HomeMy WebLinkAbout040-1223-10-000
STC - 104
AS BUILT SANITARY SYSTEM REPORT
s
OWNER S
y
ADDRESS J ~O LA-*#6-)Z/V
SUBDIVISION / CSM# Lo k=-fzs 7 2~ f}Ti 01, 3 ACID LOT #
SECTION-Z~L-T N-R_L_7_W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
aX I ( 1
v
Q
n
INDICATE NORTH ARROW
P ovide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
1
r
BENCHMARK•
ALTERNATE BM: rd uNQA- o" 9 9
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: W6-(5K5 Liquid Capacity:
Setback from: Well NA House S- Other m 76
Pu K- Manufacturer Modeltt Size
Float\seperation Gallons/cycle:
Alarm ~SQ1cation
SOIL ABSORPTION SYSTEM
Width: Length 75- Number of trenches
Distance & Direction to nearest prop. line: / / .Sour ct
Setback from: well Housey Other
ELEVATIONS k[/
Building Sewer ST Inlet. 0< l-E::> ST outlet Z
PC inlet PC bottom - Pump Off'~
Header/Manifold Header/Manifold t ` Bottom of system V
Existing Grade !G 0~ Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB: 9
LICENSE NUMBER: _ 1z,10 /
INSPECTOR:
3/93:jt
yVisrconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:ST. CROIX
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
218984
PeTMt§?,NS"hmpAUL & SALLY ❑ City ❑ Village [Town of: State Plan ID No.:
Troy
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
c° FV 66 A9400373
TANK INFORMATION ELOVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic t- 'If ~l Benchmark
7 53 6 qq 6
Dosing
Aeration Bldg. Sewer Ct
Holding St / Ht Inlet 9\p 44 6
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Verntto Airlntake ROAD Dt Inlet
Septic NA Dt Bottom
Dosing J NA Header/ Man. q 8
Aeration NA Dist. Pipe tr . 9g, 7~
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade ,g q Q
Manufacturer Demand
611,1. ; 74
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length Dia. I f Dist. To Well I F
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Tren es PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type O Model Number:
System: ~D tt~G~ 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 x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of 1 xx Seeded/ Sodded xx Mulched
Bed /Trench Center ^ ' r Bed /Trench Edges r' Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (include code discrepancies, persons present, etc. `1? I
LOCATION: Troy.16.28.19W, SE, NEI,P
0~ot 55, Southern Pacific Road
C 7-
11a -
Plan revision required? ❑ Yes ❑ No f
Use other side for additional information. a 1141
SBD-6710(R 05/91) Date inspector's Signature Cert. No.
I
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION
~~I`Ir■■'11 In accord with ILHR 83,05, Wis. Adm. Code COUNTY
" CR i
STATE SAN TA$Y PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than t/ 4Q q 8
8% x 11 inches in size. ❑ Check if revision to pr&ious application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPEPAY OWNER PROPERTY LOCATION
L L S ~'/a F4,S Tz N,R E
4 , (o
S~ S
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
74 76
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER /J AO
W Mf ?_0 6 30/ --Z Lo v m 3
II. TYPE OF BUILDING: (Check one) CITY ❑ 6 NEAREST ROAD
State OWned -yj 0 VILLAGE: 77~ ❑ Public ®1 or 2 Fam. Dwelling-# of bedroom PARCEL AX NUMBER(
III. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo ( ~J
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
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.X New 2.E] 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 eepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 430 Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GAL NS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED q. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ~ g 8 ELEVATION
Feet 9 L Feet
VII. TANK CAPACITY Site
in al Ions 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 Holdin Tank
Lift Pump Tank/Si
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber' Name (Print): PI ber's Si re: (No Sta MP/MFRMNo.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
wag W ( Sid <
4- V-
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved San' ry Permit Fee (Includes Groundwater ate sue Issuing Age Sig
S charge Fee)
Approved ❑ Owner Given Initial
Adverse Determination U O
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 '
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.
f 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.
