HomeMy WebLinkAbout038-1148-70-000
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER Lj Q,, K5&y\-
ADDRESS
SUBDIVISION / CSM u o tm -S k(;o-'' LOT # I5
SECTION___L_7T 31 N-R_~k W, Town of :)4,L `Pr.c~ r I
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 1~0 FEET OF SYSTEM
~ 1~
t
J
u
f
INDICATE NORTH ARROW
Provide tbac and elevation ormation on reverse of this form.
Provide 2 imensions to center of septic tank manhole cover.
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity: SCJ
Setback from: Well House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location`
SOIL ABSORPTION SYSTEM
Width: a Length ' 0 Number of-' refteiu?z
Distance & Direction to nearest prop. line:
Setback from: well: House Other
.ELEVATIONS
1 /
Building Sewer ~i ST Inlet. ~y 7 ST outlet
PC inlet Al ?4- PC bottom Pump Off
Header/Manifold cY Bottom of system 9,1,
Existing Grade - Final grade'
DATE OF INSTALLATION: °l
PLUMBER ON JOB:
LICENSE NUMBER: ~S L
INSPECTOR: C rn dY~.
3/93:jt
Wisrqpnj~in Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
PeSWANSOrmit ROGER El City El village Town of: State PlRD ?N
CST BM elev.: Ins M Elev.: BM Description: ~ Parcel Tax No.:
O U i L~e.v.
L5 )0 14 (r o /
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosi n
Aeration Bldg. Sewer
[Holding St 1,0W Inlet 7 d~' ~J
TANK SETBACK INFORMATION St/ Outlet
7 !Z
3!
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic i5d _g. s NA Dt Bottom
Dosing NA Headert X0'1
a, ~c io.76 ~ ~ Q
Aeration N Dist. Pipe /J P~ v
p l, 93 ,
Holding Bot. System /01 , oa
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand , -2/
it
Model Number GPM
TDH Lift Friction S e
Ft
Loss
Forcemain Length Did. Dist. To Well
SOIL ASS RPTION SYSTEM
BED/TRENCH Width Length / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 5D DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type Of r ~ ~ rf Model Number:
System.. >SO -9f - 7S OR UNIT
DISTRIBUTION SYSTEM
Header / Distribution Pipe(s) x Hole Size x Hole Spacing Ve~To r I ntake
Length °l / Dia- Length ~ Dia. Spacing (o
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems
Depth Over Depth Over „ xx Depth Of xx See / Sodded xx Mulc e
Bed Center Bed /.T*e:Bich Edgesr Topsoil es ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
L ION: Star Pral i 17.31.181, S NE, Lots 15 & 16, Brav D,rriive
Pz ! K .•.y.'"~ t.,' \ y~ i1Q . E y ! , ~Obl- yr e f ..l -l 'L~' o"! S~,e 1 /'~.C2 t•.r / / ^
Plan revision required? ❑ Yes 2'N
Use other side for additional information.
SBD-6710(R 05/91) i Date Inspector's Signatre Cert No.
~4 / 4
_~OI~.HR 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 'ZQ 9 60 q
8% x 11 inches in size. ❑ Check if revision to revious 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
FI1eq-0-k 5LA3 4L 0 ►N 0 5;W '/a AlEy S T N, Rf W6
/ r) W
PROPERTY (OWNER'S MAILING ADDRESS LOT # BLOCK #
CITY, STATE ZIP COD PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
wr 5 y a-~ S- 17/-r) cp 1~3•Z3 IK W1 w v VV-% Shores
IZI
11. TYPE OF BU DING: Check one
CITY NEAREST ROAD
( ) State Owned ❑
VILLAGE : Sf4V` f 4) >r P Q r
C21 =N OF: Dv-,
❑ OkN'l
Public K1 or 2 Fam. Dwelling- # of bedrooms PARCEL AX N RO =7
III. BUILDING USE: (If building type is public, check all that apply) 3 8' - 1
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. M New 2. ❑ Replacement 3.E1 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 3o ❑ 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. SYSTEM ELEV. 7. FINAL GRADE
6 Oa REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
/v e /-S 0-0 i /TJ /a'- 5'1, 2 Feet 95. Feet
VII. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New JE-xisting Gallons Tanks Manufacturer's Name oncre structed
te Con- Steel glass Plastic App
Tanks Tanks
Septic Tank or Holdin Tank D 2 t,s 4t r
Lift Pump Tank/Si hon Chamber
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Pri Plumber's Signat o Stamps) SAP/MPRSW No.: Business Phone Number:
Ua 159-3
cak~
Plum's Address (Street, City State, Zip Pods):
1 '9 GQ(~
IX. CO NTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing A nt Sig ure (No m
Approved ❑ Owner Given Initial Surcharge Fee)
19
000 Adverse Determination
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 in
5. Onsita 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.
H. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
111. 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 mainsiwater 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 1.15 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.
