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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS
l °1 S o 10 Li
SUBDIVISION / CSMI_X' l/' t r sf LOT
SECTION_,,~?C T N-R /~W, Town of
ST. CROIX COUNTY, ICOS N
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
3
10
1r
J-•
10
1fi
D INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
s
BENCHMARK' n //0~1 nsdc~ •~y
ALTERNATE BM'
SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION
Manufacturer: h,e e Liquid Capacity: 0_Z>_
Setback from: Well e House Other le,- 7L.
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
;SOIL ABSORPTION SYSTEM
Width: fob ( Length _f Number of trenches
Distance & Direction to nearest prop. line: /o
Setback from: well: O //ouse G/~ Other
ELEVATIONS
Building Sewer j • ST Inlet. ST outlet - v v
PC inlet PC bottom Pump Off
Header/Manifold Ile yv~ Bottom of system
Existing Grade Final grade
0 or
DATE OF INSTALLATION: / Qq
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
L9AaMWl;art T" IR tIE 28.31.A&V j SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT
Safety and R;iildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar rTnit
Permit Holder's Name: ❑ City ❑ Village R Town of: State PI o..
ev.: Insp. BM Elev.: Description: X Parcel Tax No.:
BM 0-28-3369-60-000
TANK INFORMATION ELEVATION DATA A9300253
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic (n f Benchmark
Dosing
Aeration Bldg. Sewer 7 y
Holding St/Ht Inlet !/Z,
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/1 WELL BLDG. AirI to ntake ROAD Dt Inlet
irl
Septic NA Dt Bottom
Dosing NA Header/Man.
Aeration NA Dist. Pipe
Holding Bot. System 7 7
PUMP/ SIPHON INFORMATION Final Grade Ael
Manufacturer Demand 2
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length Dia. 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 Of CHAMBER Moe 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: STAR PRARIE 28.31.18.816
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:
_ m m
SANITARY PERMIT APPLICATION
DILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY &)-o
STESJIT CeRPEIT#
tjM-Attach complete plans (to the county copy only) for the system, on paper not less than fi/J /fYj_fP
8'fi x 11 inches in size. ef en to revious 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 'a, S T , N, R E (or
PROPERTY OWNER'S (LING ADDA 4S LOT # BLOCK #
on 1252 V,
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION "E OR M NUMBER
. TYPE OF BUILDING: Check one CITY , NEAREST ROAD
11 ( ) ❑ State Owned VILLAGE f
❑ Public1 or 2 Fam. Dwelling-# of bedrooms A RGEL TAX u
111. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo
2 ❑ Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 80 Mobile Home Park 1120 Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPF OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. New 2. El Replacement 3. El Replacement of 4.0 Reconnection of 5.0 Repair of an
S em System Tank Only Exist'n ystem sting System
03 Iq a (Z a, 4 - y
(,oToZ~
B) A Sanitary Permit was previously issued. Permit #
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. (Gals/day/sq. ft.) (Min./inch) ELEVATION
Feet D Feet
VII. TANK CAP CITY Prefab. Site
in allons Total # of Manufacturer's Name Con- Steel Fiber- Plastic Exper.
INFORMATION New istin Gallons Tanks Concrete structed glass App'
Tanks Tanks
Septic Tank or Holdin Tank l Q
Lift Pump Tank/Si hon Chamber I F] El
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber' Name (Print): Plumber' pS)pnature: (No Stamps) MP/MPRSW No.: Business Phone Number:
w
Plum is Address (Street, City, State, Zip Code):
d cV
IX. COUNTY/DEPARTMENT USE ONLY
Disapproved S Itary Permit Fee (include g roue Wet Date ssue Issuing A ent big No S mps
Approved E] Owner Given Initial
Adverse Determination
60 I
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
i
SBD-8398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
i
l
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 renew-di 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 (SF) 6399) to be
submitted to "he r.ounty prior to installation.
5. Gnsite sewage .ysferns-must be properly maintained. The - .:c tank(s) must be-purnped 1 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 appligation must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax nomber(s) of
where the system is to be installed.
II. Type of building being served. Check only one and complete of bedrooms i` 1 or 2 ~:amiiy 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 tark replacE:rrrent, reconnection, or
repair.