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)
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-71
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PAGE OF
CrC) ~ec~1On o~ e(1 Sys~e~ 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 Pips
Mash May Or SynlMlk Covering
Min. 2' Aggregate
over pips -
DI~Irlbutlon - Tse
pips o O o
1 6' Aggrseo1:
Beneath Plp o Perforated Pips Below
o -Coupling Terminating At
Bottom 01 System
PruPoSCD t'1nk~ gre,cIt
co 111M IN OIL. FILL ~C
DISTRIBU'TIOIJ PIP E
APPROVED ~4WrIETIC COVER
° _--MATFRIht- OR 9" OF STRAW
2" OF g6GREGATE OR JJARSN NA`j
~0 fo OF 12-21/Z GGREGATE
LEV. a EE
~ F F . T-..
DISTRI5UTIOW PIPE TO BE AT LEAST RICHES BELOW ORIGIUAL. GRADE
AMU AT LEASTZO INCHES BUT MO MORE THAM q2 IAICHES BELOW FINAL GRADE
I
MAXIMUM WrIj OF I~XCRVATImti FXoM OKI&INAL 69ADE WILL BE 11.ICHEs
MIKiMUM 9£f'm OF EACAVATIOW FKOM aKI(AWAL 6944E WILL BE INCHES
SIGWED: /7 1
LICEWSE UIJMB R:
J -9
D AT E : Z6
,
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3
Labor aid Human Relations
DNasiord.5f Safety & 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 ~'T G~Zs1 X
not limited to vertical and horizontal reference point (BM), direction and %of slope, scale or PARCELI.D.#
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION Za
C- - M -'B*,i e t bet-\IJ 1 S S C-tt U t-T Z GOVT. LOT SEE 1 /4 tJ F 1/4,S /b T ,N,R 19 E (ol&w
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
110 t'l . 1 1 RLK3 5T- 55 - 61_ovOR sl+f~' w 3 Hd WbD I-P 1JNJ
CITY, STATE ZIP CODE PHONE NUMBER []CITY (]VILLAGE MOWN NEAREST ROAD
kUk~NZ - lS W I SLJoZZ (7(S qLS _ 8/61 o`-f SoUM%Rta\--VVttAc f.
L_ ~Z New Construction Use Pj Residential / Number of bedrooms Lj [ ] Addikn to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 6110 gpd Recommended design loading rate - bed, glx:W e • trench, gpd(ftZ
Absorption area required $ S 8 bed, ft2 S 0 trench, 112 Maximum design loading rate o - 7 bed, gpd/ft2 0. 8 trench, gpd1ft2
Recommended infiltration surface elevation(s) 51:ffAJOTE ON Pti &t?' 3 ft (as referred to site plan benchmark)
Additional design / site considerations \,Zt_t1j M M &Q p Z -Meu C, S, Ehc~4 S 'X 1 S' LOA► 6
Parent material 5Vb1'Y1GjvT- GQ'Ek Sl' > 0 G RA y L--L Flood plain elevation, if applicable N, A ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN RLL HOLDING TANK
U= Unsuitable for stem S ❑ U 10S ❑ U ®S ❑ U RIS ❑ U INS ❑ U ❑ S O U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ftin. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed
Trench
] o-\Z 1~~~ 3J3 - S 3bllx M *V- cS Zvi oS 'a. b
Y
o `t z 'S 6 - Gh s 1 c , "k to c g I v o . 0.5
Ground 3 ZI-3~ -S`11- VA. \S O S5 ~S - 0-'1 u.13
elev.