4r,
The monies collected through these, surcharges are used for monitoring groundwater, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
V.
.),6 /Y 416 900
Sfa r~wa ~ wl 'P
1~.
y ~
x
,
CIW
vo~
6
5 63
a
f bed a`~ ay
3 p X S`d ,Oru. vH 1Q
,p.
QY•
S ca1~, 1 ~d
a
F.
i
/r
a
jj"
r
t
w `
r
r PAGE OF
CroSS Sec1'lon oi~ Sys~er►-~
f r
Fresh Air Inlets And Observation Pipe
Approved Vent Cap
Minimum 12' Above
final Grade
20- 42' Above pipe _ 4' Cast Iron
To final Grade Vent Pipe
MonA May Or Synthatk covering
win. 2' Aggragals -
Over Pipe
Distribution
Pipe o 0 0 0 - Tae
I 6' Aggrego/e
Benaatb Plpe a Perforated Pipe Below
Co*lag Terminating At
Bottom Of System
ii
P~pPo1eD fines'. 9~ f%clt
~ItJn~ tort
SOIL. FILL
DISTRIBUTIOu PIPE
• APPROVED S~WPETIC COVER
Z"oFl►6GR~GATE c C MATERIAL- OR 9•. OF STRAW
OF ('1ARSN HAy
OFAGGREGATE
tLEV. OF 17 t- 3
DIS-rR105UTIOM PIPE TO BE AT LEAST y W1CHES BELOW ORIGIUAL GRADE
AM) AT LEASTZO I:JCHES BUT IJO MORE THAI) 42 IAICNES BELOW F1UAL GRADE
MAXIMUM W N OF EXCAVATIO" FX011 ORs&rdqL 6RADF- WILL BE -3~ IMC14ES
MINIMUM M 1i OF EXCAVATION FR0/'1 0 I14IWAL GRADE WILL BE .30 WCHES
SIGNED:
LIGEUSE IJUMBER:
a
DAT E : s~~/ ~y
Wisconsin Department Industry,
Labor and Human Relations SOIL AND SITE EVALUATION REPORT Page / of
Divisioh of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY 1
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, butch 7 ~l'Di
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. /7
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
MO 6"r A. Swa/15011 GOVT. LOT S'W 1/4 A4F114,S 17 T 3 / N,R If E (or+~V
PROPE OWN R':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # ,
02 / rotVe r,` u'e t c%' r✓am ~Sfiare s
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY . ❑VILLAGE XOWN NEAREST ROAD
s .5 S /Da S ( -3a3G Sfr r; r ~ f3retv.- Dt-,'ye_
~(f New Construction Use[ J Residential/ Number of bedrooms [ j Addition to existing building
j ] Replacement Public or commercial describe
Code derived daily flow 6 00 gpd Recommended design loading rate . bed, gpd/ft2_ •,19
trench, gpd/ft2
Absorption area required /500 bed, ft2 /„21,,2 trench, ft2 Maximum design loading rate . bed, gpd/ft2--trench, gpd/ft2
Recommended infiltration surface elevation(s) _ W. 7 ft (as referred to site plan benchmark)
Additional design/ site considerations i/~ 6c, r a a r S/~m 1,r ro✓e
Parent material ,`S loam-1, / Flood plain elevation, if applicable AIA ft at
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem l? S ❑ U ❑ S ❑ U ❑ S ❑ U ❑ S ❑ 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 Tiranch
A d /U p -3 e- S/ ran . i~[ Cka,- Cbm-yen . S .
A.2 9 -12 la ~ 5/3 31 wk /
r ; a C/PA's Cr~.Hina .,5
Ground
f-L '7/_,/ S% n,(-l n Sk b/ Cka r" -Fed • S
elev.
eft. II83 a1,3'/ S `/R sbKr,'~b/e 4l S
JJ/
Depth to e 31 GG Syn 7
,L/ ~i St SJ., le r hcjs e.
