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S(G STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER f1~1 ✓ id rl
ADDRESS O/c( E 0"d
SUBDIVISION / CSM# C5-i (l al 3 LOT # Z
SECTION ;?'2- T 36 N-R__J1 W, Town of ~f 96 esi1A
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: /P4e,*,~,"i1 f~Fu9 r f
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: I'jioe ks 6"10, Liquid Capacity: law
Setback from: Well (a& House S 5 Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: S Length 6 ® Number of trenches 2
Distance & Direction to nearest prop. line: /e2-
Setback from: well: I'ZO 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: P/7111-
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Y~
L &TaQk1pertF5Lntofj9WH 32.30 • A,1 AjE SEWAGE S E101' OLD E '
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary -Permit o.:
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village R Town of: State Plan D o.:
n p. Rh41ev1I.F, B Description: X Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9300040
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
TANK TO P/ L WELL BLDG. Airito ntake ROAD Dt Inlet
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Loss mead
Forcemain Length Dia. Dist_Towell
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM
INFORMATION Type O CHAMBER Model Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header T Manifold Distribution Pipe(s) x Hole Size L 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 Fxx Seeded / Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: ST. JOSEPH 32.30.19.342B,SW,NE, LOT 2, OLD E WEST
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
DILHR SANITARY PERMIT APPLICATION couNTY
In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PER IT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑
8% x 11 inches in size. Ch 2k i rev sion to rev ous 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
A"LA, S t.1 Y4Ak '/a, S 1Z T ' 6, N, R 19 X(or)Q)
PROPERTY OWNER'S MAILING ADDRLIESS LOT # BLOCK # f n
,16,5 d £ Z / If ,7
CITY, S
944M /Zie J5, 3 TATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 81.15;
4161e 11. TYPE OF BUILDING: (Check one) CITY FNEI EST ROAD
❑ State Owned O VILLAGE : h 61
❑ Public 121 or 2 Fam. Dwelling-# of bedrooms A L (
111. BUILDING USE: (if building type is public; check all that apply) 636` 16 93_ 0V --0
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
40 Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 1130 Other: Specify
IV. TYffPP~E OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. IQ New 2. ❑ Replacement 3. ❑ Replacement of 4.0 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 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) -t-I q1.50 ELEVATION
4( D 6" ,75 -r22 92. xFeet ~ V eet
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 Holdin Tank 14e>6 l c1
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.
Plumb ' Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW Ng- Business Phone Number:
- W11 32Z 7Z
l
Plumber's ddress (Street, City, State, Zip CodA &L-1i i 677 A K6
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater [Date lpsued Issuing Agent Signatur (No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination I : ~ ~1-4 / I - 9 1' V!7'
. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-8398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS ,
1, A:,sanitik y;permit is valid for two (2) years.
2- Y6ur'sahitary 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 tc~ this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/f=.t>rt;>wal Form (SBD 6399) to be
submitted to the county prior to installation.
5. Onsife !ewage systems m--st be properi y -riairitaitied. The scpt r: tar >:'v,) must he-k°yrn~~ed by a li-,Jensed
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. Propprty owner's name and mailing address. Provice the legal description and parcel tax number(s) of
whefe'the system is to be. Pnstal-led.
11. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelliig.
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.
Vt. Absorpti,-~n system information. Provide all information regr,er=.°^d in #1-7
Vll. Tank mfg;, oration. Fill in the cape."ty of every new aid/or a"71k; ist the total !umber of
tanks and n.anufacturer's narile dr~Fdic~rtt~ prefab or site constru•_~rx•d and tank :naterial. t •,r; r'1 4te lior ali
septic, parr r/siphon and holding ?:inks ;his system. Check ex::,t;fimertal approval oiii~< inks received
experiryi-Wai product approval from Dlt.. 01
Vlll Responsibility statement. Installing pluwkk,ar is to fill in name, h-t e number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumbei must sign appli(-; 'm i~' m.
IX. County/ Department Use Only.
X. County/Department Use Only.
Car --'ell glans and specificatior° rot smaller than t3'/z must be ';ubfnittf,fd tr the, county. The
plaris r.„.sl' include the following plot plan, drawr to ~'-6 ~F r - J'h complete ;?K,; rr :2t nrr of-
hol 0 ;.-nk(sseptic tank,.) r.r *her treatm{-nt tanks; ho, ' . well:: vvav~?r ater service;
streams -=ri7 lakes, pump or siph~,,, tanks; distribution bo- -a,,, t_~so~l~tion sycte°rr~; ral.1,•.:,.i,1e !t system
areas; ar:tJ ` e Location of th ; ui'x':ng served, -13) horizor!. •rtica 31P1 :'1 , _ } f.rc - r in.t.