SdGr- 0 sq - o.~ o.g
Depth to
limiting
factor
? ci r
Remarks:
Boring # s
1 0 -IV 1a~t ~ 3 l3 - s Z `F s b~ ►m'Fv. e S
Z € Z lq-4o 1wi2 31f; S1' Z S61n Yn CS O,S v•b
3 ~o-CIS -).&`/R 3/y - S 1 sbk wiv'F~ ~s 0 y S
Ground
elev. IL/ 4S-90 • S `>fZ Y/6 _ S d G►- o s9 wt 1 0 7 . U'
9Z-3 ft
Depth to
limiting
factor
7 90
Remarks:
T Name:-Please Print Arthur L. We e r e r Phone. 715-425-0165
eg rer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022
Signature: Date: CST Nurnber:
93-y~ y-/9-93 M00576
PROPERTY OWNER SC$&4Q L:r't SOIL DESCRIPTION REPORT Page of .3_
PARCEL I.D. #
Depth Dominant Color Mottles Texture Structure Consistence Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bmiclary Bed Trerxh
C- o. S o- 6
0-N. tO` T 3/3 - Sj 1 Z`~S b Vvt ~h S
>;`s> Z 13-ZS 1o~t~ 3!b S1 13 b1~ ti► fh ~S o. S 0 6
Ground 3 25-91 l opt Q y/6 - S v S g v,n J o• 1 a
elev.
gift.
i
Depth to
limiting
factor
59t
Remarks:
Boring #
S o. S u. ~
~.u.,.~;``~Z 10-30 1~`ZtZ - S 1 ~ 2'~' 3 h►'t ►'n C S 0 S -6
3 3o -y) -)•S71Z 3/y - S O Sg e S o-l o.$
Ground
elev. 4 41-9o 16.1 R V& - S n :5.5 m~
ab.1 ft.
Depth to
limiting
factor
Remarks:
Boring #
o_q ~o y~~13 sib 2`FSbk cS o.s 06
S Z °1-'L- a 10 L 2 3l 6 - S) 2 S bk g S! o. 6
3 2$ 36 7 ~S y R 3/5/ - S O S S 1~ ~ c S b•~ v•$
Ground
elev. y 3L-91 yZ YI
- S O S9 m) v'~ 0 8
6
$ S,~ ft.
Depth to
limiting
factor
y 9 z"
Remarks:
Boring # i
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
PLOT PLAN Page - of 3
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Bt~
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"1NN-t-L~ )--ri 111 S U \t.(e `T1A~ `Ttt e4 i~,tZE )10 3 Tt CLueb 1 K.1 T?°ti c- S~ 1v~
~`aN1't 1 ZC-JK1'S . IN S TtCt, L Uqt 1v rc~ L-x-Tt .12 Ai i kl L` S y STEM EL eU *r b 4 S _
~vZ1/U G_ 1#.t14 Tfc'LLl~ru1V. Two `'MeQCtte-S, LmCN S"1 S` W-G
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oz• 1/-69-93 (1!S) ~L2S-0165 ~ooS-)6
CST Signature Date Signed Telephone No. CST #
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
. Labor and Human Relations
DYision of Safety & 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 I X
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: GPROPERTY LOCATION
4 1/4,S /4 T 2-a ,N,R 19 E (o~W
c, M - B%f r=- 4t DE1-~N s s ctt 0 ~t z
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. {NAME OR CSM #
-7 IQ) t3. ~"L~LdJ 9T- 55 - 6I-0k3e5t sl"rw 3 v'4 t'r1~Dt'f10N
CITY, STATE ZIP CODE PHONE NUMBER OCITY ❑VILLAGE MOWN NEAREST ROAD
`Z~v - l S W 1 514%ZZ (715) q? S - 8161 ' vuu ' 11 StASWau \_3111cltic RD.
New Construction Use Residential / Number of bedrooms Lj [ ] AdcrtfiQn to existing building
[ ] replacement [ ] Public or commercial describe
Code derived daily flow bu o gpd Recommended design loading rate - bed, 9p(W ° ' I trench, 9pdjft2
Absorption area required & S 8 bed, ft2 S o trench, ft2 Ma)dmum design loading rate o - 7 bed, gpd/ft2 0.8 trench, gpolft2
Recommended infiltration surface elevation(s) 5ffe AjaTe- NV Pft&E 3 it (as referred to site plan benchmark)
S x l S 6 .
