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r1 ~ Ica STC - 104ri AS BUILT SANITARY SYSTEM REPORT
OWNER,.
ADDRESS/ZS
SUBDIVISION / CSM#-i e ~j LOT #
SECTION T, ?TN-R.' ~Z W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
oGm>
f5h'I
Sd ~ ~a
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK I/ PUMP CHAMBER / HOLDING TANK INFORMATION
9
Manufacturer: Liquid Capacity: 9/ 2,
Setback from: Well--,W_ House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width:
~6_ Length ; l Number of trenches
Distance & Direction to nearest prop. line: 'tee„ Z7S
Setback from: well: 2 House 522 ' 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:
PLUMBER ON JOB: `J
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin Department of 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
P WAj2WerKA LEEN/STRUEMKE, TIMOT q City E] Village IR Town of: State Plan o.:
SOMERSET 0112-9090-90-n()() I
CST BM Elev.: Insp. BM Elev.: BM Description: rcel Tax No
TANK INFORMATION ELEVATIO ATA S OS/75~
TYPE _MANUFACTURER CAPACITY STA ON BS HI FS ELEV.
Septic add af/ Benchmark „~57Gp~ /do ,
Dosi mg- Att .6/r(. X , /G), 3
Aeration Bldg. Sewer
Ora
ing St//10 Inlet
TANK SETBACK INFORMATION St/ Outlet
Verit
TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet
Air ~
Septic S®' 2- _359 NA Dt Bottom
Dosing NA Header--
Aeration N Dist. Pipe 5?Q 9~
Holding Bot. System 997'
PUMP / SIPHON INFORMATION Final Grade
Manufacture - Demand , 9 jP~
Model Number GP
TDH Lift Fri System TDH Ft
Forcem Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED / Width Length / No. Of renches PI No. Of Pits Inside Dia. Liquid Depth
DIMENSION DIMEN I
:EA acturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM
INFORMATION Type Of ~ IT M oe
system: Crr~J >)L)
~i
71
DISTRIBUTION SYSTEM
Header Distribution Pipe(s) x 'Hole Size x Hole Spacing Air Intake
1
Length Dia. ~ length Sot Dia. ~ Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Sy s Only j
Depth Over Depth Over xx Depth Of Seeded / Sodde Mulche
BedrtT welrcenter 7-3~ BedfT7 Edges ~`7-6~ Topsoil E] Yes E] No ❑,Y,e/s [I No
COMMENTS: (Include code discrepancies, persons present, etc.)- jA x,,r-° E` %i S~~7~
LOCATION: SOMERSET 15.31.19.889 SE N7, OT 1 L0 R 217TH
~ r ',1>C
e
17
Plan revision required? ❑ Yes 2-19 /
Use other side for additional information. AA 15
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
F
t
SANITARY PERMIT APPLICATION
' 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 a ( 90A7
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.
PROPE OWNER PROPERTY LOCATION
j '/a %,S T N,R / E(or W -IT -ALL / t- ,
PROPERTY OWNER'S MAILING AD RESS LOT # BLOCK #
CfTY STATE ZIP CODE PHONE NUMBER SUBDIVI ON NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one) TY NEAREST OAD
❑ State Owned O VILLAGE
C& JOWN OF: 2
II 1 r 2 Fam. Dwellin of bedrooms PAR ELTAX NUMBER(S)
❑ Pub c [0 o g-# III. BUILDING USE: (If building type is public, check all that apply) 0,w
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 80 Mobile Home Park 120 Service Station/Car Wash
50 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.,Z New 2. ❑ Replacement 3.E] 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 ® Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 420 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
;7 1/ Feet Feet
CAPACITY
VII. TANK Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the un rsigned, assume responsibility for installatio of the ongite wage system shown on the attached plans.
Plumber' Name rint): IPlumbe s S hat mp MP/MPRSW No.: Business Phone Number:
i
Plumber's Address (Street, ity, S te, Zip Co
,4,
IX. C NTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Ag t Smapature (N tamps
Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination / C
X. CONDITIONS OF APPROVALIREASONS 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.
11. 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 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.
