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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 'ADDRESS iZ& a-okz--
SUBDIVISION / CSM LOT ~
SECTION _T'I N-R,-1f--W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
r
7
6 0
o i'
/25
T
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
.ti
BENCHMARK:
ALTERNATE BM: A0 ~~ezog~~
SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION
Manufacturer: A1Liquid Capacity: 1~C>
Setback from: Well House ` Other
Pump: Manufacturer Model#j :7 Size
Float seperation % Gallons/.cycle:
Alarm Location s
SOIL ABSORPTION SYSTEM
Width: / Length P~ Number of trenches
Distance & Direction to nearest prop. line: f/O2 a~sole,
Setback from: well: House ~O / Other
f 7
ELEVATIONS /
Building Sewer ~1. ST Inlet; , b ST outlet
PC inlet PC bottom r' Pump Off ~d•7,
Header/Manifold i Bottom of system P 8
Existing Grade r8 Final grade f0 7 J/Y(
DATE OF INSTALLATION:
PLUMBER ON JOB: u/~( ^
LICENSE NUMBER:
INSPECTOR:
3/93:jt
/I NVisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Hyman Relations INSPECTION REPORT ST. CROIX
Safety and BuTdinn Divisi97 /
[ei^ (ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION
PeWHtiq%NargfHOMAS ❑ City ❑ Village ~R Town of: State Plan o.:
CST BM Elev.: 1 Insp. BM Elev.: BM Description: Parcel Tax No.:
/oa [ /W, 4S l 6 ,f rb!;t
TANK INFORMATION EL VATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic -~-a Benchmark l00
Dosing /00
Aeration Bldg. Sewer $ 9q, q /
Holding St/ Ht Inlet 9, a Cj ,,o 7
TANK SETBACK INFORMATION St/ Ht Outlet O 5
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake /
Septic NA Dt Bottom 13 • ~0- 7
Dosing NA Header/Man.
Aeration NA Dist. Pipe 333 /0S 47
Holding Bot. System 41,04 /w/M
PUMP/ SIPHON INFORMATION Final Grade -73
Manufacturer J Demand
c
Model Number 9,~ 'GPM
TDH Lift Loss 1,7 S edema - TDH Ft
Dist. To Well 6L~
Forcemain Length po' Dia. 2
I 7_1
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length 1 No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 5 /O O DIMENSIONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM
INFORMATION Type Q rZe<J Ali) CHAMBER Model Number:
System: IrlU /36 €'oD ✓ ~ OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
, r~ a ~ i• i, >SO
Length Dia. Length ~(v Dia. f' Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over 4 xx Depth Of xx Seeded / Sed4fd xx Mulched
Bed /Trench Center ` Bed /Trench Edges Topsoil Yes ❑ No 'Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Springfield.9.29.15W NW NW 110th Avenue
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. $ ( P / L ft -l.J 6 a
SBD-6710 (R 05/91) Date Inspector's Signature Cert No
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: .
SANITARY PERMIT APPLICATION
DILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY ,
ell?
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than
8/2 x 11 inches in size. ❑cnec k if revision to previous application
-See reverse side for instructions foe completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. S9 0
PROPERTY OWNER / PROPERTY LOCATION
/ P / Li1'/a J/4/1/4, S T r2 , N, R W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CITY, STA E ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one) El State Owned VILLAGE : i NEAREST ROAD
❑ Public X 1 or 2 Fam. Dwelling-# of bedrooms ~ TARCEL TAX UMB R( )
III. 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 only one in line A. Check line B if applicable)
A) 1. ® New 2.E] Replacement 3. ❑ Replacement of 4.0 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 0 Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 430 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
0/Q 0 S-® Q D D fi lD -7 Feet DAIS Feet
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 Holdin Tank e
El F1 I El F-1 X El
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 Signature: (No Stam ) MP/MIfwoPo.: Business Phone Number:
y0
Plumber's Address Street, City, State, Zip Code): „
1Y 170 6~,elv A-, 000~ a/
IX. CO TY/DEPARTMEN USE ONLY
Groundwater a e ssue Issuing Age Sign No S ps
❑ Disapproved Sar),Va Per(m~it(F (includes
rcharge Fee)
Approved ❑ Owner Given Initial C;:2 kl / (/V'
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: l
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
• f
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
sugmitted 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)
Page Of,ze
PRIVATE SEWAGE SYSTEM
Conditionally
[11PPROVED
Perforated Pipe Detoil
DEPT. OF 1 TRY, LABOR 8 N BUIl61NGS RELATIONS
0 I 0 SAF
SEE RRESPONDENCE
Crd view
Pp,foroled
Fri Cop l. / > r VC r',pe
e
Holes Located on Elwtom,
Are Equally Spocea
e FA70 M
Ne,l 10 E'1
i,,_.r•,1,~~ r,:
Ft.
