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STC - 104
AS BUILT SANITARY SYSTEM REPORT
C t q
OWNER c w 5 S Pry
ADDRESS f 4 CIA ei
/V p I✓ , (G !IL s h 4/
SUBDIVISION / CSM# G" S`M AL JrG 7 LOT #
SECTION 31 T) I N-R 18 W, Town of S f~~ PraGrp
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
qp1=~J ~
Q w~
t 1/
a
Sp ~ ~ o0
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: Tr cc = 100 -60
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: W IC5cA Liquid Capacity: X TO
Setback from: Well House 'If- Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: f9 Length 5 4' Number of trenches- W
Distance & Direction to nearest prop. line: 3 ~-o s 1`
Setback from: well: j 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: 10 d" /.f S t t Q h 6 E P h
LICENSE NUMBER: 3 Z
INSPECTOR:
3/93 : jt
L0QAV Q&p,,S,TMf IPJ WIE 31.31. ~~I~EWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT
' *Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) sanitary ermit o.:
Permit Holder's Name: ❑ City ❑ Village L] Town of: State P an I o.:
ev.: Insp. E ev.: escription: ~i Parcel Tax No.:
1111d rld TANK INFORMATION ELEVATION DATA A9300260 7
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic l.Zi-Q / 2 Benchmark O, 60
Dosing ,10~
Aeration Bldg. Sewer s SS
Holding St/ Inlet g~ ~,Y ,
TANK SETBACK INFORMATION St/ Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom .11 7t
Dosing NA Header / Me+lo.--
Aeration NA Dist. Pipe 3 g
Holding Bot. System 7OS
PUMP / SIPHON INFORMATION Final Grade
Manufactunr a Demand 301
Model Number GPM
TDH Lift Lriction TDH t
Force Dia. Dist. To well
SOIL ABSORPTION SYSTEM
,BED/TRENCH Width Length ! No. Of Trenches PIT No. Of Pits inside Dia. Liquid Depth
DIMENSIONS /,f5 ~ DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION TypeO raw i Mode Number:
System: 1114 OR UNIT
DISTRIBUTION SYSTEM
Header Distribution Pipe(s) x H le Size x Hole Sp g Vent r Intake
Length Dia. 5` Length _5Z_ Dia. JL Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade tems Only
Depth Over ® ~P n Depth Over xx Depth Of xx Seeded /Sodded xx Mulched
Bed /Trench Center 3Q Bed/ Trench Edges j®- Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRARIE 31.31.1e.518B
Plan revision required? Yes ❑ No
Use other side for additional information. 07 2C2 74etia~-
\ SBD-6710(R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: s
i
I
I
"
f
SANITARY PERMIT APPLICATION
t~a~llnlln In accord with ILHR 83.05, Wis. Adm. Code COUNTY, ..~OI
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than /
8% x 11 inches in size. LJ c h / "eck if a ifprevious application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
P ERTY OWNER PROPERTY LOCATION
5E Y., YJ67%,S 3l T3(,N,R tr W
PROPER N 'S M ILING DR LOT BLOCK
CITY, STATE ZIP CODE PHONE NUMBER R CSM NUMBER
&41) Z47 1 -3 7-3.3 C'S, W./ p
~ft
II. TYPE OF BUILDING: (deck one CITY NEA S~ R AD
) State Owned 0 VILLAGE : ! d`` o t VE
ID TOWN OF:
❑ Public 1 or 2 Fam. Dwelling-# of bedrooms f P
ARCEL TAX NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply) 0 3 l ( 3- 7 r 719
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. TYPEQF 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. ❑ 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;Seepage essurized Distribution Pressurized Distribution Experimental Other
11 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
r DO REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
u f ~.Z. 7A ' 7 , X Feet 4 • 1Okeet
CAPACITY
VII. TANK Site
in allons Total # Manufacturer's Name Prefab. Con- Steel Fiber- Plastic App.
INFORMATION New istn Gallons Tank ks Concrete sructed Pr - glass Appp.
Septic Tank or Holdin Tank Ta s Taniks
~ q t a
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 MP/MPRSW No.: Business Phone Number.
joOa fi< tJOAif j<11.4 3 3
Plumbero,,~ ddress (Street, City, State, Z•ip/ Code): / G !
(,A A, Nt• w R t o t n 0 44 t4/I f
IX. CO TY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Ag nt Si o
C-PApproved ❑ Owner Given initial Surcharge Fee) 97111111LI11
Adverse Determination
X ONDI_TIONS OF APPROVAL/ EAS NS FOR DISAPPROVA _
SBD-6398(R.08/93) 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 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. Ohsite 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.
