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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNERS
ADDRESS &2XI
SUBDIVISION / CSM# cA m6,' 1 a N; J( 5 LOT # 2-
SECTION. . 2-7 T _21 N-R / % W, Town of rr
ST. CROIX COUNTY, WISCONSIN s
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
N/2z -74 R14 o.40 5M. Tbp i';a;e~sF~1
A _ST
D21vE 70., WELL
' j
GARAGE H OUSE
ay~r~d~ -h-SxS~II I,
ion ~ S°
q/ 0
5A) L7E_ R- ~ -7r,
A
f3 E T) I
l Six `I d ~ I I
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: %P P: P,,!F 4 - 57 X07 "1' ~ _ /moo. oc 3. z 3
ALTERNATE BM:. 76/"" s - 7.t om f• o 11
SEPTIC TA2f / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Gyd; s e✓ Liquid Capacity:
Setback from: Well ~o 2 House /s'' Other438'•Te
Pump: Manufacturer Model# Size
Float seperation- Gallons/cycle:
Alarm Location
.SOIL ABSORPTION SYSTEM
Width: /8' Length yo Number of trenches
Distance & Direction to nearest prop. line: 7s to sm~<f~ /of /:tea
Setback from: well: 85 House 4541 Other Lo sT A ~ / N ¢
ELEVATIONS /V/mot..
Building Sewer ST Inlet;6.3/ ST outlet.
PC inlet - PC bottom Pump Off
Header/Manifold S,/3- Bottom of system
Existing Grade Final grade
I
DATE OF INSTALLATION: /
PLUMBER ON JOB:-
LICENSE NUMBER:
INSPECTOR:
3/93:jt
LOC41
a orandH umaRSelOatNions~sjr29.19,NW,Nj1} Mf E1WAD County:
Safety and Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) sa ~1Pe
Permit Holder's Name: ❑ City ❑ Villar ❑ Town of: Sta o.:
MILL"KV EGAN Insp. BM Elev.: BM Descri Parcel Tax No.:
7 « C 6c4iyte/J 00
TANK INFORMATION ELEVATION DATA A9300180
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic O Benchmark a L b - 160, Dosing _X 6b 36 0 G' ~S7Sf IN S$ /Ou ,
Aeration Bldg. Sewer
Holding St / Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet G~~,
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic S l 62 /5-/ LS S ' NA Dt Bottom
Dosing NA Header / Man. 71 6) $
Aeration NA Dist. Pipe -7,7 Holding Bot. System 7 9.
PUMP/ SIPHON INFORMATION Final Grade ~ 7.
Manufacturer Demand ? a.5~ (JU,O
Model Number GPM
TDH Lift Friction System TDH Ft
Loss Head
Forcemain Length Dia. Dist. To =Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width LenNo. Of Trenches PIT No. Of Pits inside Dia. Liquid Depth
DIMENSIONS
DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK _
INFORMATION TypeO CHAMBER Model Number:
System: 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 xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON.27.29.19,NW,NE,LOT 2,HILL FARM ROAD
~ J GL42Gd-q
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. O f Alc+l
SBD-6710(R 05/91) 3-.64, Date Inspector's Signature Cert. No.
~
ADDITIONAL- COMMENTS AND SKETCH,
SANITARY PERMIT NUMBER:
DLLHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code CO NTY
STATE SANITARY PERMI
-Attach complete plans (to the county copy only) for the system, on paper not less than ZjagA-
8% x 11 inches in size. ❑ Zous 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
GG~/L 4144 l'/a E S 2 T 2 , N, R/ E (or)S)
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
vOSoiy !.~/Z SAO/~ 38Yi ~7G~ SUM /3/,eD h~/L< r
II. TYPE OF BUILDING: (Check one CITY
El State Owned VILLAGE NEAREST ROAD
X_.jQ)NN OF: UA Spy /LL iARM A 101#0
❑ Public [0 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMB R
111. BUILDING USE: (If building type is public, check all that apply) (9Z Q _ Z Q _ Z 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 1130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. (91 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
130 Seepage Pit Pressure 430 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) N• 3,pp' ELEVPj
s ION
N .74" ~Sb lPy S 7Z-o D. S. s 3, o
Fe t , 117,m'Feet
CAPACITY
VII. TANK Site
in alions Total of Prefab. Fiber- Exper.
INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holding Tank ~D~l' / Gt/ci S.c~
Lift Pump Tank/Si hon Chamber ELER =E, EJ I EJ Ll
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) MP/MPRSW No.: Business Phone Number:
ee,, s fRo/~B BEN to /,I P - 6, 11 - z y7 3z s~
Plumber' Address (Street, City, State, Zip Code): /
J' G 0-r I A~- AA1w ~Ic4 nto7~T ~l5. ~fi()/ 7
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includesg Groundwater ate I (ued Issuing t (N )
❑ Approved ❑ Owner Given Initial Surchar Fee
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.
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:
X
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.
Vlll. 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 tanks septic tanks 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)
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 ~n delays of the permit issuance. ,should this
development be intended for resale by owner/cohtractor,(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•propertyNG()1/4 ~_1/4, Section Z 7 TA Z -
N-R
Townships Soy,
Mailing address ~,&o r _
G
Address of site 79~ A O
subdivision name PgJiP X
Lot no.-el-
Other homes on property? yese~'No
Previous owner of property 44
Total size of parcel
Date parcel was created -7/1
'Are all corners and lot lines identifiable? _4____
Yes No
Is this property being developed for (spec house)?_X Yes No
volume
~0Z
1 and. Page Number ZSPZ,- 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.S~». oq , and that I (we)
own the proposed site for the sewage disposal system presently (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._"T_ De,
Signature of applicant Co-applicant
Date of Signature Date of Signature
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 f THIS SFACC Rescnvco roR RecoRoma O^iA 1
WARRANTY DEED
5n22~~ (~c~ T
VOL 1_S1~1pl:lr _ REOSI-ER'S CfFICE
ST. C;Ioix co., 41'I
This Deed, made between .-Humbird Land Corporation, Fi c'J For Record
j A Minnesota Corporation authorized to do business 1
j 'in_.wisconsin JUL 12 1993
{ . Grantor,
i and ..INlllgr-- at ~c~-+4~.+~2--0'-0. ~~1 +1
Re wer of Deeds
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration......
F~
j RETURN ,TeO
i conveys to Grantee the following described real estate in ...U.,_QXP1X % ~-f~ ~
County, State of Wisconsin: , 05, ~o wa~dl~ta/~
Lots 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12
in the Plat of Humbird Hills, Town of Hudson as filed Tax Parcel No :
and recorded in the office of the Register of Deeds for
St. Croix Couaty on April 7, 1993 in Vol. 5 of Plats, Page 1;1
99, Document No. 497107. i~
Lots 13, 14, 15, 16, 17, 18, 19, 20, 21,''42, 23, 24 and 25 .
in the Plat of Humbird Hills 1st Addition as filed and recorded `J
in the Office of the register of Deeds for St. Croix County on
April 7, 1993, in Vol. 5, Page 100, Document No. 497,108.
O, .
This xg..nRt......... homestead property.
(W (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And.-.Hmlzi rd..L nd-.Col R4r8.t.ion
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements shown on the above mentioned plats.
and will warrant and defend the same.
Dated this ........12th day of ...Ally
19-.93.-. '
Humbird Land Corporation, a Minnesota Corporation authorized ~toodd-oobuss7in~ess in Wisconsin
...............................•---....._...........--••----.-(SEAL) BY.-...----•--•-.--.._.._....Gr 7 " ' (SEAL)
• Austin J. Baillon President
-
.•---•-...-•-•---••••--••------------------•••..__......•--._..__....(SEAL) -----.-.--_------•••----•---------...._.....----____................(SEAL)
•
AUTH13NTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
ae
y County.
authenticated this day of 19______ Personally came before me this 11-Aday of
.Tiny 19_.93_. the abLOe•1*Aned
- f -
• - AuStifl_.,T,._.~sillpn,-• President _o'f•....',..t io
TITLE: MEMBER STATE BAR OF WISCONSIN Hppl~i,Fd_ T{and_-Cor oral io y
p ~ 1 I
(If not.
:a_
authorized by § 706.06, Wis. Stats.) ~~-0 • + i
to me known to be the person Z4 e ecuted t* J
foregoing • strument and acknowledgA 4 saW 0 N,tO t
THIS INSTRUMENT WAS DRAFTED BY 6J v H N h . I / q ,,tLD•~, [
Xueppersr..Hackel..A-lfueppers.......................... .
1350-.Capital"_Gentre, --St.-.Paul.--Mti. 5.5.102_ Notary lie S-r.--.--C .Q./.1~---- ~
County, Wis.