X y - In(-. h eq
Inches
Hole Diameter Inch
Lateral 11 - Inch!(,:,'
License thud wr: _ h 6y0 Manifold Inches
hate,:Force Pain Inches
jr of holes/pi Pe .S
Invert Elevation of lateral*~r,,~ Ft.
S.94-20177
-116-
a P e o
e
0
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r I a
rt
1 /
' s
I
- - R
PRIVATE SEWAGE SY TE
- -
D VI SA ETY A U1 DIN S
/c Page ~ Of
Straw, Marsh Noy, Or
Synthetic Coverinq~
Distribution Pipe
Medium Sand
G
Topsoil - F
E D
b
PRIVATE SEWAGE SYSTEM % Slope
E3ed Of - 2 12 Force Main Flowed
Conditionally Aggregate From Pump Layer
A P ROVED
E ~,2
DEPT. OF IN Y, LABOR i NUMAN FMAT" Cross Section Of A fAound System Using ,
DIV{ OF AFETY iLBIN63 ~
A Bed For The Absorption Arco G
SEE C RESPON CE t, F t . ii
Si~gned: i Ci ~p21 Ft.
L i cerise Number: M P Ilan F t.
J J~,S'6 F t .
Date:
-9, Ft.
lil Force Main
From Pump
Distribution Bed Of
Pipe Aggregate
I
Observation Pipe Permanent Markers
Plan View Of Mound Using A Bed For The Absorption Area
S94-20177
PAGE OF
PUMP CHAMBER CROSS SECTION AId; 'SPECIFICATIONS '
VENT CAP.
r-T ,r.
4"C.I. VENT PIPE
WEATHER PROOF APPROVED LOCKING
fOJUNCTION BOX MAIJHOL COVER
& FROM DOOR,
i2"MIU.
WINDOW OR FRESH
AIR INTAKE L~~~
GRADE l
' 4" MIAJ. }
i
L . ~ I B" MI IJ.
CONDUIT
OVID
IAILET ; IGHT SEAL I III
APPROVED JOINT A rna,l y I { I I APPROVED .iG J'
C.-I. PIPE ~lOY I { I I W/C.I. PIPE
EXTENDIMC. 3' D I 111 ALARM EXTEIJDING
ONTO SOLID SOIL B I t I UNTO SOLID 5 )t
C ~BdR qua K6S I I OK)
ELEV.
