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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS
SUBDIVISION / CSM# LOT # S
SECTION_d _T, ~N-R_ff~W, Town of /mod
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
t
E
p /
i
I e-tJ si p / ~f cam'
I j.
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK. f ~OprB r
ALTERNATE BM•
SEPTIC TANK / PU P CHAMBER / HOLDING TANK INFORMATION
Manufacturer: f Liquid Capacity: Z
Setback from: Well House Other
Pump: ManufacturerZMc Model# Size
Float seperation Gallons/cycle:
Alarm Location
:SOIL ABSORPTION SYSTEM
Width: / Length Number of trenches
Distance & Direction to nearest prop. line: 7 ~D f
J.
Setback from: well: House Other
ELEVATIONS
Building Sewer ST Inlet; ST outlet
PC inlet - PC bottom Pump Off - -
Header/Manifold Bottom of system
G~-0~e h~ 6Z.
Existing Grade Final grade Sr e)
DATE OF INSTALLATION: /
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
T ~'~s~rt partr~'i~r#t~c rn~~3tty?S _ 1 ~3W,- T% I~AtE ?gpGEtYt~tM Roar] County:
Libor and Human Relations INSPECTION REPORT
Safey and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 1
Permit Holder's Name: ❑ City ❑ Village [j Town of: State Plan ID No.:
V
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9400084
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ~~OD Benchmark
Dosing Z. V41- ►-1 0 ri(,
Aeration Bldg. Sewer Q
Holding St/ Ht Inlet 7((, u2 ~S 9.7.7
TANK SETBACK INFORMATION St/ Ht Outlet 9G jo,24S ,Z
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header/Man. 9/.9~
19
Aeration NA Dist. Pipe c{ 7462
Holding Bot. System r
PUMP/ SIPHON INFORMATION Final Grade r04 f 9J-
Manufacturer Demand
Model Number GPM
TDH Lift Friction Syesatem TDH Ft
Loss I
Forcemain Length Dia. FFii Dist. To Well 71
SOIL ABSORPTION SYSTEM
BED/TRENCH Width/ Len No. Of nches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN I Nt DIMENSIONS
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK L
INFORMATION Type O CHAMBER OR UNIT Model Number:
System:
DISTRIBUTION SYSTEM
Header /Manifold I Distribution Pipe(s) I x Hole Size I x Hole Spacing I 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.)
T.OC_ATTON: Troy. 16.29.1 9W, T.ot 35, South Paci f i C Roach
Plan revision required? ❑ Yes ❑ No -
Use other side for additional information. 7
SBD-6710(R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: ,
D~LHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COkq,
STATE SANI A PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than a
8% x 11 inches in size. El 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.
=NE PROPERTY LOCATION
s N % t/4,S T N,R E(O
ROPERTY OWNER' MA IN ADDRESS LOT # BLOCK #
CMITYT ZIP CODE PHONE NUMBER SUB V ION NAME O CS UMBER
11. TYPE OF BUILDING: (Check one) CITY NEAREST OAD
❑ State Owned VILLAGE ; v ~ .z
❑ Public ®1 or 2 Fam. Dwelling of bedrooms ~ PARCEL T Nu R
111. BUILDING USE: (If building type is public, check all that apply) O
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. X New 2. ❑ Replacement 3.E1 Replacement of 4.E1 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 12. 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
0140 D j 9m, Feet 9X 4 !Feet
VII. TANK CAPACITY Site
in gallons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
ZQ7
Septic Tank or Holding Tank. F1 F] I
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite s ge system shown on the attached plans.
P m er's Name (Print): Plum 's Signature: m idWMPRSW No.: Business Phone Number:
r c r `Jl~
d
bars Address (Stre t, City, 'State, Zi ode):
IX. OUNTY/ EPA TMENT USE ONLY
❑ Disapproved Sa ary Permit Fee (Includes Groundwater Date Issued Issuing A gna o Stamps)
10 I Surcharge Fee)
Approved I ❑ Owner Given Initial CV'~~ _Z2 ~ y
Adv rse Determination ~ f CU
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-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 onstte sewage systere, 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:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
11. 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 13% 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 thje`county; E) soil test data on a,'115form; 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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Ii1.0 'NATION
51482
JAYEYOA
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SET . • , . , • Z . 1►
QN'3SN 5AO2.'2' ,
DAY of FE,BFKJARY. 19.88. • • ' .
35
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 7 of
Labor and Human Relations
Division of Safety & 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
PZl'/4 ERTY OWNER: PROPERTY LOCATION
/ z GOVT. LOT tJ 1/4 ,V/F1/4,S /6 T N,R / E (ore
PROPERTY OWNER';S MAIL ADDRESS LOT # BLOCK # SUBD NAME OR CS #
.2 os; ` S 35 CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE MOWN NEAREST ROA
c~ w o ( ) 7FOV 15-. ~
h(] New Construction Use [x] Residential/ Number of bedrooms y [ ] Addition to existing building
Replacement [ ] Public or commercial describe --t -
Code derived daily flow 41Po gpd Recommended design loading rate .bed, gpd/ft2 trench, gpd/ft2
Absorption area required 9Go bed, ft2 7&D trench, ft2 Maximum design loading rate . 7 bed, gpd/ft2 -d trench, gpd/ft2
Recommended infiltration surface elevation(s) o. ' ft (as referred to site pla benchmark)
Additional design / site considerations _3' cu 7' A" aka tridr/you ~S~sr~,
Parent material Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable for s stem ®S ❑ U ❑ S (3 U ❑ S ® U ❑ S O U ❑ S 4U ❑ S O U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Bourclary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
i4
/ o -a s Z -
Ground Z p G t6/~ r CS /v~ Y -
elev.