limiting
factor
Remarks:
Boring #
1'0--q /O Y9 313 Mine S l YAh , / e P r Caavnc~~ • S ~
Mj A,2, 19-13 16 Y9 iif
Wk m / /e Clear am-'A
Ground 13, Z 2 t 13 S S M S/ mcd, m skk I f ,a I& C/ r +
elev. .IIY,133 o2S36 S M N1 'r S/ w C Sb T b/e. cle r -fe
to C !n-/e0 5ya 7~y loose-
Depth . S~
limiting
factor
.760
Remarks:
CST Name:-Please Print nd Pr Phone:
K A Sc,IGlrtso 715--z/aS-3~' 1(0) -
L2 2C
/address:
6;-AVe_ /_)rIVP S,~j Brse~ (-sCC)'yY, ~ Se/0~25
Signature: Date: CST Number:
`/~8~e/ /s'lDOloDlo
PRCP UiTYOWNER ~ x sv~ SOIL DESCRIPTION REPORT Page-7 of; S
PARCEL I.D. # 7 c~ l~SD r S
Depth Dominant Color Mottles Texture Structure Consistence Bourxiary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trey
A! 0 -C1 D 313 /l e- 51 ran, C lea C6~naton - s . G
sl wk m / b/ Clew 5
,I,2 q-112 /0 \/'R `'1 H
Ground Slut /2-o2y SyR y/ ~I sl ~„oal rN sb,' -fr,`ab/e C' r `"l 5-
el 'evIft • 71133 1134 S /R It 4,< C sdK r,` C/~r few , y :,5
Depth to 71 C y (oD S yR S r s, r to s e 1w., 41 1-15-
limiting
facto
Remarks:
Boring # 3 C/P~rr ~aHU.e. ~S ,!o
Al 0.-q 0 A10,1 e sl rare. i
9-/ IU ~R iI sl uk m / V b/e. C/ea r CM -m '5 inc/ in s6K /z NeOl' fad
Ground
elev. 7f" 83 oZ5--3G 5 YR `'l~ C Sbk e/,ar few
gift.
iC &-44 S Y A It j i SIn /c I r ~OOSe Y►o,~~ . e/ -5-
Depth to
limiting
factor
Remarks:
Boring #
X11 0-6 /0 YR 313 /I/p„e .51 ran. ; h ka r 4/mon ~ S , to
s +I s/ wk M Clear r~M o~
13-vt 9-/8 S I12 y1v S/ m sdK r`~6~~ c%pr feW ~41 15
Ground . `
tr / wK c- sbK / C/ea~
elev. Ih33 /8-a8 SYR q141
93. 7 ft.
ZtC x-70 5YQ .I St Sig le r se none ,
Depth to
limiting
factor
70 r,
Remarks: From d stl r &r,
Boring #
AI a-~ /0JK 4j3 /kwe- 5 rRn, t ~Q Clfe,r cam-, E ,4,
/1~ 41-7 /U-13 .r SI NK C/Mr Cpn~aa~i y .S
ft... - (j,2,2 t 5- Y!Q it S f' M'd ,x sbK - ri.6/e elect r- f c j
Ground
Ii 51 wt S6Krl/e G/eav gip,,) , ,9' , S
elev. y/l
FITS / f'30 ✓R
3v'-70 j YR Lllq / I S* Sih G r /00.5 t" /tOn 0 ~ ' S
Depth to
limiting
factor
770,r
Remarks: Cro P Sk rface-
SBD-8330(8.05/92)
PF)PEMTYGWNER /tociPr 4. Sula on SOIL DESCRIPTION R;.,, ORT Page of S
PARCEL I.D. # /7, 31
1
Boring # Horizon Depth Dominant Color Mottles Structure I
9 Texture Consistence (Boundary Roots G P D/ft Bed ftnch
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. III
10YR '113 ! of s/ ran . -i lab/e ' ~~x to
n...r........ 822t -/O /S s/Y P~ $1 K C 5.6k Clea ( lee" • 7 . S
Ground ZC/33 / ' 32 S ~~Q wK - 5,6k
elev. ~r,Q/le- Cldd/ -1cer,J - ~f
ft. .ZG 3,2-70 SYl~ fG05e 404 e 1
Depth to
limiting
factor
6
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Groun ;
elev.
,.x
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to I
limiting
factor
_ Remarks:
S3D-8330:'1105:^2) -
N M CO ap t1) _ N rn , 66.46 -
sol os
x.06 so , col
s 00 8
\ P I - -
611 GZ'66 J '~a
O N CO
~-rti J
N~. N NN \
_ N M ,06• oL
Cfl
91 £LI ,eL'911 ,Ib'S6
h I
N ~ N
S c~
t0~ 1 s, sS
a O ) J~ 64
.6~ T
/ 9205
(Q
tea.
U-) c
Q 0 OD st N CO N
\60' \ I M = y~L
GMT)
(D -Z
Oo ~o (D Q I C
V I ,96'111 I
10
'ZOE I ` ,90'811 V
w ) 1 y
~ N
Na J
Q M / L 11
6b'£01 ~ ~ X01 ~ `^.I
N
O N
(D M
to
N
o LO
N C7c4 (fl I
_ CO ti-
- ~h
w-
- - _ - 3^ d~8- Z v
S T C - 100
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property qP,~ SW sa..
