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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER RIAM AU T JO
ADDRESS 3
SUBDIVISION / CSM# &M0A ACS LOT
SECTION--/5 T 31 N-R__/ W, Town of~se
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
I T A
141L
~~LL
tq~
691
5 ~
r ;L - SX 75' 71E1VC#ejCNDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: P" STEEL
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION
Manufacturer: W~e_.,_ S Liquid Capacity: aeo
Setback from: Well 4 2 House o other
nufacturer Model# Size
Float seperation Gallons/cyc
Alarm Location
:SOIL ABSORPTION SYSTEM
Width: -Length ~2 Number of trenches .2
Distance & Direction to nearest prop. line: lJ)A=sT. S
Setback from: well: House ,E/ r Other
J
ELEVATIONS 7. y1 at Jr
/
Building Sewer ST Inlet: 1W,jE/ ST outlet 91
PC inlet PC bottom A (A Pump Off
Header/Manifold _100 7y Bottom of system 9 9,9 y
Existing Grade /Q® Final grade
S
DATE OF INSTALLATIO j
PLUMBER ON JOB: ~i
LICENSE NUMBER: 3dc®I
INSPECTOR:
3/93:jt
~t ~/~rr ~x ,~Q 216TH AV
~cb~,~'rlrtrrt rtEft3s~tt~ 15-31-19
Labor and Human Relations rl'^1VYGC , i,TtVI County:
INSPECTION REPORT ST_ CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION
193442
Permit Holder's Name: ❑ City ❑ Village ❑xTown of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9300099
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 4420 cov Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet
Air I
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
Forcemain Length Dia. Fi 7 Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O 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: SOMERSET 15.31.19.881, SE,NW, LOT 4, 216TH AVE.
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:
r
DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
~v
• STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ , .2/y
8% x 11 inches in size. c k f rev.ion to pfeeviou 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 VW1/a,S i5- T 3N,R / fajW)
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
T,# .SUE - 4y, 1 &h
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
Q IVORT/fE/! .S
II. TYPE OF BUILDING: Check one NEAREST ROAD
( ) ❑ State Owned CITY VILLAGE : A*
jQWN QE:
❑ Public 1 or 2 Fam. Dwelling-# of bedrooms PA
RCEL TAX NU
III. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo ~
2 El Assembly Hall 6 1:1 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 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. ~ 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 N 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). ~~V TION
C?' Feet Feet
VII. TANK CAPACITY Site
in allons Total of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New xistin Gallons Tanks Concrete gtructed glass App.
Tanks Tanks
Septic Tank or Holdin Tank ' F1 F1 F1 1 7
Lift Pump Tank/Si hon Chamber
Vill. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumb s ignature: (No Stamps) MP PRSW N Business Phone Number:
J:ZD S~ %
)!5 W
"
Plumber's Address (Street, City, State, Zip Coder
n yze;rzo r`
IX. COUNTY/DEPART ENT USE ONLY
❑ Disapproved Sa itary Permit Fee (Includes Groundwater Date Issued Issuing ent sign e (No m
00 Surcharge Fee)
*Approved ❑ Owner Given Initial zg~ t -
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*senitarKTermit is valid for two (2) years. ~
2: YoLr'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. Onsife 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.
IL 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 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.
~.,..ti' ~ ' , i y' ^x,; ^"zi"p ~ 4 , 4
SBD-6398 (R.11M)
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), then Ia 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 144)
011
Location of• property 5e-1/4 nk)1/4, Section 5
, T-RAW
Township ~o ~Prs •e. l
Mailing address 2~ Z Az
~o vt~►_~~~ eT wz .
Address of site , p S A~'1
subdivision name /vOrAelln nA•K5 Sk4ar c Lot no.
Other homes on property? - yes No
Previous owner of property gg~m Ee4r- R Faub e,, r'
Total size of parcel a • S acr{s
Date parcel -was created '7
Are all corners and lot lines identifiable?_Yes No
Is this property being developed for (spec house)? Yes „ f No
Volume..and.Page Number o27~ 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. 569 , 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. .
si ature of applicant Co-applicant
1 .
Date of Signature Date of Signature
MA`r' Eb '93 07:45HM HEM FALLER P. 3/3
I ^PAZE RESERVED P45R 1kCG6RD174Ir 6ATA
"'rlocuNErvT NO. ! WARRANTY pF-ED
STATE BAR OF WISCONSIN FORM 2 198211
4935 I
v .,9$$Par,E'71
- - . - _ REGIST7K
E I
Peter P. Taubenber5er. ST.C..............................
