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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER e` /t,,Ga z a / A- Y" 6lP~'IGIJV~~' "
ADDRESS q? -1,F,
SUBDIVISION / CSM# LOT
SECTIONT N-RW, Town o f IJ~~vrL GC~lx7
ST. CROIX COUNTY, WISCONSIN
PZ
PLA9 VIEW
SHOW EVERYTHING WI IN 100 FEET OF SX TEM
foo
e•
i
INDICATE NORTH ARROW
I
Provide setback and elevation information on reverse of this form-
Provide 2 dimensions to center of septic tank manhole cover-
t
BENCHMARK: A -c-e- "!57 J~i'7~P S /-P l~ .~t_ k
ALTERNATE BM:
jJ d ~/~p ~►,/1 L~ ~fi J~ /i
SEPTIC TAN / MP CHAMBE HOLDING..TANK INFORMATION
Manufacturer: Gyee_Liquid Capacity:
i
Setback from: Well/e0 House Other
Pump: Manufacturer Modell Size ,
_
Float seperation '~7-- Gallons/.cycle:,0y0
Alarm Location .-ten S i CY~i I'✓~
SOIL ABSORPTION SYSTEM
Width: ,3 5 Length ~ Number of trenches j ~X~ oe
Distance & Direction to nearest prop. line: ~~_SzL
r
Setback from: well: House Other
ELEVATIONS
Building Sewer 7 6a ST Inlet.
ST outlet 6
PC inlet "705
PC bottom Pump Off
Header/Manifold -~aC*;~ 1 _ Bottom of system 04
Existing Grade w Final grade
DATE OF INSTALLATION: f^
PLUMBER ON JOB:
/~j`J~.-~
LICENSE NUMBER:
INSPECTOR:
3/93 : j t
Wisr,onsinFepartmentof Industry, PRIVATE SEWAGE SYSTEM County:
Labor J`ndlfumaX Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan o-:
FIRST NATIONAL BANK OF GLENW D _ _
GLENWOOD CST BM Elev-: Insp. BM Elev.: BM Description: Parcel Tax o.
TANK INFORMATION iLEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
7-
Septic S f'i ! Benchmark b 00,
Dosing g, DOG , J 06
Aeration Bldg. Sewer 07,
7
Holding St/ Ht Inlet 7 a g ~/7r / {
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Aenttake ROAD Dt Inlet to ~3
Septic NA Dt Bottom 61
Dosing Tc l ~g o' ~(Y > U' NA Header / Man.
Aeration NA 11 Dist. Pipe
Holding Bot. System s /0q,
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand ;q I r
Model Number ( ' GPM (f~~,y_,~, oi 10,6' T
TDH Lift Friction 3 Systems TDH 1,1s Ft W
Loss Head
Forcemain Length Dia. a Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width , Length No. Of Tr ches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS y DIMENSIONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM
INFORMATION Type O , , CHAMBER Model Number.
System: / Gk,- > 100 aaL~' ~Tr OR UNIT
DISTRIBUTION SYSTEM
Header/manifold Distribution Pipes x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. ?JU Length 4qL Dia. I I Spacing I L ? ,`l1 D
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over p xx Depth Of (o , xx Seeded / Seeded- xx Mulched
Bed /Trench Center ~g Bed /Trench Edges Topsoil U- Yes ❑ No ( es ❑ No
COMMENTS: (Include. code discrepancies, persons present, etc.)s 5.1
LOC~iIION: GLENWOOD 16.30.15.264,Nt,SE,300TH ET
c l 1I
<l , r f 'V
-fat
Delp :1) Aj
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. ( [77 l- ' a (o
SBD-6710 (R 05/91) Date In pedor's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH ,
SANITARY PERMIT NUMBER:
i
L,
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(4 J
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SANITARY PERMIT APPLICATION
■
1`■'■Itre In accord with ILHR 83.05, Wis. Adm. Code COUNTY '
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 a a.t~ bs
8% x 11 inches in size. Check if revision to pre,/ious application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. S 9 6 ~_3
PROPERTY OWNER - a PROPERTY LOCATION ~r
S T -fdN, R JJ E (o
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
y ic~a_ .
ITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
/ wo S &-2 13 1(2 S / - -
II. TYPE OF BUI DING: (Check one) ❑ State Owned VI AGE / w o Neg~tES Rgnp
TOWN OF: 6 1
EL TAX NUMBER(S) `~U~ v
❑ Public [91 or 2 Fam. Dwelling-#~ of bedrooms 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
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check my one in line A. Check line B if applicable)
A) 1. ❑ New 2. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.E1 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 E~ 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 (s . ft.) PROPOSED (sq. ft.) (/Gals/day/sq. ft.) (Min./inch) y ELEVATION
s eet
he)
CJ~~V 3 7 ~j 7 S- /o/ JFeet
VII. TANK CAPACITY Site
in altons 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): Plumber' ignature: (No Stamps) ti MP/MPRSW No.: Business Phone Number:
7~ a
9 jr-
Plu er's Address (Street, City, State, Zip Code :
L
1X. C NTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Ag t Signatu
Approved F-1 Owner Given Initial Surcharge Fee
Adverse Determination TI nJ 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 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)
w
PLOT PLAN
PROJECT First National Bank of Glenwood ADDRESS 204 E. Oak St. Glenwood City Wi 54013
NE 1/4 SE 1/4S 16 /T 30 N/R 15 W TOWN Glenwood COUNTY ST. CROIX
MFRS BYRON BIRD JR. 3318 y t DATE$'1/94 BEDROOM 3
CONVENTIONAL IN-GROUN RESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND XXXXX SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE 800 Gallon
HOLDING TANK SIZE LOAD RATE 1.2 ABSORPTION AREA 375 BED SIZF, 8'X 47'
L BENCHMARK V.R.P. Base of White Stake Red Ribbon ASSUME ELEVATION 100'
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
SYSTEM ELEVATION 104.5
Scale = 1/4 inch = 20 feet
Note: Old System to be
Properly Abandoned
Note: Mound will be Note: >200' to 300th St.
Placed on 11 % Slope from House
3 Bedroom
House
Note: Basal Basal Area=1300ft^2
Area to be left -1 LB•M• S SyOld
stem
undisturbed Area
B-2
B-3 Driveway
Q Well
1V'
s4~a f'~ x' 3001h St.
r~
Property Line
V,
cc{'
894 30773
• _ , t Page Of
Distribution Pipe D, ail For A Aw Lateral Network
d a
Alternate Position Of .
Force Main
PVC Distribution Pipe PVC Force Main
P
Holes Equally Spaced
PVC Manifold Pipe On Bottom
X
S
1 X
X 2
* Last Hole Should Be Next To End Cap
* Sq4
Y P~Ft.
~-S ? j Ft.
X Inches
Y Inches
l
Signed: Hole Diameter Inch
License Numbe
~Lateral Diameter ~Z Inch(es)
Date:
Manifold Diameter _ Inches
Force Main Diameter c2 Inches
# Holes Per Pipe
Invert Elevation Of Laterals Ft.
f 0_r) 1 5-
t `
Page Of
Straw, Marsh Hay, Or
Synthetic Covering
Distribution Pipe
6" Topsoil - H c
3 E p
% Slope
Bed Of 22 Force Main
z Plowed
' s Aggregate
Layer
(6" Below Pipe)
D Ft.
NCO
. Cross Section Of A Mound System Using Ft.
F -Ft.
A Bed For The Absorption Area t.
~ ~ L..
G ,~eQ Ft.
Si ned. A Ft. H
J __Z,5-Ft.
B ~7 Ft.
License Nu er:
K
Date: L Ft.
J ?F~ Ft.
I i r' i Ft.
WJ. J Ft.
L
J Observation Pipe--,
B K
A I
o -
W
- ( Force Main
7- 1
Distribution
Bed Of i - 2 2
Pipe
I Aggregate
Observation Pipe Permanent Markers
A~9~ 3077Plan View Of Mound Using A Bed For The Absorption Area 3
t PA(-,F (;F
! PUMP CHAMBER CROS5 SEC T IOIJ ANG SPEC IFICATIOki S
VENT CAP
4' C.I. VENT PIPE
WEATHERPROOF APPROVED LOCKIMG
25' FROM DOOR, JUNCTION BOX MANHOLE COVER
WINDOW OR FRESH 12"MIU.
AIR INTAKE I ~fJctic L ls~
GRADE
41
y.. MIN.
COUDUIT 18"h111J.
19"MIN. ~
IAILET PROVIDE
AIRTIGHT SEAL I l i
* A I I*~
v"As
k) w" ALARM
l
*
C APPROV I I ON
ELEV. FT wI~TH i I
APPI~~SVED PIPE
V ONTO PUMP,' OFF
D SOLID SOIL
PROPERLY E CONCRETE BLOCK
ILHR 83.
