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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER__,, "o A/ neJ
ADDRESS. e-,,j
SUBDIVISION / CSM~~~ LOT
SECTION -37U T 3% N-R~W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
INDICATF NORTH ARRO~q
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank nu3nhole cover.
BENCHMARK: ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity: Z"6#0 CI
Y. 711- -1t
Setback from: Well ~I`' J✓ House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: l Y Length Number of trenches
Distance & Direction to nearest prop. line: L6
Setback from: well: House Other
ELEVATIONS
Building Sewer ST Inlet. ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB: ~f..✓i~C"~ f'✓
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labc,-~and Human Relations INSPECTION REPORT ST. CROIX
-Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan o.:
COUNTER, SCOTT/STEVE PETERSO lk
Star 1:)-raJ_-rj_e
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA l
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic -Q/V.Q-,, ECG ply Benchmark S /
Dosing,
Aeration Bldg. Sewer
g.._~
Holdin St/14 Inlet
TANK SETBACK INFORMATION St/ Outlet 6-3 7"' ,5 7/'
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic }_<Zj NA Dt Bottom
Dosing NA Headed.
Aeration A Dist. Pipe
H o rd ing Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Man r and ` 5,77
me___ k S. a9 lk?
Model Number GP
TDH Lift Lrictio TDH Ft
Forcemain gth Did. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of renches PIT No. Of Pits Inside Dia. uid Depth
DIMENSION SC) DIME
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEA anufacturer:
SETBACK
INFORMATION Type 0 vl e,, - / CH ER Mode Num
System: -e
UNIT
DISTRIBUTION SYSTEM
Header/Manifold „ Distribution Pipe(s) x Hole Size x Hole Sp Vent To Air I ke
Length ~ Dia. Length _(/2~: Dia. Spacing Co
SOIL COVER x Pressure Systems Only xx Mound Or At-Gra ystems
Depth Over Depth Over „ xx Depth Of xx Seeded/ Sodded xx Mu c ed
3 Topsoil El Yes C] No E] Yes E] No
Bed /Ti,2n3:Ja-Center C~ r~ 30 Bed /T- Edges 3
q- " I
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATI 9 N: Star Prairie.30.31.18W, Lot 18(A), Riverview Road
, /L
Plan revision required? Yes ❑ No
Use other side for additional information. 5-.-
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
I
I
i
SANITARY PERMIT APPLICATION ,
CO TY
• v'~Ln■'t In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than a oZ gOjo5
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 PROPERTY LOCATION
c S t/4S,''/4, S T,?f , N, R E (or
P W0_ OWNER'S MAILING ADDRESS LOT # BLOCK #
A0 0_1 JJ 4 A-1 60t a / ..vie.
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NA E OR CSM NUMBER
Q
11. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE NEAREST ROAD ,
"a. u, i"G /Qi d¢f/' r ~c7 OQ of
❑ Public M1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMBER(S)
Ill. 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. bd 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 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
G6' A.JCL- •2 Feet QQ~ 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 Q
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 Stamps) /MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Sip Code):
167,d .S c o V" A ,C °
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Ag t Sig ture (No S ps)
Surcharge Fee)
Approved ❑ Owner Given Initial
Adverse Determination °;2~
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety s 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.
ll. 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)
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137
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page _ of
L,bor and Human Relations
D'"!si°,n of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but St. Croix
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 OWNER: PROPERTY LOCATION
Peterson Construction GOVT.LOT SW 1/4SE 1i4,S30 T 31 N,R 18 IX(or)W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM #
1023 N. Knowles Ave. 18 na Crestview
CITY, STATE ZIP CODE PHONE NUMBER [:]CITY []VILLAGE EYOWN NEAREST ROAD
New Richmond, WI. 54017 (719 246-5650 Star Prarie Riverview Rd.
New Construction Use *:g Residential /Number of bedrooms 6 [ ] Addition to existing building
j J Replacement [ ] Public or commercial describe
Code derived daily flow 9 0 0 gpd Recommended design loading rate .5 bed, 002 .6 trench, gpd/ft2
Absorption area required 18 0 0bed, ft2 15 0 0 trench, ft2 Maximum design loading rate _-5 bed, gpd/ft2 66 trench, gpd/ft2
Recommended infiltration surface elevation(s) 96.20 ft (as referred to site plan benchmark)
Additional design/ site considerations additional alternate area for soil report of 10-27-92
Parent material O u t w a s h Flood plain elevation, if applicable n a ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem fIS ❑ U ]IMS ❑ U 7 as o u ®S ❑ u ❑ S o u Os Odi
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 0-8 10 r3/3 none 1 2m r mfr w 2f .5 .6
7<
INMWW 2 8-22 10yr4/4 none sl 2mgr MFR gw if .5 .6
Ground 3 22-48 7. 5 y r 4/ none I f s Osg mvf r gw na .5 .6
elev. 4 48-80 10yr4/4 none S Osg ml na na .7 .8
99.20 ft.
