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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
/'e-
ADDRESS--Z2 O
A
o,
SUBDIVISION / CSM# LOT #
SECTION T~N-R_Z4W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDICATE NORTH ARROW
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Provide setback and elevation information on reverse of this form-
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: 5e a:;<,-
ALTERNATE BM•
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: i' - D-7 Liquid Capacity:
Setback from: Well House !gyp / Othe?/,S?~
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: o~ Length Number of trenches
` ,
Distance & Direction to nearest prop. line:
;zS
Setback from: well: am House
/'to Other /,}y e-/70~
ELEVATIONS Building Sewer ST Inlet.ST outlet
PC inlet PC bottom Pump Off
Header/Manifold S % Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION: PLUMBER ON JOB: '
LICENSE NUMBER:
INSPECTOR:
3/93:jt
s ~
Wisconsin ,DepartmentofIndustry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION
Wit Holder's Na ❑ City Village 11j Town of: State P l
CST BM Elev.: Insp. BM Elev.: BM Description: X Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 4 617_ Benchmark Zoo,
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
TANK TO P/ L WELL BLDG. Airl to ntake ROAD Dt Inlet
Septic 150 / ~lb6 l 'go, NA Dt Bottom
Dosing NA Header/ Man.
Aeration NA Dist. Pipe d~3(o q5-,&q
Holding Bot. System q, a y 9q,
PUMP/ SIPHON INFORMATION Final Grade '
Manufacturer Demand
/06/S
Model Number GPM
TDH Lift Friction System TDH Ft
Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length s , No. Of Tr hes PIT No. Of Pits Inside Liquid Depth
DIMENSIONS 5- 1 DIMENSIONS D
Manufacturer:
SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING
INFORMATION TypeO " , r CHAMBER Mode Number:
System: 7jOb /~/D /CJU/4 OR UNIT
I If"
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 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: Erin Prairie.4.30.17W, SW,NW, 170th Street
` ~ xa
i {py~
® I{
Y
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. 9g (u'," ' Al
Rokdd
SBD-6710 (R 05191) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
.
i ea
SANITARY PERMIT APPLICATION
n
In accord with ILHR 83.05, Wis. Adm. Code COUNTY.` Iv d
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ~t) / p J5
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
/ Y4 JO/ 4, S T, N, R E (or
PROPERily NER'S MAILING ADDRESS - LOT # BLOCK #
I---
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
CITY NE E T RAD
II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE r]~i f J ~
TOWN OF: 1
EL TAX NUMBER(b) / v
❑ Public 91or2Farn.Dwelling-#ofbedrooms PARC
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
50 Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1.0 New . X Replacement 3. ❑Replacement of 4.0 Reconnection of _ 5. El Repair of an
2
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 4Seepage 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
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) EL VATION
6'-13 clIv, Feet O Feet
1 6Vff /1
0
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plum ignature: (No Sta P MP/MPRSW No.: Business Phone Number:
1,-An i r S' ~1l-"~d1~
Plumbe Address (Stye t, City State, Zip Coddr
IX. COUNTY/DEPARTMENT USE ONLY
L] Disapproved Sanitary Permit Fee (includes Groundwater a e ssue Issuing Agent Si n ps)
U Surcharge Fee)
KApproved ❑ Owner Given Initial / Q/1 11 f, . ~j
Adverse Determination Q V
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(8.08/93) 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.
11. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling.
111. 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 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, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
PLOT PLAN
PROJECT Michael Kelly ADDRESS 1777 170th St. New Richmond Wi 54017
SW 1/4 NW 1/4s 4 /T 30 N/R 17 W TOWN Erin Prairie COUNTY ST. CROIX
MPRS BYRON BIRD JR. 3318 DATE 11/1/94 BEDROOM 3
CONVENTIONAL XXX IN- ND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 648 BED SIZE 12'X54'
BENCHMARK V.R.P. Base of BOX Elder Tree ASSUME ELEVATION 100'
❑ BOREHOLE (DWELL *H.R.P. Same as Benchmark
VFNT SYSTEM ELEVATION 94.8
12" GRADE
VERING Well
12" IM 2'
i K 4S'
3 Bedroom -.a I
54' 24' House
Sewer
Line
60'
Driveway 4/
T
Failed System Area OF,ailed System Area
170th St. M.