Additional design / site considerations ~.t_r_4 M M &g D Z ~-@v Gttn Cacti
Parent material S~1 t~i.E>uT' oven StV+ jb # G Rh V LT-L Flood plain elevation, if applicable N, A ft
S = Suitable for system COM/ONTIONAL MOUND IN GROUND 111SSURE AT-GRADE SM'I M IN FILL HOLDWIG TANK
U=Unsuitable for system ms ❑u ®s ❑U 0S ❑U ®s ❑U ®s ❑U ❑s OU
SOIL DESCRIPTION REPORT
Depth Dominant Color Motlles Structure Cov9slence GPD/ft
Boring # Horizon in. Munsell Qu. Sz• Cora Color Texture Gr. Sz. Sh. Boundary Roots Bed conch
10-j1 L 3)
3 s 1 1 Z`~ sbK vvt ~v. ~S Z~~ o. s n.
~ S bk
2. 1Z Z( tp~Z.316 G~- sl \ 1tity~ cS lv~ o.~ 0.5
Ground 3 Z1-31O-S`11~ Y16 \S O S5 vh~ r~ S - o--? u.43
elev.
gam. Sft. A S 4 (z S 4 Gv- O S5
Depth to
limiting
factor ,
c% `
Remarks:
Boring # 1 0 -1q 1Wi \2 3 /3 - S 1 Z `F S b1~ h►~h C S o. S o.l
Z Z t ~l -`l0 lO`L ~ 3~ fo S 1 ~ Z. T S~k y►t C S O, S o. b
3 Lo-vs -).Sy12 3/S! - s 1 c sbk ~nnv'~1~ 0-S o y o• S
Ground
elev. L/ 4S-90 S `m y o s9 wt 1 0 7 v.
qZ_3 It
Depth to
limiting
factor
7 90 "
Remarks:
T Name:-Please Print Arthur L. We e r e r Phone. 715-425-0165
egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022
Si nature: Date: CST Number:
~3-4~ y-t9-93 M00576
PROPERTY OWNER SC! {V 1--TZ SOIL DESCRIPTION REPORT Page Z of
PARCEL I.D. #
Depth Dominant Color Mottles Structure Bed T
Boring # Horizon in. Munsell Gnu. Sz. Cont• Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trerxh
1 0-t3 1O`I2 3!3 - S11 Z`- Sb"VLfh cs o.S o-6
o. S O- L
~ z 13 -zs do ~ s ! ~ ~ s t) Z'F s bk f►~ e s
Ground 3 2.5-C)1 l~yQ L - S v Sg vv) o•~ a•S
elev,
q~.1 ft. '
Depth to
limiting
factor
7 °1 l "
's
Remarks:
Boring #
zi SDK ~`Fti. C S O,S I u, ~
4,: Z -30 1O`11Z 3!~ - S 1) 2'~ 3 bk ►n ~t^ C S o.S ' 0-6
3 3o-yf -I,S172 31y - S s9 0-S 04
Ground
rn c~•7 Io•$
elev. L/ 141-9o IO`y 2 Vl(- S 30J
ab.1 ft.
Depth to I
limiting
factor
Remarks:
Boring # 1 p _q `o y2 3! S s
Z q-Z~3 do~i23l6 - S>> 2'FSbk ~g o.S v-6
3 28-36 - ~S ti f2 3/ O S S lK c S b•-7 d•$
Ground
elev. L] 3L-9Z » yZ Y/6 - S 39 m) u' i o S
ft.