Location of property ,$I 1/4 A16 1/4, Section 17 ,T 31 N-R /S W
Township S'TLr- Prairie Mailing address
9602 13r-ave- /.~r;Ve -50m er56~ Ascons: ~ 5y0o2S
Address of site,mime- a_5 Agt QyQ
Subdivision name 61i` S Lot no. /
Other homes on property. Yes No
Previous owner of property rs haui2a
Total size of property
Total size of parcel
Date parcel was created
No
Are all corners and lot lines identifiable? No
Is this property being developed for (spec house) ? Yes X No
Volume 16,39 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 office of the County Register of
Deeds as Document No. 506 6(pl , 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.
Sig ture f Applicant Co-Applicant
Date o Signature Date of Signature
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
r
MAILING ADDRESS e
Dy-
PROPERTY ADDRESS ~C~✓n
(location of septic system) Please obtain from the Planning Dept.
sue, ICJ s 5iV
CITY/STATE -Omer <<SC~~
PROPERTY LOCATION ~5 (,J 1/4, 41L 1/4, Section, 17 T_.ULN-R_LS' W
TOWN OF SAC /'Y?2A,,'P _ , ST. CROIX COUNTY, WI
SUBDIVISION .'A." f "2 A e S LOT NUMBER
CERTIFIED SURVEY , 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
ye pi
County Zoning Officer within 30 days of the three ration date.
SIGNED:
DATE: 5/~9 A?
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1- loot THIS a►AC9 RtagRVID FOR 019COMiNG DATA
ARRNTY DEED
• ' ~ WYoe 1039PAGE114
This Deed, made between .Roger •L . Kirshbaum • a~k~a f - Cdi
Roger_.-i arshbaum-•and_•Judy__A. Karshbaum_.a/k/R-•- Rec•dTbrReoord
Judy .Kar.aibaum., husband and w1fe. OCT 4 1993
Grantor,
and.....Roger_..A._.Swans.Qn at 11:55 A~
Reols~ef of Deena
, Grantee,
Witnesseth, That the said Grantor, for a valuable consideration......
conveys RETURN To
conveys to Grantee the following described real estate in ..5 t.,...Y Q .X......_...
County, State of Wisconsin:
Lots 15 and 16, Block "D", Wigwam Shores
in the Town of Star Prairie. Tax Parcel No:
TOGETHER WITH an easement for ingress and
egress over Brave Drive as shown on the Plat.
s 0
F~
This s-- 11Ot.___...---. homestead property.
(is) (is not)
Together with all and singular the hereditament& and appurtenances thereunto belonging;
And.... Roger...L..---KarshbAum.-and --.Judy..A-•---Karsbbaum-...........................................
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrancea except
easements, restrictions, and rights-of-way of record,
and will warrant and defend the same.
;~Rq&qg. ted thi 1.3t day of QQr4bar.......................................... 19.-93..
. ••-•-••--........(SEAL) ~lt,i ls'u .l~ A ...(SEAL)
_ L. Karshbaum a/k/a , Kdy A. Karshbaum a/k/a
Roger Karshbaum Judy Karsh'baum
...................•---....--.-.•-...-------•---•--•--•--•------.....(SEAL) (SEAL)
• • •
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN'
ss.
•--..5_t~....Cx.Qi.if.---......__County.
authenticated this day of..... _ 19 Personally came before me this ...I.St...... day of
..................QntdJ_12j=...... 19-.91. the above named
Rngex_..L_,...J.ax abtlamw---and-•----.
.Indy...A.....K-axahbaum...................
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, --••••--•------.......•--•--.......~,,,u..,,
authorized by 706.08. Wia State.) _
to me kn be the pebson .5 who executed the
foregoi n men, t, sled owledge the same. aft THIS INSTRUMENT WAS DRAFTED BY ',3rj\
..........T._..._.
C~,.. [._....GaylQxd..Ax.>iuxnex-------------•---••--
C~ ~.C 4... .-•-~f l S o
RiVi:x.. a~ S.,.._~• 4022......................... Notary Public ..-7.t.Q !c. ............County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission W,p Vrmanenf, (if not, state expiration
are not necessary.) _ • • (a 22
date:
•Naosse of persons sirnins In any capacity should be typed or printed below their signatures.
WARRANTY DBHD STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc.
FORM No. 1-IM Milwaukee, Wis.
//0 -q3
ST. CROIX COUNTY
,.r. WISCONSIN
y •'i r i
ZONING OFFICE
ST. CROIX COUNTY COURTHOUSE
911 FOURTH STREET • HUDSON, WI 54016
- - - (715) 386-4680
SEPTIC INSPECTION / WATER TEST REQUEST FORM
Specify desired test(s) & remit appropriate fee with application.