C) complete specifications for pumps and controls; dose r r~; + elevation dif;erences fr cti-," ioss'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 (`e: , !oi- ; r.un: ? ar cf
regulated practices which -an effect groundwater.
The monies collected through Yhese surcharges are use~"-)r rgre+_.ndv a.:- ci:-4 AIL
water contamination invesligatior~s and establis:nrneei -,t ~;a;,+'r ~ ds
SBD-6398 (R.11/88)
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 permit issuance. ,Should this
development be intended for resale by owner/contractor,(spec
house), thenia 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 /L./cam ~c nx n /~ru ~
Location of, property 5'6J 1/4 X1/4, Section T 3C N-R L W
Township Sl
Mailing address
Address of site
Subdivision name_ e Si`'7 I 3 , Lot no. 2
--r
Other homes on property? yes No
Previous owner of property
Total size of parcel o Ike
Date parcel -was created
'Are all corners and lot lines identifiable? _ -Yes No
Is this property being developed for (spec house)? Yes ~_No
Volume 3 and, Page Numbers 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. 3(. 31x% , 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.
I
Signature of applicant Co-applicant
Date of Signature Date f Signature
j
STAf BAR 7 K'I U~ .`7 FCS 1
QC1 C, ~i M1'{=47 NO f
RE
vo;
,i,,! b4:', e
1
K V_
Gruel ~r
ana Pa„. l_a J_ Perro;l (si11.31e),_ Riarlel. L. P,r on, (sIC4 ~~)A ...T.Fab._a-a. 19__81
AA.
Cheryl J. Perron,- (sl._.gle)... . - a310:25 A.
. - - -
3.
Wi
tlIC n` °•'Ql, That the sal, Grsnr.,oz, for s valua3 ie cu f_,, a loa.- One .($1•()0) Dollar and other good and_.valuaaC``})l e.-cons 1d ration
• , fi° j ' -
convey,, to t:r+a!It,~e the `.ollou:ing deac~..l a+., real estate, in _ -St. 411E .ix R URN TO
County, State of Wisconsin:
Tax Key No..----- - - -
Lot 2 of Certified Survey Map as recorded in Volume
3, Page 856 on August 23, 1979. Subject to ease mints, restrictions and reservations
of record, if any.
This _-is_not----------- homestead property.
(is) (is not)
Together with all and singular the hereditaolents and appurtenances thereunto belonging;
A,d Edward T. Johi_storl -
- -
-
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
and will warrant and defend the same.
6th
Dated this - - day of - - - -
~ ~
-
(St.~L :t
- - ) - - u"'AL)
• - --Edward. T__.J n- -
(FAL) -
c
ACKN0Vf LED GM F,I T <O
el LI TiA E NT I C ATYO N 'A
-l•lu:•
Signatures authenticated this day of STA_TF OF WfSef)hSt i tsit
_ i9-- Minn. as.
Washington . . .....County.
' Personally came before t.,e, this 6th...... -..day of
Dec.,-. - he above named _
• 4ward T-...Johnston
_ E410 rd -
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by § 706.06, Wis. Stets.) - -
-
TH,S fNSTRU~-aENT WAS JRdFT£O S`r to me kl/o `.n to~oe the p.' Son executed tl:e
fore ping inst ozn-+'.. and cl no;cmme.
'4 Anderson- Freitag, Inc. f
New Richmond, Wis-onsin 54017
.Richaru G. `.rai Lag
Notary Publf W' 4h t ~l, i on County, Nl;;,.
(Signatu e, rray be auth,.lt`catcl or ackflow?edg d. Roth bty. Con r.is, nn is p n,.ati ,.t. (If not, state cY,)ir.tinn
are not ncce4~ary.l date JUiy .31) 19
•Nxo. of v reins 5gn'r,y in sny cape:-'ty ahead •ao type! e,r p:-int<d b?ln, their aigca?r:r«v.
l SY Z s 2's" O T YAK fl -A CO. Inf.
For"4N_t ? i N ->a4_. Wis. (3"t
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUY ER_ /-ex 01,1" nz. f 6trn
ADDRESS Q IJ 4' E'.c-41- FIRE NUMBER 45
CITY/STATE /_'c1(S ZIP
PROPERTY LOCATION:Stl1/4 ,1/4, SECTION, T~N-R~W
TOWN OF .1/ ~t , St. Croix 'County, '
SUBDIVISION C.5tk7 , 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 ttie 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 te.