V. Type of system. Chec~: appropriate box depending on system type.
VI. Absorption syrs?o!?~ ;rformation. Provide T11 information reques-t-4 f11-7
VII. Tank InfUr~ ,wl, ri- n the capacity o+ , .-ry r,ew and/or exit k st ii-_- t,)'.A ' ~ .!l ber of
tanks and d =c" t'S name. Indlcwi-, pt ,'ab or site uonsje;,tit.kii eanr tank ma!erial, i for all
seP pl _ane holding tanks c. .;,is system. Checrc r ~irr er;t.3l :ipprovai c-. ks -eceived
exper , 'Ja; product apprhval;from DILL q.
VIII. Responsibility statement. installing plurr~-° is to fill in nave wer,se number with a^nrop,i ae ;prefix (e.g.
MP, etc.). address and phone number. Plu;nber must sign app (.i,p.;on form.
IX. County/Department Use Only.
County/Department Use Only -
X.
Complete 7°ans and specifications not s_^.,Nenr than 8% 11 incl ~ lust be subn, t}r,_: It, The
plans moss the food whng: A) ric. n drawn to sc=ale; co"i ^ca";Cn of
holding septir. tank(s) or other trF -trnent tarks; buiidi+ ; •-s: yve 5; w «<<°er service;
r.Yrs ..-.~.es rrr. .distribution n t iX ..rr l.~i~ ~ -,,,.n t r'r~.
stream_ ; pup or siphon tar-k-, ~ es; r ~a, ~ nt ~ system
.areas, cl Focatlon of the bur (`r,.,(j ;:1erved; B) r?c, izonta! c' ~ ICo ek" oi'
C) complete specifications for pumps sand controls; ;lose volume, c levat:on driference$; '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 pct 413 included the Creatiom °J .surcharges (fees` 4),, i number of
regulated practices h;ch can effect groundwater.
she nionies c: te:i through these'sorcharges mon;torijr cr;;.< ~dl..;ate gr::ur -
water eontaminatiw, irives`igc!i, rns and estabiishr . ci' w,Tandards. -
SBD-6398 (R.11/88)
Plot Plan
Project Name Byron Bird Jr.
System Elevation CST# 3479
L Benchmark
H.R.P.
C7 Boring Q Well
1
,t
v
1
. V
i ~fl
Y
1
PROJECT ADDRESS
1 /4~/'1 /4/S i`r~7/ NIR/l V TOWN C0 NjY X
MPRS Byron Bird Jr. 3318 DATE
BEDROOM CLASS PERC1:7--CONVENTIONAL IN-GRO RESSURE
CONVENTIONAL LIFT_ Mom HOLDI G TANK
SEPTIC TANK SIZE LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK S~E
ABSORPTION AREA PERC RATE,/ BED SIZE -
► Benchmark V.R.P. Assume Elevation 100'
Location of Benchmark /e",40 -
* H. R. P. --,err z - G o e77.e ^ ± ~e e~`~_
1:1 Borehole Q Well Scale Feet
O Perc Hole System Elevation
Uent
12"
Grndp
TYPAR COVERING
2"
12" 3' 4 g' O 3'
I' Sewer Rock
6' 1.2'
l ~
414
1-7
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 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 - G v`D
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL .D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
CtI„~ - GOVT. LOT 1I4V4J 1/4,Sa2fT N,R lt- E (o®
PROPERT to"+l_ING ADDRESS ]]L;OT# BLOCK# SUBB MORCSM# CITY STATE ZIP CODE PHONE NUMBEn Ty ❑VILLAGE OOWN NEAREST ROAD
a i ri "4 A T-
[ New Construction Use [ Residential / Number of bedrooms 3 [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow ~{5 0 gpd Recommended design loading rate F 7 bed, gpd/ft2, 5, trench, gpd/ft
2
Absorption area required _ 63 bed, ft2 trench, ft2 Maximum design loading rate __j Z bed, gpd/ft2- 2(,trench, gpd/ft2
Recommended infiltration surface elevation(s) 1c - ft (as referred to site plan benchmark)
Additional design / site considerations c~ yS -
Parent material Flood plain elevation, if applicable e&z ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem S ❑ U 5k S ❑ U ❑ U 'Ea!S ❑ U ❑ S U ❑ S RU
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 Trench
t f : t G GJ "
yy4
,xe<,{{{}}}{{{...ytyyy,.~`<.. a o - , a ~ f~ d~'~-c_ ~ m r t✓ .