30'
36' 45'
2'
B-1
I 3%
55' I Slope
Vent I
B-2 20'
B-3
400' to
Property
Line
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
A
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently
serving the z~'C'~~ ~e residence located at:
1/4, ~1/41 Sec. , TN. RTown of
r
Upon inspection, I certify that I have found the
tank and baffles to be in good condition, and it appears to be
functioning properly.
c
Last time serviced
Did flow back occur from absorption system? Yes,.X-,No (if no, skip
next line)
Approximate volume or length of time: gallons ~D -minutes
Capacity:
Construction: Prefab Concrete- steel other
Manufacurer (if known):
Age of Tank (if known):
(Si ure) (Name) Please Print
(Title) (License Number)
(Date)
Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes)
or Licensed Disposer (NR 113 Wisconsin Administrative Code)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
condition, I certify that the tank to the best of my knowledge will
conform to the requirements of ILHR-83, Wis. Adm. Code (except for
inspectio pening over outlet baffle).
Name A r--~~
Signature MP/MPRS
5/88
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of
Labor and Human Relations
Division of Safety & 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 411"_1101X
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
cjM
y e~4ellv 7e GOVT. LOT 1/4 ~1/4,S T N ,V j E
PROPERTY 0 N R':S MAILING AD SS LOT # OCK # SUBD. NAME R CS #
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE OVVN NEAREST ROAD
[ ] New Construction Use [ Residential / Number of bedrooms [ ] Addition to existing building
Replacement f Public or commercial describe
Code derived daily flow W gpd Recommended design loading rate gibed, gpd/ft2_trench, gpd/ft2
Absorption area required bed, ft2 51~511 S trench, ft2 Maximum design loading rate - ,gybed, gpd/0_. trench,
gpd/ft2
Recommended infiltration surface elevation(s) 9y~ ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable ft
S = Suitable for system CO VENTIONUAL MO D N ROUND PRESSURE AT BADE SYSTEM I FILL HOLDING T NK
U= Unsuitable fors stem S❑ S❑ U S❑ U S❑ U ❑ S U ❑ S U
SOIL DESCRIPTION REPORT
Borin Depth Dominant Color Mottles Structure GPD/ft
Texture Consistence Boundary R
Roots
Boring # Horizon in. Munsell u. Sz. Gr. Sz. Sh.Q Cont. Color Bed Trer>ch
Ground ,
~elev~
ft.
Depth to
limiting
factor
Remarks:
Boring #
:Ground.....
Depth to
limiting
ffac
Remarks:
CST Name:-Please Print r Phone: '21 ~ 47 lb
Address: J JG ~ ` y ~ ^ ,i~~~ -6!
Signature: ate: CST Number:
PROPERTY OWNER /Kd4.,a, Zz 1 SOIL DESCRIPTION REPORT Page of
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourxlary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
77 -77
57
-a r
Ground r^
I
ft.
Depth to
limiting
factor C ~5
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
Soil Test Plot Plan
Project Name Michael Kelly Byro ird Jr.
Address 1777 170th St.
New Richmond Wi 54017
M #3479
Lot Subdivision Date 11/1/94
SW 1 /4 NW 114S4 T 30 N/1317 W Township Erin Prairie
Boring O Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Base of Box Elder Tree
System Elevation 94.8 * H R P Same as Benchmark
Well
45 2
3 Bedroom
54' 24' House
Sewer
Line
60'
Driveway
T
Failed System Area O; ailed System Area
M.