Rec'1
- i~ ~ TJA~N I
-
10:~
,:olxe_s innd warrants to Plea D. A`1 do an. Jennifer Itirur---------
- -
ii
-
1:,
the f~!'I qq
.7'Nill[; 4e5C1]}Jed real estate 111 . ^fa. _._._COUIIty - I'
Tax Parcel No:.-•---••----------------------
Lot 4, Norts eij-i Oaks Estates it the 70wr_ O
Somerset, S-,. Croix County, Wisconsin.
Ij
H
I~
I
FED t
I
:
I.
I~
Tt:s is no
homestead property.
(is) (is- not)
E'Xception to Nvarrartc-s: e•aSements rest ictfons anCi .-fights-Cat'-way of
record, if any.
r_1_,ted t:i llst - - _
- day of
I
r-,-.J./~ (SEAL) SEAL)
(SEAL) ..........(SEAL.)
r
_
AUTHENTICATION ACXNOWLEDGMENT ~I
' P 'aubenber,er__-_- STATE OF WP-,C0NTS1Y-
I
* Count-.
asthe ;tica;ed this ....of... fA ° -------mber._., 19- Personal rrllxxe hefc a me iris day of
1 Ir -t he above named
-
- - . -
~I. ~ f
iY Y ~ P_.a gj oT 1 .a r' d
1 T L
TITLE:'_rIRM-8ER STATE BAR OF WISCONSIN
(If not, Vv t
authorized § ;06A~, Wis. Stats.) to me known to be.the person . v~~gLt.ed the
l f e.a mg ins n1,21 d acIA hj~b Mfft- .
Ij -111-9 IN5TRUMEN- WAS DRAFYEO DY t~
_-iLad p--------------
- Atcn,,a a
Totarti Public County, wis.
(Signatures may be authenticated or aekn•,x ledged. Both My Colilnlisziol, i_ 1) Zdiient. (If o', state expiration
are not neeea3srv-j 1 1 )
dote: - 19
''--'N.aan of Demona eigninP in",, . -a .nY caPa... - -
citl ..,.nsld be tl'pGd nT Uxir tr,~ b al~ tl
_ II
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
ADDRESS S23 2 J 6"K A V E FIRE NUMBER 5 a 3
CITY/STATE _<mineoS er WL -ZIP-
PROP ERTY LOCATION: SECTION T_2[_N-R r9 w
TOWN OF ~OYVI~ , St. Croix County,
SUBDIVISION/OMkv~n Q~41S ~57~fl"rs , 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 expiration date.
SIGNED:__
DATE: leg, `
St. Croix co. Zoning office
911 4th St.
Hudson, WI 54016
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND P.O. BOX 7969
PERCOLATION TESTS (115) MADISON WI 53707
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNSHIP/MV WLITY: LOTNO.:BLK. 0.: SUBDIVISION NAME:
SE ~4 1VW 1/4 15 /T31 N/R 19Ltor) W Somerset 4 In /a Red Oaks
COUNTY: ONOWIM BUYER'S NAME: MAILING ADDRESS:
St. Croix Jennifer Kruger 745 Parkside Dr., Vadnais Hgts., MN. 55127
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DES RI: PERCOLATION TESTS
Residence 3 n/a New ❑Replace 18-29-92 n/a
I)a :
RATING: S= Site suitable for system U= Site unsuitable for system
ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLEI ING TANK: RECOMMENDED SYSTEM: (optional)
gS ❑U S E] ®S ❑U
C S DU ❑ S EJU conventional
DESIGN RATE:
If Percolation Tests are NOT required If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: class 2 Floodplain, indicate Floodplain elevation: n/a
PROFILE DESCRIPTIONS page 10 PMD
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST- TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
102.64 0-8, 10yr4/2, L.;8-32, 10yr4/3, sl.; 32-45,-
0- 1 90 none >90 10yr5/4, sil.; 45-90, 10yr4/6, S.
102.64 0-10, 10yr4/2,s1.; 10-31, 10yr4/3, sl.;-
g_ 2 89 none >90 31-89 1 4 6 S.
101.44 0-6. 10yr4/2, L.; 6-24, 10yr4/3, sl.; 24-44,-
g_ 3 96 none >96 1 5/4, sil.• 44-96 1 4/6 S.
0-8, 10yr4/2, sl.; 8-29, 10yr4/3, sl.;-
g_ 4 84 100.44 none >84 29-84 1 r4/6 S.
0-12, 10yr4/2, sl.; 12-40, 10yr4/3, sl.;-
B- 5 84 100.24 none >84 40-84 1 4 6 S.
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH
P-
P-s~e design rat
P-
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope. 97.94 for area #1
SYSTEM ELEVATION 96.94 for area #2
3
I
&41 6-d
= 1'14;1 1
rri
.~i_....
:rn
1 -i._ =
E
I
Js
3
3
3
,
.
1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON:
Gary L. Steel 8-29-92
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
554 200th. Ave./ New Richmond WI. 54017 2298 1715/1-246-6200
CST SIGN E:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
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