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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS F3~57 baia Gw
SUBDIVISION / CSM# LOT
SECTION T N-R_67 _W, Town of ~
1109
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
All Lt,
A
YAP
\y
f
l~
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
1
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: G,),e e & C, e, Liquid Capacity: 11,160
i
Setback from: Well House 4~ Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: 51 Length &Po Number of trenches Z
Distance & Direction to nearest prop. line:
Setback from: well: 5G' House 71~ " 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: 'y-2-
PLUMBER ON J013: LICENSE NUMBER:
INSPECTOR:
3/93:jt
L r`Tlsi; a,tkW]P§JrWst~9. 29.19.7$Wrf iTT€ PEWEE g,fS*TaUBEN LN. County:
` 4abor and Human Relations INSPECTION REPORT
Safety and Buildings Division
(ATTACH TO PERMIT) sanitary ermit o.:
GFIERA'E INFORMATION
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan D o.:
CST BM E~lr-, Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9300060,01'a
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Gj?C Benchmark
Dosing
Aeration Bldg. Sewer
"
Holding Stj~K Inlet '9
3 50
TANK SETBACK INFORMATION St/ Outlet 'p" ( ?s
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Airlntake
) ~~S NA Dt Bottom
Septic 56 i+
Tidy S, /03, iGD,
Dosing NA Header/-
off.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade / 03, 33
M4nufacturer Demand .,i 6 s r "
L
Model Number GPM
TDH Lift Friction System H Ft
Loss Hea
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH width Length No. Of Trenches PIT N Of Pits Inside Dia. Liquid Depth
DIMENSIONS 11~1_ DIM N
LEACHING nufacturer:
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM
INFORMATION Type O CHAMBER Model er:
System: /P r~~ ^ c111 77S j OR UNIT
DISTRIBUTION SYSTEM
Header 4#40"0004 Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length _~L 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
Trench Center B tTrench Edges 3 Topsoil ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 19.2 9.19.7 0 9 , NW , NE , LOT 4, AUDUBEN LN.
Z~Zl
r
ll o4;"7 s
Plan revision required? ❑ Yes 9-16
Use other side for additional information. 5y
SBD-6710 (R 05/91) Date Inspector's Signat a Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
f y
I
UILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNT
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than El 8% x 11 inches in size. hec f :116Vreevious 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
t-e,e G,'l A-, ()'/a ►tJ Y., S 1tj T Z-', N, R !5 (or)(
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # s4
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER N
Ljz d /(p LL q Clive
11. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
❑ State Owned VILLAGE 4 tid "a ❑ Public .5-2-0 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX M
III. BUILDING USE: (If building type is public, check all that apply) Zd 3 Vo
1 ❑ Apt/Condo
2 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
50 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. 9 New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.0 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
d O . .60 ,75 ° W• g3 Ir2 17V~ PFeet pas 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
-1 1 F]
Septic Tank or Holdin Tank dz;, /
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.
Plumbs 's Name (Print): Plumber's Signature: =Sta MP/ PM RSW No.: Business Phone Number:
z Z ? 77Z 3z41'~
Plumber' Address (Street, City, State, Zip Code):
z
~h 4J, l-
IX. COUNTY/DEPARTMENT USE ONLY
Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Agent S' nature (No Stamps)
Approved E] Owner Given Initial/ Surcharge Fee) ~3
Adverse Determination 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. r
2. Your,sanitary permit may be renewed before the expiration date, and at the time of renewed any new
criteria in the Wisconsin Administrative Code will be appliGable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permr t Transfer/renewal Form (SB ) 639,91, to be
submitted to the county prior to installation.
5. Onsife sewii9e syst..,ms must be properly maintained. .h -tie tank(s) m :vt be F•UMIDed b ii:tensed
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 npjmberis) 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. Absorpti.:)n system information. Provide all informat on requesters ;n #11-7.
VII. Tank :,,{,l-Elation. Fill in the capac=ty L. ,,ve=ry rew and/or existirr_; it. ist the tc fal f- l Jn num;3er of
tanks and manufacturer's name. indicate prefab or site construct:~d ann tank nialerir•L for all
septic. pump/siphon and holding tanks for this system. Check ax f. ,1 approva. r i` t,~ Jks received
experin _ntal product approval from Dlt_t-iR
Vlll. Responsibiiity statement. Installing piumt-r is to fill in name, sic e:~ se n!~!nber- with appropriate prefix (e.g.
ti1P, etc.), address and phone number. Plumber must sign application to rm.