I
SBD-6398 (R.11/88)
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of .S
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 'S
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
PROP TY OWNER: PROPERTY LOCATION
GOVT. LOT - 1/4 /J 1/4,S T N,R Vor&
OPERTY OWNER':S MAILI DD ESS LOT # BLO K # SUBD. AME OR CSM #
A) ~A
CCITY, STATE ZIP CODE PHONE NUMBER CITY VILLAGE [STOW NEAREST ROAD
s
New Construction Use Residential / Number of bedrooms 3 [ 1 Addition to existing building
Replacement Public or commercial
describe
ll [ ]
Code derived daily flow gpd Recommended design loading rate ~ Z ed, gpd/ft2 &-trench, gpd/ft2
Absorption area required ~ bed, ft2 trench, ft2 Maximum design loading rate ? bed, gpd/ft2-,gtrench, gpd/ft2
Recommended infiltration surface elevation(s) It (as referred to site plan benchmark)
Additional design / site considerate ns
Parent material Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U=Unsuitable fors stem ~S ❑U RS ❑U ®S ❑U ZS ❑U ❑S ®U ❑S ®U
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 _ _
elev.
_
W ft.
Depth to
limiting
factor
Remarks:
Boring #
7 I -
ZYZ _-1 J 4u'lt 176'.) -~21,, s--:
61
Ground
elev.
ft.
Depth to s F
limiting
factor
Remarks:
CST Name: Please Print Phone: _
Address:
Signature: Date: CST Number:
PROPERTY OWNER SOIL DESCRIPTION REPORT Page,;;:2-of`- _3
PARCEL I.D. #
Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench
Ground
elev.
Depth to
limiting
factor
Remarks:
Boring #
Ground
ele . _
A)Z
ft.
Depth to
limiting
factor
Remarks:
Boring #
5 v
62
Ground
elev.
ft. -
Depth to - Al limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-e330(R.05/92)
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240.73 N 1° 33' 45" W 653.13
ASSUMED BEARINC
Z I MONUMENTED WE
BEARING N 0° 5a'
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 CZ`~~ 1 ( GtX~11-~ + JM'b IJ Location of property YA 1/4 VI W1/4, Section 1 5 ,T'31 N-R Lj~a~
1 9 W
Township U-~rn2h~1k.-~ Mailing address
Address of siteOu?~~1 21~7`~' ~CU~ 5Y D25
Subdivision name kKO'L 1 C1I~~ -RA J Lot no. _
Other homes on property? Yes No n,,
A I-
Previous owner of property JO n
Total size of property 0 "CL{`
Total size of parcel
Date parcel was created 2 J
Are all corners and lot ines identifiable?_Yes No
Is this property being developed for (spec house) ? Yes No
volume 1101 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 o fice of the County Register of
Deeds as Document No. ZZ C1 ~ , 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.
5Zz-gqq
j/
Signature of Applicant Co-Applic nt
tI-- I- qH1 1-1- gL
Date of Slanattirp nata cif Signature
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
p St. Croix County
OWNER/BUYER a`I'~&44l k~Sl~ 1 k
MAILING ADDRESS g02Z5
PROPERTY ADDRESS XP,At-fA 21'7 c . h Q I U40 Q
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE _L 01 /,azoa f 7 Ott
PROPERTY LOCATION n_ 1/4, Vjt }j 1/4, Section t J T 3 -N-RcL W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION ~/lor~~ ~~1 e' Q LOT NUMBER 1 2_
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: - l a `t
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
066
522994
QUIT CLAIM DEED
Individual (s) to Joint Tenants
No deliquent taxes and transfer entered; 1;,`s~i .o
Certificate of Real Estate Value for Rawrd
filed ( ) not required Certificate of
Real Estate Value No. OCT 3 1994
~A 4:40 P
County Auditor
by
Deputy
STATE DEED TAX DUE HEREON:$
Dated: , 19
FOR VALUABLE CONSIDERATION, John E. Walsh, a single person, Grantor(s), hereby convey (s) and
quit claim(s) to; Kathleen L. Walsh and Timothy T. Struemke, grantees, as joint tenants, real
property in St. Croix County, Wisconsin, described as follows:
Lot Twelve (12), Northern Oaks Estates
together with all hereditaments and appurtenances belonging thereto, subject to the following
exceptions:
NONE
The grantor certifies that the grantor does not know of any wells on the described real
property.
Affix Deed Tax Staff Here John E. Walsh
STATE OF MINNESOTA )
) ss .
COUNTY OF 0~ )
The foregoing instrument was acknowledged before me this 191 day of
19~, by John E. Walsh, a single person, Grantor.
Notarial Stamp or Seal
WAYN8K&eWDERSON
NOTAwb IYNNMTA
Ele P P 0 P 0 P t INGTON COUNTY
4gna of n Taking Acknowledgement
This instrument was drafted by:
Wayne D. Anderson, I.D. 209624 Tax statements should be sent to:
106 South Main Street
P.O. Box 142 Kathleen L. Walsh
Stillwater, Minnesota 55082 433 - 165th Street
(612) 439-4695 Somerset, W(p 54025
I