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CROIX COUNTY WISCONSIN ZONING OFFICE o x x x n x r n■ _ ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 July 14, 1994 Ms. Ruth Harleen 21955 County road C Somerset, Wisconsin 54025 RE: Septic Inspection for Ruth Harleen Dear Ms. Harleen: An inspection of the septic system for your property was conducted on May 8, 1990. This property is located in the SE', of the NE; of Section 30, T31N-R18W, Town of Star Prairie, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a three (3) bedroom home. If you have any questions with regard to the above, please do not hesitate in contacting our office. 'Sincerely, es . Thompson Assistant Zoning Administrator mz i L 1rON9artS 4hRiM IE 34.31.0AVWer?.%E~►i j§E1§Ir#tM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) Sanitar mni GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State P X I Elev.: Descriptio Parcel Tax No.: I BM 1 038 1:121 Be TANK INFORMATION ELEVATION DATA A9300199 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Verit irIto ntake ROAD Dt Inlet TANK TO P/ L WELL BLDG. A Air 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 oss mead 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 CHAMBER INFORMATION Type O 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 30.31.18.502E (CTY RD C) 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: SANITARY PERMIT APPLICATION 7DIL0ILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY ~p r ~ STATE SANITARY PE MIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 1 ?3svs 8% x 11 inches in size. E] 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. PROPERTY OW PRRQPERTY LOCATION 001 /Z- '/a, S C7 T , N, R E (o PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE r ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER eG(~ / ~Ea1 / L:I II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD El State Owned VILLAGE ❑ Public 5,,1-or 2 Fam. Dwelling of bedrooms 3 PARCEL TAX UM 111. BUILDING USE: (If building type is public, check all that apply) lb 3 a m 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) 1.0 New 2.E] Replacement 3.E1 Replacement of 4.JR Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # ~,4fg OO A3` Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurizep Distribution Pressurized Distribution Experimental Other ~Xr 5f~' 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: X~ ' S r 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATEPERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (s q. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 1015' 401112-17f .c dy d 5 Feet l0/. 49' Feet CAPACITY VII. TANK Site INFORMATION in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. New lExisting Gallons Tanks Concrete structed glass App. Tanks Tanks I -1 1 F] 71 Septic Tank or Holding Tank G G X_ 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. Plumber's Name (Print): Plumber's Signature: (No Stamps n MP/MPRSW No.: Business Phone Number: l'1 t n i~ ?10 ce, lu is Address (Street, City, State, Zip Code): 14 G ` ndy ~c mac" ' S co IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Sign Approved ❑ Owner Given Initial ! Surcharge Fee) Adverse Determinationi (e 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 (late, and at the time of renewal any new criteria in the Wlsuoc sin Administrative Code will be appiicabie. 3. All revisions to 't ;rc permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Forrn (SBD 6399) tp,be submitted to ,I:e :aunty prior to installation. 5. --Ot;s,le sewlge . s . ' -rns must be-properiy maintained. Y?:: _.,~?ptic tanks) 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 admInistra.tor or the State of Wisconsin, Safety & Buildings Division, 6(18-266-3815. 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 numbers) of where the system is to be installed. ll. Type of building being served. Check only one and comfiiete 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 sys!ern. Check appropriate box depending on system type. Vt. Absorat _ tern information. Pr^•vid- all information r,-,~3'sted in ##1..7 Vli. Tank d? Fill in the capacity 4f ,/~r,r new and/cr t ;e total r? ,1 r....n-,&er of tanks vfil: .bOWijcturer's narne r idii-aie, prefab or .3ite i:_'. x' ui:'ed a''.' ;ai)i ,iiateila! l ti for all septic, (r,,;,:-.1/siphon and holding c. this system C:t;f> proval on y : Tanks received expo induct approval frcrr. i-H, Vill Pespors-.ibmiy statement. installing piurntt,-r is to fill in na Re, license ~r, rit~R with appropri:+.ie prefix (e.g. IMP, etc', FYdAress and phone number. Plumber must si,r, r.pplicatio^ tc~ li*i. IX. Countyi'Depart:-lent Use Only. X ounty,/Depwtrnent Use Only. Cc.i~~h'ete pla specif ±,sor i-! _ naller than 8'/, uhes rr.: - ~ul n ittoc 'o f'-'corarity. The r., ;sf inciudc fo!0. Wii g u;an, draw-, t,: Vith _ Yler n: of flCl?s{i ; 6((S), seg4t''''-nk(s) or ?er fP"(?atme..t !a`.' Wale' rflrl;ri~ N~,.ter service; Stream- --d iaKeS !