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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS bd
SUBDIVISION / CSM# LOT
SECTION_T N-R_1~_W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
- 8~
f1s
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
t
i
BENCHMARK:
ALTERNATE BM: 11,42 dl l ,yl,~lp,d_
SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION
Manufacturer: 1426 Liquid Capacity:
Setback from: Well House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
-:SOIL ABSORPTION SYSTEM
r ~
Width: Length Number of trenches
i
Distance & Direction to nearest prop. line: Z~I/_
Setback from: well: _ House .ZS Other
ELEVATIONS
Building Sewer ST Inlet; ST outlet
PC inlet PC bottom Pump Off
Header/Manifold 7s Bottom of system' 7
Existing Grade Final grade DATE OF INSTALLATION: X: ~ S
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:`
3/93:jt
L~s~ipartwC+~'f~lf~'y 9.31' 19 O/ATE SEWAGE SYSTEM County:
Labor and Ruman Relations INSPECTION REPORT
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary ermit o.:
Permit Holder's Name: ❑ City ❑ Village R Town o : State Plan I o.:
v.: Insp. BM Elev.: BM Description: Parcel Tax No.:
/A 0), 16A,10 I 012-1075-50-ono -1
TANK INFORMATION ELEVATION DATA A9300286 lb
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic S eG Benchmark
Aeration Bldg. Sewer
Holding- St/k# Inlet (o/ /De7, /3
TANK SETBACK INFORMATION St/Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic > ~3 NA Dt Bottom
731 e-
Dosi g NA Header f#A&A. 3
Aeration NA Dist. Pipe Q
Holding-° Bot. System 9S ?,q. Z2
~
PUMP/ SIPHON INFORMATION Final Grade
Manufact Demand 10
25"
Model Number GPM
TDH_ Lift Friction s em T
Forcemain Length Dld. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width i Length No. Of TJenches No. Of Pits Inside Dia. Liquid Depth
/ DIMEN I
DIMENSIONS
LEAC Manu a
SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM
INFORMATION Type O mur , CHAMBEy Moe Number:
System: ✓ ~ > mo 2,g 4A -aR IT
f6,Z15, DISTRIBUTION SYSTEM
Header 49 . „ Distribution Pipe(s) „ x Hole Size x Hole Spacing Vent To Air Intake
Length ~P- Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Onl
Depth Over a Depth Over xx Depth Of xx Seeded/ S ded xx Mulched
Bed / IJ~4M(Center 31- Bed / T.r~clges Topsoil es ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: SOMERSET 9..31.19.126F
~Q~
v
Plan revision required? ❑ Yes Q'No l
Use other side for additional information. 6-) RSBD-6710 (R 05/91) Date Inspector's Signatur Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
'ZI =awkn_F~Jl R In accord SANITARY with ILHR 83PERMIT.05, Wis. Adm. Code APPLICATION couNTY
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than Q~~Q
8% x 11 inches in size. ❑ 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.
PROPER WNER PROPERTY LOCATION ~
%-SZ t/4, S T , N, R E"(or
PROPERTY OWNER'S MAILING DDRESS LOT # BLOCK #
CI STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
❑ State owned VILLAGE : .~►~'d _
❑ Public M 1 or 2 Fam. Dwelling-## of bedrooms PAR LT I )
III. BUILDING USE: (If building type is public, check all that apply) 5"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. W 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
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 ./i ch) ELEVATION
Feet Feet
VII. TANK CAPACITY Site
in all ris Total #of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank
Lift Pump Tank/Si hon Chamber El I F1 F~ I F1 El
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumb 's Nam (P ' ' Plumbe is Si natu : ( ps MP/MPRSW No.: Business Phone Number:
, -291
r
Z
PI Addre Street, City, State, Zip Code):
um
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved San'{tary Permit Fee (Includes Groundwater a e Issued Issuing Agent ml~)
60 Surcharge Fee)
R1 Approved ❑ owner Given Initial ,
PD
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 8 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 'he county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed
pumper wherever 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 8 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.
ll. 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 81/2 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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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page J 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
PROPE TY WNER PROPERTY LOCATION
GOVT. LOT 1/4 1/4,S T N,Ror~
PROPERTY OWNER'-.S MAILING ADDRESS # LOT # BL # SUBD. NAME OR /V M#
E
[!:LATE y ZIP CODE PHONE NUMBER ❑CITY ILLAGE OTOWN NEAREST ROAD
I ,
:212 1
~T LLI
bC] New Construction Use kj Residential / Number of bedrooms [ ] Addition to existing building
j J Replacement [ ] Public or commercial describe
Code derived daily flow gpd Recommended design loading rate bed, gpd/0. trench, gpd/ft2
Absorption area required 4 bed, ft2' trench, ft2 Maximum design loading rate 7 bed, gpd/0R trench, gpd/ft2
Recommended infiltration surface elevation(s) y 7 ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material /3. /2 l Flood plain elevation, if applicable W '14 ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U=Unsuitable fors stem ®S ❑U ®S ❑U ®S ❑U MS ❑U ❑S OU ❑S ®U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Gu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Ground
elev.
