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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS
SUBDIVISION / CSM# LOT #
SECTION _T !7N-R .9 y W, Hoff NoR7-W )-A410saAl
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEAT OF SYSTEM e 4,rpxy J~Rzx-
L-~,~~• /00.00'
c 3l, P~ oGER~ /a5o Ghs T.7uK Lni15 T
rg-
8t'
' SAD •v CE
V
~ ~ /off
INDICATE/ NORTH ARROW
/./0 Sch l 0
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: Alr-u IAJ /00 ,00"
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: GJjEs Liquid Capacity: I q So
Setback from: Well G</r House 3l' Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length "JS' Number of trenches a
Distance & Direction to nearest prop. line: / Z,TS
Setback from: well: $~l House r Other
ELEVATIONS
Building Sewer ST Inlet. ST outlet Gl
PC inlet PC bottom Pump Off
Header/Manifold ~-9 Bottom of system 91~_00'
Existing Grade /CO. 36' Final grade /00, _5-cD'
DATE OF INSTALLATION: /Q p
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
F1 I
WAconsin 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 aTown of: State Plan 02 7
LARSEN, LAWRENCE X
CST BM Elev.: Insp. BM Elev.: BM Description: / Parcel Tax No.: North- Hurlson / oo • ` / oG, ~ :!~a "krze (iii
TANK INFORMATION LEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Ifl _ / d 5 Benchmark /~3 67 U U >
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet z(, 79 gg, d '
Vent
TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet
Septic Tay 3 >a S ' NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe G, f18~ 9L.7
8' to .
Holding Bot. System ro 5 , q `,oz•
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand /,A 7'
Model Number GPM
TDH Lift Fri ' in System TDH Ft
Forcemain ngth Dia. Dist. To Well
Head
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length NooTrenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 5 DIMENSIONS
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type Of 7 46t-0 CHAMBER Model Number:
System.-t/&-A-6*' l a a / GclGl 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 Depth Over r 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.)
LOCATI//ON: North Hudson.12.2~9.20W, SE, SW, Lot 3, Station Lane
.r
e / -A ~
7q /
Plan revisiohrequired? ❑ Yes [9~No b Use other side for additional information. 1/0
SBD-6710 (R 05/91) Date Ins a is signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
t
SANITARY PERMIT NUMBER:
_ i
D1lLHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code C u Y
STATE SANITARY ~PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than o`-7 a-7
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
kE~.icr ,¢l E.V SE %4 S cj Y4, S 4? T o?9 , N, R o?0 E (o
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
snag 5.1m as Aj.
Cl STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
DSO/j w, 7q0 /S 3gf--ddb sT CleOIX '5r. 770AJ
II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
❑ State Owned VILLAGE
:lJopril ~fU~OSaN ST/'fT/oilV 44NE
❑ Public 01 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMBER(S)
III. 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 OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. P, P 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 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 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
(Da 7SosQ 1;- '7S0 sq.x:i-~ • S 94 •00' Feet >00.09'Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank /Q50 /,950 wi ~S F
Lift Pump Tank/Si hon Chamber F1 I L1 F]
c
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumbature: (N p MP/MPRSW No.: Business Phone Number:
,OA &os_ C-. ~C~Ps 33s5- ~~s 3~~ ags-a
Plumber's Address (Street, City, State, Zip Xeis
-7i 6- '`'/-51r N , o,,j l.~e . Selo !
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanita Permit Fee (includes Groundwater Date issued Issuing Agent Signature (No Stampa)
Approved El Owner Given Initial Surcharge Fee)
j/ //l
Adverse Determination `
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit rr;ay be renewed before the expiration date, and at the time of rene°.val 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 (39D 6399) to be
submitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumper' 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.
Vil. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallon,.;, 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 k 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
holdir g tank(s), septic tank(s) or other treatment tasks; building sewers; wells; water .rain:,,/Neater service;
strearrs~z and lakes; pump or sipphon tanks; distribution boxes; soil absorption system is', reel: (,-ement system
areas; and the location of the building served; B) horizontal and vertical elevation points;
C) corplete specifications for pumps and controls; dose volume; elevation d fferences, `ric ;-.n loss; pump
perfornin. nce curve; pump model and pump manufacturer; D) cross section cf the scii ala c> ption system if
required by the county; E) soil test data on a 115 form; and F) all sizing information.
I
GROUNDWATER SURCHARGE
1 ,i.3 'Wisconsin Act 410, in:;luLed the creation of surcharges (fees) for '.uln'
regulated practices which can effect groundwater.