~INFlr) or siph~_wi Xank.S; distrlbUti<o o ,ystern s. ra(l:• rI-iert system arezv! ^ 'he locati.:1 of the ng served, B) horizc.-- 1'_, C(rt,c",. 0f on refere C) complete specifications for pur;.ps and controls; Jose aievat;oi, dMerences; fruvon loss; pump performance curve; pump model and pump manufacturer; D) dross section (.it the soil absolption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. - - - - - - - - - - - - - - - - - - GROUNDWATER SURCHARGE: 1983 Wiscc^sin Act 4'G included the creation of surcharges (fco s', I- a number of regulated pract:c:e~, ,n cn can effect groijnd,,V+D.tnr. i i The n;c)vies t oilectec , lough these surcharges are used for monitoring elrotindwater, ground. water t o ,$an,ination inves~igations and establishment of standards. - - - - SBD-6398 (R.11/88) STC-loo This application form is to be completed in full and the oc~ner(s) of the property being developed. An signed es will only result in delays of the permit issuance. iShou ldathis development be intended for resale by owner/contractor,(spec mouse), then a 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 f Location of property 1 /4 ,/L-1/4, Section U T_.Z/N-R/W Township fd~ Mailing address Address of site Subdivision name Lot no. 2 Other homes on property? yes,V_No Previous owner of property C v° C v' Bh Total size of parcel Date parcel was created 122 < S 2` 111-797 Are all corners and lot lines identifiable? -Z-Yes No Is this property being developed for (spec house)?__Yes ,!C-No Volume2,7.7 and Page Number of Deeds. as recorded. with the Register INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WAIZitA ITY DEED which includes a DOCUMENT NURDER, VOLUME AND PAGE HURB R & THE SEAL of THE REGISTER OF DEEDS. certified survey, if available', ;would be helpful so asdto oavoid 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 1(we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am of the property described in this information form by e virtue (s) of a warranty deed recorded in the office of the Count Register as Document Ito. 4- SI-A9~ 1 and that z of own the ► (we) presently proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described , for the construction of said system, and the same hpasroperty been duly recorded ~lie office of County Register of deeds as Document No. Signature of ap¢licant Co-appl cant r Date o 93 Signature . Date of signature i f ' I~ DOCUMENT NO. S E BAR. OF WISCONSIN FORM 1-1981 THIS SPACE RESERVED FOR RECORDING DATA a 2 WARRANTY DEED 499 _ .VOL ! PArE 3-19 1 =!I REGISTERS OFFICE This Deed, made between _Robert T. Severson and ii ST. CROtX Co., WtS, Mar J. Severson individual; ll --and as trustees Recd. for Record this 5th y - ' of the Robert and Mar Severson Family Trust Grantor, Q and..Geor--------------------------------------------- anMclue, a single.. person and 10:15 A Ruth Anne biarleen a sin le-- erson, g P as oint tenants - Grantee, ii Witnesseth, That the said Grantor, for a valuable consideration---_-- r conveys to Grantee the following described real estate in ___-St._ CrOlX-_•. RETURN To County, State of Wisconsin: Part of SE; of NE4 of Section 30-31-18 Tax Parcel No: described as follows: Lot 2 of Certified Survey Map filed May 22, 1978, in Vol. "2", Page 596. EM This - homestead] rope-`.. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And that the title is good, indefeasible in fee simple and free and clear of encumbrances except and will warrant and defend the same. Dated this - day of -----M. 19 8 S on.- 7 - EAL) (SEAL) Robert T. Severson, * Mary IS everson, iriclivi dually and as trustee -ifl-d Vidua7:ly"arid a"s trizs'tee 4f___tkie__-Robex_t_-_and__Mazy_--_---__"(SEAL) of___the- Robert ..and. an_ d Mary---_-----(SEAL) - - - Severson Family Trust Severson Family Trust ACKNOWLEDGMENT Signature (s) ...N/..ti-------------------------------------------------- STATE OF WISCONSIN ss. St. Croix County. authenticated this ........day of..... Nf A 19 Personally came before me this day of 19-U. the above named Robert . Serson and rY. J. Severson- TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized b I .,-,-----•---5----------------------•-------- y § 706.06, Wis. Stats.) tom oZe. th~ son who executed the fo Acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY , DOAR DRILL & SKOW S C P. 0. BOX 69 . . : --NEW---ICI-P'0ND-r---KT---• 5$41- ---0b~•----..