•ae`°a~ PUMP
• NG ~ OFF
D K~p~Np~
CONCRETE BLOCK
RISER EXIT PEP,MIlTED OWLy IF TANK MAUUFACTURER HAS SUCH APPROVAL
SEPTIC E lca-t; 0 SPECIFICATIOKIS
DOSE 7-5"0
/v TANKS MANUFACTURER: / esa- & IJUMBER OF DOSES: ~ PER DAy
TAMK SIZE: ILO 91~GALL0US DOSE VOLUME
ALARM MANUFACTURER: SV 9 7-/ 0 INCLUDIIQG BACKFLOW: GAI-LOrfS
MODEL NUMBER: CAPACITIES: A = INCHES OR GALLOK; 3
SWITCH TYPE: g = A INCHES OR GALLO''S
PUMP MANUFACTURER: 40'0?0 AA'f C=/#-J'-INCHES OR `-Z GALLOK23
MODEL NUMBER: 0X P 22 D= INCHES OR 6a GALLOKIS
SWITCH T`JPE: sJ'~~e~~.Po OFn MOTE: PUMP AND ALARM ARE TO BE
MINIMUM DISCHARGE RATE-,;2Z--'7--f--GPM INSTALLED ON SEPARATE CI UITS JJ
VERTICAL DIFFERENCE BETWEEN PUMP 6FF AND DISTRIBUTIOUVIPE.. FEET-
+ M~~I~~UII~MUM NETWORK SUPPLY PRESSURE . ~ ..w . ? 5 F.EE 9 1 _
+ 1FEET OF FORCE MAIN X /ppFxFRICT101J FAC'fQa.. EEis 2 017 7
TOTAL OyIMAMIC. HEAD = F;Fr ET
~ D
INTERNAL. DIMENSIGNS OF TAIJK: LENGTH ;WIb1'H_ ~ ;LIQUID OEPTH
SIGUE D: LICEMSE UM6ER:1~~ 7 DATE:
1J
4+ f.1 Via,. SEE F iMA!ID 1 OOH
SP33
MAX. SOLIDS 5/8"SPHERE MAX: SOLIDS 5%8" SPHERE ; /4 SPHERE
1 /3 HP 1%3 HP 1 /2`AND 1 HP
1750 RPM 1750 RPJVI 3450'RPM
I
I
• Available in automatic or manual • Available in automatic • Available in manual or automatic
• Non-clog bronze impeller • All bronze construction • Automatics feature reliable
• No suction screens to clean • Non-clog bronze impeller diaphragm pressure switch (1 /2 HP),
• Oil-filled, double ball bearing motor • No suction screens to clean wide-angle float switch (1 HP), both
with built-in overload protection • Oil-filled, double ball bearing motor with piggyback plug-in
• Carbon/ceramic faced mechanical with built-in overload protection • Dual shaft seals standard. Seal fail-
shaft seal • Carbon/ceramic faced mechanical ure sensor capability available (wired
• Great for septic tank effluent, shaft seal to alarm device) on manual pumps
elevator pits, high capacity sump • Reliable diaphragm switch • Non-clogging 2-vane cast iron
service, industrial circulators • Completely field serviceable sewage-type impeller
i • Reliable diaphragm switch with • 1-1 /4" NPT discha* • Rugged cast iron construction
• 1 /3 HP, 1 o 11 5 • 1 /2 HP (SPD50H) and 1 HP
piggyback plug-in
• Rugged cast iron construction E (SPD100H) motors. Ball bearing
~p,G
• Completely field serviceable S~ aw construction and oil-filled
• 1-1 /2" NPT discharge ' 0~ ® • 2" NPT discharge (3" flange opt.)
• 1 /3 HP, lo 115V or 230V • ' 1 /2 ~HP,A0` 15V or 230V and 3o
'2004 6p -or 575V - 1 HP, 1 e
tt 230. V, 30 230V, 460V or
.177
,82
11 91
C
8 j 8
a -
0d 0 0
0 10 20 0 40 50 60 a0? , 0 10 20 80 40 60 60~ 4 4 ?R ~a 21 72 86 720 114 ,11
ACtTY.S.fl.P.M. P CAPACITV•U S G"P.Mk 4a d1.S. G.P.M. 4, , ,
1-4 4Y -*14--- - 1% - rl
4- 6'b -
l:' F
i -
> a TOTAL DYNAMIC HEAD FEET/ I -
HEAD CAPACITY CURVE METERS O.~
MODEL137-139 CAPACITY GALLONS/LITERS o
30' -
CAPACITY _
_HEAD _ UNITS/MIN a OO
8 FEET METERS GAL LTRS NAT
25' S 1.52 104 394
10 3 05 79 300
= 15 4.57 64 242
6 20' 20 6.10 36 136
a 25 7.62 8 30 E
26 _ 7.92 0 0
v
a 15'
yY~'L
r-
1- 4 zt
to,-
i
.t
2
12y4
o -j
U.S. 10 20 30 40 50 60 70 8o 9o 100 110
GALLONS
80 160 240 320 400 4
LITERSI
0 FLOW PER MINUTE S
CONSULT FACTORY FOR SPECIAL APPLICATIONS
e Three phase pumps are available in 200/208V or 230V. a Mercury float switches are available for controlling single
• Electrical alternators, for duplex systems, are available and and three phase systems.
supplied with an alarm. a Double piggyback mercury float switches are available for
is Mechanical alternators, for duplex systems, are available variable level long cycle controls.
with or without alarm switches. a Long cords are available in lengths of 15-25-35-50 feet.
a Combination starters are available. a Over 130°F. (54oC.) special quotation required.