A,3 - ft. 3 To- yj S' S - !yi / e S - , 7
Depth to V#_ /V S s / - -
limiting
factor
Remarks:
Boring #
2 -70 o c G 564 `tr f'r 6-5- s
Ground
ele ft 3 3o- 6 Am 'W y r e- S . S
.
Depth to
limiting
factor
Remarks:
CST Name:-Please Print Phone:
~ D
Address:
Signature: Date: CST Number:
4/2 4Z2 33
1
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 Z-~~ S G c c , 2 , 3
elev.
ft. ) -~/-z L S t M
Depth to -/09 y S S - - 8
limiting
factor
Remarks:
Boring #
Ground
elev. IrG rh v ~r Gs I v , / , S
ft.
Depth to
limiting 3 S d h„ / c s - ,8
factor
Remarks: 2 ~e
Boring #
L o C 2 r~ S 1 '1'
vk r C S l v'F 2. 3
Ground
elev. _ z .5
O S •u c •
97.9 ft.
Depth to 2 - S 5 D l ~r _ . ~
limiting
factor
Remarks:l
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
i
Remarks:
SBD-8330(8.05/92)
r
S T C - 105
r '
SEPTIC TANK,MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER c\~~
ADDRESS FIRE NUMBER
CITY/STATE ZIP
PROPERTY LOCATION: S 1/4 , M 1/4, SECTION T L9 N-R_j_j_W
TOWN OF , St. Croix County,
V.
.
SUBDIVISION LOT NUMBER 3S
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 a 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
A completed and returned to the St. CVo " Co. Zoning officer within
30 days of the three year expirati0 te.
SIGNED:
DATE: 2/ ` ESL
St. Croix.co. Zoning Office
kr 911 4th St.
Hudson, WI 54016
4
•r ,
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,& 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
Location of propertySr- 1/4 Alk"c- 1/4, Section Z8N-R
Township
Mailing address 3
J J~9'Z 1/ 3b- l~l~Z
Address of site
Subdivision name c~~- a te i Lot no. 3's
Other homes'on property? yes No
Previous owner of property z~-.~(il~-rti
Total size of parcel
Date parcel was created
a Are all corners and lot lines identifiable? Yes No
' Is this plr/operty being developed for (spec house)? Yes NZ o
Volume 167T and Page Number as recorded with the Register
of Deeds.
L----------
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 CERTLFICATION
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. c~I_ 6r-? , 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
reco ded in t e office of County Register of deeds as Document
No.
J
Signatur f applicant Co-applicant
Date of Signature Date of Signature
Q 0 14PAGE 618
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1882 THIS SPACE RESERVED FOR RECORDING PAT^
5.565.3 WARRANTY DEED I '1 ` .f r
S 4T. ~~M.niR~M//~~~Ippry~~+.a •.X4 C
0 10IO.* t~A
This Deed made between ......EZEKIEL LUTHERAN CHURCH Kbed Tin Rt cxpra
....--.--.-of RIVER ...-AL.... WISCONSIN I
. APR 2 0 1994
Grantor, 3640 P.~
and......PE1iTA. 0 HSTRUCTIQI`1..,..IN~~.s annesota•. .
corporation•,.. >~~zi;;flrc,rr> +
a
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration.--...
_
conveys to Grantee the following described real estate in CTO].W............. RETURN To
County, State of Wisconsin:
Tax Parcel No:._
Lot #3S, Glover Station Second Addition,
Town of Troy, St. Croix County, Wisconsin.
rRA- N-; LETI
EE-H
U' C-e
This i.S.M.t.....
1ddc (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And.._.••-•Ezekiel Lutheran Church o_ f River er Falls,_. Wisconsinx
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
municipal and zoning ordinances, easement for public utilities, and building
restrictions of record,
and will warrant and defend the same.
Dated this 19th day of - Apri 1 , 19.. 94
EZEKIEL LUTHEB.(~IV CH OF RIVER FALLS
---.......••--••---••-.---...--..(SEAL) . t.... • • ......................(SEAL)
* . Curtiss 0... Larson,---Presi.dent.........
!n
.......(SEAL) ----..li°' ......................(SEAL)
* * Luane- Dayi-s,-.Secretary
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
St. Croix Be.
.........•••---.County.
authenticated this day of 19 Personally came before me this ...-19th day of
April , 19..94.. the above named
Curtiss 0. Larson and Luane Davis
*
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not .
authorized by' § 706.06, Wis. Stats.) to me known to be he pOrsm, who executed the
foregoing instrurpe t jahd •Sckno ' 19dge the same.
THIS INSTRUMENT WAS DRAFTED BY '
C.. M... BYe...
Sandraz.5i iienjen ,Q
Attorney at Law Cbixk
Notary Publi't . Count Wis.
.
,gnatures may be authenticated or acknowledged. Both My Commisstpn-+i9, pet I}n~rd..(,if:,n3t _ state expiration
.e not necessary.) (f
date:
*Names of persons signing in any capacity should be typed or printed below their signatures.
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160
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