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AS BUILT SANITARY SYSTEM REPORT:' ..a
OWNER
~:C~2 x tea.
ADDRESS,
SUBDIVISION / CSM# LOT # za
SECTION ~7_T - _N-R W, Town of u
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WTTUTN 100 PEPT OP SVqTPM
S; ocK~,t J?'
70 .
1,
Go
Gn~+cF
~~,JPt fi~ INDICATE NORTH ARROW
Provide se ack a v tion information on reverse of this form.
Prove 2 imensions to center of septic tank manhole cover.
,o
BENCHMARK:
ALTERNATE BM:, 117 s rnl ~?~/f/ J
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: 1t~ S 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: -~Q House 7ja' Other
ELEVATIONS
Building Sewer'//J/_yg ST Inlet, ~ 7/ ST outlet
PC inlet PC bottom Pump Off
Header/Manifold,_5s- Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION: - -
PLUMBER ON JOB: /
LICENSE NUMBER:
INSPECTOR: l
3/93:jt
Wiscoksin 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
JOHNSON, TROY X
CST BM Elev.: Insp. BM Elev.:
BM Description: 'rey Parcel Tax No.:
I A9500294
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic S ~C4q C. 41 je~ Benchmark
Dos g
314 C. . 6 wj.
Aeration Bldg. Sewer
Holding f.. St/ Inlet 1,091
TANK SETBACK INFORMATION StIt Outlet 3/' dog i
Vent
TANKTO P/L WELL BLDG. Airl to ntake ROAD Dt Inlet
Ar I-
Septic > SD ® r g' NA Dt Bottom
Dosing NA Header / Man. i
Aeration A Dist. Pipe
44-ol Bot. System d0 D.~ ~10'
PUMP/ SIPHON INFORMATION Final Grade
Manufart er Demand
you-~~- 7 d /o S. 71
Model Number GPM
riction System TDH Ft
TDH Lift..- F
Loss ead 7-7
Forcemain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No_ Of renches No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS D71 E
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEA Manufacturer:
SETBACK
INFORMATION Type Of y7,` - U; C M B E R Mode Num er.
System: R UNIT
DISTRIBUTION SYSTEM
Header ~ ~ Distribution Pipe(s) x Hole Size x Ho -Veit To Air Intake
Length Dia. Length Dia. Spacing 67
SOIL COVER x Pressure Systems Only xx Mound Or At- de Syst Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded Bed /Tienali.Center Bed l yEcl9es Topsoil
❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) A C c,,Jf
LOCATION: Troy-7.28.19W, SE, SE, Lot 10, South Fork
Plan revision required? ❑ Yes 2-'No d
Use other side for additional information. 7~ da 9 d
SBD-6710 (R 05/91) Date Inspector's Signatur Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION Safety and uilding WaterlSystem!
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707-7969
0 Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 1/2 x 11 inches in size. 5Z A- .
• See reverse side for instructions for completing this application State sa~nitaarr Permit N~umner
The information you provide may be used by other government agency programs ❑ Check if revision 1 to previous application
[Privacy Law, s. 15.04 (1) (m)]. r te Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Propert wner Nam Property Location
1/4 1/4, S T , N,R (or&
Prope. y ner's Mai Addr ss Lot Number Block Number
Y=- ZZY! Ay
City, t t
X- If o Zip ode Phone Number Subdivisi Nam or CS Number
117-
II. TYPE F B ING: (check one) ❑ State Owned ❑ Ity Nearest Road
❑ Village
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) C
1 ❑ Apartment/ Condo e7
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 box on line A. Check box on line B, if applicable)
A) 1. jW New 2. E] Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11,0 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 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
VII. TANK Capacity
in gallons Total # of Prefab. Site Fiber- Ex er.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel Plastic p
New Existin strutted glass App.
Tanks Tanks
Septic Tank or Holding Tank ❑ ❑ ❑ 1:1 E]
Lift Pump Tank /Siphon Chamber 1:1 El El 1:1 1:1 1:1
VIII. RESPONSIBILITY STATEMENT
I, th undersigned, assume responsibility for ins ation onsite sewage system shown on the attached plans.