ANCHOR ~gly IT PERMITTED ONLY IF TANK MANUFACTURER HAS SUCH APPROVAL
r KS AS NECESSA
4//a"S-
SEPTIC wR83.15(4)(b) WAC SPEGIFIGATIOUS /~,-,eX-,,Cro:vo2 (1C
DOSE
TANKS MANUFACTURER,- _Gt~•P.-~ C"C ~
NUMBER OF DOSES: PER DAS
TANK SIZE Lo D GALLONS
n / DOSE VOLUME
ALARM MANUFACTURER: INCLUDING BACKFLOW:
GALLONS
MODEL NUMBER' t~
CAPACITIES: A-.cIkICHES OR , ~ GALLOWS
SWITCH TYPE; I P ~1• ~ C'c..,(DY.~~
PUMP MANUFACTURER: -INCHES OR /(L GALLONS
C INCHES OR .L7"s~. GALLONS
MODEL NUMBER:
SWITCH TYPE; 1 /-r D--t INCHES OR GALLONS
MOTE: PUMP AND ALARM ARE TO BE
MINIMUM DISCHARGE RATEGPP1 INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE., O-L
+ MINIMUM NETWORK SUPPLY PRESSURE . . FEET C9 4
+ FEET OF FORCE MAIN X F>/ =-2,.5--~- FEE 3 0 7 h
loo FT.FRICTIOU FACTOR. FEET l!
TOTAL DYNAMIC. HEAD FEET
INTERNAL. DIMEWSIOAIZ OF TANK: LENGTH
;WIDTH +;LIQUID DEPTH
LICENSE NUMBER: / DATE:~1
r M n -C~'J~►r'Y"Y Cl1 FiV E
i to
W t
F-
W
30
TOTAL DYNAMIC HEADICAPACITY PER MINUTE
EFFLUENT AND DEWATERING
SERIES 53 55 57-59 i►7 177.139 t~
28 165
M LTRS LTRS LTRS LTRS
_ LTRS
EFFLUENT ANDDEWA7ERING 1.52 163 78 391 231
231
3.05 129 276 300 231
4-57 72 163 242 22,
z_7 227
26 5 \ SEWAGE AND DEWATERING 6.10 101 1 136 36
2i3 227
\ Z62 30
~p. 216 223
24 9.11 2(
\ _ - 220 1-2 206
15.21
- L 191 \ i
'
22 q 1829
_t 161
21 34
24 38
4 MODEL\\ MODEL I Loclx vatie: 19' 215' 2, S7
20 651. 163 ` 165
!611 ` I \ i TOTAL DYNAMIC HEAU'CAPA CITY PER MINUTk
SEWAGE AND DE WATERING
SERIES 267 26! y,p
18
2>q
1d- LTRS L7 As LTRS lu1$ LTRS1
i \ \ 1.52 IOB 366 192 4 p..
3 - _6bt
16, I j 3.05 227 273 360 _ 59y
JO 11 I 4.57 76 163 ?3A 11
a< r 6.10 30 125 101
r \
\ II 762
14
^ 9 11
29?
\ 10 67 x - k10 227
.x \ 12.19
,N 46 174
12 yQ. , / 13.72 _ 106
15.21 45
MODEL 1.Yalve: 21i' 35' 53'
35
10 ` i 293
30 ~ ~
8 MOD LS %
4 37
6 Zp
MODEL
5 284
MODEL MODEL
282
2 MODELS
• 53, 55,
59 MODEL- MODEL
57,
U S: r. •H-.: 20 a30 40'° 9 267
60 70 N' ,
-GALS r1Qr`" ,50,E ~~M~tggk*gp7 100 11.0'120' 30 _140-A50.160,'
1170:;.18p
LITERS 80 t ~ - t=!s~4,'r»ma1,.,rr'r ;r~,.L,•-~a
160 240 320 400 480 560 640 650
FLOW PER MINUTE S94 30773
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3260 Old Millers Lane
v Q~LL~e-,Q' P.O. [lox 16347 hfdllL'i3clUlel5 Ol...