Standard All Models - Weight 47 lbs. 1/2 H.P.
SELECTION GUIDE
SELECTION GUIDE 1. Integral float operated 2 pole mechanical switch, no external control required
137/139 Series Control Selection 2, Single piggyback mercury float switch or double piggyback mercu,y float
Model Volts-Ph Mode Amps Simplex Duplex switch. Refer to FM0447.
M137/139 115 1 Auto ' 10.4 1 or 1 & 6 - 3. Mechanical alternator "M-Pak" 10-0072 or 10-0075.
N137/139 115 1 Non 10.4 2 or 2 & 7 3 or 5 & 6 4. Combination Starter. Refer to FM0514.
D1371,39 230 1 Auto 52 1 or 1 d 8 ' - 5. See FM0712 for correct model of Electrical Alternator "E-Pak".
E1371139 230 1 Non 52 2 or 2 & 7 3 or 5 8 6 6. Mercury sensor float switch 10-0225 used as a control activator, specify
'H1371139 200-206 1 Auto 8.2 1 & 8 - duplex (3) or (4) float system.
1137/139 200-208 1 Non 9.2 2&7 3 or 5 & 6 7. Four (4) hole "J-Pak", junction box, for water tight connection or v,',,ed-in
'J137/139 200-208 3 Non 2.2 2&4 3 6 4 or 5 6 6 simplex or 2 pump operation, 10-0002.
'F137/139 230 3 Non 3.0 2& 4 3& 4 or 5& 6
*G137/139 460 3 Non 1.5 2 & 4 3 & 4 or 5 & 6 8. Two (2) hole "J-Pak", for Watertight connection or splice, 10-0003
No molded plug
Three phase units require a control switch to operate an external magnetic or combination CAUTION
starter. All Installation of controls, protection devices and wiring should be done by a q u sU t e d
For information on additional Zoeller products refer to catalog on Combination starter, licensed electrician. All electrical and safety codes should be followed Includ:~q the
FM0514, Piggyback Mercury Float Switches, FM0477; Electrical Alternator, FM0486, most recentNallonalElectricCode(NEC) and the Occupational Safety and Hea 1- Art
Mechanical Alternator, FM0495; Alarm Package, FM0513: and Sump/Sewage Basins, (OSHA).
FM0487.
RESERVE POWERED DESIGN
For unusual conditions a reserve safety factor is engineered into the design of every Zoeller purnp.
MAIL TO: P.O. BOX 16347
Louisville, KY 40256-0347 Manufacturers of . .
ZZ71Z-Z1R- SHIP T0: 3280 Old Millers Lane
ZZ7. Louisville, KY 40216 ~ /rY PUMPS /SNCE /939
(502) 778 7731 • FAX (502) 774-3^24 ~UIL
SOIL AND SITE EVALUATION REPORT Page of?
ID71ILLIHIRR in accord with ILHR 83.05, Wis. Adm. Code COUNTY
,,M
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but PARCEL I.D. #
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
0 GOVT. LOT 1/4 n/w1/4,S T N,R 13- for) W
PROPERTY OWNER:' MAILING LOT # BLOCK # SUED. NAME OR CSM #
O.~ _ O - ul0
9" 4 /9
CITY, STATE ZIP CODE PHONE NUMBER CITY OVILLAGE (MOWN NEAREST ROAD
New Construction Use p(] Residential / Number of bedrooms [ J Addition to existing building
[ ] Replacement [ J Public or commercial describe
Code derived daily flow Y.~F-d gpd Recommended design loading rate ~ -bed, gpd/ft21i4-~ trench, gpd/ft2
Absorption area required //imbed, ft2 Oe trench, ft2 Maximum design loading rate l_J~_bed, gpd/0, ! tench, gpd1ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design / site considerations 4FVAd e L-L A V. &R u P/neR S%d& o C- -10 #Ae d /o.~ 7~i
Parent material GL.,+e is j rl:IZ Flood plain elevation, if applicable ft
LSU= Suitable for system CONVENTIONAL MOUND IN GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
Unsuitable fors stem El S U S ❑ U ❑ S [@u ❑ S ®U [I S ® U ®S ❑ U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Bw-dary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trer>ch 5A r
6
D - O 2 L✓ Y
.v>::.