Plu ~be Namn1P1 Plum er's Si e' tam ) MP/MPRSW No.: Business Phone Number:
Plum er' Address (St irg, Cit Stat i Code)•
r
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sani a y Permit Fee (Includes Groundwater ate Issued Issuing Ag t Sig ur No amps
Approved ❑ Owner Given Initial Iff "I, Surcharge Fee)
Adverse Determination ~
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SHD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Ruildings 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 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 onsirte 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 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 1/2 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 contamination investigations
and establishment of standards.
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8117
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3
Labor and Human Relations
Division of Safety & Buildings in accord with I 9 s. Adm. Code
1t COUNTY
Attach complete site plan on paper not less than 8 1/2 x 1 in size. Plan ude, but
not limited to vertical and horizontal reference point (BM ion aF Y lope, e r PARCEL I.D. #
dimensioned, north arrow, and location and distance to st r ;
APPLICANT INFORMATION-PLEASE PRINT A FORM ~Tt~ REVIEWED BY DATE
L
PROPERTYbWNER. - ,9004 ,ES OPER TION
-rpoY T~Nai DER To t4k3 S' ~"'O'S , . ~L 1/4 SE 1/4,S 7 T28 N,R E(
PROPERTY OWNERS MAILING ADDRESS ? LOT1k , OCK # SUBD. NAME OR CS
CITY, STATE ZIP CODE PHONE NUMBER* f TY []VILLAGE OWN NEAREST ROAD
-}vDSoAD WI . 5L/0/& (-1s)3J71-iLsZ 1-Ro 1--iv. YQ,,Pe .Ple
[ New Construction Use J r esidential / Number of b6drooms 7 [ J Addition to existing building
Replacement [ j Public or commercial describe
Code derived dairy flow Cv oU gpd Recommended design loading rate bed, gpd/ft2 trench, gpol112
Absorption area required bed, 112 74-0 trench, ft2 Maximum design loading rate bed, gpd/ft2 ' trench, gpdV
Recommended infiltration surface elevation(s) -lze- M . 3 ft (as referred to site plan benchmark)
Additional design / site considerations uSE 7e8A1C-&5 OVGy 01) S4114--e- 4'1 12e I& OXZL-- S
Parent material Se5 73 " 9VW4'A4"7- Flood plain elevation, if applicable iVfi9t- ft
S =Suitable for system CONVENTIONAL MOUND 7IN-GROYND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING U = Unsuitable fors stem CC'S [I U ❑ S C~ 's- 11
U ❑ S b o Ch's' 0 U 0 S 9-1:11-'"
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourxlary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Twich
S Ground Z /_2"12 D 7 D S ~~Q CS " -s G
elev.
0 ft. -3 0 ^ylo 7 ~
Depth to
limiting
factor
Remarks:
Boring #
/0 %P3/i Si/ •Q ~-e 4s /af N
z y~ s yX y s. D S T
Ground
elev. 3 C'S O
19,&o ft. - Al
Depth to
limiting
factor,., ~i
Remarks:
CST Name:-Please Print Ro BE R-,- 24 LB P Cc k7- Phone:
Address: Ulbricht & Associates 7- z (Q - C'S7iy 2 S~ L
private sewane consultants
Signature: 655 O'Nell Rd. Date: CST Number:
Hudson, Wis. 54016
3
PROPERTY OWNER SOIL DESCRIPTION REPORT Page of
PARCEL I.D. aY LOt / d - S 0 U1tt- FORK
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Barrlary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed 5-rich
:3. 0 -17 10 311 s./ .2-f sbk sti / , s
/ D
9 rP
Ground
elev.
/D p.SO ft.
Depth to
limiting
factor
7
Remarks:
Boring # L,2 - 10
7,4--y
P yl~ - ~s o s ~.e cs - 7 ;
Ground
M~ elev.
5 S S .
ft. ,3 - /0 Y, e
,r 71,60
Depth to
limiting
factor
Remarks:
Boring # 9 /0 y 3/i Si! .C GQ e S /0f Q N ,
2 s o CS 7
Ground
elev. 1,7 • P
~0 3. ?0 ft.
