 4" Cost Iron
1o final Grade Vent 'Pips'
Synthelic covering
min. 2" Aggregate
Over Pipe
Distribution -Tee
pipe 0 0 0 0 0
6 ' Aggregate 0 pertbreled Pipe Below
Beneath Pipe 0 -Coupling Termineling At
2----*' . Bottom Of S.yslem
loZ.O ~
~I
Fresh Air Inlets And Observation Pipe
Approved Vent Cop
rY~/U G Minimum 12" Above
114 Final Grade
LL
" Above Pipe _ 4" Cost Iron
b
1o Final Grade Vent "t
'
Synthetic Covering
Min. 2" Aggregate
Over Pipe
Distribution -Tee
pipe 0 0 0 0 0
~y Aggregoto 0 Pertbraled Pipe Below
Beneath Pipe o -Coupling Terminating At
Bottom Of S.rstem
S ys7~~y la 2 ..s-
Fresh Air Inlets And Observation Pipe
Approved Vent Cop
Minimum 12" Above
Final Grade
/06 . SD'
2 " Above Pipe _ 4" Cast Iron
Vent Pipe'
"To Final Grade
Synthetic Covering
min. 2" Aggregate
Over Pipe
Distribution - Tee
pipe 0 0 0 0 0
' Aggregate 0 Perforated Pipe Below
Beneath Pipe -Coupling Terminating At
Bottom Of System
s /sTE~y
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/V w e0V S 7,40 C7/0A.)
Wisconsin Department of Industry, SOIL DES(.KIPTION REPORT Saietyyox a Buiiurngs Division
wl 53707
Labor and Human Relations
(Attach Soil Profile Location Map - To Scale - On A Separate, Signed Sheet) Madison. , WI
q56 -4106'1 y se s 7y Page % of Z
Customer Name va uaUOn Date use or Vegetative over
'B~}nCi tL s TWA S
E7C, A w, W 5 9
owest roun water P ~am evation
7 /03 -Do poaT ftU-( ustomtr rtra 15f 00k1-11, / 100,e
unt Mo te m nsPtr q.ersy
y ST• c~Po% 1C :vw yy 8 0,~
Lot Legal ription y,wrn eometr an Dept ~a^ SW T~ENvr/ S
,elq w Towti o>c TeOy T.PEvc s
orizon Depth Dominant Color Mottles Structure Remarks: clayskins Loading
In. Munsell u. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Boundary ores H and other GPD/ft.2
04 /o Y~ L/Z /arty 1, 5 bK (M v-,,e / f s P/a w~~ b S'
.3
P f- 9-/s /0 Yoe 3/ s'/ ~,-f s 6K nn v f,e I F S
7 2,, /S- /o g/ Sil Gfsd~ / v 5 S
C _SD /oYZ 51(S' s,S cs '
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114 ro'o
Structure Remarks: clayskins ! oading
Horizon RD omi;nt Color Mottles
Munsell u. Sr. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Boundary ores pH ,_and other GPD
't.- /R t; s k
13 2- o /2 51.1 6e /vf -5
o ye s/Y
INAL
3 eFle 11A 7-, 0") INAL
Horizon Depth Dominant Color Mottles Structure Remarks: clayskins Loading
In. Munsell u. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Bounda ores H and other GPD1h.2
D-~ /aY,e y/Z /o~~, l,~ s6,e •w► rrfie /f s /aw-SdL s
0 ye J/y IS// i f sk 41)~e f s - 3
13Z G 3a ✓o R ' - S/ -Ae '%die /,f 113, , 3
aA",s 1L - cs 11 0 Gig
mom
yi~v,>t i _ fora conventional septic s stem. -
Horizon Depth Dominant Color Mottles Structure Remarks: clayskins Loading
In. Munsell u. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Boundary Dores H and other GPD/ft.2
-F Hoye z /o,~,, if s6 11-f~ 1 4 s 710 C" . s
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Horizon Depth Dominant Color Mottles Structure Remarks: clayskins Loading
In. Munsell u. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Bounda pores, H and other GPD/h.2
5 ®/aru-~Q , s
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HOMESITE SEPTIC PLUMBING ~ t
6bS O'NEIL RD., HUDSON, WIS. i01 r s _
ROBERT ULBRIOHT
r41S. MASTER PLUMBER LIC. NO. 33D7 M.PAS.