(Signatures may be authenticated or acknowledged. Both my Commission is permanent. (if not, state expiration
are not necessary.) date:
r' . 19._...---•) r
*Names of persons signing in any capacity should be typed or printed below their signatures. .y am -
` WARRANTT DEED STATE BAR OF WISCONSIN Wisconsin Leval Blank Co. Inc.
,i FORX No. 1 - 1762 Mil-uk", Wis. `
' J.. a . . ,'i.. isr,
r
.
i
S T C 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER S4,* /yI/IL~.C
ADDRESS C~f'ZS2~ FIRE NUMBER
CITY/STATE_~~,,y7 ---Zip 5-:Ov/~
PROPERTY LOCATION : ,f6U 1/4, IYL'- 1/4, SECTION Z 7 , T z c N-R-ZfO
TOWN OFLc~/sa,~ , St. Croix County,
SUBDIVISION c ,jJ J'-'/ LOT NUMBER Z
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
completed and returned to the St. Croix Co. Zoning officer within
30 days of the three year expiratio date. f
SIG `~J / p
DATE :
St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
F'ib
Wis6on'sin
and Humart Relations Industry, SOIL AND SITE . EVALUATION REPORT op Page ! of 3
Division of Safety ii 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 S7 C,~ U IX
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
'SAM M ILL0 GOVT. LOT N/W 1/4 NL. 1/4,S~ T Z9 N,R E (or) W
PROPER OWNER':S ►~~QQILING ADDRE LOT # BLOCK # SU~~• NAME RR CSM #
7kOU i t5i2odlc P, Z ~I, I Qfl /QIjLL.$
CI7y STATE IP CODE PHONE NUMBER ❑CITY ❑VI GE OWN N REST ROAD
Lj, New Construction Use kj Residential / Number of bedrooms 3 [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow gpd Recommended design loading rateO.-7 bed, gpd/ft2 01 trench, gpd/ft2
Absorption area required 6 qs bed, ft2 S65' trench, ft2 Maximum design loading rate O.7 bed, gpd/ft2 O .'t trench, gpd/ft2
Recommended infiltration surface elevation(s) No).-iU - 93-00 ft (as referred to site plan benchmark)
Additional design / site considerations So+J r, - 93.50
Parent material Flood plain elevation, if applicable It
S = Suitable for system CONVENTIONAL ROUND 79S -GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem ~S ❑ U l S E3 U ❑ U 4S ❑ U MS ❑ U ❑ S U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounds Roots GPD/ft
1$ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tiench
b~"
Z &4
d-I /Uy~k3 L Cr m r
4A 1C. C 6.6
/OVA, hK
Ground 192-12-7-117 zoyf, s o. a
elev.
/Of~•/aft.
Depth to
limiting
for
? .Z 5
Remarks:
Boring #
Q co t23 / L r Z d.Q b'
9 -Z-Z /Oy~4 SC ~ceb I A sb C Z 0. L
z
°
n;
Ground 2~ +C 3 4 SL M z6K ~VI C / O.
elev. 83 2-/L j-~ P-514 s ,n, 1 •7 are
9~.
Depth to
limiting
factor
Remarks:
CST Name:-Please Print ljav'ey N$a ~ Phone: 46 rs
Address:
Signature: H Date: ~3 ~ CST Number:~~~~
3
• . 'PROPERTYOWNER ~AMIa)LLI*'*-- SOIL DESCRIPTION REPORT Page Z of
PARCEL I.D: #
Depth Dominant Color Mottles Texture Structure Consistence, Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Y Bed Trerx~
3 ~av
3
Ground $ 3-1K /aye, 4/4 5 ~ ► 7 Q.$
elev.
C" ft.
Depth to
limiting
for ~
? S
Remarks:
Boring #
.~A."~ 1 N► q 6K m ~r c: Z GA O.S
%
z& t/4
Ground b +i24 s M 0.7
elev.
Depth to
limiting
W tor
Remarks:
Boring #
wr- c Z o.4 o.s
o- o e3 I Q0
c
v+.i+(vi,,,viti?•vv
19, nj*Zo 16YP--41A .0
Ground
elev.
97
Al ft.
Depth to
limiting
factor
? 0/ -06
Remarks:
Boring #
vJvx.,. •vvv
vv~~~av:ti::.: •iiti..{
4i~ Cv\,''ti
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
S8D-e330(R.05/92)
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