IX. County/Department Use Only.
X. County/Department Use Only.
Couplets: ;Mans and specifications not ; alier than x, 11 inrl ^^d! t be submitted to the .ounty. The
plans nw ' in,;Iude the foliowing i; plot p?an, drawn to sc F ;pie e dirge 7 : c- - tion of
holding tank (s), septic ta. k(so r :&ler treatment tanks; t of ~!n c veiis; ova. er c tar service,;
sireanif l Lind lakes, pump or ~;iphc•'~ tanks, distribution boxes, bsQrption sysiern !ep+-+ ; -ieM system
areas:. and the location of `h(: 5u_ ,;;ng served: 3) horizontal rtic~' eieva~i-a^ refe e^nue _)oinr~:;
C) complete specifications for pun;ps and controls; close volorrs , elevation differences; fricti-n 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 inchided the creation of surcharc-o s (`re~;s) foz nfjm:i -!r c,,'
requlate(I practices which car effect groundwater.
The nnon;es collected thro:J l3 ZhC1,3-_ s!_rcha.gk . 1-;'7 ~17' f.,.
water contamination investigate yns anrJ establftitcr :t A sta t:sartrs.
SBD-6398 (R.11/88)
JOB
TIMM EXCAVATING Z
` SHEET NO. ~ OF
Route 1 Box 192
WILSON, WISCONSIN 54027 CALCULATED BY DATE Z 9- 9~
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
SCALE
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PRODUCT 205-1 Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE I-000-225- 050
" JOB L e 6" / ~tS
TIMM EXCAVATING SHEET NO. 2 OF z
Route 1 Box 192
WILSON, WISCONSIN 54027 CALCULATED BY DATE y i5` y3
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
SCALE
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PRODUCT 205-1 Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE I-800-225-63BO
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Pa g
e /of 3
,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 r cfzo 1X
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
Lem 1 L Li:7>- GOVT. LOT Iq t j 1/4 jVF 1/4,S /g T -Z9 N,R ~ 9 E (or) W
PROPERTY OWN R':S MAILING ADDRESS L BLOCK # SUBD. NAME OR CSM #
5 0 C, RAY A# IVIALI..JQ,COV/
CITY, TATE ZjP CODE PHONE NUMBER ❑C ILLAGE TOWN NEAREST ROAD
u&Scl + -A 6/9 ( ) v Tie®e ~T &OOK. Rh
p(f New Construction Use [0(( Residential / Number of bedrooms [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow gpd Recommended design loading rate 0 77 bed, gpd/ft2 D ~S trench, gpd/ft2
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate _0 .3 bed, gpd/ft2Qg trench, gpd/ft2
Recommended infiltration surface elevation(s) - THM f ft (as referred to site plan benchmark
Additional design/ site considerations NLr~YIn►>Q - 91 -r.,6 t 97-00 P2IMIAky - 101,'0 . d9,S0
Parent material Flood plain elevation, if applicable ft
S = Suitable for system CC IVENTIONAL M UND IN GROUND PRESSURE 78G7DE STEM IN FILL HOLDING T K
U=Unsuitable fors stem S❑ U S❑ U 91 S 1:1 U S❑ U S❑ U ❑ S U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends
-7 1(3w / 5 L I rh r C
tj
0 31 7. 'S y CL
Ground I SS S y 3 115- d T4
elev.
/oja~ ft. • 13 / y S c y~ .7 Oil
Depth to
limiting
facto A-
Remarks:
Boring #
A- o~/►~ V1
c 1 r
4••
-2 ! 7.sye 4 S C nit r 0,
Ground 9 at-47 -7.S 4 ni
elev.
/ ft. 7-R6 o 4--L4 C)
Depth to
limiting
factor
/0.00
Remarks:
CST Name: -P K ri Phone:
K 3~6-40~
Address: k:)0 fax 9 Signature: C' Date: 9 CST Number-
PROPERTYOWNER SOIL DESCRIPTION REPORT Page 2 of .3
PARCEL I.D. # L* M W LL4 C-OVt
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
L n, 77- C 7-
, S- 24 7S Y 4- - S~ .ti, rh ~r 0,
Ground - 7-5 YIZ - S~ C rh C 0-7 elev.
ft. $ - d vie 414 5 h,1 6,710-3
Depth to
limiting
4ctor
Remarks:
Boring #
7-21~ 7S?~k3/4- q,
Ground 82 2S .SY - S l 0,7 0
elev. 8 0-~ /6Y ~4 14 0 C
11
/oill ft.