-- of _ y Publ ' x •'C O County, Wis. (Signatures may be authenticated or acknowledged. Both y Commission is permanent. (If not state expiration are not necessary.) ' p~ date : _ *Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc. 1 oocUMEtv7 NO. STATE BAR OF WISCONSIN FOAM 3-1982 THIS SPACE RESERVED FOR RECORDING DATA QUIT CLAIM DEED Geor9ann McClure a single person Quit-claims to _uth..Anne Harleen, 4_- kngle__person.................... the following described real estate in ....St CrO 1 X.......................... State of Wisconsin: County, RETURN TO I Part of SE 1/4 of NE 1/4 of Section 30-31-18 I i described as follows: Lot 2 of Certified Survey Map f i 1 ed May 22, 1978 i n Volume T Parcel No: "2," Page 596. ' i This is not homestead property. Q(~0 (is note Dated this day of .....--May , 19.90.... --.......(SEAL) (SEAL) Geor ann.- MCCl ure..... (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature (s) STATE OF WLSSA-N,%N f~l7inr /~p~ GCS ss. authenticated this ........day of ..........................119 / . .....County. Personally came before me this . day of - "elo- 19/J/~ _:ZL/.._ the above named TITLE: MEMBER STATE BAR OF WISCONSIN 2PQanG1-•_. _ (If not authorized b y ~ ~os.os, wig. stets.) to me known to be the person who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY may be authenticated or acknowledged. Both MStaCommblson is , • County, are not necessary.) Permanent. (If not, state expirat' n date $REi~1DA"A:-JOHNSOW ,1990 NOTARY PU3LIC MINNESOTA! QUIT CLAIM DEFn My commission exoirns d.19_0d SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ADDRESS: At-5 15- FIRE NO: LOCATION: - ~C 1/4 1/4, SEG./A_T j _N-R_,e- TOWN OF: Sf f, y L ST. • CROIX COUNTY__X- SUBDIVISION: LOT NO. 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 to help with the cost of the 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 the St. Croix County Zoning a certification form, signed by the owner and by a master 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. Certification from will be sent approximately 30 days prior to three year expiration. 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 form must be completed and returned to the St. Croix county Zoning officer within 30 days of the three year expiration date. ell, SIGNED: I. DATE: 8/l/9 3 St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 . PLU PLAN qq, 'PROJECT 9t&M 17W-e e17 ADDRESS o%',(6. .Soyjt r e, > e~5' `1/4 1r,1, 1/4/Sa /T j?/N/R 1V11 TOWN COUNTY MPRS Byron Bird Jr. 3318 DATE -:6--5 BEDROOM CLASS PERC CONVENTIONAL_ IN-GR0- PRESSURE CONVENTIONAL LIFT MOUND_ HOLDING TANK 00~ Cs~-n c e ~x~ S f~ `t SEPTIC TANK SIZE /oapD~.~l LIFT TANK SIZE -ewe DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA PERC RATE Z- 3 BED SIZE 1.2 X s~3 Benchmark V.R.P. Assume Elevation 100' Location of Benchmark 7o Q ' t * H. R. P. - ob - 0 Borehole Q Well Scale = Feet 0 Perc Hole System Elevation oz, t. \N U Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ' TOWNSHIP ,0 SEC.,O T~N-R W ADDRESS ST. CROIX COUNTY, WISCONSIN Co~cr/~~~c oue ~avcl~✓u`'L ~/7. ~S SUBDIVISION LOT F" LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I1HR 83 ~ CSC SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM , ? C> o 111~~~ ~ x f I o I f /Hrltr I U cv.t i i M INDIC TE NORTH ARROW BENCHMARK: Describe the vertical reference point used / 0 Elevation of vertical reference point: 'd Proposed slope at site: 26 SEPTIC TANK: Manufacturer: _Z~ e /T Liquid Capacity: Number of rings used: Tank manhole cover elevation: 10 Tank Inlet Elevation: OZ. 02 Tank Outlet Elevation: Number of feet from nearest Road: Front 10 Side,O Rear, Ts feet From nearest-property line Front 10 Side,0 Rear, _ feet Number of feet from: well , building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) 'L _ _ SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: " ' Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturers Alarm Switch Type: 'Number of feet from nearest property line: Front, O Side, O Rear, © Ft. Plumber of feet from well: Number of feet from building:_ , (include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: lam- Lenith: Number of Lines: Area Built:6°2 Fill depth to top of pipe: 14 , Number of feet from nearest property line: Front, fO Side, O Rear, Pt .41:) Number of feet from well: Number of feet from building: / (Include distances on plot plan). / SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil sbsorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector / 'J Plumber on job: Dated: License Number: 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O-. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION ADISON, WI 53707 State Plan I.D. Number: SE NE 4 f Sec . 30 , T31-R18 CONVENTIONAL El ALTERATIVE (It assigned) Town of Star Prairi Lot C Holding Tank ❑ In-Ground Pressure ❑ Mound 00921 - NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Ruth Harleen 6089A Courtley Alcove, Woodbury, H1 - BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELE CST REF. PT. E s AZ-6, •d' Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Byron Bird Jr. 3318 St. Croix 135446 SEPTIC TANK/ TANVko4s2"hWe G, MANUFACTURER: LIQUID CAPACITY: NK INLET ELEV.: TANK OUTL EV.: WARNING LABEL LOCKING COVER ~1 PROVIDED: PROVIDED: S / O / v , YES ED N0E~0 BEDDING: VENT DIA.: VENT MATL.: HIGH WATE NUMBER OF ROAD: PROPERTY WEL BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: >a5 d. ❑YES NO -B yes-N NEAREST-~ 95 DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVDED: ❑ YES E] NO El YES' 0 NO ❑ YES ❑ NO GALLONS PER CYCLE: MP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF PU ❑ YES ❑ NO NEAREST 100- SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID BED/TRENCH TRENCHES: MA ERIAL: PIT DEPTH: DIMENSIONS Sd GRAVEL DEPTH FILL DEPTH DISTR'[ PIPE DISTR. PIPE DISTR. PIPE ATERIAL:.. N DISTR. NUMBER OF PROPERTY WELL: UILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. NLET: ELEV. END: cl e01, (J✓ PIPES' FEET FROM LINE: AIR INLET: r a $ Arm 02 -7 P11 -P NEAREST YC/ w1 MOUND SYSTEM Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST e in in county file for audit. Sketch System on Reverse Side. SIGNAT E: JTITLE: SBD-6710 (R. 06/88)-~ ::DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 'Z1'6 8% x 11 inches in size. Chec if revision to previous application 41 -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY O R & .9 PROPERTY LOCATION Y, ~/a,S T-571 ,N,R E(O , rl~ J~- /I-- - )1~ PROPERTY WNER'S AILINGZADDRESS OT # BLOCK i CITY, STAT ZIP CODE O E NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE 0115515I DING: (Check one) ❑ State Owned CITY ^ NEAREST ROAD VILLAGE t rlr~/ 0 G ❑ Public 1 or 2 Fam. Dwelling of bedrooms PARCEL A NUMBER(S) ©3E-_! _ ,A III. BUILDING USE: (If building type is public, check all that apply) I Dc) 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 120 Service Station/Car Wash 5 ❑ Hotel/Motel 90 Office/Factory 130 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 4.0 Reconnection of 5.E] Repair of an ystem 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./inch) eELEVATION b freet 0.7 Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App. Tanks Tanks structed Septic Tank or Holdin Tank AN+ /1~w I G `G Lift Pump Tank/Siphon Chamber VIII. RESPONSIBILITY STATEMENT 1, 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: ffkr n tw s~761 Plum Kr, Address (Street, City, State, Zip Code): d gfe~ IX. C UNTY/ EPART ENT USE ONLY Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Ias n Agent Signature (No Stamps) approved ❑ Owner Given initial Surcharge Fee) ~~v" Adverse Determination / X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11188) DISTRIBUTION: Original to County, One Copy To: Safety s 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: 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 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 (8.11/88) APPLICATION. FOR BAN17ARI PERMIT 8TC-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 Lot 11sals by ow+et/conttactot,(spec house), then a 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 e,4-h 1'{a-rte -e h 3~-~-R 18 w E i Location of property s _i/4 /4, Section 3 0 T.-- Township 56mer6e t Mailing address 9P~©~~r5ef, l.~ L Address of site subdivision name Lot number Previous owner of property Robe. rt -T. Sever-s o h Total else of parcel t a c r2 Date parcel was created Ate all cornets and lot lines identifiable? X an o Is this property being developed for resale (spec house)?