Depth to
limiting
factor
1
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County OWN
ERBUYER -Y'p l/ a n 4( TPn n `-4 r ~TDA
r)6 &-Yl
MAILING ADDRESS S- l< C,U /j D~C~
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE~liL~ ~-C
PROPERTY LOCATION 5;0E_: 1/4,'F 1/4, Section ---7_, T c7`, N-R l~
TOWN OF ray y ST. CROIX COUNTY, WI
SUBDIVISION F l f LFb_ rk LOT NUMBER O
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.
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:/ y ~9 S
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
S T C - loo
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 -Froci V f -eam ~&v- Jd d1 n 5
Location of property 1/4 5%_1/4, Section 7 ,T(~Le N-R l~ Q
Township_F~-oMailingaddress /1~/ S,
- d/ r-) 1s - 9'I
Address of site ~1 G
Subdivision name ~~Qte,M JamLot no. /U
other homes on property? -Yes x 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 N!o
Is this property being developed for (spec house) ? Yes yt No
Volume 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 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. S_ LZ-22~/. , 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.
ign ur of Applicant J-Appl'i ant
l~ a5
~
Date of S ature Date of Signature
ign
FROM :EDINA REALTY HUDSON 19%,08-31 16:45 #259 P.01/01
S S 329 VOL 0PAC- 1pi
State bar of Wisconsin Form 2 -1981
WARRANTY DEED FEGISTa'S OFFICE
DOCUMENT NO. ST. Mix C}MM
- RoOd fof Reooro
Brian K. Smith and Carol I Smith, f/k/a
Carol 199
Nicholson, husband and wife,
Troy C. Johnson and Jennifer J. ~ PA~Dow'
Conveys an(1 warrants to
Johnson husband and wife,
THIS SPACE RESERVED FOR RECORCING DATA
NAME AND RETURN ADDRESS
the following described real Cstate in St. C nj x
County, State of Wisconsin;
I
(Farce( Identification Number)
Lot 10, South Fork* Addition in the Town of Troy, St. Croix County., Wisconsin.
g
I
This is homestead property.
Exception to warranties: Easements, restrictions and rights-of-way of record, if any.
~r
Dated this 3 day of August }g 9~
(SEAL) C (SE LW w
Brian K. Smith
- I
(SEAL) O--1-1 W <2 (SEAL)
• Carol. T. Smith, a/Va Carol I. _
Nicholson
AUTHENTICATION ACKNOWLEDGMENT
SlgnatlirC(S) Brian K. Smith, Carol STATE OF WISCONSIN
SS.
1. Smith, a/k/a Carol 1. Nicholson
County.
authenticated this day of August 19 95 Personally came before me this day of
19 the above named
M Kristina Ogland
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by §706,06, Wis. Stats,) to me known to be the prrson who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Kristina Ogland
$ttCrn"V A AW Notary Public County, Wis.
(Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration date:
necessary.)
•Nmms or persons sixning in nny enpz6Iy should be typed or primed bcloay their signnwres.
WARRANTY DEED VATS BAR OF WISCONSIN W;SCOnSirl Legal Blank Co., Inc.
ponh4Nn, -t9bt Mitwaukoe.pNis.
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
■ N a ■ r ■ ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680
December 8, 1995
Hartman Homes
P.O. Box 326
Somerset, Wisconsin 54025
ATTN: Becky
RE: Septic Inspection for Property Located at
423 South Fork Drive, Hudson, Wisconsin
Dear Becky:
An inspection of the septic system for the above address was
conducted on November 2, 1995. This property is located in the SE;
of the SE; of Section 7, T28N-R19W, Lot 10, South Fork Addition,
Town of Troy, St. Croix County, Wisconsin. At the time of the
inspection, this septic system was found to be code compliant for
a three (3) bedroom home. Should you have any questions, please do
not hesitate in contacting our office.
in rely,
e. 7
ames K. Thomps n
Assistant Zoning Administrator
St. Croix County, Wisconsin
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