Louisville, Kentucky 40216
(502) 778-2731
8
wr. sin Human Department Relations Industry, SOIL AND SITE EVALUATION REPORT P
L; end age _ Of
r vision of0afety d Bulldings in accord with ILHR 83.05, Wis. Adm. Code
lt~
COUNTY
t
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but ro
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCE 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
fa c.Jt1t7C GOVT. LOT 1/4 1/4,S T 30 N,R E (o
PROPERTY OWNER':S MAILING ADDRE LOT # BLOCK # SUBD. NAME OR GSM # Sk -.1 1 0_~
Ct
CITY, STATE _ZIP CODE PHONE NUMBER CITY ❑VILLAGE OWN NE REST RO D
Y2, 16, a.;, o c
[ ] New Construction Use Residential / Number of bedrooms [ ] Addition to existing building
jD. Replacement [ Public or commercial describe
Code derived daily flow gpd Recommended design loading rate 7 bed, gpd/ft2 2 trench, gpd/ft2
Absorption area required, bed ft2 3/s trench, ft2 Maximum design loading rate Z bed, gpd/ft2-/ Z trench, gpd/ft2
Recommended infiltration surface elevation(s) /d % ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM I FILL HOLDING 1U
U =Unsuitable fors stem ❑ S ~ ET S ❑ U ❑ S U ❑ S Z U ❑ S ~ U ❑ S U
SOIL DESCRIPTION REPORT
Borin # Horizon Depth Dominant Color Mottles Structure GPD/ft
g Texture Consistence Baxtcry Roots
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
4 v r 3JZ
Ground 0 J Sr
elev. -51
ft.
Depth to
limiting
'
factor
Remarks:
Boring #
O' r3 z 5; rn In-6, C'S i ~1~
J_ IdZZ
Ground A
elev.
/O~dft.
Depth to
li
miting
307
jactor , _r -
7T
Remarks:
CST Name:-Please Print Phone:
Address:
~ Pr' Gtr ~ ~ O
Signature: Date:
CST Number:
757
(as/so'a)QCWGIs
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~t Soil Test Plot Plan
Project Name First National Bank Glenwood
1 Byron Bird Jr.
Address 204 E. Oak St.
Glenwood City Wi 54013 _
CS-t'3479
Lot Subdivision Date 7/14/94
NE 1/4 SE 1/4S 16T 30 N/R 15 W
Township Glenwood
Boring O Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Base of White Stake Red Ribbon
System Elevation 104.5 * H R P Same as Benchmark
0
r
0
v~ o
100' 33 40' B-1 15' *B.M. 180'
>20% Slope 3
36' 45' 11% Slope Bedroom
104' House
8 Note: >200' to 300th St.
B-2 from House
Driveway
B-3 • Well
894 30773
v - ~ t
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER 1= 5 NA ey\cj, Ij'` e,r G (-e44 , tO e od
MAILING ADDRESS ~c 4 Ci S f- C~~ G, a
PROPERTY ADDRESS (S 3 (o~5 S+ C~ ( K w f C c Cam, tii S ~G/ 3
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE r
PROPERTY LOCATION 1/4, S 1/4, Section N-R (S W
TOWN OF i ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER ,
CERTIFIED SURVEY MAP , VOLUME O' 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 ear expirat' n date. ' )f
SIGNED: , uk) ` .
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
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 C-c Y sf NC'jS6T"S of
Location of property L 1/41/4, Section ((p ,TyN-R SSW
Township _ ;(e.y, LAj 61) cI Mailing address 3C' ~x--O-t~ S~
GI ~ cu~ti~ cQ
Address of site
Subdivision name jU 0 r-L-0 Lot no.
Other homes on property? Yes LANo
Previous owner of property
Total size of property
Total size of parcel 2~2_A
Date parcel was created 93 (da-Ze 1 t ~~~C /~I~ZC£~l)
Are all corners and lot lines identifiable? ✓Yes No
Is this property being developed for (spec house)? Yes "o
Volume ALL- and Page Number g S~ 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.
~I
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, he office of the County Register of
Deeds as Document No. 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 of Applicant Co-App icant
Date of Signature Date of Signature
D%_J%A-TWNT NO. 2UIT CLAIM DEED,. 'E ORESWEPY
~.i
499651 0l ~1~ G~ 285 ST. CROIX Co., M
Rec d for Record
RICHARD J. KLINEFELTER and AUDREY A. KLINEFELTER, MAY 2 6 1993
jointly as Husband and Wife, quit-claims to FIRST NATIONAL at 8:30 A.M
BANK OF GLENWOOD, a National Banking Corporation the
following described real estate in ST. CROIX County, State of PAOSW
Daft
Wisconsin:
RETURN TO: Bakke Norman, S.C.
