HomeMy WebLinkAbout038-1093-60-000
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
~K
ADDRESS
SUBDIVISION / CSM# LOT # i
SECTION -T--1LN-R OW, Town of sS
ST. CROIX COUNTY, WISCONSIN
ZWITHINF 7!~
SHOW EVERYTHING F SYSTEM
d~
N
i
INDICATE rORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
) 1
yBENCHMARK: Gl1L
ALTERNATE BM: y `
I
SEPTIC TAN / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer:_Li/quid Capacity:
Setback from: Well House Other
Pump: Manufacturer Model# - Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length Number of trenches
- Distance--&-Direct-ion -to-nearest-prop:-lime: }
50'. Setback from: well:->- Housq<:224LL Other /
ELEVATIONS
Building Sewer ST Inlet: 7 ST outlet
PC inlet PC bottom Pump Off
~
Header/Manifold 5,00) Bottom of system9,~O
Existing Grade
7 Final grade
DATE OF INSTALLATION: 09-9
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labc_j and Human Relations ST. CROIX
A Safety8nd Buildings Division INSPECTION REPORT
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION
Peft'Ag ameKENNETH ❑ City E] Village Town of: State Plan o.:
Star Prairie
CST BM Elev.: Insp. BM Elev.: BM Description: / Parcel Tax No.:
4901
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark /OS,6v /00
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet rjd 4$ j
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
TANKTO P/L WELL BLDG. Airito ntake ROAD Dt Inlet
Ar
Septic >7S' NA Dt Bottom
Dosing NA Header / Man. g Z
Aeration NA 11 Dist. Pipe 'j, `l Z 6 . a y
Holding Bot. System /a (4 a
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
oss mead
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length f No. Of Tre es PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMEN I N
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type O /"Za cJ Moe Num .
System:- o a61 1 (OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER 06 f~ . x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over .C } Depth Over 10L{ xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges 61) Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, person present, etc.)
LOCATION: Star Prairie.22.31.18WV NW, SE, 118th Street
q.q
t
Plan revision required? ❑ Yes ❑ No ~r I
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
F
SANITARY PERMIT APPLICATION
~ COUNTY
In accord with ILHR 83.05, Wis. Adm. Code arc /
ERMIT #
STATE S1 T ~4~C'Jl
-Attach complete plans (to the county copy only) for the system, on paper not less than
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.
PROPERTY OWNER . / P O ERTY L ATION 0& - ~J« _,17 C1111 Y., S oZy.Z T , N, Rl E
PROPERTY OWNER'S MAILINSrADDFftSS LOT # BLOCK #
CITY, STATE ZI CODE PHONE NUMBER 9 SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one) CITY ` NEAREST ROAD
II State Owned VILLAGE f^a/ri
L
- TOWN OF:
D6ublic ❑ 1 or 2 Fam. Dwelling- # of bedrooms ARCELTAx NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply) D
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 80 Mobile Home Park 120 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. ~9 New 2. ❑ Replacement 3.E1 Replacement of 4.0 Reconnection of 511 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 1:1 Mound 30 ❑ Specify Type 41 El 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. SY TEM ELEV. 7. F AL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 7-f"_?,
~L _c ~B r eet 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 Holding Tank d'~ WG
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 a (Print): Plumber's lure: (No Stam MP/MPRSW No.: Business Phone Number:
n
r~
Plumber' ddress (Street, City, State, Zip Code):
-3 OO
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary ermit Fee (includes Groundwater Date ~,ue I
Approved ❑ Owner Given Initial 'V ~A_ Surcharge Fee) 1_ kk/')jj-~~
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS t
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 maintaired. 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.
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 mains/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form; and F) all sizing information.