30'
36'
170th St. 12'
3%
55' Slope
B-2 20' B-3
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
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 Gil
Location of property,,5/~e,/l/4 1/ , Section, Zj N-R(fq57
Township /0111ey Mailing address Z, 7 ?7 G~
Address of site
subdivision name Lot no.
other homes on property? Yes_, No
Previous owner of property
Total size of property ~o ~y rs
Total size of parcel _ ~a marts
Date parcel was created
Are all corners and lot lines identifiable?/ Yes No
Is this property being developed for (spec house) ? Yes _,Z No
Volume :t-2 7 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. GO 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.
- 5, -'9 ~
Signa ure f Appl ca t Co-Applicant
L)J,? e Col L~
Date of Signatur Date of Signature
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
/
OWNER/BUYER
MAILING ADDRESS
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION 1/4, 1/4, Section T_,Z4f N.-R. W
TOWN OF1 ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
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: .f i lqq q
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
STATE BAR OF WISCONSIN-FORM I
DOCUMENT NO.
r WARRANTY DEED
32860 VOL 587 PACE l5 0 THIS SPACE RESERVED FOR RECORDING DATA
- - - - - ---i REGISTERS OFFICE
I;
THIS DEED, made between Marvin W. Anderson & Erma K._ ST. CROIX C0.. WIS.
_ Anderson, husband -_and_wife as join-. Recd for Rerord th1s_12th.
AU0ft---A.D.1975
- -te--n---a- - nt- s - - - . - - Gran-tor daY af__
I
and Michael J. Kelly. & Car~L_ce11X_F._husband t_.fi:3A
and wife as _ joint tenants
Grantee,-
Witneeeeth, That the said Grantor for a valuable consideration Qne _ Ragtstar Of Deedt:
Dollar and-other valuable consideration
CROIX
_ _ -County, RETURN TO L R REINSTRA
conveys to Grantee the following described real estate m.._.. ST
State of Wisconsin: 127 W. 2nd Street
.i
New Richmond, WI
Tax Key
This is not--homestead property.
i
A parcel of land located in the SW 1/4 of the NW 1/4 of Section 4,
Township 30 North, Range 17 West, Town of Erin Prairie, St. Croix
County, Wisconsin, described as follows: Commencing at the NW corner
of said Section 4; thence South 00 42' 30" East (true bearing)
1096.40 feet along the West line of said NW 1/4; thence North 870 44'
10" East 33.01 feet to the point of beginning; thence North 87° 441 10"
East 330.00 feet along an existing fence; thence South 00 42' 30" East
198.07 feet; thence South 870 44' 10" West 330.00 feet; thence North
0° 42' 30" West along the Easterly right-of-way line of an existing
J
town road to the point of beginning.
Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining;
And antors E l~lr
G-r-
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except and will warrant and defend the same.
Executed at -V+ebstorp'AS _ this _ - day of August: 1o 75
SIGNED AND SEALED IN PRESENCE OF ('SEAL)
% Marvin W. Brso__n
(SEAL)
d~yce Jacobso '
Erma F. Anderson.
(SEAL)
Vicki Petersen
(SEAL)
Signatures of
authenticated this 'f I't
Title: Vember State liar •,f Wisconsin r Other Par:,,,
Authors, ed vn(I- S,•c. 7ch 06 vii. - - -
STATE OF WISCONS!N
Burnett August 1975
Pers,pally ''ame bct r,.. 9th v ,t ,
the above named .:arvin nderson and Erma K. ••nderson -
Jj/^
to me known t., be Ih,• k „i,. j. r,.• ,n ~ n• ,r l k ~e,~s;, d the ti . /
This instrument was dr ! - ila-rbara D. Creaghe
L. R. REIfi,STPJ~, tt", ney r3urnett (7-tity. wis.
r P-ih111
New ; Richmond, S:'T 17 T3 L~ • . June 17s . 19'T9
The usr.)f wRnes!>es is ,.)pt1~.n.,'. %1v C"mmtsst n 'Expires) 'i
Names of Irerons stgntng in in .hyald be tvped or Printed below their signatures. ~ewut,,co^ro.,w~
. -
WARRANTY: DEED-STATE BAR N!sc-utitif?7-, FORM NO t - 1971