The r.,e~r iaa collected throLigh these surcharges are u,-icd.for, r~.o.mtorirtg gruurrcv;ater; giourrd--
watei i;ontamination investigations and establi shrne-nt of siarid rd±3
SBD-6398 (R.11/88)
~E~Icl~r►'ir}PK- S'P/KE iN ,t/oPr/fOkUo~7
C,+ERR Y -ME r E/, c J = /no, oo
.PLB 67
/~tgER
E~~E ,0'ssP~ gNT 'Ill ~l PLOT & CROSS SECTION PLANS
Q~ Q,P~',VgG` _ g~ 40;-V" V 40;-V" ZAPPA BROS. EXCAVATING INC
E ~„'E'~r~ TAPE ^k H` s PLUMBING UNIT
Acr. f _
PROJECT .
A B
8
WEsT
Pqo PeRr'( 3~- - -
-c K i Pa Pc N ~FAST-
AQo P-orY
/"/'PRonosEd 41AI6
yS-- ~ ,o Rr-sl0e llcr
Poh~ 91'
fR~nosEA
5o' -
rKoa,.~sfl~
DIP, VE -JA
SoHS.I B,~aPE~ry Li.~E NO
SCALE
SriFre.~ L ~},"E
FRESH AIR INLET AND OBSERVATION PIPE
APPROVED VENT CAP
MAXIMUM 12'
ABOVE FINAL 'GRADE
4' CAST IRON VENT PIPE
MAXIMUM OF 42' ABOVE
PIPE TO FINAL GRADE
SIGNED:
MARSH HAY OR SYNTHETIC COVERING
LICENSE: /V(P/PS 3395
MINIMUM Z' AGGREGATE DATE:
OVER PIPE
DISTRIBUTION PIPE
I_,~ • • • TEE SOIL STING BY:
,PvE e.~ oiV
ELEVATION BED W AGGREGATE
•
BOTTOM PER SOIL BENEATH PIPE PERFORATED PIPE BELOW
TEST IS • COUPLING TERMINATING
% • 00' FT. AT BOTTOM OF SYSTEM
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page I of 3
Labor and Human Relations
` Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
• COU
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
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
PR PERTY OWNER: ) PROPERTY LOCATION q
„1Lj AtAx-r- Lgasp-V GOVT. LOT Sr; 1/4 SW1/4,SIZTZt ,N,R~~ E(or)W
PROPERTY OWNER'.S MAILING ADDRESS L T # BLOCK # SUBD. N ME OR CS #
S; el )'X A l 674
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY VILLA ❑rOWN NEAREST ROAp
( ) IR t-1 1U Srd-rro>J L 1411 t-
New Construction Use [p(1 Residential / Number of bedrooms faNK [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow gpd Recommended design loading rate Q,- bed, gpd/ft2 01 trench, gpd/ft2
Absorption area required bed, ft2 tre,nch~ 112 Maximum design loading rate ~•7 bed, gpd/ft2 6• T trench, gpd/ft2
Recommended infiltration surface elevation(s) - A - 46, ~66 ft (as referred to site plan benchmark)
Additional design / site considerations Q k>" 9S A-)/
Parent material Flood plain elevation, if applicable It
S = Suitable for system CONVENTIONAL UND N-GROUND PRESSURE AT- RADE SYSTEM IN FILL HOLDING T K
•U = Unsuitable fors stem S❑ U S ❑ U WS ❑ U S❑ U S❑ U ❑ S U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
-fig iUYR2 st- ] 6k rh - Cw z
[3 -7Z
Ground $ Y Z-// g 16Y,P-4 4 S r _ 6-'7 Z
elev.
/0l,67 It
Depth to
limiting
Remarks:
Boring # C tti Z 16-4 10,.,2)
-2 /OY
Z $ i s- SC t2 3 Z 5 rn n, w Z 6.
K 124 4 r m ~ 6*~
Ground
elev.
/®6,42 ft.
