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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS j _
SUBDIVISION / CSM# LOT #
SECTION T_?N 'R W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
121,16 is -
1~o r o INDICATE NORTH ARROW
ov'.i-d setback and elevation information on reverse of this form.
1-4 H r
ST (IR&A PrOv' de 2 dimensions to center of septic tank manhole cover.
cck)cT`a
d
c
BENCHMARK •
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: //J.--~ n 75 _ Liquid Capacity:
Setback from: Well o ~ ouse ~3 Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width:/o7- / Length `g J t Number of trenches
Distance & Direction to near st prop. line: X20
y/~,
Setback from: well : A; House Other
ELEVATIONS
Building Sewer ST Inlet ./y ST outlet moo?
PC inlet PC bottom Pump Off
Header/Manifold /d1-S4 Bottom of system -5-Z
Existing Grade O Final grade /a --?-~g~
DATE OF INSTALLATION: f- p2 U
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93: jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Hunan Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
' Sanitary Permit No.:
(ATTACH TO PERMIT)
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village ❑ Town o : State PI
HEITMANN, WILLIAM X
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel T
16S 1 / lL;
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark /001
Dosi ng
Aeration Bldg. Sewer ad 3 10 3- 5
Holding St/Ht Inlet 3- q pa y
TANK SETBACK INFORMATION St/ Ht Outlet /tea, 7 y
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic X00 N~ 30 >-3o NA Dt Bottom
Dosing NA Header/ Man. J,7 g ~Og 5
Aeration NA Dist. Pipe lop, c`3
Holding Bot. System /1 g C/, y q
PUMP/ SIPHON INFORMATION Final Grade 5,2 /0/,0
Manufacturer Demand /o y. 68
Model Number GPM
TDH Lift Friction System TDH Ft
oss Fi
Forcemain Length Dia. Dist. To well
SOIL ABS RPTION SYSTEM
BED/TRENCH width 1 Length No. Of Tr ches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type Of J CHAMBER Mode Number:
Qv, -CV
12 0 I 80 Ult. X)b OR UNIT
System:
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: STAR PRARIE 13,31.18.716,NW,NW,LOT 12,132ND STREET
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
a '
SANITARY PERMIT NUMBER:
I
~°-SANITARY PERMIT APPLICATION
ZjTDILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
ST 6ro I" )c
STATE SANITARY PE #
-Attach complete plans (to the county copy only) for the system, on paper not less than ~ 'l IT1~0 /y/~_
8% x 11 inches in size. ❑ Check if revision to prbvious application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
44) ; AJc u'/a O/a, S/ 3 T3 , N, R f E (or W
PROPER ER'S MAILING ADDRESS LOT # BLOCK #
t F5- -2 12-2A_.j. 12
CITY, STATE ZIP CODE PHONE NUMBER SUB VISION NAME OR CSM NUMBE
III. TYPE OF BUILDING: (Check one) ❑ State Owned 11 VI~GE NEAREST ROAD
32---d St.
OF'
❑ Public ®1 or 2 Fam. Dwelling-# of bedrooms - PARCEL AX Nu MBER(S)
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 Recreationar Facility
30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 80 Mobile Home Park 1120 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. New 2. ❑ Replacement 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 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
j ` REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
J J V y J., % Feet Q Feet 44 VII. TANK CAPACITY Site
in gallons Total # of Prefab. Fiber- Exper.
INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank ~'a e
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) MP/MPRSW No.: Business Phone Number:
rc*>r i cK 0 " I A~i4~ 2540~9 3 j if 2 457 Z6Y'76
I m is Address (Street, City, State, Zip Code):
PP6
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanita ermit Fee (Includes Groundwater Date Issued Issuing Agen tam
Approved ❑ Owner Given Initial d Surcharge Fee) B
/ o•~
Adverse Determination I Du
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Pib-67) (R.11/88) 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; (Jose 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 William L. Heitmann Jr. ADDRESS 2187 132nd St. new Richmond Wi 54017
NW 1/ 4 NW 1/4S 13 /T 31 N/R 18 W TOWN Star Prairie COUNTY ST. CROIX
MFRS BYRON BIRD JR. 3318 O~ DATE 5/21/94 BEDROOM 3
CONVENTIONAL X)OC IN-GRO D PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 648 BED SIZE 12'X54'
BENCHMARK V.R.P. Top of Telephone Box ASSUME ELEVATION 100'
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
VENT SYSTEM ELEVATION 99.0
12" GRADE
TYPAR COVERING
1"3' 6'Q3'
i ' SEWER R
12'
20' K B . M. Porperty Line >100'
Pro Driveway
105' 0 3 Bedroom
House
50 15' g
ST
35'
0, B-4 25, o
B-1 r
30' t I
ep A I I 60'
60' 13' ~ I
I I Bed = 12' X 54'
6% s ope
25 I - Vent
B-5 -2
18
Property Line >100'
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of
Labor and H. an Relations
Qivyior, of'6W & 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
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 OVNFR: PROPERTY LOCATION
GOVT. LOT # 1/4k/,~114,Sl3 T 3 N,R f E (or6
PRO RTY OWNER':S MAILING ADDRE S LOT # BLOCK # SUBD. NAME OR CSM #
c~- 4 X42 r • c 'e
C . , STAT I}? CO OE PHONE NUMBER ❑CITY ❑VILLAGE fi2rOWN NEAREST ROAD
p S 7/'fU a cr
New Construction ;e yj Residential / Number of bedrooms [ J Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow _ gpd Recommended design loading rate Zbed, gpd/ft2 a trench, gpd/ft2
Absorption area required C213 bed, ft2 _f;.gene 12 Maximum design loading rate __7_bed, gpd/ft2 ~trench, gpd/ft2
Recommended infiltration surfaee elevation s)' 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 IN FILL HOLDING ANK
ui*❑ S U
O_i
U=Unsuitable for system OS ❑ U 0 S E] U [~rS El U ZS ❑ U ❑ S
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
-12 /d r
Ground ~-(J y -,7 r
elev.
ft.
Depth to
limiting
factor
3
Remarks:
Boring #
j
Idol 31 12L--Fl
Uj ^f- Cg,
00
Z„~ G/ s O d
Ground l
elev.
/0 Z ft.
Depth to
limiting
factor
Remarks:
CST Name:-Please Print Phone: E`
Address: LXJ Y r
Signature: _ ,Date: CST Number:
PROPERTY OWNER SOIL 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
Ground 3 2-~ /D J /),7
elev.I
L17 f
ft.
9Depth to
limiting
factor
Remarks:
Boring #
0- 3 z r yK;fir
to S~ S
~.6
Ground.... Z' ( r V
elev.
/QOM ft.
Depth to
limiting
facto 7 2
Remarks:
Boring #
01'r cs S: 4
Ground 44 3C4 127 AIX. J
elev.
ft.
Depth to
limiting
? ?
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
` Soil Test Plot Plan
Project Name William L. Heitmann Jr. Byron Bird Jr.
Address 2187 132nd St.
New Richmond Wi 54017 CS 3479
Lot 12 Subdivision Prairie Rich Date 5/31/94
NW 1/4 NW 1/4S1 3 T 31 N/1318 W Township Star Prairie
Boring Q Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft Top of Telephone Box
System Elevation 99.0 Rep 98.5 * H R P Same as Benchmark
20' *B.M. Porperty Line >100'
Pro Driveway
105' o 3 Bedroom
a
House
0
0
A
50'
0' B-4 25' o
B-1
30
ep
Pri A
60' 13' -3
6% slope
B-5 25' -2
1 g Property Line >100'
Scale 1/4" = 10 Ft/ When dimensions aren't stated
I ~ . 4, ~ t.: 'L•.,;:,. ~....~:..-t t+:i'y- r+a.'e ~ G•''.~~ •n`3^.~,~
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27 N ,
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STC-105
I
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER J~
MAILING ADDRESS ZI ' 3Z"
PROPERTY ADDRESS 5_. VVL e a < I-ILL Vv_
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE e~.1 -1~ c~ yv t
PROPERTY LOCATION 1/4, 1/4, Section T N-R W
TOWN OF ~LaC L2 r 2 r i' ST. CROIX COUNTY, WI
SUBDIVISION Rg ; r i c LOT NUMBER-17
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.