Outside water lines are often turned off during winter months,
making access to the home necessary. Please make arrangements with
this office to insure a time when entry can be gained.
❑ Water (VOC's) $185.00 .Septic $25.00
Water (Nitrate & Bacteria) $35.00 (Visual inspection)
Owner: Requested by: ~r
fy"i
Addre6~; Address:
City & State: , City & St. /~P Le-1
Zip Code: Zip Code: 27/o i z_
Telephone N4: ( ) Telephone N4: ('213T 4~~_ !~21d
Property address (Fire N2 & Street)
LocationSlt/ Sec._Z7_, Tj~_N, R /y W, Town of Dui` .,cam
St. Croix Co., WI. Tax ID N4 Parcel D N4 9
d/3 `
House color: Realty firm: Loc Box Combo: ✓
Water sample tap location: Sir
TO BE COMPLETED BY PROPERTY OWNER
*PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVEI SE OF THIS FORM*
Is the dwelling currently occupied? ❑ Yes o e~y If vacant, date last occupied: ~ Septic system installed by: Year:
Septic tank last serviced by: Date:
Previous Owner's Name(s):
Have any of the following been observed?
❑Y ~99 Slow drainage from house.
❑YN Sewage Back-up into dwelling.
❑Yi Sewage discharge to ground surface,
road ditch or body of water.
❑Y Slow drainage from the dwelling.
❑Y Foul odors.
Other commen relative to system operation: ✓
I certify that the above information i comple~t and true to the
best of my knowledge.
OWNERS SIGNATU DATE:
4/93
t 'T
11 1 OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION
1
N
J .
q
TO BE COMPLETED BY INSPECTION AGENCY
System design &/or permit on file? ❑Yes ONo
Soil series per SCS Soil Survey: sheet #
i
Type of soil absorption system: OBelow grd OAt-Grd ❑Mound
Approx. size 'X OGravity ODose OPressurized
Ft.2 ❑Bed ❑Trench ODry Well
OHolding Tank OOutfall pipe
OBSERVED DEFICIENCIES 00ther ❑Unknown
Septic tank
Setbacks: ❑House ❑Well ❑Prop. line 00ther
Dose tank
Setbacks: ❑House OWell ❑Prop. line 00ther
❑Locking cover ❑Warning label OPump/Floats
OAlarm ❑Elec. wiring
Soil Absorption System
Setbacks: Oliouse OWell OProp. line 00ther
❑Ponding: ❑D'scharge•
General comments :
INSPECTORS SKETCH OF SYSTEM LOCATION
N
r
Inspector
Title
` a r fir' , '~v 1 , y`~ ~~sj r~ ~A~ ~~'S
t ~ t` `i xr~~'o ~•~v J a 'a~L
21
a
Premier Group 70619th Street South
Hudson, Wisconsin 54016
(715) 386-8207 _
(612) 436-8433
LAKE CABIN
3 season - 24 x 28 cabin on a great fishing lake.
Unique double lot for privacy. Almost 400 ft of r `
lake shore. Cabin was recently remodeled. Enjoy
the view from the large screened porch overlooking
the lake. Good fishing right off the dock!
Addr 962 Brave Dr L#
SQUAW LAIKE• City Somerset Fire # 962 Dist 6
Sec Twsp St Prairie C St Croix
The lake is a seepage lake with excellent fishing. Ext Yr Bit 1960,s Ht Style Cabin
Species include walleye, northern, crappie, Lot Size SMFL TFF Tax Yr 19- _
sunfish and perch. The DNR has aerators in the 1~ A 672 S 704
lake to keep it from freezing out. There is also L C 0 Approx Rm Size it Baths WT Sch Somerset ,
a program to control the algae. As the map LR ( ]MB BB -
indicates, the lake is long and narrow with DR Dwshr Disp. Ei20'test on file
several bays for fishing and excellent wildlife Kit Refri ( R&0 ( )Yes ( )No
habitat. The DNR personnel in Baldwin are FR WS R 0 Avg Ht $
familiar with the lake and the programs. MB C. Wtr C. Swr. Avg Util $
BR Well Septic Poss Date Closing
THE CABIN: BR [ Frpics C. Air Bsmt
Gar [ ] GDO ) Deck [ Patio
Much remodeling has been done in the past year. A Rec Rm Ldr UFFI [ ) Y ( ) N O UKN
new ceiling was installed and insulated. A new Legal/Disdosve
was installed as well as new kitchen Lot 15 & 16 Block D, Wigwam Shores Town of
floor
cupboards. There is a new hot water heater. The Star Prairie, St Croix County, WI
ister Roger Karshbaum Ph425-0234
mechanical systems are as old as the cabin but are S/B/C 3.2% L
7-7
functioning. The cabin was built in the early Brkr Century 21 Premier Grou # 230 PK386-8207
sixties. The well system was repaired last year.