- -
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
. ' PLOT PLAN
PROJECT Ken Jenderney ADDRESS 821 Coleman Dr. New Richmond Wi 54017
NW 1/4 SE 1/4s 22 /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 )000( IN-GRO PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 900 BED SIZE 18'X50'
BENCHMARK V.R.P. Base of White Stake Red Ribbon
ASSUME ELEVATION 100
❑ BOREHOLE (DWELL *H.R.P. Same as Benchmark
VEm SYSTEM ELEVATION 95.2
12" GRADE
TYPAR COVERING
2'
13' 6'Q3'3'®3'
a SEWER WICK 18'
12'
210' P.L. 838'
5'
B-2
30' I - Vent
95' I I
I B-3
I 0'
30' I I 5% Slope
loor
I
I I
10' -
00
Pro Driveway 15' 20 130' to Replacement Area
(See Gary Steel Soil Test)
20'
Pro 3
Bedroom
House
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of
Labor and Human Relations -
Divisiori
. c ~fety & Buildings
in accord with ILHR 83.05, Wis. Adm. Code
COUNTY cc
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. - 1013
- b
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED a DATE
PROPERTY OWNER: PROPERTY LOCATION
1^ CIE r At/ GOVT. LOT Lj 11451/4,S T 3] N,R E (or (W)
PROPERTY OWNER':S M ILING ADDRESS LOT # BLOCK # SuuBD. NAME OR CSM #
1 /c r. - CSm o e. 13
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE WfOWN NEAREST ROAD
e,,_ Q n 15 YO !S) of d - C., r ~ e.• .
New Construction Use Residential / Number of bedrooms ?j Addition to existing building
]Replacement [ ] Public or commercial describe t
Code derived daily flow 4150 0 gpd Recommended design loading rate ~ J bed, gpd/ft2 , 4 trench, gpd/ft2
Absorption area required T /L/V bed, ft2 :2 $0 trench, ft2 Maximum design loading rate-z-7 bed, gpd/ft2_?trench, gpd/ft2
Recommended infiltration surface elevation(s) .S' ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material Flood plain elevation, if applicable ft
S = Suitable for system C NVENTIONAL MO ND IN-GROUND PRESSURE AT-GRADE SYSTEM jq FILL HOLDING TANK
U = Unsuitable fors stem 91 S ❑ U S ❑ U j 0S ❑ U S ❑ U ❑ S ®,U ❑ S ]ru.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
00,11 /77 Ar-
Ground 3 y f , , , . 8
v.
ft.
Depth to
limiting
faces ~
,r3~
Remarks: I/C~ rt S ne
Boring #
1 - AV4ev- rum s l d r C w l~ .5 , b
.Ground....
lev.
ft.
Depth to
limiting
factor
3 Remarks: _922e Cc- S 1-3-Z
CST Name:-Please Print , Phone:
r
Address:
Signature: Date: CST Numbe
3
7-11-
PROPERTYOWNER JC fr SOIL DESCRIPTION REPORT Page of
PARCEL I.D. # R''•
Depth Dominant Color Mottles Texture Structure GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Consistence BoLn* Roots Bed Trench
3 s S'I'C C 6 -3S 10,4 d~24d-=4-
/I.5
Ground T L t ® G S /1i,A
p~elev
f/.
5~ ft.
Depth to
limiting
factor
d
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
Soil Test Plot Plan
r
Project Name Ken Jenderney Byro~4rd Jr.
Address 821 Coleman Drive
New Richmond Wi 54017 CS 3479
Lot Subdivision Date 7/13/94
NW 1 /4 SE 1/4S22 T 31 N/R 18 W Township Star Prairie
Boring ()Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft.Base of White Stake Red Ribbon
System Elevation 95.2 * H R P Same as Benchmark
210' P.L. *B.M.838'
5'
B-2
30'
95' 5% Slope
20'
B-3
30'
V
-1
00
20'
r+ Pro Driveway 20'
Pro 3
Bedroom
House
SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
454. C ro X
STATE SANITA Y PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 159 04-0
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. OOU
PROPERTY OWNER PROPERTY LOCATION ki cle,41e,,4 on
U)Y4 t/4, S T,3 1, N, R / 9 E (orffi
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
eo
CITY, STATE tl OD E PHONE NUMBER SUBDIVISION NAME OR GSM NUMBER
7 / `I -
II. TYPE OF BUILDING: (Check One) ❑ State Owned VILLLLAGE NEAREST ROAD
❑ Public 911 or 2 Fam. Dwelling- # of bedroom PARCEL TAX NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply) 0.31 - D b c)
1 ❑ Apt/Condo
2 ❑ Assembly Hall 60 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 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. X 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 Z Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 420 Pit Privy
13 ❑ Seepage Pit Pressure 431-1. 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
75o Q • J / eet 1,9 7. 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 Holding Tank X Gb4 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.