Depth to
limiting
factor
+80"
Remarks:
Boring #
1 0-12 10yr3/3 none 1 2msbk mfr gw 2f .5 .6
8 2 12-23 10yr4/4 none sil 2msbk mfr gw if .5 '.6
3 23-4 7.5yr4/6 none sl 2msbk mvfr gw na .5 .6
Ground
elev. 4 40-8 7.5yr4/6 none 1 Osg mvfr na na .5 .6
99.51
e aye ..~---Depth to
limiting o `y
factor
+84"
Remarks:
CST Name _Please Print C a no:
Gary L. Steel
Address: 1554 200t Ave., New Ric and WI. 54
Signature: y 12~-9-94 ate: cstm CST Number:
02298
i. e"~
PROPERTYOWNER Peterson Construction §OIL DESCRIPTION REPORT Page •2 3
PARCEL I.D. #
Depth I Dominant Color Mottles Texture Structure GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Consistence Boaxiary Roots
g~ ITS
1 0-9 10yr3/3 none sl 2msbk mfr gw 2f
I;< 2 9-32 7.5 r4/4 none sl 2msbk mfr gw if .5
Y
I
Ground 3 32-8 7.5yr4/6 none 1 fs Osg mvfr na na .5 .6
elev. i
99.7 ft.
Depth to
limiting
factor
+82"
Remarks:
Boring #
MWIE
~<a
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
St+
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev. j
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
r:.
STEEL'S SOIL SERVICE
m!f 289th.-axe .
Gary L. Steel Peterson Construction
C.S.T. 2298 S[14SE4 S30-T31N-R1814 New Richmond, WI 54017
MPRSW-3254 Star Prarie, township (715) 246-6200
lot #18 AIN
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STC- 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER Scott Counter. Steve Peterson, and John Peterson
MAILING ADDRESS 1304 210th Ave. ; New Richmond, WI 54017-6132
PROPERTY ADDRESS 1' Riverveiw Ln; Somerset, WI 54025
9.1~
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION 1/4, SE 1/4, Section 30 &.T 31 N-R 18 W
TOWN OF Star Prairie ST. CROIX COUNTY, WI
SUBDIVISION C r e s the i w LOT NUMBER 18
CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER
I
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 irati '
I
SIGNED.
DATE: J
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 Scott Counter Steve peterson_, and John Patarenn
Location of property 1/4 SE 1/4, Section 30 ,T31 N-R_. 1Q W
Township Star Prairie Mailing address 1304 210th Ave;
New Richmond, WI 54017-6132
Address of site Riverveiw Ln ;Somerset, WI 54025
Subdivision name Crestveiw Lot no. iR
Other homes on property? Yes XX No
Previous owner of property John Peterson& etl
Total size of property 1.698 acres
Total size of parcel
Date parcel was created fy/,~tv, rZ9q
Are all corners and lot lines identifiable? XX Yes No
Is this property being developed for (spec house)? Yes XX No
Volume 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. , 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.
Signa re of pplicant Co-Applicant
~e q cam- C
D e of Signature Date of Signature
r 1 .+•4._, 'rry.; ' rr ~rti•#i ,X.. Y
. ,1 II A
~1I • I '11,19 a►AC[ R[bARY[D TOA "CORDING DATA !
DOCUMENT NO. !STATE BAR OF WISCONSIN FORM 1-1988! !
WARRANTY DEED I)
von 106&r►c~ , ~tCl~I-cR'sCFlCE
513867
~I ST. CROIX CO., W1
1! This Deed, made between _.Peerson-_Properties, p9.'4rAaccrd
a .kji-icons.in...general.-busines..partners..ip,_-- - ,i.
MAR 8 1994
I
- -
Grantor, 83'0 _ A' M
Y
a;;a-.__._Angel_a:.Joy I.:eter... on, a single person,
1 R c[~eas
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration.---.. warurtN To
;
St . CI'O1X
conveys to Grantee the following described real estate in
r
County, State of Wisconsin: -
Lot 18 o f C r e s t v i ew Addition in the Tax Parcel No:
t Town of Star Prairie
II
Elm
i3 not
This homestead property.
.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
I
And .....Grantor
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
municipal zoning ordinances an3 easements of record
and will warrant and defend the same.
94
I
Dated this ~ day of March 19-•-•
_
I
'
PETER P EAL)
x
(SEAL) BY' I
- Rob C. Lindus real es
ohn
L. Peterson Aiit7iorized----artiler to cdri
i
A.. or.zed a r to. con ae e p e 11
vy eal (SEAL)
1
• . Peterson
Ste hen F
it
jl Authorized partner to convey
-
real estate
AUTHENTICATION ACSNOW LBD(iMSNT II
as l ylreal gestate WISCONSIN ss.
TATE OF s~ e ° a'Fgf John terr~ne s~o
orize~- a
-
County
jl
authenticated this,~~_day f.--March 19.94 Personally came before me this day of
i' 19........ the above named
G. E. Norman I~
TITLE: MEMBER STATE BAR OF WISCONSIN
Y
X t1Ao~(1X Q(Q~)(}~(+)C X to me known to be the person who executed the
foregoing instrument and acknowledge the same.
1 ,
THIS INSTRUMENT WAS DRAFTED BY
! i.
AKKE . ! R~tAN.,
New Richmond, WI 54017 Notary Public County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (if not, state expiration
are not necessary.) date: , 19..------•)
I,I samme• of persons sisoins in any espaeity should be typed or printed below their signatures. 1~.I
STATE BAR OF WISCONSIN Wiseonsin Leal Blank Co. Ine.
WARRANT! DEED FORM No. 1- 1985 Slilwaukee, Wis.
R. ~ t;,I: d7k~,i ~;tif`s ~R' .r.^i • ...,r v s t f ,
w -