Baldwin, Wisconsin
Tax Parcel No: 0/4!(- /d 3 6-t/
The North Half of the Southeast Quarter (N 1/2 of SE 1/4); and the
Southeast Quarter of the Southeast Quarter (SE 1/4 of SE 1/4); all in Section
16, Township Thirty North, Range Fifteen West. 16-30-15
also
Parcel 1: the Southwest Quarter of the Southeast Quarter (SW 1/4 of SE
1/4) of Section 16, Township Thirty North, Range Fifteen West.
16-30-15
Parcel 2: the Southeast Quarter of the Southwest Quarter (SE 1/4 of SW
1/4), of Section 16, Township Thirty North, Range Fifteen
West. 16-30-15, all in St. Croix County, Wisconsin.
F
ELF . '
This is homestead property.
f
Dated this / _3_ day of 1993
cY (SEAL) (SEAL)
'Richard J. Klinefelter •
SEAL) (SEAL)
'Audrey A. mefelter •
AUTHENTICATION ACKNOWLEDGEMENT
Signature(s) of STATE OF ISCONSIRN }
) ss.
Sr. CROIX COUNTY }
authenticated this _ day of -19 Petsonally came before g~gg his day
o
t, 4L r . t( 1 0 . the above named
✓l
y-
VfAw
TITLE MEMBER STATE BAR OF WISCONSIN to qy k+•bt Op'pbodpr who executed the foregoing
(If not, i t~] 45g k' d acknow• gaol tue same.
authorized by § 706.06, Wis. Stats.)
Zo .
CV THIS INSTRUMENT WAS DRAFTED BY: +r
Notar f~'61icG County, Wisconsin
BAKKE NORMAN S.C.
BALDWIN, WISCONSIN My Com 'ssion ~s ~e anent' Of not, state expirab*qn date:,.
10 S 8 19
I
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
ST. CROIX COUNTY GOVERNMENT CENTER
• _ 1101 Carmichael Road
- - Hudson, WI 54016-7710
(715) 386-4680
September 9, 1994
Patti C. Robertson
Asst. V.P./Loan Officer
First National Bank
204 E. Oak Street
Glenwood City, WI 54013-0338
Dear Ms. Robertson:
On September 1, 1994, a sanitary septic system was installed on the
property located at the NE 1/4 of the SE 1/4, Section 16, T30N-
R15W, Town of Glenwood, St. Croix County, Wisconsin.
The replacement mound was installed by Byron Bird, Jr., MPRS03318,
inspected by this office, and is a code complying system.
Should you have any questions, please contact me.
Sincerely,
Mary J. Jenkins
Assistant Zoning Administrator
cc: File
FIRST NATI O NA BANK
ST
DG GLENWOOD
204 E. Oak Street
Box 338
Glenwood City, WI 54013-0338
Ph.: 715-265-4211
FAX: 715-265-4388
September 7, 1994
Zoning Office
St. Croix County Government Center
1101 Carmichael Rd
Hudson, WI 54016
Attn: Marilyn:
The First National Bank of Glenwood had had a septic system installed in the NE 1/4
of the SE 1/4 of Sec 16, T 30N R15 W, in Glenwood Township. Could you please send
to this office an inspection letter noting that the system was installed and that it met all of
the codes at the time of installation.
I appreciate your time on this. If you have any questions feel free to contact me.
Si rely,
Patti C. Robertson
Asst V.P./Loan Officer
PCR:wmc
S
J
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE.
~r1 s ■ ■ rnri ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
,
Hudson, WI 54016-7710
(715) 386-4680
December 21, 1993-'~
First National Bank
204 East Oak Street
Glenwood city, WI 54013
Attn: Patti Robertson
Dear Ms. Robertson:
An inspection of the septic system serving the property located at
1536 - 300 Street, Town of Glenwood, St. Croix County, was
conducted on December 15, 1993. A water sample was also collected
to test for the presence of coliform bacteria and nitrate
contamination.
Our records do not date back to the time this septic system was
installed, so it is impossible to determine what the system
consists of or how large the drainage area may be. At the time of
the inspection, no vent pipes were visible, and what appeared to be
the septic tank (cover) had been covered with a large wooden
object, preventing inspection. With no written documentation and
the lack of visual evidence, it is not possible to determine
whether the system is properly functioning at the present time, or
how soon the system will fail completely.
