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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
,21 ✓Ta(Jl t
ADDRESS
So ne r 5 2+ u-21 5
SUBDIVISION / CSM# LOT #
SECTION__L_T_3LN-R_/jW, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
6" ° 36~tQ
/ s-A
,m.
;3 a .
~ P
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
i
BENCHMARK: 0.
ALTERNATE BM:
SEPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: o o~~ Liquid Capacity: 1006vflo,i
Setback from: Well ~s House-,.:;?15 Other
Pump: Manufacturer Model#' Size
Float seperation Gallons/cycle:
Alarm Location _
SOIL ABSORPTION SYSTEM
Width: Length Number of trenches / Ze-
Distance & Direction to nearest prop. line:
;~a_ _
+ J
Setback from: well: House Other
ELEVATIONS
Building Sewer ST Inlet; ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Of-- Bottom of system 177,21,4o1,
Existing Grade 1-7011) Final grade 96- 7
DATE OF INSTALLATION:
PLUMBER ON JOB:
iyr
LICENSE NUMBER: I
INSPECTOR:
3/93:jt
Wiscons+.+Departmentof Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human 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 PI n o.:
STANDAERT, JOSEPH & SANDRA X
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
106
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic y C j Benchmark 1~~,1L /ao
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Ventto
TANKTO P/t WELL BLDG. Airintake ROAD Dt Inlet
Septic ~a5~/ l as S/ NA Dt Bottom
Dosing NA Header / Man. 8G 9
Aeration NA Dist. Pipe 13, q6 9~ , 7
Holding Bot. System /Y, 33 5,83
PUMP/ SIPHON INFORMATION Final Grade /0'r > 90 .u /
Manufacturer Demand
Model Number GPM
TDH Lift iction System TDH Ft
oss mead
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No.O reriches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS la' 5L/DIMEN I N
SYSTEM TO P/ L BLDG WELL L-A19 LEACHING Manufacturer:
SETBACK _ CHAMBER
INFORMATION TypeOf r Mode Number:
System: .27 / QQ 130' >02~ 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 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: Somerset.11.31.19W, NW, NW, 230th Avenue
I3 ,a~
I} t .
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. d 6
SBD-6710 (R 05/91) Date I spector s Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION
' In accord with ILHR 83.05, Wis. Adm. Code COUNTY
STATE SAI~RMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than moo,,[[
8% x 11 inches in size. 1:1 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. &Q I
PROPERTY OWNER PROPERTY LOCATION
ZLIP
~O t v l~J'/a /'/a, S T ,;Z?, N, R E (o
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
o 1~o
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
Inc ~ '-6 y
E:l . TYPE OF BUILDING: (Check one) ITY ARE 30A~
11
El State Owned V CITY f~17
❑ Public D1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply) -16~/-
1 ❑ Apt/Condo
20 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. ❑ New 2. [NrReplacement 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 Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 Seepage 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. SYSTE ELEV 7. FINAL GRADE
ELEVATION
REQUIRED (sq. ft.) PROPOSED (s . ft.) (Gals/day/sq. ft.) (Min./inch) . I -W
3 - Feet . Feet
VII. TANK CAP CITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank v'e?~ G/" 77- M
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's nature: (No Stamps) MP/MPRSW No.: Business Phone Number:
Plumber ddress (Street, State, Zip Code).
s n /!Z off /
IX. COUNTY/DEPARTMENT USE ONLY
Groundwater ate ssue uing Agent ignature (No Stamps)
it Fee Su
P❑ Disapproved San' T
rchar(includesge Fee)
Approved Owner Given Initial El'/L(j
Adverse Determination
.
X O DIT S O $RPR VAL/ EA NS FOR ISAPPROyAL: at
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.
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)
Plot Plan
Project Name Syron Bird Jr.
Address
3Z/ 'i'6 479
Lot -Subdivision Date ? 1,2 1 / /4 S,/,/T ~ N/R Township ~o m .er5
O Boring o Well PL Property Line County mil` G~,X
t& BM or VRP Assume Elevation 100 ft.~~
System Elevation"- *HRP
kw
d ~y
fill
D
d
0 5
~a
112el. I ~,,10
3f
ell
Scale 1/4" .10 Ft. When dimensions aren't stated
Plot Plan
Project Name Byron Bird Jr.
Address
C 479
Lot Subdivision Date 7-1,_-2
-may
1/ /4 S T IN/R4ZW Township
0 Boring O Well PL Property Line County .55I` Gro,X
L BM or VRP Assume Elevation 100 ft. 7,,,- ot~-
System Elevation *HRP
y
i
`D
I
5-
s4'ef, 41
~
Scale 1/4" =10 Ft. When dimensions aren't stated
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 SE'Ufi ~~`C~ l~l (~Cc el,6 residence located at:
1/4, Sec. T_;~L_N, RIq W, Town of
SO"XI~✓S~ Upon inspection, I certify that I have found the
tank and baffles to be in good condition, and it appears to be
functioning properly./Oe,
Last time serviced
Did flow back occur from absorption system? Yes No (if no, skip
next line)
Approximate volume or length of time: gallons minutes
Capac i ty: /~~0~~ IISr
Construction: Prefab Concrete_ , Steel Other
Manufacurer (if known):
Age of Tan f known): r s~
(Signat ) (Name Please Print
-3 r
(Title) (License Number)
~/L/
(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
inspection opening over outlet baffle). '
Name Grr Signature P/MPRS
5/88
ti_...,.,
/
2
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~ ~
~
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Wisconsin Department oflndustry, 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
5 ' G
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
PROPERTY OWNER: PROPERTY LOCATJ j N
C u u h GOVT. LOT A/ 4 X4/1/4,S T N,R l E
PROPERTY OWNER':S MAILING ADDRESS LOT # BL K # SUBD. NAME 0 CSM #
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY VILLAGE OWN NEAREST ROAD
o.n N a r- er o
[ ] New Construction Use [ Residential / Number of bedrooms [ ] Addition to existing building
(]`Replacement [ ] Public or commercial describe
Code derived daily flow _4t2:~Ijpd Recommended design loading rate . 7 bed, gpd/ft2^jtrench, gpd/ft2
Absorption area required f7 bed, ft2 trench, ft2 Maximum design loading rate ._bed, gpd/ft2trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material ~ w a Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING GTTAUK
U = Unsuitable for s stem SS ❑ U 2P, ❑ U O?S El U 19'S El U ❑ S 5W
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
Ground ...L~
elev.