The depth is about 130 ft. deep. There is a new
submersible pump and piping to the pressure tank
and the controls are new. AGENT OWNER
N-278R
DIRECTIONS: Hwy 35 North from Somerset to 210th,
PRICE: $49,000 turn right, 3 miles to 100th, turn left
1/2 mile to Brave Dr-follow private road
to sign.
Information is considered accurate but we accept no liability for error. Listing may
be changed or withdrawn without notice.
IOU.........
07►ORIUNITY
Each Office Is Independently Owned And Operated REALTOR'
i
a i ~ •
r
STAR PRAIRIE T31N.R.18W.•55
POLe COUNTY
.r Lvorr 11 _ o
flier J-D COsa/ ; y - L-- M SL~
Fo- 2-Y,
•./CV/u,(~ r=•r ncSM P, rs r. R -
led >i i C < \ III } a Q'\i • • ye 3•.('JI;:.r is= Si•~ q , .
Snres6 cco O C~.t-J ~T~~ Z_ c♦ , ;I
/s.l/ yr ° /JC7 Q>~ ~D C 5~ \ ; t \ 1<: i>. ,i Ra..c/ra 1t I is
VV.. .77 ♦ ~ .2 ~ 2n ~x,F~ s iG:, f~Gl ' _ i . t * (
^ .`S r' ► `I Ott -
f Krfs°,".° Le.':J~A1v. ~Lt Sv: tri oa°ss- tt~sr iis~
n/r/a ^ ~ Jf~/ :=2•` 1Jr7 s~ • `~15 u'~ H UN~
Y` \"•JJ)r_r D C~; •Ci ',t Ne,.rta^ sfV~ Z a Lo/son 1 H RAIRIE
L♦ 4 ~ L h'e/J eq 3 - s
a \ ~ = .•eri C 4• w. k1~ ~ I' C' "s~'v~::; on1.J.tee
' r''v"':F I. Ci~,~Q.>., - ~ .jam Den.[/X. '>er ~e < <fcI ~ 7arno:
7• ~ A. ~ o'e•.- .-.r:~°~ I .Sni cas '•t! a C t s S.[.,t
l r lO r; 1 c t• a ~V e/••J'
'r+on/ , , ` +1 Ie! !{S I - •i c.~ C C 4 ,w:ryF ¢se -:dsi l e0
~ • Lq <e.. •J 2 1 < /.O Gnc vCJ. C. / 7 .G 1•• = 1~ 1 ~yt /C/Jin1 ,
Ntr iv, V'-+~•~4~Y.:a<t/ < y ti . .vn Jf r i ~i%e:. Ys✓,1.Z : : °,ry C `C r .d• e~aa-~•e` Yj/k O
T•r t•^' klC tit -.cr•c J: J7 .:e N F•t a Yet` , afi 'J` ♦r N
•Cwa'.Je^ Y ' r -r
< 3 } ~.I. :~cG SQU~N L` 1 C 1 - \ / "•'S '.'I? ••'✓aid ;M.,i N
L ~ .1•' } ci 1 r/
, C s
cTr Ol: Q ~,n ♦ _l.n. w A'ane,•rj c Andersa 1]n,<
/~~f ^a . ~ . ur+c
r.
tJyrV - c.Y~ itT• /c_ i7 - v' •e
C.+!~•. a, Srti.
t 8 i. ^~siie~ ~.l I ~veJc r Ins' .'OJla ~1 "Fj, J,
Jan yy Y / k
L.7 n• YrC ~ G i0 Y, •E•
' ~ 0 Bc// '8 'i,yy:••~n/ .o /r : e F) 47 ~ j.?~ C cEc fJER~ ; 1 ~ , .t: [,tn
`,t' N: 1• K Qom. F':::. ji~n:.ec:. L lhn)P /oJ Cry WJ//V [ A m./r n,9J
1 „ /JG:9 a I• "•'~P ♦.i:: a'y.' I~e~') Jmnno on • C° A'[~Te✓ '~roe~^e. ~ ~1
W • •C f L.. c.//e J r C4: .L• • a . Ir nyr : SPCC L ^c-.•, [ I`,1 / V
1 ` / ys ~,•.~i!3eo r.ann 7e I~~•I~ J°R'Q- • ~K.'e.'^e rd ; Torn.•j` ~•i~1 40
s ~I' . L• I
1 V r .w ~r.cr}••.t y1'. c' . I i~ i+cejr Fear •,Sr>%P _c- • < C Fnc_~-.~ ^ruer t,' ~<~J W N
V' af~''r~R. _ Cr.:c..I.^r I2~ rf'. y ts-: L~r ^h,. 1~ - i< ` ~•ll coy - ~~K.t I~~i-~~~V ..1.