Zzft.
Depth to - -
limiting
factor
yy7
Remarks:
Boring #
Ground
elev
ft. 11 ,r
Depth to
limiting
factor
L eF~ r l - / V
00 2
Remarks:
CST Name:-Please Print / Phone: C - X
L
Address: GO~kjCF
Signature: Date:
I
PROPERTY OWNER A) I SOIL DESCRIPTION REPORT Page. Hof
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. nt Color Gr. Sz. Sh. Bed Trench
Z, n
s , C
Ground _ ` JOB ~J
elev.
-IL ft. ,
I-J
Depth to _
I
limiting
factor
Remarks:
Boring #
--27 3
.Ground...•
elev. ,Y-y ft.
Depth to
limiting
factor
Remarks:
Boring #
A/ Ld
-.x S- ZJ
Ground -
elev. _
-4 Ls
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
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S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER m 0023
ADDRESS o~~tY .,A-, ~ FIRE NUMBER
CITY/STATE , e-r-6e-+ Lv_Z ZIP J~~'IOc
PROPERTY LOCATION : JLW 1/4 , -IC-2.14, SECTION, T,,:~LN-R 21 W
TOWN OF150rner5 , St. Croix County,
SUBDIVISION , 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/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 expiration date.
SIGNED: &22
j
DATE : ~90
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 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.
L-1,7
owner of property fl i rn /,Y()
Location of,property5 UD 1/4 J 61/4, Section W
Township _ ~5oYh ej-6f 4-
Mailing address U10 SA= A
59 t»
Address of site j ,e- om~~Sp __T46ao~
Subdivision name Lot no.
Other homes on property? yes No
Previous owner of property
Total size of parcel., /,<a?a~~
Date parcel -was created I " M 7Js
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)?-,Yes No
volume o 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. To,4 I (we) presently
own the proposed site for the sewage disposal that
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. ,
Signature of applicant Co-applicant
Date of Signature Date of Signature
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 81982 THIS SPACE RESERVED FOR RECORDING DATA
OUITT CLAIM DEED
505489 va 1034PAGE x.43
F. CISTIER'0 OF = v
f ,-.r) t`
Susan Mickolichek, a single person -.ac*d for Record
SEP 14 1993
quit-claims to Kim Con i to 12:40 P .
the following described real estate In St. Croix County,
State of Wisconsin:
RETURN TO
Tax Parcel No:
Part of SW 1/4 of SE 1/4 Of Section 9, Township 31 North, Range 19 West, St,
'Croix County, Wisconsin described as fellows: Lot 5 of Certified Survey flap
'filed April 18, 1975 in Vol. 1, page 110, DOC. No. 326442.
Together With a non-exclusive easement for ingress and egress across the
part of existing roadway described as Lot 9 of Certified Survey Map in vol.
1, page 116, being part of the S 1/2 of SE 1/4 and NE 1/4 of SE 1/4 of
Section 9-31-19.
MAWFU
FEE
This i s not homestead property.
XIXX (is not)
Dated this_ day of September , 19 93
(SEAL Usdn 1C OT1C a (SEAL)
(SEAL) _ --(SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Yh,nnQ~
Signature(s) STATE OFD
Wa shw► 33
County.
authenticated this-----day of 19 Personalty came before me this 4)A-day of
September 19 9 the above named
56-s6-91 cc- of '1c hek, a 'ngT person
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, „ to nown to be the person who executed the
authorized by § 706.06, Wis. Slats.) fo g g jpstru ent a k ge the same.
THIS INSTRUMENT WAS DRAFTED BY
Attorney's Title of Stillwater
1835 Northwestern Avenue _
Stillwater, MN 55082 Notary Public- 1Na sl. CouI1ty, A1t1
(Signatures may be authenticated or acknowledged. Both My Commis i rm n nt (If not state expiration
are not necessary.)
date: t10TAR9 PUBLKr-MMM~SOTA , 19 )
Names of
Persons signing in any capacity should be typed or printed below their signatures. My C~Ilift bilikN MM 19, 1997 N fF 2201
STATE BAR OF WISCONSIN
QUIT CLAIM DEED FORM No. 3-1882 Nelco Forms, P.O. Box 1075, Green Say, YJI 54305-1075