Business
Plumber's Name (Print): Plumber' nature: (No Sta ps) MP/MPRSW No.: Phone Number:
&a_ Sj~c 33U = 6C~
Plum is Address (Street, City, State, Zip ode):
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Sta s)
Surcharge Fee)
Approved ❑ Owner Given Initial OG G)
I Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
J
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary-Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested in ##1-7.
VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of
tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all
septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater, ground-
water contamination investigations and establishment of standards.
. I
I
SBD-6398 (R.11/88)
PLOT PLAN
FR•OJECT ADDRESS-~2/zG~~,,
1/4/$,2/T3/ /'-W TOWN` ru COUNTY
S~Cvo~~ yo/~
MPRS Byron Bird Jr. 318 DATE - O
BEDROOM CLASS PERCCONVENTIONAL IN-GR D PRESSURE
CONVENTIONAL LIFT__ MOUND- HOLDING TANK
SEPTIC TANK SIZE LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA PERC RATE BED SIZE
\ Benchmark V.R.P.
Assume EI vation 10
~ 0'
Location of Benchmark e4-- 5i,
* H.R.P.
0 Borehole Q Well Scale Feet
0 Perc Hole System Elevation
Uent
12"
Gradp
TYPAR COVERING l
2" i
12" 3' 4 6' O 3' 3' O 3'
Sewer Rock
6" 12' 18'
10 / 02o ao
07 tz,
r.. f`
~r I
i
T moo.-k~, ~ 3~ ~
0
s
• Wis6: nsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor and' HuFi*n Relations
Divisiah of Safes/ & Buildings in accord with ILHR 83.05. Wis. Adm. Code
COUNTY
Attach',-omplete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but PARCEL I.DSt. Croix
. #
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. 038-1093-60
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
Ken JendernGOVT. LOT NW 1/4 SE 1/4,S 22T 31 N,R 18 '*()W
PROPERTY OWNER':S MA!i_ING ADDRESS LOT # BLOCK # SUED. NAME OR CSM #
na na res.
CITY, STATE ZIP CODE PHONE NUMBER [-]CITY ❑VILLAGE DOWN NEAREST ROAD
New Richmond WI. 54017 ( 716 246-2057
[x[ New Construction Use [x] Residential / Number of bedrooms [ ] Addition to existing building
[ ] Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate _ _5 bed, gpd/ft2 , 6 trench, gpd1ft2
Absorption area required 9 0 0 bed, ft2 7 5 0 trench, ft2 Maximum design loading rate _,_5_bed, gpd/ft2,_6_trench, gpd/ft2
Recommended infiltration surface elevation(s) 104.15 ft (as referred to site plan benchmark)
Additional design i site considerations na
Parent material stream terrace Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable for svstem ® S ❑ U Q S ❑ U [RS ❑ U Ea S❑ U ❑ S U ❑ S F au
SOIL DESCRIPTION REPORT
Depth Dominant Color Motbes Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 1 0-8 10 r3 2 none 1 2msbk mfr r1w ?f -9 -6
2 8-17 10 r4 4 none cb
Ground 3 17-84 7.5 r4/4 none' 2m r mvfr na na .5 .6
elev. e ° a
107 _ Rift. ° ` .