J, ESB
_ ~~,Jf'•a:c -f;.~~?~O/•e Gc~c Lj ..,;)/..r•_> I ;zSTR D .fr nciax~a.-•~<:
_ T r.~• ~ t.?'- ~ 7~cs ._"M -1• ••-•C~ : ~ 1 i_ • ,t•N 4.. _ 1 ♦i s[p[ ~ G
.ncs ,Tres I Gn;i•1 -ZI0 ".i"/a " -~,•,.r'"c•:r: w~ ,~t -•ii .`12. nce~^~~ •1 , ..'a~^ rr'
' ~.c er..f~ G/cu~c/• L I 12' ~e•~u ~:.xh•M::I C ` _ I LernC.a ed ert
' k A Jr• 1 A• F ( ~ ~ 1 3-o-•~a1 ` i /u ~ er O ia/ke rr
aser.h 1eT •I~=•: ~c .c ~ ~~s+ ~ - ~ ~ / ~ ~_dr w . ~=t.~. .rora. d ELur I ISjLj
P. o d /-'.7rc scn~ :7•~ i 0 E :^7'cr t•+•1 •+-~:I. 1 ' :'+I1 ~7~ f c~c 1 C
t: I to lr: l J _"tr: `G,,..,' fc ~.•=)-4'• r.: e::J _ a h
_ 1` rerlti
'L•<f ifG•'-s CrrJ Imo' i,•'!J ti • -r ( Gr^c r•Cr< y no•-aO J.'
O Gc / rZ'or:° ~j ~::<~a :r /:c J) furs -•13:•'J ~s s; , c vG. :rJ j> .-es e~ LN ES
1o t7. tre~ea~ I ~ .ro t_.i = f'l L,
"r._as A. 40 '1 ? •~-.4 -co /eo RIC111.:OND
e-13 7
•C,.1 1 3~ ¢'L'~I"s < <,I. r.♦~ltc,'='~'?~ r~~•~ I ..~~i ~TL` CC ~ 1•
\ i ~ ` f'I C..♦n ~ ; I ./•Fe ~ ~f.:lfi£ .'1 . •v 31
110 58
\ oa :era G r^.'-?I` \ K
W~//~~ M S / 1 01~~/ LW RIC tN
WIG '
t vs
r
r i
• I r a s
0 ~ N n 1 ~ • : •~-.,,'may ~y~•! ~':ti \ °%r . ..:0 r0i _
l/4-NE 4
• 6'50Z
}
655 n 654 653 P 65 ' .3.6~r.'
a~
F
_
ry 3 Z
- _ / /649,
' - ~ 5 Q / ^,92.62
13 64.,-
4 647
295 0 ` i~
PP_
I~
September 15, 1993
Roger Karshbaum
540 N. 8th
River Falls, WI 54022
Dear Mr. Karshbaum:
An inspection of the septic system serving your cabin located at
962 Brave Drive on Squaw Lake, was conducted earlier today. At the
same time a water sample was obtained in order to test for the
presence of Coliform bacteria and Nitrate contamination. We will
forward the results of the water test to you as soon as we receive
them.
I was not able to find physical evidence of the septic system or
its location. Our records do not date back to the time this system
was installed, so it is impossible to determine exactly what the
system consists of or how many square feet of drainage area there
may be. Accordingly, I can neither verify the code compliancy of
the system nor determine the condition of that system.
Given these factors it is impossible to estimate the useful life
remaining in the system and I cannot guarantee or warrant that this
system will continue to function properly in the future. I cannot
predict how long this system will continue to accept sewage
effluent nor how soon the system will fail completely. In an
effort to prolong the system's life as long as possible, I
recommend that steps be taken to minimize the wastewater flow from
the house which enters the system. For example, repair any leaking
water fixtures and/or replace them with water conserving fixtures,
reduce time spent in the shower/bath tub, wash dishes only when
there is a full load, etc. I would also recommend that you have
the septic tank pumped at a minimum of once every three years.
Should have any questions or concerns that I can clarify for you,
please feel free to contact me at this office between the hours of
am.- 5:00 pm., Monday - Friday.
Since ely,
J es Thompson
ssistant Zoning Administrator
cc: file
09/27/93 11:19 $715 962 4030 COMM. TEST LAB 344 S.C. CO CRTHOUSE 16002
COMMERCIAL TESTING LABORATORY, INC.