Depth to
limiting
'fACtor
X00
Remarks:
Boring # q
~a
41- .s yre 4 4- 5 I c 1 0 d
1S4 C) C pt,
Ground
f e1nS01 ft. $ s4-1/4 A 414 S ~ C rh ~ l 6.7 W
Depth to
limiting
4.ctor
-a
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
Past 3 a~ 3
Lor Z 11'/~41.~14C~v{
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S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
3 ~
ADDRESS 3 , Arse L-r- k FIRE NUMBER- y 7
CITY/STATE c S Y1 1LL ZIP Sao i
PROPERTY LOCATION: __ILLJ1/4,416_1/4, SECTION- [9 , T ZJ N-R_ /Y W
TOWN OF_ A(C.,_-40_7 , St. Croix County,
SUBDIVISION /11c,8atovc , 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 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/Ile, 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 Co. Zoning Officer within
30 days of the three year expiratio date.
SIGNED: ~ •
DATE:
St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
STC-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 pormit issuance. ,Should this
development be intended for resale by owner/contractor,(spec
house), thenla 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 property fUteh14 ri'i- 1/4, Section , T _Z9 N-R W
Township
Mailing address
I
Address of site
subdivision name__ Lot no.
y
Other homes on property? yes--- _No
Previous owner of property It4e Lei A,~t-5svt
Total size of parcel - L, /4c 7 h
Date parcel-was created
Are all corners and lot lines identifiable? X Yes No
Is this property being developed for (spec house)? Yes A No
Volume-fz/q 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 & 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 County Register of deeds as Document
No.
L
Signature of applicant Co-applicant
Dat of Signature Date of Signature
10
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_ DOCUMENT No. STATE BAR OF WISCONSIN FORM 1+1988 THi• GPM% esscevco roR- INII *A7A
WARRANTY DEED
481653 116ER 94 PAG
- REGISTER'S OFFICE
This Deed, made between .clyae__E.__christensen_.and......... ST.CROIXCO. %M
Donna M. Chrisensen- I ..husband__and__wife__as_ 1oint__tenants_ Reed for Rowd
, Grantor, AFRO 71992
and- _Lee_ R,-_ Gilles- -and- Debra. L,__ Gilles,__ husbad a~_ _i_fe_ Of $;30 A. M
as survivorship marital property
- -
- - - - - - Grantee, 0 e .
Witnesseth, That the said Grantor, for a valuable consideration...... Regt>~xof D"
conveys to Grantee the following described real estate in Sx...-Croix........... RETURN To
County, State of Wisconsin:
Lot 4, Mallacove Addition to the Township of Hudson. iQ !e~_L lQ J
Tax Parcel No: _ ! _ _
(R. NSFEt
This 7.S--nQt homestead property.
(jp) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And....... ....UVde._.E...-Chri..s.teas-en._and.Dom&-M.__Chris-tensen
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements, covenants and restrictions of record, if any. glfd any liens, encumbrances
created by the act or default of grantees above
and will warrant and defend the same.
1 ~IGr~~c.~VL.._ .
Dated this 31st------------------------- day of - - 19.92...
-
(SEAL) 1 (SEAL)
r
Cl de E. Christensen . Donna M. Christensen
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
a
Siknature(s) Clyde_F,__Christensen anc'..___.__.... STATE OF WISCONSIN
Dorms M: Christensen. husband and wife as.
- . . . --4z -l Fraliy County.
t............
County, State of Wisconsin: 111
ll
• Lot 4, Nallacove Addition to the Township of Hudson. iq l:~~:~~,q
Tax Parcel No: _
N r E-t
ill&
This i.a..nQt homestead property.
y}gI) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And.......... C]yde.C.-.Chr s. teas en._and.Dojma..X.__Chris.tensen------------------------------------------------------
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements, covenants and restrictions of record, if any.al"d any liens, encumbrances
created by the act or default of grantees above
and will warrant and defend the same. AA Y - o
Dated this ---•-----------31st-------------------- day of Zi4~ ICJ-------•-----------•-- 19 92
. - - (SEAL)
---•-•---(SEAL) C~Z' 0 r
. G1 de E. Christensen . Donna M. Christensen
........................................•-••-•-•-•--.....•••-••...--•(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
$ignsture(s) Cly_de_ E,__ Christensen _ an-(' STATE OF WISCONSIN
.na.%--(~Iristensen. husband acid wife SS.
Iaop
f ----------------------County.
authenticated y of._F . 19-92- Personally came before me this ................day of
19 the above named
e amuel R. ari
TITLE: EMBE TATE BAR OF WISCONSIN
(If no •
authorized by $ 706.06, Wis. Stats.) to me known to be the person who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
DetiymnoLd_ C_ax.i.,..by..- Samuel--lt.-•-Car-i_.............
P.O. Box 229, Hudson, WI 54016
• Notary Public County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.)
date: 19--------•)
*NOM" p= ygrsous signing in any capacity should be typed or printed below their signatures.
a11RD STATE BAR OF WISCONSIN Wisconsin Leual Blank Co. Inc.
1TARM TTn. f tAAR