Depth to
limiting
fac
Remarks:
CST Name:-Please Print Phone:
N~•1~N
Address: P C~ 1 141
Signatur Date: 3 CST Number: 54e4
t-j
PROPERTY OWNER SOIL DESCRIPTION REPORT Page 7- of 3
PARCELI.D.#LOTS
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trend
Y2 Z Z - S~ P st< rnr- -w -Z A1 ,
o-K 13 16 P, 1119r
Ground ~2 1- 1 JOY 3 S44e
i 3ft. is/-Ri >
Depth to
limiting
factor
qn, ~y q 3 S 4. S - 4imp
7JVA~
Remarks: k~~L Sid iNLLUS~d~.l l~J Oj21Zd1J
Boring # a
1 /cy2 Cw
i~, ew 6.7 6Z
Ground ell
elev
c)C ft
Depth to
limiting
factor
Remarks:
Boring # _
0-1 /aYre / S 1 n~ s~K ~►r C 2ri) 0
13- $ 9-2Z Jay,e3 - s C~- C w
Ground -S 7. S v,2 4/3 Stu, M vv 'VZ Depth to - R Y9 4 14- 5 A r -
limiting
fac
Remarks:
Boring #
K
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
a \ / o,eTu
130
~ \
~i 01%
N~A $3
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER Z CMG fe.- «"f
MAKING ADDRESS 9 ~ 4y., e / 4cle • /7 ~S~r, / SSl
_245~2
opt ~Onc N~ri
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE All 5 4~Oi 6
PROPERTY LOCATION S4 1/4, _ y 1/4, Section T_02.2_N-R o2.b W
TOWN OF /(/ari /`7~Clc~3G77 ST. CROIX COUNTY, WI
SUBDIVISION ..5~( Co,-,e' LOT NUMBER
1113 /-57-5
CERTIFIEDSURVEYMAPSa6`,1/1/ ,VOLUME/1tM9,PAGE4,LOTNUMBER_ 3
-19W *vIr
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 expiation date.
SIG mac'
DATE: Z YS'
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
8 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 of property. 4-,7e L.
Location of property fF 1/4 ` kv-' 1/4, Section / ,T_,:?.,9_N-R_ `DW
Township Mailing address /7j ,00Orr / /9c e. .
Address of site ~fo7so„ ~vnc /Ut, r/uc+~sry,, SS~O/6
Subdivision name -574. Lot no.
Other homes on property? Yes X No
Previous owner of property _j~lno Lais6r,
Total size of property - / 3 air<s
Total size of parcel _ /..3 acr~_s
Date parcel was created
Are all corners and lot lines identifiable? ~C Yes No
Is this property being developed for (spec house) ? Yes No
Volume 1113 and Page Number /.~3 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.
II
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. y``-a 6z11<1 , 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.
S' nature A lica -
q pp cant Co A
Picant
102 /3~5 -~~-9
D to of Signature Date of Signature
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DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA
WA.VqAATY D)ED.
VOL Ill lrw D3
52641
REGISTER'S OFFICE
This Deed, made between ST CROIX CO., WI Rec'd for Record
Timm 4thv J . Larson, a/k/a Timothy MAR 2 1995
John Larson . Grantor,
and Lawrence J Larsen and Jean L Larsen at 10:00 A.M
Husband and Wife Survivorship y
Marital Property "W,-
ter lL ofDeeds
Grantee, x--.~..-_-.--
Witnesseth, That the said Grantor, for a valuable consideration
RETURN TO
conveys to Grantee the following described real estate in St . Croix (10
County, State of Wisconsin: (rJ/ S~0/6
F
Tax Parcel No:
Lot 3, St. Croix Station in the Village of North Hudson
St. Crois County, Wi.
,I
Y"RAII ` FEb
15(. o0
1-:EE
This is noL homestead property.
(is) (is not-)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And Timn yJ T arSQn
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
and will warrant and defend the same.
Dated this 23rd day of February , 19 95
(SEAL) (SEAL)
-(SEAL) / (SEAL)
Timothy J Larson a k a Timothy John Larson
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF Wttef) c N
Ss.
County. ~s
authenticated this day of 19 erso ally came before me thci,~s,~ day of
19~the above named
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the person
authorized by § 706.06, Wis. Stats.) foregoing instrument and acknowled~ '
THIS INSTRUMENT WAS DRAFTED BY
Charles E.G. Larson Sr.
r
•Notary Public --County,-A4s~
(Signatures may be authenticated or acknowledged. Both My Co ssion is per anent. (If not, state exp ation
are not necessary.) date: 19 Q0
'Names of persons signing in any capacity should be typed or printed below their signatures.V SB1 NTF 0020
WARRANTY DEED STATE BAR OF WISCONSIN Nelco Forms. P.O. Box 10208, Green Bay, WI 54307-0208
FORM No. 1-1982