Should you have any questions, please feel free to contact me.
Sincerely,
Mary J. Jenkins
Assistant Zoning Administrator
a
• i
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
ST. CROIX COUNTY COURTHOUSE
1 / ~Qrm -QeJ • HUDSON, W1,54016
(715) 386-4680
SEPTIC INSPECTION / WATER TEST REQUEST FORM
Specify desired test(s) & remit appropriate fee with application.
Outside water lines are often turned off during winter months,
making access to the home necessary. Please make arrangements with
this office to insure a time when entry can be gained.
❑ Water (VOC's) $185.00 1q Septic $25.00
X Water (Nitrate & Bacteria) $35.00 Visual inspection)
Owner: lpys{- C~,(- 61(,_ylujnG~ Requested
„ .
Address: ~q n" Address:
City & State:
f /L rs>cV City & St.
Zip Code: q01 Zip Code:
Telephone N°: (Z[) Telephone N4: ( )
Property address (Fire N4 & Street) : IS 3CP ,_?CD14\ Sfr-e e~-
Location: j, G Sec. , T 3o N, R S W, Town of 61ej rya
St. Croix Co., WI. Tax ID W Parcel ID N4 0& -/a 3h_ efo
House color: Vj& Realty firm: Lock Box Combo:
Water sample tap location: 4ic t;rv o f PlekSa Saute 5icu ov r fe4 zr of kX11--11
TO BE COMPLETED BY PROPERTY OWNER
*PROVIDE A SKETCH ~OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS
Is the dwelling currently occupied? X Yes ❑ No
If vacant, date last.occupied: _
Septic system installed by: ay1 Year':
Septic tank last serviced by:i ~ Date:
Previous Owner's Name(s) :
Hav any of the following been observed?
❑N Slow drainage from house.
Y ❑N Sewage Back-up into dwelling.
❑Y ❑N Sewage discharge to ground surface,
road ditch or body of water.
❑N Slow drainage from the dwelling.
Y ❑N Foul odors.
Ot er comments relative to system operation:
I certify that the above informat, is complete and true to the
best of my knowledge.
DATE : i J
OWNERS SIGNATURE: 11V\
&A, ~ p
i
OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION
(N 7
n.e.,cJ
TO BE COMPLETED BY INSPECTION AGENCY
System design &/or permit on file? ❑Yes ❑No
Soil series per SCS Soil Survey: sheet #
Type of soil absorption system: OBelow grd 0At-Grd ❑Mound
Approx. size- 'X OGravity ODose ❑Pressurized
Ft.: ❑Bed. OTrench ❑Dry Well
❑Holding Tank ❑Outfall pipe
OBSERVED DEFICIENCIES OOther OUnknown
Septic tank
Setbacks:.OHouse_. OWell OProp. line 00ther
Dose tank
Setbacks: OHouse.OWell._. OProp..'line. 00ther
.OLocking cover OWarhing label OPiimp/Floats -
OAlarm ❑Elec. wiring
Soil Absorption System -
Setbacks:. __OHouse _OWell OProp. Tine 00ther
❑Ponding: ODischarge:
General comments:
INSPECTORS SKETCH OF'SYSTEM LOCATION
N
Inspector
Title
ST. CROIX COUNTY ZONING OFFICE
St. Croix County ;Courthouse
911 4th Street
Hudson, WI 54016
Telephone - (715)386-4680
The St. Croix County Zoning Office offers the service of septic
and water inspections to Lending Institutions, Realty Firms, and
private individuals.
Completion of this form I& Hspent~ RQ that =g property can hg
located.
Please provide the following information, enclose appropriate
fee made payable to St. Croix County Zoning Office, and mail,
along with form to the above address. Testing will be done as
soon as possible after fee and form are received.
WATER TESTING----------------------------FEE: $ 35.00 V
(For nitrates and coliform bacteria)
WATER TESTING FEE: $185.00
(For VOC'S) /
SEPTIC SYSTEM INSPECTION----------------- FEE: $25.00
(Determines if system is properly functioning at.-time of
inspection) I,.
