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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ~LQG1.rJ C~~6 .y
ADDRESS 5/ 'g 115- j
SUBDIVISION / CSM j67~f a e LOT
SECTION T;Z I N-R Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
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BENCHMARK:
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: iG~tde "~,F-,r Liquid Capacity:_~,,Qdo
Setback f rom : We l l_ House Other
Pump: Manufacturer Modelt Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length Number of trenches /
Distance & Direction to nearest prop. line:
Setback from: well: S6' House 7 Q' Other
ELEVATIONS
Building Sewer ST Inlet. ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION: T ~ ZZ .9 S ~
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Ljabor and Haman Relations INSPECTION REPORT ST. CROIX
Safety.a6cl Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Permit Holder's Name: ❑ City ❑ Village Town o : State Plan o.:
BJORNSTAD, JOHN QA Hudson CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
04 i,~
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic %4 ? Benchmark /00,7 /v0
Dosi ng
Aeration Bldg. Sewer q<L 7y
Holding St/ Ht Inlet ~,3 9 0/y S/
TANK SETBACK INFORMATION St/ Ht Outlet L, G5 9VIa 7
TANK TO P / L WELL BLDG. AirI to ntake ROAD Dt Inlet
Air I
Septic NA Dt Bottom
Dosing NA Header/ Man.
Aeration NA Dist. Pipe 7,31 ?3. r/
Holding Bot. System 8.17 9a, 73
PUMP/ SIPHON INFORMATION Final Grade } 96,S8
Manufacturer Demand
Model Number GPM
TDH Lift Lrict n System TDH Ft
Forcemain Leng Dia. Dist. To Well
Ff
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 15 15-0 DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION TypeO 17 CHAMBER Mode Number:
System: " a8 ' >SD' ~+///4 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 I xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges w- I Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Hudson.7.29;19W, SE, NW, Lots 114 and 115
i
Plan revision required? ❑ Yes [~/No
Use other side for additional information. / Irl-f VU _ '`G•~
SBD-6710 (R 05/91) Date Insp ctor's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
I
i
SANITARY PERMIT APPLICATION
• couni,TY
• In accord with tLHR 83.05, Wis. Adm. Code
1
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 2 ) Y & P
8% x 11 inches in size. check i revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
L APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
fQ Gam%a, S T , N, R E (or) 00
,,j 57
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
S;I- /Z /"S
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISI NAME OR CSM NUMBER
Ljrr-
II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
toe
EZ TOWN OF. le"YI& C/ El State Owned ~j ❑ VILLAGE . d /~d -2 we,,
❑ Public ❑ 1 or 2 Fam. Dwelling-## of bedroom9! PARCEL TAX NUMBER( S)
III. BUILDING USE: (If building type is public, check all that apply) Q a O- l ~O
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 LJ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 80 Mobile Home Park 120 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. W New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.0 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 [9 Seepage Bed 21 ❑ Mound 300 Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 420 Pit Privy
130 Seepage Pit Pressure 430 Vault Privy
140 System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PEA DAY 12. ABSORP. AREA 3. ABSO. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
SD REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) a -(o 7 ELEVATION
CJ 7 Q Q O c ~P Feet fjr, Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
l 7-M D M n
Septic Tank or Holding Tank i _Lc~ Wild L1 1 0 El [I I El I Fj
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.
Business Phone
Plumber's Name (Print): Plumber's Signature: (No Stamps) M PRSW No.: Number:
Plumber's Address (Street, City, State, Zip Code):
l '
IX. COUNTY/DEPARTMENT USE ONLY
Issuing A ent Sig .
Disapproved Sanita Permit Fee (Includes Groundwater Date Issued No s)
urcharge Fee)
Approved ❑ Owner Give Initial M
Adverse Determination /
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 '
f
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, 6013-266-3815.
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.
Ill. 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 muse: 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
area§; 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)
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Wisc6nsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page - of
Labor and Human Relations
Divisidn df 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 sf 4-a' 't'
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
Oyu, 4:r nary 71j £ GOVT. LOT 1/4 d~ 'w 1/4,S 7 T N,R ~x(or~N
PROPERTY OWNS ':S M LING ADDRESS LOT,# BLOCK # SUBD. NAME OR CSM #
CITY, STA E ZIP CODE PHONE NUMBER CITY ❑VILLAGE OW NEAREST ROAD
0(
P New Construction Use Residential / Number of bedrooms 3 [ J Addition to existing building li
[ J Replacement [ J Public or commercial describe /t
Code derived daily flow ~O gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2 ..4 trench, gpd/ft2
Recommended infiltration surface elevations
12,111- 11- It (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable ft
S =Suitable for system CONVENTIONAL ND I ROUND PRESSURE AT -GRADE YSTEM. IN FILL HOLDING TANK
U = Unsuitable fors stem S ❑ U 0S U S ❑ US ❑ U uS ❑ U ❑ S IRt
SOIL DESCRIPTION REPORT
Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
77
}
jGround C
Depth, to
67 ' 7 S e 5 it h Ie,r s /
limiting
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Remarks:
Boring #
7. ,
ki`;:~:::;.•`•:,,;:%?? / A'?.. / ° ' l" ,J y., 2,- /v!~ %=J V I Y ` ~7 t 'j
4.4 Z ~'C y~. L- ! 1. b•-~ ltd/l. y s7 ~ ~ w .
Ground
Depth to
limiting
factor
Remarks:
CST Name:-Ple Pri t Phone: c~
G GJe
Address: /070 3 5 yti U'S o W S
Signature: a CST Number:
do~YY
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PROPERTY OWNER SOIL DESCRIPTION REPORT Page _>of
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PARCEL I.D. #
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft ,
Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench JZ T - War
Ground Z3~ S° 2 S 6'~ 9a' ✓
eley.
41,
Depth to 5 ' r G n /c v g
limiting
factor
Remarks:
Boring # [
s
Ground
-41 o4,
YT If
t
Depth to
limiting
factor
it q
Remarks:
Boring # '
V/-
G'
Ground
elev. S j®2 y S.~ ✓ .
45
Depth to
limiting
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER <,1ohn -o/Lnl5i1gj
loflo i~/~clae/16n . SA Al SAD/(
MAILING ADDRESS
3a L.
PROPERTY ADDRESS fi~~ittQoojd !L! t djdfon. I SW/ 4
(location of septic syste Please obtain from the Planning Dept.
CITY/STATE A6l 61y, //i , 5-9'01(-
PROPERTY LOCATION SE 1/4, N1n/ 1/4, Section T Z 9 N-R W
TOWN OF //UUS0AJ ST. CROIX COUNTY, WI
SUBDIVISION e- 40060, LOT NUMBER
CERTIFIED SURVEY MAP , VOLUME49S, PAGE yyS , 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 ex . ati date.
SIGNED:
DATE:
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 L7o-/i r1 ./S R AJSTA0
Location of property SE- 1/4 /V P1 1/4, Section 7 Z
, T 9 N-R /9 W
Township /7
_UdSaN Mailing address
Address of site ZoT //V-//,s' ads-in. j" S~I~IG
Subdivision name 1d4ewoodJ &ih Lot no. 91-//J-
Other homes on property? Yes No 1
Previous owner of property
Total size of property zlm/y
Total size of parcel / aem
Date parcel was created Aral,
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? x Yes No
Volume 69 and Page Number yyr 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. ~T9 Z yZ 6 , 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.
292y20
Sig ture Applicant Co-Applicant
Date of Signature Date of Signature
i
,n(gLUMLNT NO ; WARRANTY DEED II TH:i SPA-:E R. ;ERVEO FOR R`c^(1R_IINv D>rq II
s" i;ST.ATE BAR OF WISCONSIN FOR14 2 1982
B H Development, Inc., a Wisconsin corporation, I''Id~re Ror;,~
. JUN 2.1 X994
. _
1:25 P. ~
conveys and warrant.: to _._..IOhC]. JOXC1St d.-.._ ~pc'~ j
_ ~l i.
RETURN TO
the following described real estate in - -
State of Wisconsin:
Tax Parcel No-----------------------•----•--
Lots 114 and 115, Edgewood Estates II in the Town of Hudson, St. Croix
County, Wisconsin.
This iS riot homestead property.
(Wiis not-)
Exception to warranties: Easements, restrictions and rights-of-way of
record, if any.
Gated this . . day of . Y 1994
B & H~ Develof nernt, Inc.
. ---(SEAL) By t~iGrZA GG (sEAL)
- -
' ---William .C...Harwell
-(SEAL) _ - - (SEAL)
- -
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) -dluw<7-111 .__C- RAVA-Ie----- STATE OF WISCONSIN
St. Croix gs'
authenticated this
lay vf_ A~1 igs6K Personally came before me this ................day of
- May ---------------19.94--- the above named
William_C. Harwell
-
' --t------- 0--
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by g 706.06, Wis. Stats.) to me known to be the person who executed the
foregoing in;trimi- nt and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
.-.Kristina- and---------------
- -
- Notate Public ---Count;, Wig.
- Atto> ney at Law----- - - -
(Signatures may be authenticated or acknowledged. Both My Comniissinn is pernlanent.(If not, state expiration
are not necessary.) date:
Names f p--- signing in any caga. ty sh-m b, typu' ui pi.nt,l b lo.. th r F t
WA.RR.ANTY DIED STATE BA$ OF VV T~; CON IN Wisconsin Legal Bank Co . Inc
FORM No. 2 tyti' M .ukee. W ,consm