Ground 3 X"t~ e7 0,77 _5
elev.
Depth to
limiting
factor
l~
Remarks:
Boring #
Qr 5,0
4_t
fi ' 'v2 C
G y
o5lw-lb' or A9
Ground
elev.
AD-Z--et.
Depth to
limiting
factor
5-
. ;:z Remarks:
CST Name:-Please Phone:
Address: '
Signature: Date: CST Number:
PROPERTY OWNER SOIL DESCRIPTION REPORT Page _of
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounday Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trend
4/0
1111, rm,,311-11111-
gf-
Ground d- f
elev.
Depth to
limiting
CC}t~
. f Remarks:
Boring #
t
Ooo
/0 JI;-V
Axe
o Y y i
Ground
Depth to
limiting
actor
3- / Remarks:
Boring #
t- : {ryi\+iv
Ground
elev.
Depth to
limiting
factor
L
Remarks:
Boring #
Ground
elev.
ft.
i
Depth to
limiting
factor
Remarks:
SEPTIC TANK MAINTENANCE AGREEMENT w
St. Croix County
OWNER/BUYER
0
ROUTE/t'OX NUMBER Fire tiumber a
d
CITY/STATE ZIP S" a L -sue R
58~-JST- o
PROPERTY LOCATION:', Section Z TN, R4W1
Town of s>~ znf f/P_!GSt. Croix County,
~ Subdivision ?'P/ Lot number;
54i.
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes.' Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a l'ic'en's'ed' ''ept'ir.-tank pumper.. What you put into
the system can affect the, unction of the's-ep.tic tank as a treat-
ment stage in the waste disposal system.
St. Croix Count 71 residents'•m be eligible to recieve 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 'sys't'ems agree to keep their system properly
maintained.
The property owner agrees to. submit to St..tCroix County Zoning a
certification form, signed by the owner an by a mater plumber,
journeyman plumber, restricted plumber or. a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and .(2)-after inspection and pumping (if nec-
essary), the septic,-tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration.
H
I/WE, the undersigned have read the above requirements and agree o
.
to maintain the private sewage disposal system in accordance with
the standards set forth, herein, as..set by the Wisconsin Depart- :
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration.date.
SIGNED
DATE
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
APPLICATION FOR SANITARY PERMIT
8TC-100
This application form Is to be complatod in full and signed by the owner(s) of
the property being developed. Any lnadoquacles will only result In delays of
the parmlt Issuance. -Should this development be intended for resale by
owner/contractor,(spec house)$ thou a second form should be retalned and
completed when the property Is sold and submitted to this office with the
appropriate deed recording.
Owner of property A1/G 4-4- S 14-~-
Location of property _fLIM /`Z/C() 1/4, Section T ..~•R..V
Township
Malllnq address e
Address of alto
subdivision name
Lot number - Z
Previous owner of property
Total also of parcel
Data Parcal was created
Ate all corners and lot ilnss dentlflablet ~_Ye■ No
Is this property being developed for resale (spec house)?_.d_KY4x No
Volume /035 and Page Number /-Zg as recorded with the Register of Deeds.
rr----------r-r--rrr--------- -r-------w---w---------------------------------w--
INCLUDE WITH THIS APPLICATION THZ FOLLOVINCI
A VARRANTY DEED which Includes a DOCUMENT HUMSZR, VOLUM2 AND PAGZ HUMsZR, and
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 Hap, the Certified Survey
Map shall also be required.
PROPERTY OWNER CERTIFICATION
T(Va) certify that all statements on this form are true to the best of my (our)
knowledge] that I (we) am (ate) the owner(s) of the property described In
this information form, by virtue of a vatranty deed recorded in the office of
the County Register of Deeds as Document No. _Sn -5-71-4 I and that I (Ve)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been duly recorded In the office
of the County a star of De ds, as Document No. S d S 74
Signature of Own c signature of co-owner (If Applicable)
Date of signature Date of Signature
Loo _ 440
15 14 A II y^ 10
807 806 I $ 803 802 13 16
° S MD 805 1
I vs '
-
S(MD 4NW 4 \ I . 114 - NW !14 9
/ 23
C 815 8 4 / 801 $
rr=a, ~ 'G. ~ e t+, 4
I 25 0 8 6 soo Y:. SOLD
eo I 817 \
t N' 22 / 450' lab. is.