Depth to "J
limiting
factor`
v
+84"
Remarks: `
Boring # r-
1 10-10 10yr3/2 none 1 2msbk mvfr aw 2f 1.5 L6
Li 2 110-82 7.5yr4/4 none cb sl 2mgr mvfr na if .5 .6
Ground
elev.
107.15 ft.
Depth to
limiting
factor
+ "
Remarks:
CST Name: Please Print Phone:
Gary L. Steel 715-246-620
Address: 1554 0th. ave. N Richmond WI. 54017
Signature: Date: CST Number:
4-27-94 cstrn 2298
PROPERTY OWNER Ken ,Tenderay SOIL DESCRIPTION REPORT Page 2 of ,
PARCELI.D.# Q38-1093-60
I I I GPD/ft
Boring # Horizon I Depth Dominant Color Mottles Texture Structure Consistence lBa
1 rxiary Roots . Trench
in. Munsell , Qu. Sz. Cont. Color Gr. Sz. Sh. Bed I
3 1 0-8 10 r3/2 none 1 2msbk mfr 2f .5 1.6
2 8-15 10yr4/4 none cb sl 2mgr mfr gw if .5 !.6
i
Ground 3 15-84 7.5 r4 4 none cb sl 2m r mvfr na na .5 .6
elev.
107,E ft.
Depth to
limiting
factor
+841,
Remarks:
Boring #
1 0-6 10yr3/3 I none 1 2msbk mfr cry 2f .5 .6
4 _ 10yr4/4 none sl 2msbk mfr gw if .5 .6
Ground 3 16-8 7.5 r4 4 none cb
elev.
10485_ ft.
Depth to
limiting
factor
+80"
Remarks:
Boring #
9f 5 L-6-
5 2 10-27 10 r4 4 none sicl 2msbk mfr if .4 .5
7.5yr4/4 none cb sl 2mgr mvfr na na .5 ':.6
Ground -
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
1 r
STEEL'S SOIL SERVICE 1554 200th. Ave.
Gary L. Steel
Ken Jenderny
C.S.T. 2298 1 1 New Richmond, WI 54017
MPRSW-3254 NW4SE4S22-T31N-R18W (715) 246-6200
town of Star Prarie
BM= top of mid-lot survey stake at el. 100•`
lot 20 acres
~S
5
-2q0 ply /
6-2 \
AL_
.51
151 15-i - I
51
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS (U01 / e0 &416i,14 "e , ,_)4 ' h l Cj Lt) S "YO
17
PROPERTY ADDRESS A4W ~z&afigr c,-Q v z c--,- /l 47-YI f
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION 1/4, SE_ 1/4, Section T_ai_N-R_a_W
TOWN OF c ?-f3 Pecs 1 T L ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
076
CERTIFIED SURVEY MAP __,)(VOLUMES, PAGE LOT NUMBER -L-~
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 a iratio te.
SIGNED:
DATE: _~o(
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 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 - k4nyAv,-r?V ,1C iIJ V
Location of property ,V 1/4 SF 1/4, Section Z Z. IT 3/ N-R W
Township 5 R /~2- i.CP~f Mailing address S(Z/ Z'c,/e,..Q
Address of site
Subdivision name Lot no. - -
Other homes on property? YesNo
Previous owner of property
Total size of property /q ,¢E,eFS
Total size of parcel !i
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes YNo
Volume "1~~ and Page Number lgoz - 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. ,_::~-Z 4,!> , 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.
ignature of icant Co-Apl i t
Date of Signature Date of Signature
DOCUMENT NO WARRANTY DEED THIS SPA RE',ERVED FOR RECORDING DATA
,
STATE BAR OF WISCONSIN FORM 2-1982
516014 vo 1076►Act143 -
* f l wig J C• t'sCF- -
U. IL ~ A C0., va
Helen Bjelde, a single woman _
_
. . - - RsedtbrF.'awrd
- . MAY 1. 1994
- -
8:00-- A:
conveys and warrants to ..Kenneth G. Jenderny and Lori Jo
_.Jenderny, property.. Rsax~i
- _
. .