514 Main Street, P.O, Box 526
Colfax, Wisconsin 54730 k4~
715 - 962 3121
800 - 962 - 5227 4:0k
FAX - 715, 962 - 4030 640a
ST. CROIX COIIITf 50YO NI!'ENT RSPIW NO.1 49077/01 PAGE 1
MITER _ REPORT DATE; 9721/93
1101 CARMICHAEL ROAD DATE' RECEIVED! 9116!93
HUDSON. WI 54016
ATTN: THOMAS C. Na-90H
OWNER' Roger Karshbaum
LOCATION: 962 Brave Dr.p Star Prairie
CUU.ECTOR: Jim Thompson
DATE COLLMTED: 9--15-93
TIME COLLECTED# 12215pm
SOURCE OF SAMPLE: Outside tap
DATE ANALYZ,ED29-16-43
TIME ANALYZED12200pm
MLIFORM,MFCC: 0 1100 at
INTERPRETATIONS Bacteriologically SAFE
HITRATE--N-. 3 ppe
Above 10 ppm exceeds the recommended Public
Drinking Water Standard.
Coliform Bacteria/100 mL
Nitrate-Nitragen, mg/L
LAB Ti":CHNICIAN% Pam Gane
~µOt,FNpyry.-WI Approved Lab No. 19
I Means "LESS THAN" DetectabLe Level Approved by:
PROFESSIONAL LABORATORY SERVICES SINCE 1952
&x-51
CU,~MERCIAL TESTING LABORATORY, INC.
514, Main Street, P.O. Box 526 k4j
Colfax, Wisconsin 54730
715-962-3121
800 - 962 - 5227 4:0k
FAX - 715 - 962 - 4030
PAGE 1
ST. CROIX COUNTY GOVERNMENT REPORT NO.' 49077/01
CENTER REPORT DATE: 9/21/93
1101 CARMICHAEL ROAD DATE RECEIVED: 9/16/93
HUDSON, WI 54016
ATTN' THOMAS C. NELSON
OWNER' Roger Karshbaum
LOCATION: 540 N. Bth St., River Falls
COLLECTOR' Jim Thompson
DATE COLLECTED' 9-15-93
TIME COLLECTED: 12'15pm
SOURCE OF SAMPLE! Outside tap
DATE ANALYZED'9-16-93
TIME ANALYZED:2'00pm
COLIFORM:MFCC' 0 /100 ml
INTERPRETATION: Bacteriologically SAFE
NITRATE-N' 3 PPm
Above 10 ppm exceeds the recommended Public
Drinking Water Standard.
Coliform Bacteria/100 mL
Nitrate-Nitrogen, mg/L 'l,
cb /PA %
IL?
~a C,9 ,
ti~ycly% 9~
0,
~e
F
S C
LAB TECHNICIAW Pam Gam
OF•\N~EVENOpNl, WI Approved Lab No. 19
,=v
g o t Means "LESS THAN" Detectable Level Approved by'
PROFESSIONAL LABORATORY SERVICES SINCE 1952
f COMMERCIAL TESTING LABORATORY, INC.
X14 Main Street; P.O. Box 526
Colfax, Wisconsin 54730
715-962-3121
800 - 962 - 5227
FAX - 715 - 962 - 4030
ST. CROIX C3UNTY GOVERNMiEN, REPORT NO,: 49077/01 PAGE a
CENTER REPORT DATE: 9/21/93
1101 CARMICHAEL ROAD DATE RECEIVED: 9/16/93
HUDSON WI 54016
ATTN: THOMAS C. NELSON
WNER: Roger Karshbaum
LOCATIONS 962 Brave Dr., Star Prairie
COLLECTOR: Jim Thomson
DATE COLLECTED: 9-15-9?
~IM{E COLLECTED! 12S15pm
SOURCE OF SAMPLE, Outside tap
DATE ANALYZED.9-16-93
TIME ANALYZEDS2S00pm
COLIFORMi,iiFCC4 D /lOQ ml
INTERPRETATION: Bacteriologically SAFE
NITRATE-NS 3 ppm
Above 10 ppm exceeds the recommended Public
Drinking Water- Standard.
Coliform Bacteria/100 m 12
Nitrate-Nitrogen, m9/L
Cov. 4n) tiC•4
LAB TECHNICIANS Pam GaTe
OF.WUEVFNAfNl WI Approved Lab No. 19
0 < Means "LESS THAN" Detectable Level Approved by:
ZJ 4
dy
PROFESSIONAL LABORATORY SERVICES SINCE 1952
r3
-Ilk
~ C
i
I ~
V
a v
t ~
It,
In N
OCT o)
-~Ic,
k 3
l.a
~ y
QL-
a
Q6
f~ ~ (ice