814
SOLD
19
20 811 21 ~ I
813 I
$ e SOLD
OLD I / 474 B
~ i l \
, 35 65
•I ri 355b2 3T225
' SOLD
Huai t
6 799 3
12
nP' Sta Prair;. 798 a 795
.S ME ET 1 ,
- . ' 4 /V114-$ 56604
r-1, L ST A Wt..
24
`
4 PRAIRIE 794
2 4.
~z>=
- New 797 so6.74
1
11{: Somerset y Rjchrnond ea 4 I 1 1
796 I 793
x )5 '.rf i L A L
50494 624.?4
IS6 34582 345.4 3232
C. S. M. VOL. I PAGE 1 15
a 1oR SOLD I-c SOLD m S6LbE
LO I LOT 2 1 I LOT 3 LOT .4
/91 ND
RF/MW teaml realty
1-..~.-. 103 Main St., Box 68
Somerset, Wisconsin 54025
Mks 708 Somerset Rd.
® New Richmond, Wisconsin 54017
each office Independently owned and operated
• o•E F= 1 b-9 THI_I 1 1 : 09 F _ a3
I
1- 1982 I TMIe SPAGN KlrOCRVG4 vaR RCCORDINO DATA
OOCuMEN7 NO. STATE EAR OF WISCONSIN FORM
WARRANTY DEED
505744 0L 10'35PAGE.128 l FL' S C; FICE
This Deed, made between Co., M
Rec Q for Record
Dan McCulloch a/k%a Danfel McCulloch a/ka Daniel,,,,,
C. McCulloch Grantor, S E P 2 0 1993
and Michael Hclxtman,.d~b/a .Haxtman ,Concatxvc4n ai 10 15 - A"
. Regsta►aFt x
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration......
RCTYRN TO
I:onvoys to Grantee the following described real ostate in CC017C............
County, State of Wisconsin:
Tax Parcel Nos e.3`~ /f... .0.....
Lot 24, Red Pine Estates in the Town of Star Prairie, St. Croix County,
wisconsin.
o
This is nOt... homestead property.
(is) (is not)
Together with all and sinMa-Dan-el the her ditatrlonts a d ppurtenancea thoreunto belonging;
And Dan McCulloch -McCul.,ocah
. ,
warrunts that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements, restrictions and rights-of-way of record, if any.
and will warrant and defend the same.
I) .g3.... i
ate<1 thin day September
of ........,.p......
(SEAS)
.""'baniel"C~ 1LIcCtiTTtitn. a/Tt/a'" (SEAS.)
Dan MCCulloch a/kL/ Da 'el M 110ch
.`'mac (SEAL)
.(SEAL)
*
AUTHSNTICATION ACENO'WLEDtGMENT
Signature (s) S'T'ATE OF WISCONSIN
ea.
I'
.............................County.
authenticated this day of 19...... F rsonall ame before me this /......day of
; " 19. the above named
.r r. . '
Eill.Il:.
TITLE: MEMBER STATE BAR OF WISCONSIN ~'.•~MYrt,n"~~
(If not x~ ~seK~v x a~:a..
authorized by 4 706,, Wis. State.)
to me know It 01 ha ea uted tho
foreSving instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
j Kristine Ogiand .'--r
Attorney a t aw*......
AT y Public ..........................................County, Wis,
. e xpiration
(Signatures may be authenticated or acknowledged, Both My Commission is pormano t. (it ...no..t.,_9.t&..to
are not nuce:ssary.) dates
~1~. 19..1..
.
I
. a
ST. CROIX COUNTY
00 WISCONSIN
---=ZONING OFFICE
1 r r r r r r■ ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
_ Hudson, WI 54016-7710
(715) 386-4680
Q
November 5 1993
To Whom it May Concern:
An inspection of the septic system for the Mike Hartman property,
known as Lot 24, Red Pine Estates, and located in the SE; of the
NW; of Section 28, T31N-R18W, Town of Star Prairie, was conducted
in October, 1993.
At the time of the inspection this septic system was found to be
code compliant for a three bedroom home.
Should you have any questions, please feel free to contact this
office.
Sincerely,
Thomas Nelson
Zoning Administrator
mij