S* k 2-S4 Ir /4
2 ~
Ground ljf- ,2 C a. f= 4/ Vic .
elev. I 'I
/0/.a ft. iy/w F 2 6 e 4 4 K Al. M VFW' , S
Depth to S~°o7`S i
limiting
factor
Remarks:
Boring # S "j
/4 Al
S YeL M 4.w lY .r .21A A- M 5" 5,; a q 4.1 YF AV
Ground _
elev.
410
-ZAV
110 ft. 54004f is 4V-
Depth to
li
Ior
miting co ~ Remarks: CST Name: Please Print Phone:
5; & 11000
Address: 3 2 G~ e o o d G' ul3
Signature: ~ / ~ Date:~~~r 9~ CST Number: 7~~,
PROPERTY OWNER A'014
1Vh(i,7 &n/ SOIL DESCRIPTION REPORT Page Of
PARML I.D. # 0 3 y - l0 l9 ~ o
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bo nd3y Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
l o- O yd sib ;2 S r' ~M • 6
S
7-~
Ground / rye SL' ,t a4ir M w IV F. 4/ -.0-
elev.
ft. D- F d .s scG set, 6kM
Depth to Sf'° r"5
limiting
factor
Remarks:
Boring # 0'7 /0 S/L S,6 F 4~ a Al
Ground d-6 M M F r w I V F ,..5
elev.
it. R 6 SC L -74b )h v Pr -
Depth to
limiting
factor~
t
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor F-F
i
Remarks:
Boring #
.Yr
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/- 4~ D 4 A / h i r6,-'N
MAILING ADDRESS
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE 6,1 j0_ IV r y v CJ ~ G7 k
PROPERTY LOCATION NXt 1/4, 4.1 1/4, Section, T v7- V N-R W
TOWN OF f2glAiQ fieL 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.
'X SIGNED: l w
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
S T C - 10 0 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 r ,J p IV-1
Location of property/.i 1/4 1/4, Section, T,,L N-R W
Township jZ7Ld/ / E16 Lc/ Mailing address //D
Cr,L ~ N a d G r 7'~v Lv ~ ~~yo/3
Address of site
Subdivision name Lot no.
Other homes on property? Yes___,~ No
Previous owner of property R116-5-6
Total size of property ZQ A 67 Re
Total size of parcel 7e)
Date parcel was created
Are all corners and lot lines identifiable? Yes -No
Is this property being developed for (spec house) ? Yes __X No
Volume _Z~~ and Page Number .2-7 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. &799 `G , 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.
417 3 2 /C,
Signature of Applicant Co-Applicant
Date of Signature Date of Signature
0~•~15 4 11,20 $715 425 0146 GAYLORD LAW OFC, 001
ooCUMENT NO_ ; STATE BAR OF WISCOI SIN FORM 15-198E -wis sPneE RE*LRVLP Fra FIJ~CGfeMNL. DATA
ASSIGNMENT OF LAND CONTRACT ~
473210 01 4uA4-97
VOL- REGIS t ED'S OFFt E
ST. CROIX CO., Wf"
Reed for Record
ASST 'OZ', whether One or for a zaiu.l~le carp -4~ravc:n, ;,sSiTia j a
..Z1r1~XX_-..%lZ_}__7QICa}S___c_.]E,_--•--•-,. ~i JE 1J
nd conveys to 7991
8-30 A. M
_~11~a..txen,~.-C~a~.ts~hex__~Ja~.tt,era.,-~.nd._~~,~s,.~...~To.a--•~- 'II
~~rtdvided-,C.7_ish__intarzeat_•earh-,...__--_----------------------__(..~ignee. I ~ ~I~~erataee~s ~i
i
whether one or more) the (c uuv , or Purchaser's) interest in a Land Contract k
dated. the-------- th- --.day of------ Attest---------------- 18....-, by
use~__xhar,.._l1sl_kvs.M1.1_M.__Tl~ssrn_i-Ie1e----- _l-
. Vendor to ' ~Tuxr TO A[#oflley At La `
El i!