PROPERTY OWNER'S NAME : F~ ~ F tJf I ~ - 614 W" d
PROP. ADDRESS: (S ~C 3C-0i`' S r-,ee+ CITY 6k,'A t~ 6& ~t ~I
Legal Description 1/4 of the _ 1/4 of Section , T-N-RCS
Town of u c Lot Number subdivision: 12
FIRE NUHBER IS ~Cp LOCK MK JjUMJjKR We)",
Color of house'B~ %c Realty io by house? :l {'S If so, list firm:
PLEASE INCLUDE, IF AT ALL POSSIBLE, A HAP,i.e,COPY OF PLAT BOOK,
WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET.
Testing of residential water requires a sample that is fresh. If
the home is vacant, and has been so for some time, the water line
must be purged by running the water for several hours before the
test can be conducted.
WINTER TESTING: Many times water lines are turned off, or sill
cocks are turned off, making access to the home necessary. If
this is the case, please make proper arrangements with this
office to ensure time when entry may be gained.
Firm or individual requesting services:
r.
Telephone Number (Q - -2- c,
REPORT TO BE SEN
T : ~Y a~~hanc.Sr df tyLw
14(I
CLOSING DAT
signature a w• r
Pr~ a ~irv.oa,
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-0/99/ Cro/x cb'u-/
2700 2800 2900 3000 3100 3200 3300
Misty Meadows Wood
Y 0 U T H Products & Logghe Trucking
KILN DRIED PINE SAWDUST AND SHAVINGS
The American BAGGED OR BULK
• opm ' Agenda COMMODITY FEEDS
DAVE LOGGHE * JOHN LOGGHE
Business: (715) 265-4767 ❑ Fax: (715) 265-7386
Rural Route #2 - Glenwood City, Wisconsin 54013
DG FIRST NATIONA BANK.
Is;r\ GLENWOOD
204 E. Oak Street
Box 338
Glenwood City, WI 54013-0338
Ph.: 715-265-4211
FAX: 715-265-4388
i o
4 d
October 21, 1994
St. Croix County Zoning
St Croix County Courthouse
1101 Carmichael Rd
Hudson WI 54016
To Whom it May Concern:
The First National Bank of Glenwood has sold the property at 1536 300th St., Glenwood
City, WI 54013.
We had the purchaser's sign a septic tank maintenance agreement, which is enclosed for
your records.
Sincerely,
Patti Robertson
Ass't Vice-President
PR:wmc
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
( lAMUYER James Weyer, Jr.
MAILING ADDRESS 1536 300th St.,Glenwood City, WI 54013
PROPERTY ADDRESS 1536 300th St., Glenwood City, WI 54013
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE Glenwood City, WI 54013
PROPERTY LOCATION NE 1/4, SE 1/4, Section 16 T 30 N-R 15 W
TOWN OF Glenwood ST. CROIX COUNTY, WI
SUBDIVISION - LOT NUMBER
CERTIFIEDSURVEY MAP - , VOLUME 101 19 PAGE 285 , 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.
he 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 frill 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 yeaL&,xpiration date.
~~QSrird Gi~'`~
SIGNED:
James Weyer, r.
DATE: October 4, 1994
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
COMMERCIAL TESTING LABORATORY, INC.
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730
715-962-3121
800 - 962 - 5227
FAX-715-962-4030
f
f
ST. CROIX COUNTY GOVERNMENT REPORT NO.: 54635/01 PAGE i
CENTER REPORT HATE: 12/27/93
1101 CARMICHAEL ROAD DATE RECEIVED; 12/17/93
HUDSON, WI 54016
ATTN: THOMAS C. NELSON
OWNER: First National Bank of Glenwood
LOCATION: 1536-340th St., Glenwood City
COLLECTOR: M. Jenkins
DATE COLLECTED: 12-15-93
TIME COLLECTED: 3:00pm
SOURCE OF SAMPLE: Kitchen faucet
DATE ANALYZED:12-17-93
TIME ANALYZED:I2:00pm
COLIFORM,MFCC: 0 /100 mL
INTERPRETATION: BacterioLogicaLLy SAFE
NITRATE-N: S ppm
Above 10 ppm exceeds the recommended PubLif
Drinking Water Standard.
Coliform Bacteria/100 ml
Nitrate-Nitrogen, mg/L
I
T u~y
LAB TECHNICIAN*# Pam Gaiye
Q EVENpf,
WI Approved Lab No. 19sO,.,,
O >
Z6 4A t Means "LESS THAN" Detectable Level Apprav
3
PROFESSIONAL LABORATORY SERVICES SINCE 1952