__Yes =_NO Volume _and Page Number 591, as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWINGt A WARRANTY DRID which Includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the ORAL OT THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. it the deed description references to a Certified Survey Map, the Certified survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(We) cettify that all statements on this form are true to the best of my (out) knowledge, that I (we) am (ate) the ownet(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. '4:) !Fd 9 9 • ) and that I (We) presently own the proposed alto for the sewage disposal system (or I (we) have obtained an easement, to tun with the above -described property, lot the construction of sold system, and the same has been duly recorded in the office of t~ty R gistec of Deeds, as Document No. 1• Signature of Owner Signature of Co-Owner (If Applicable) 3/~&'/g p Date of 819natuts Date of Signature I` DOCUMENT NO. S' 'E BAR. OF WISCONSIN FORM 1-198; THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 425299 'y Ot FAQ. 1, _ REGSTERS OFFICE ST. CROIX CO., WISE This Deed, made between -Robert T. Severson and Mary. J. _Severson., .individually. and_•as trustees. Recd. for Record this 5th of the Robert and Marx Severson Family__Trusty Of`_A•D• 19j7 Grantor, 4 10:15 A, AL and__Georgann McClure, a single person,.-_anc ..Ruth...Anne.-~arleen,_. a _ single person~ -r22ili as 3oint tenants nsww Grantee, Witnesseth, That the said Grantor, for a valuable consideration...... RETURN TO conveys to Grantee the following described real estate in ....St.___ County, State of Wisconsin: Part of SE4 of NE4 of Section 30-31-18 Tax Parcel No: described as follows: Lot 2 of Certified Survey Map filed May 22, 1978, in Vol. "2", Page 596. $ •o° EM This homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And........... warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except and will warrant and defend the same. Dated this --x}--•-----------•-----•- day of 1987. (SEAL) EAL) iseverson, Robert T. Severson, Maryy * " "iri3ivi dually arid' a's'" trustee irid xid*X1aTIy'"-and---aa... triig-tee t..the..JRobert.. and._Mary..._......(SEAL) .....of the.•Robert--and:_Mary......... (sEAL) Severson Family Trust Severson Family Trust * * AUTHENTICATION ACKNOWLEDGMENT A Signature(s) Nf STATE OF WISCONSIN Nf A------......---.........-----•--•--....... ss. S 9ro iX County. authenticated this day of..... N/A 19...... Personally came before me this day of 19-.A7- the above named Robert T. Severson and Mary-J. Severson TITLE: MEMBER STATE BAR OF WISCONSIN „•~~u,,,,,•~, (If not, ----••......:''.2.--•---•--•-••-:...•-•--......--•••------•--••-•-•-•-•••-••-. authorized by § 706.06, Wis. State.) a~ to m ••V••e• S v6 t1M * on who executed the fo . powledge the same. • THIS INSTRUMENT WAS DRAFTED BY J ; DOAR~ DRILL 6 9 & SKOW~ P. O. S.C. - ~ P BOX - - - UEL RIONPI(D,L 540-7-r.-069 of y Publ' OiX ..................County, Wis. (Signatures may be authenticated or acknowledged. Both y Commission is permanent. (if not, state expiration are not necessary.) date: ,t~*=---. , 19~1~.) ~ -Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc S T C - 105 w SEPTIC TANK MAINTENANCE AGREEMENT n St. Croix County OWNER/ BUYER P"+ k N a r e o ROUTE/BOX NUMBER ' &L) 8°1 A Cou r+1 A 1 co v P Fire Number : V CITY/ STATE rx, ~D tti ru ZIP .SS") ;t S rr PROPERTY LOCATION:.'SC NE k, Section 30 , T 31 N, R 18 W, Town of Somer5e ~7 St. Croix County, Subdivision Lot number Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Prover maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed 'se tic tank pumper. What you put into the system can affect the .unction o t e septic tank as a treat- ment stage in the waste disposal system. St. Croix County residents may be eligible to recieve a grant for a maximum of 60% of the cost of replacement of a failing system, whIET 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 County Zoning a certification form, signed by the owner and 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. w" lw~ - 6 mu. 14; g mz g J, - i 8 Im O 1 I t t ~ % a I 1 mm C', COS ~ Sk ~ t _ t I Z v tit B a 8 r -1 0 .4 m m f m AL : 6-4 ..,:ate PLU_F PLAN -KOJECT afx r~-c2~rLADDRESS L Gtr c ~Go~e d`~ 114fYe 1141,S vR N/R IV TOWN H cr OUNTY M.PRS Byron Bird Jr. 3318 DATE BEDROOM? CLASS PERC_ CONVENTIONAL, IN-GROUND P SSURE I~f CONVENT NAL LIFT MOUND_ HOLD NG TANK SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING K SIZE ABSORPTION AREA PER C RATE .~iBED SIZE Benchmark V.R.P Assume Elevation 100 Location of Benchmark * H.R.P.' D Borehole Q Well Scale Feet 0 Perc Hole System Elevation !5FZ_ ,7 Uent 12" Grade I I TYPAR COVERING t 2" 12" 3' 4 6' O 3' Sewer Rock w 6 1.2' I I i /t 4/11 fro / I ~c~ r