1
!NN. INSTALLE I & DESIGNER LIC. 10. OM
Addrtlonal Remarks: ` ~ .
7~1SE 6, 7.i'oN s
d o X
r
Other Site features:
N. A.
ii Limiting factors/Depth: CST Signature Date Signed Telephone No. CST rY
SOD-8330M 01/90) f~
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
I,, St. Croix County
OwNER/BUYER Ta h n e a 4 d An , N• 6•
MAIIdNG ADDRESS ~yb3 ~~/~~'r ~U~ • /~~do~~yN ~E's s yy
y
PROPERTY ADDRESS4 9 Core J~oa d 1%
. (location of septic system) Please obtain from the Planning Dept.
N-uds0/1
CITY/STATE
PROPERTY LOCATION s~ 1/4, 'sue 1/4, Section T Z f N-R l W
TOWN OF TWO l ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER l
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 needee
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 pir tion d
SIGNED:
DATE:
St. Croix County Zoning Office
. Government.: Center.
1101 Carmichael Road
1judson, WI 54016 11/°~
` V
STC-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), thenia 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 d A m N• ~s• Be &G Ll w~~
Location of property5&11/4 SW /4, section J , T2: N-R ~ W
Township
Mailing address. YO 9- e0un t y Ro a d FF C nekl d d dress)
5 dint: as above
Address of site
Subdivision name C/4-r4rPIL-_-'-w Lot no. ~d
Other homes on property? yesX No
n ,p
Previous-owner of property Da of d le• kh l5 h eoti
Total size of parcel o~~ 3 8 a cres
Date parcel .was created July
9 9
Are all corners and lot lines identifiable? Yes No
Is this property Oeing developed for (spec house)? Yes No
Volume 9S7 and Page Number 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 & 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) an (are) the owner(s) of
the property described in this information form, by virtue of a
warranty deed recorded in Be office of the County Register o:
Deeds as Document No. 3 ro , 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
recor ed in the office of County Register of deeds as Document
No.
Signature of applicant C app ca
Date of Signature Dat6 of S a re
I
"o SIACE WSEMO fW F*COFC* 4 DATA
DOCUMENT NO. WARRANTY DEED
STATE BAR OF WISCONSW FORM 2 -1982
' 0 957 PAa375
REGISTERS OFFICE
SE/MWY ' 1
R. Kni h bed for beW
JUL011992
rson d 10:55 A. M
L ,,.,~..Q and J! 11(i N. Q31j e ,
corners and warrants to
as ioint with riuht of survivorsluP,_._- -
tenon O .
furni 1TO
logo" d9sat"d maaf esum In c * (`rg i X ry•
tfn
Stme of Vastxxxt m Tax PwM1 Na
Lot No. 10, Clearview Addition
Subj~ to Declaration Establishing Protective Covenants and other easements
of record.
FEE
Tt~sis riot homestead pmpery
(jai (b not
Excepuoo to wwrandw
,t992
June
Dated is 30th of (SEALI
lilt.
• David R Mip_t (SEAL{
(SEAL) ACKNOWLEDGEMENT
AUTHENTICATION Minnesota
STATE OFA&VOO
Signature(s) Hennepin Countl~•
J personally came before ms fts 30th day of
s t9 92 the show named
ulhentlcated oft day d • 19 -
Dav'd R. Kni ton
TITLE: MEMBER STATE BAR OF WISCONSIN 10 me known to be the person wha exeaAen ft
to same.
110 no4 bre~9 i and a
authorized by 708.1]6. V~is State
THIS INSTRUMENT WAS DRAFTED BY
David J. Butler AttArne * David J. Butler County.
6625 Lyndale Ave So, Suite 526 Notwry Public expiration
(Signat MY ,t
ures mar be atAheritlcated or ackrwwbdyed• Bath daW
ar e no necessary.{
• NWW d PIWO *Vw* M AM COP" "N t* t1W «o"° t~w. "nh S vo- AggpCIAT10N
STA=N0. OF N fleet HMs ROO& Maftm weconWn 57104
WARRANTY DEED 2-19P.