RETURN TO
-
the following described real estate in --Sta.. CrPix Count
State of Wisconsin:
Tax Parcel No:
I
I~
The North Half of Northwest Quarter of Southeast Quarter (N} of NW} of SE}) of Section'
Twenty-Two (22), T-wnship Thirty-One (31) North, Range Eighteen (18) West.
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This is not._.__-. homestead
;I - property.
(is) (is rot)
Exception to warranties: ;
I
i Dated this -Y' day of A-PR.~-~- 19 9
I
- - - --(SEAL) (SEAL)
Helen Bjelde
- --------------------------(SEAL) - - -(SEAL)
i
s
AIITHENTICATION ACKNOWLEDGMENT
r.
i Signature (a) STATE OF WISCONSIN
ST. CROIX ss.
authenticated this --------da of 000~&l t,y;` RI_~ Personally County.Q Za
Hele B oelde before, 19 this the above y named
y`__. MO,°
'1 • •
---j
71 F
= ~Y ps~f-
TITLE: MEMBER STATE BAR OF WI t7
(If not,
b - - -
il by ~ 706.06. Wis
PUBLIC to me known to be the person - . who executed the
j fore ing ' stru rt d ack ~ e same.
11
THIS INSTRUMENT WAS DRAFTED q,~,(~ w '-er• n d
r Y 1- r
REINSTRA, VAN DYK b NEED HAIfY M- -
201 South Knowles Aee : ; P: 0: ox~ 127 1' t t Ch 1t e L 2 , DN Pe- i I r) "
- -
PI~~f_.Aichplotid1. WI•_54017 5~ , CrrO ' ,,yy~
- - Notary Public ~ - County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.) date: (Z 2 5 1 19..7...)
I
•Names of persom signing in any capacity should he typed or printed below their signature.
I~ WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc.
FORM No. 2- 1782 Milwaukee. Wisconsin
ST. CROIX COUNTY
WISCONSIN
t ZONING OFFICE
p p x n N UNION _ „,■„b ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
_ - Hudson, WI 54016-7710
(715) 386-4680
September 22, 1994
Attn: Becky
Hartmon Homes
P.O. 326
Somerset, Wisconsin 54025
RE: Septic Inspection for Ken Jenderny
To Whom It May Concern:
An inspection of the septic system for Ken Jenderny property was
conducted on August 29, 1994. This property is located in the NW;
of the SE; of Section 22, T31N-R18W, Town of Star Prairie, St.
Croix County, Wisconsin. At the time of the inspection, this
septic system was found to be code compliant for a three (3)
bedroom home. If you have any questions with regard to the above,
please do not hesitate in contacting our office.
Sincerely,
Mary a. Jenkins
Assistant Zoning Administrator
js
i
i
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or .
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested in ##1-7.
VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of
tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all
septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form; and F) all sizing information.
- - - - - - - - - -
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
PLOT PLAN
PROJECT Ken Jendernev ADDRESS 821 Coleman Dr. New Richmond Wi 54017
NW 1/4 SE 1/4S 22 /T 31 N/R 18 W TOWN Star Prairie COUNTY ST. CROIX
MPRS BYRON BIRD JR. 3318 DATE 5/21/94 BEDROOM 3
CONVENTIONAL )000( IN-GROW PRESSURE CONVENTIONAL LIFT HOLDING TANK
SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
MOUND
HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 900 BED SIZE 18' X50'
BENCHMARK V.R.P. Base of White Stake Red Ribbon ASSUME ELEVATION 100'
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
VENT SYSTEM ELEVATION 95.2
12" GRADE
t6' PAR COVERING
12" 3' Q 3' 3' Q 3'
WER R K 18'
12'
210' P.L. 838'
5'
B-2
95' 30' Vent
I
I
I 0' B-3
I
30' I 5% Slope
I
I I
10' -
00 15' T 20' 130' to Replacement Area
Pro Driveway (See Gary Steel Soil Test)
20'
Pro 3
Bedroom
House