1/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:- Z -
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 ~n delays of the parmit issuance. , should this
development be intended for resale by owner/contractor,(spec
house), thenia 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
, K ~o
Location ofproperty 1/4 1/4, Section , T N-R W
Township _ S~ei Ia.f _
Mailing address ? (1 I 2~'l5\
Address of site
Subdivision name r c Q-~~ APT ,
Lot no.
other homes on property? yes-_,2~_No
Previous owner of property,
Total size of parcel
Date parcel-was created
'Are all corners and lot lines identifiable? _2c-Yes No
Is this property being developed for (spec house)?Yes No
Volumer~ 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 & 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 of ce of the County Register of
Deeds as Document No. c , and that I (we) presently
own the proposed site for the ewage 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 County Register of deeds as Document
No.
131 z
sign ure of appl ant 46-a i nt
Date of Signature Date of Signature
_J
DOCUMENT NO. WARRANTY DEED THIS SPA::E RESERVED FoR REGORDIt.G DATA
f STATE BXR OF WISCONSIN FORM 2-1982
' 519894 nn REGISTER'S OFFICE
YOI 1O7~P~SF~ ~i? - ST. CROIX CO., N
_ Recd for Record
Herman B. Hulsey and Sandra K. Hulse husband and wife, o _e
_
as joint tenants- AUG 4 1994
at 1.00
conveys and warrants to William L. Heitmann and Kellie M.
- - - - - Re&W of Deeds I`
Heitlnann:.husband.-snd--Wife, -as--marital- property with
~ rights-.of- suryiyorship__-----. _ _
3 I -
s~ RETURN TO
't. .
S t
the following described real estate in Croix County, k,
r State of Wisconsin:
Tax Parcel No-
Lot Twelve (12), of Prairie Rich Subdivision of the Town of Star Prairie; being
located in the Northwest Quarter of the Northwest Quarter (NW} of NW}) of Section
Thirteen (13), Township Thirty-one (31) North, Range Eighteen (18) West.
II
: ZZApT II
1
u••~
r ~ I I
- i
I I
45
t , is
This - not homestead property.
(is) (is not) li
a.
Exception to warranties: I~
Dated this -----lY day of .August.... 19-94 II ,
(SEAL) ...-(SEAL) ;I
- - -
- y
Herman B, - - - (SEAL) 4 Hul a -
- _ ...(SEAL) I
Sandra K. Hulsey
r
AUTHENTICATION ACKNOWLEDGMENT
I ,
Signature(s) Herman B. Hulsey and STATE OF WISCONSIN
-
Sandra K._Hulsey
------County.
auihen'ic tea "h' o=- St----------, 1994_ Personally came before me this ----•-------day of
, 19---- the above named
Hendrik W. Van Dyk
t..
TITLE: MEMBER STATE BAR OF WISCONSIN
f ' (If not,
authorized by $ 706.06, Wis. Stats.) to me known to be the person who executed the
' foregoing instrument and acknowledge the salve.
THIS INSTRUMENT WAS DRAFTED BY
-
REINSTRA VAN DYK 6 NEEDHAM, S.C.
~ ZQ1 Sout ~-~KnowIes Aver, P-:- O:--Box I27 - - - - - .
-Kehl. FUr-hmond, • WI--54017 • - Notary Public -County, Wis.
l (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.) date: - 19--------•) a
•Namee of persons signing in any capacity should be typed or printed below their signatures.
' e- Wisconsin Legal Blank Co-. Inc.
- WARRANTY DEED STATE BAR OF WISCONSIN Milwaukee. Wiscnnsin
FORM No 2- 11"
.'r a 4 c : x S 1 ' 1 . ,f,~. % ..u,;y.. 'i. r, f ro j~ c,4.A '+~p- , : V !r. 'I:'ft+ '0 ~ >
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