Depth to
limiting
factor
>9V
Remarks:
Boring #
~tk K ~:tu
>°a
eti
~'~}yy 4
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
PLOT P LAN Page 3 of 3
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CST Signature Date Signed Telephone No. CST #
33 \ _ _
~~~0~'~ 69 p3 2~ \ ~2,p 0 \\0
I I 1 I \ s o. \ \
10,
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~ s 55
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/ m 147, 097 S. F . \
m. ` 2 \
o, 1 / .•2290 \
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_ x8.22'' 252.08'
- - ~.S 0~ 727.49'
L POINT OF
1 BEGINNING E 1/4 CORNER
SECTION 16
F. T28N, R19W
WN ROAD) EAST-WEST 1/4 SECTION LINE
FOR A SHARED
54 AND 55.
UNPLATTED LANDS
THIS INSTRUMENT WAS DRAFTED BY CHRISTOPHER J. NEPERUD SHEET 1 OF 2 SHEETS
92-1969
'L
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNEWBUYER
MAILING ADDRESS 9.1
PROPERTY ADDRESS
(location o septic system) Please obtain from the Planning Dept. aG^E 4
r
CITY/STATE)
PROPERTY LOCATI'O'N 1/4, 1/4, Section T_N-R~W
TOWN OF J t9 ST. CROIX COUNTY, WI
SUBDIVISION J J' D LL k& t`LOT NUMER
CERTIFIED SURVEY MAP , VOLUME )0403 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
County Zoning Officer within 30 days of the three year expiration date..~~~~
SIGNED:
DATE:
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 PO. j q - ~h
Location of property _1/41/4, Sectio Tj!K N-R W
Township T(' pi/ Mailing address
Address of site 3 d ,1 GZ ,~C'_,
Subdivision name SAtion ;0 Lot no. ~s
Other homes on property? Yes /1 No
Previous owner of property ye Den 41 S• Sc 14I tz_
Total size of property 3,S11 (1. c.y ~e' ,S
Total size of parcel 2 , S 9, 0, C' y
Date parcel was created-
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes No
Volume IND and Page Number 016 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 t ffice of the County Register of
Deeds as Document No. n 0 M , 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.
Signatu of Applicant Co-Applicant
Date of Signa ure Date of Signature
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA
f WARRANTY DEED
5201.09 vet , `
10,9 Par, REGISTERS OFFICE
Dennis R. Schultz ST. CROIX CO., WI
This Deed, made between ReC'd for Record .
-
AUG 1 1 1994
. - - = Grantor, 10.55
and Paul S. Hasklns and-Sally J. Has7Cins_z--as----------------------- Q f•M
---------marital- survivorship property,---------------------------------------- -
Registera~Deeds
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration......
RETURN TO
conveys to Grantee the following described real estate in ...St...Croix.....---_.-- Dennis R. SC U1tZ,
County, State of Wisconsin: 113 South Main Street, River
Falls, WI 54022
Tag Parcel No-
Lot 55, Glover Station Third Addition,
Town of Troy, St. Croix County, Wisconsin.
~~ly~~
This ...-_.._.1S_,40t homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And_........•-Dennis R.. Schultz
-
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 11th day of AUgUSt--••--- 19__.9_
-----------'(SEAL) c - (SEAL)
* * ---------lennis..R..-Schult.z-------------------
---------------------------------------------------------------------(SEAL) -------------(SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
ss.
St. CroiX County.
authenticated this -------.day of--------------------------- 19-•---_ Personally came before me this llth___day of
19 94--- the above named
-----------J)enn~s_ _ R. __5chu1t.Z----------------------------------
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not-
-
authorized by § 706.06, Wis. Stats.) to me knga►li'It%ye,th~d'vgrson who executed the
foregoi~ gl~sjrjimen7}tj ~I}dy;~~sycknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY `•fj n ~/J
. M. Bye : . R
-
*d fix.nzn
Attorney at Law Notar ably t Croix county, wis.
Q
(Signatures may be authenticated or acknowledged. Both My Gpx i+~sion is ri"nent. (If not, state exp r tion
are not necessary.) date: ABt"'1~
19.-'--'--•)
'Names of persons signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc.
FORM No. 1- 1982 Milwaukee- Wis-