^Z ft.
Depth to
limiting
factor
Remarks:
Boring #
011
Ground
elev.
'A"t.
Depth to
limiting
7 fac_tgr-
S~ Remarks:
CST Name:-Please Print Phone:
Address:
Signature: ate: CST Number:
PROPERTY OWNER S/u~~,'at•,-OIL DESCRIPTION REPORT Page of
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
54 G
Ground
elev.
p~ft.
Depth to
limiting
factor
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)
V) z
m
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0
-
262.76 397,27'
W)
w w
N 0 CO o
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\ul 364.25' 3~ 33
D
w W ~-0 w
m W ~ ~ 0
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D
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D o 8
z
.A N N m
m
m
8
262.75' 397,25' -
w
8
w
co g
o
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co 0
Cn -
8-
660'
W
O
Z
M
3 60
-
00 0
D
s~
n 360
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 ?~s~ph ¢ it c -Syanc1(?-e'4-
Location of property.///&/ l/4-,,;?. 1/4, Section T~~N-R~W
Township morn er5e~ Mailing address (p/3 ~ 30 V due.
Address of site ~-z-~
Subdivision name c~-- Lot no.
Other homes on property? Yes_No
Previous owner of property
Total size of property
Total size of parcel
Date parcel was created a
Are all corners and lot lines identi fable? Yes No
Is this property being developed for (spec house)? Yes _,~l No
Volume ~d and Page Number g,~?~7 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. and that I (we) presently
own the proposed site for the s age 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-Applicant
Da e o Signature Date of Signature
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER 7" r S r
MAILING ADDRESS ;?D 4 --S6`-~-t ers~&e
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
f_W
PROPERTY LOCATION /VO 114, /,1GC.,) 1/4, Section ` l T, N-R21'
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP , VOLUME ~Q~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.
I
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: .j
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
i _
!i IDOCU +ENi NO. M WARRAMW DEED TNfB SPACE RESERVED FOR RECORDING DATA
STATE BAR OF WISCONSIN FORM 2-1982
REGISTER'S OFFICE
V. C"X CO., W1
Recd for Record
al 8:30 AM
Ra xicl P. Baill~'1
I
II MAC 1
I
conveys and warrants to J -J...Standae-t.-arid--Sandra.1b1.-_..-..._ !I a
Stmdaart,.: husld. and. mife,...as . marital ..Fragexlt. I I b of D"*
w.thxigbU._Of.surV.i.~ig1..........
- _ - -
11
RETURN TO
St. CLb1X ~
We following described real estate in .................County,
State of Wisconsin:
Tax Parcel No:.. a3 ~ `
i
CAmnencing at the Northwlest corner of the Northwest Quarter of the Northwest Quarter
(NW} of NW}), Section Eleven (11), Township Thirty-ane (31) North, Range Nineteen
(19) West; thence Easterly along the North line of Section Eleven (11), 660 feet to II
the point of beginning of the parcel to be described; thence South at right angles,
660 feet; thence East at right angles, 330 feet; thence North at right angles, 660
feet; thence West at right angles along the North line of Section Eleven (11), 330
feet to the Point of Beginning, containing Five (5) acres, more or less.
i
,nis deed is executed solely for the purpose of fulfilling that certain Land Con- i
tract between the above parties dated May 15, 1980, recorded May 21, 1980, at 8:30
a.m., in Volume "612", page 111, as Document No. 364300.
f iit s'ISFER
l
Tbis .-..not.---•--------- homestead property.
(is) (is not)
Exception to warranties:
I QQ
Dated thi [ day of ------Februar'y------- 19.$8....
-------(SEAL) . ----(SEAL)
• a--.--B-aliiars....
...(SEAL) . ---------...-...-.(SEAL)
• • _ -
AUTHENTICATION ACKNOWLEDGMENT
Signature05 Of__RdY[naid P, Baillar STATE OF WISCONSIN
ss.
.
......---•----------•--•--••--County.
authen ' is ../!?-day of-~~ rualY--........ 19-_88 Personally came before me this day of
19------.. the above named
• Needhm
TITLE: EMBER STATE BAR OF WISCONSIN
(If-----
b!F
to me known to be the person who executed the
a
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Reinstra, Van Dyk & NeedhM, S.C.
....AtW]flL1y5--at:-Lw---------------•---•-----------------•--•-• •
.-_.1dEW..Richx C7[lds.-Wiscm5ia..-54Q17-0.12.7---.. Notary Public County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.)
date: 19------•)
-Names of persons signing in any capseity should be typed or printed below their signatures.
STATE BAR OF WISCONSIN Stock No. 13002
KC-1101W Co-v" FORM No. 2 - 1982