SIGNED•
'
DATE:
St. Croix co. Zoning Office
911 4th St. C d
Hudson, WI 54016 9xu~
S C S yZ ON C-Z- Soils 0ti1-,41;1- loom co,r+1ol-eX
Safet Builu~ngs Division
x 7969
= Wisconsin Department of Industry, SOIL DESU(IPTION REPORT P.O. lob
Labor and Human Relations Madison, WI 53707
(Attach Soil Profile Location Map - To Scale - On A Separate, Signed Sheet) page of
yiy- /ate
ustomer Name i w uaUOn ate urnnt Lan Use or Vegetapve over Parent Matena s k/~S
I XA /00 y P: rr4Fv o vT
Estimated a shallowest roun water P ain E evation
ustomer ress L ~ • • Y~
Gt,( ~ stem loa m Rate in a ons Per q. Ft. Per Day
y- ~S
County ax arce No. b+ ` Z 4 Rek 3 i ef31 ~ 3-13
Sf C,f~a~ <or-
Lot Legal Description -FOWAN t o/c, eometry an Dept ope an Aspect No e t!i taLcsT~ [y
S c1` . 2 7-c> S900 - .41oa i yGE-
s`f TOS EP /y` st d ,PE.~IVr,P,f'.S ~ s
Gr~ N SEC• 3"~ a R 1 ~W
Structure Remarks: clayskins Loading TAE
Horizon Depth Dominant color Mottles
In. Munsell u. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Bounda ores Hand other GPD/ft.
0-l7- 10a 3/2- J,f, s6k nM''ie cw 3
3
$ 12 -2-f /vile s/y 1 s6& f~ 2v ~ea
n~f 2 C cv
13 i Y--y"P /U Yw S/LQ 1"'5-k
69,
- ':~7/E IIA riot v Tze-,) 9t!o, 5 -
Structure Remarks: clayskins Loading
!Ho %Domun r Mottles
u. Sz. font. Color Texture Gr. Sz. Sh. Consistence Roots Boundary ores H. other GPD/ft.2
s./ 1, TSht .wtfR Si / 1, f, sb K n,•tf2
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7v e'w IM 2 nt~ c c~
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Horizon Depth Dominant Color Mottles Structure Remarks: clayskins Loading
In. Munsell u. St. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Boundary ores H and other GPD/ft.2
13 30 2 l1,4 cw • 3
/3, 5,9 t 57
MrXT~~~ aF
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vet % •o.t~ _ _ rJ G ~ y~A
Horizon jDepth Dominant Color Mottles Structure Remarks: clayskins Loading
Munsell u. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Boundary ores H and other GPDA0
/o Y/P 3/3 A 3
Zf
4 2ti /0Y R f p-
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60
y,~ 4~CP - S D,, s .e c4,
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Depth Dominant Color Mottles Structure Remarks: clayskins Loading
In. Munsell u. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Boundary ores H and other GPD/ft.2
/v !oye 313 Si/, lr , ,F 4, fe 2rrf- cw '3 7
6 '4z /0-Y 14Y4 y S// ,f Jhk 'e zvf- e-w 3
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MOT TGi v /N JN G LV $ /'p tJ HOMESITE SEPTIC PLUMBING CO.
of P~ T ~N 85S O'NEIL RD., HUDSON, WI5.5W01
R08EKT ULBRIGHT
a'V Ly, ~O/~Q ` s -11S. MASTER PLUMBER LIC. NO. 3307 M.P.R.SL
',!N. IFI;7ALLE'i & DESIGNER LIC.140. OD663 '
Additional Remarks: v 1
8 3 - g y - 13
P4-re- , -1- - °t 3, 13 hAS loxawc- h'^T~~° o,z
+ F.vy 6 -e ax-,e~
y_T~'o.~ .
l4 i 64, T&E/v c4- = 9~- .Sci ' ro 2 A Qe~.4
Garb 7-,r e.v a, = 9Z~ o ` , - ~i^ f3 yr
Other Site Features:
lZ" `Po/G- /WIlev /fr
Boer- ~ S ~1,, - ZVP Z
Limiting factors/Depth: CST Signature Date Signed Telephone No. CST #
SOD-8330 IN 01190) To P of 23 7 f
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TIMM EXCAVATING
Route 1 Box 192 SHEET NO. / OF
WILSON, WISCONSIN 54027 CALCULATED BY DATE y - ~3
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
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PRODUCT 2054 ~ Inc., Groton, Mass.01471. To Order PHONE TOLL FREE 1-800-2256380
' JOB
TIMM EXCAVATING SHEET NO. Z OF 2
Route 1 Box 192
WILSON, WISCONSIN 54027 CALCULATED By DATE ~'F3
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
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PRODUCT 205-1 Inc., Groton, mass, 01471, To Order PHONE TOLL FREE 1-800-225-6380