Sr T} i 1 t Far t ¢13 E. `m St
- -
liver-falls, l-54
_ - _ - as Purchaser I ;citptIC111 7 7.25 (11)
on lands in _St... •roix_ County. State of Wisconsm,
tosefliar wwi E the debtcainess tliereiu referred to and) aU the interest of the
Assiano= in tl ti ,;ontract and the lands described therein, which Land Con- i
tract was re,:orded in t Le C;.rt . a of the Register of Deeds of aai County, on .
-
Au U 114 81 , as Document Numb 2571
er-. - , in
(=Si O" C .age;
oovenan;s that there is now owing and unpaid on said Land Contract, the sum of i!
and a per cent per an=um franc ,
that ks gw)' w_, z of the above described interest in the Land Contract and has 1,aud right to assign the same,
and that the `'e *tAle of Assignor's interest is the same as at the, time of ree i.-ding tae Layid Cuutraer-
P kR4GSy.k _ - E f' z ! NG :F T1:US IS AN ASSICY NMI ENT OF FURCaASER'S INTE sEST. (Str;.ka either I- or 2.)
By Due r and recording this assib'm=ent, the ssig tee agrees:
7'i. b..ee assumes and agrees to pay the obligation secured by the Land ~ ontract, to comply with all Ii
te-rlPs arc. of the Land Contract, and to hold harmless and indemnify Assignor as to the perfurmunr_e of all
obligidor_,, •°:rr•, aLad conditions of the Land Contract. (OR) l
-1 `
ea 4e-!~and,
o -r-e-
r--•-:6 -A --mil; ti-- :°Lr!._r-~.:~f~Z.. i:] Y.'~•- .'T - -
1i°Gep - s tl to i °teLe all melkt:t Ed Amig:Aee _ _ Of- a copy *F. .7. C3.oct:. r
, a t__ _ _...4 iii the ....5...... .1.,., ,.-:1 -1 T -7 77_4, -..7 Tt--piirpeseB,
- 4;_oa TT_.
T ..-......v- --T-i
L2. This " _ _T4 4
Shell t X -lewed t i- } .t-....ekedulvd 1-c' _ s
4ta 1r • v gne. ft a4 r . 4 - r }t., of a_ `i to b nee. 'WIF _J..~a7~-lea .~`+Ini Ge5traft '
This _._IZ( homestead property.
(ia) (ys not) f
' 4uruSt '
3-t
Dated LhLi - . day of
I
IrA )
'U
Ben amity-
- .,,Wh tgp--Personal_Representati e
of the Estal~e o-f Richard W Whitten
__(SEAL)
s ~L )
#
AUT$ENTIOATION AOXWOWLEDG24ENT
S;~Q+..,,,ar<~ $ea7iartLlTt H._ Whten_ STATE OP WISOONSIN 1
! - county'
a en 'ca tbls Au t 18 al - personally cake before me this -------------day of
- 19__------ the above named
ii - -
' _..:-.1.A E
TITLE- MEMP= STATE BAR OF WISCONSIN -
(1: riot,
i` authorized b § 748.06, Wes- Stats.) to me known to be the pers~)n who executed the
ii
foregoing instrument and w--knowledge the same-
i. PHIS INSTRUMENT WAS DRAFTED IJY ~f
C. L._ Gay_lords..Attorney----------------------------
-County, Wis.
~i River Falls- WI 5402? _
Notary Public ,
My Commission is permatrnu (If not. 5taie expiration H
`algriat'nt'eS may br 8.utheTst3C3Leu Oa Both ,
d$ x zTe+ i+ {
..xd b -low it112 81$natHTin. ,
of paL;'sns virniMa ~C+ SIIY,aspauq+ shvuld .
MATE OAR OF-
No. ss - M2 Stock Na. 1307 5
ill IfYfi~ ~+iJtLhL '
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