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 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 (R.11/88)
SANITARY PERMIT APPLICATION COUNTY
In accord with ILHR 83.05, Wis. Adm. Code / L Cr0 )
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than a~~~8~~
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.
PROPERTY OWNER PROPERTY LOCATION
0,0Ce 5 fr04qcq W '/a/VE S ~ T~1,N,RIL E(or
PROPERTY NER'S MAILING ADDRESS LOT # + BLOCK #
6c: A- I Z z
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION N E OR CSM NUMBER
Pe W < < S f O ry (2-17 ),Z 3 3 C. ~:"Ifib. so SG 7 9P
11. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ CITY VILLAGE: NEA T 7 D
jQI=N OF: 60 e
❑ Public ❑ 1 or 2 Fam. Dwelling4 of bedrooms PARCEL TAX NUMBS (S)
III. BUILDING USE: (If building type is public, check all that apply) 6F _ fl/ / 7-. 70
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 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. k] 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 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) ELEVATION
Z 7 a 7 - Feet g~ • Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank B t S t' F-1 M
Lift Pump Tank/Si hon 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'=;2~ No Stamps) MP/MPRSW No.: Business Phone Number:
~04 5t,Ah eph lz q~ T , 2-4 7 3~3
Plumber's Address (Street, City, State,, Zip Code): T
IX. CO NTY/DEPARTMENT USE ONLY
Issued Issuing Age Signat
❑ Disapproved Sanitary Permit Fee (Includes Groundwater M7/16(~M\/
Approved ❑ Owner Given Initial Surcharge Fee) Adv
erse Determination 44- X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(R.08/93) 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
date and at the time of renewal any
Y 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.
111. 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 8'/s 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-6398i(R.11 /88)
' SANITARY PERMIT APPLICATION
DILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
STATE SANITAR PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than g 8% x 11 inches in size. ❑ Check if 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
40(- )6 T-T Q u E E V S'/= '/4 F_ S T 3Z, N, R/ E (ory:0
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
Poll( V!` / Z- Z
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
❑ State Owned ❑ VILLAGE
=N OF: 'S Te 0- , r. ' L n., It I~D /)eD
❑ PubliC 1 or 2 Fam. Dwelling-## of bedrooms ' PAR EL TAX NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply) Q 3 _ Z 7- ?0
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
50 Hotel/Motel 90 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.E] 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./inch) ELEVATION
o o I L 97L / q1, 00 Feet 9'7. S- Feet
VII. TANK CAPACITY Site
in gallons Total # of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank 2S~ R "S"e
Lift Pump Tank/Si hon Chamber 1-1 1 El
Villl. 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) MP/MPRSW No.: Business Phone Number:
ce -~0 Mh' S'}32 ZY 3Z_P3
PlumbeP )r r's Address (Street, City, State, Zip Code).
v -0/7-7- ¢ cv /e,' c.,k o 40-=
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued ssui /jgent signature (No Stamps)
Approved I El Owner Given initial Surcharge Fee)
/~0
A verse Determination ~~k /X?
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 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.
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 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 1154orm; 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)
' • ~aJ ~ r2J ~ ; - .r u: ; y~oz. ~ a rya .s ~sr c ~
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Wisconsin Depaar RitofIndus~' SOIL AND SITE EVALUATION REPORT Page Of
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
PROPERTY OWNER: PROPERTY LOCATION /
GOVT. LOT 1/4 1/4,S T N,R (orl
PROPER OWNER':S MAILING ADDRESS LOT BLO K # SUBD. AME OR CSM #
CI TATE ZIP CODE PHONE NUMBER CITY VILLAG MOWN INE , EST ROAD
L, 4 L L R -
New Construction Use ~Q Residential / Number of bedrooms [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow gpd Recommended design loading rate gybed, gpd/ft2_,2_trench, gpd/ft2
Absorption area required _ bed, ft2 trench, ft2 Maximum design loading rate __,~bed, gpd/ft2_,L_trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material - Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem ® S ❑ U OS ❑ U ® S ❑ U ®S ❑ U ❑ S O U ❑ S Ell)
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. nt. Color Gr. Sz. Sh. Bed Trench
'I...~
Ground s J
elev.
ft.
Depth to
limiting
factor
LL
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CST Name:-Please Print . J Phone:
Address:
Signature: i Date: CST Num r
PROPERTYOWNER."~, _~~`a'L f A> SOIL DESCRIPTION REPORT Page of°
PARCEL I.D. # -
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
'~:~tix•:iii: i.4"4
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Boring #
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,L ft.
2
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SBD-8330(8.05/92)
o_ R
X d oC.g-~o..l o ~s~'tr:
~ So,-~ ,E3oc~s
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER_ DoU c- ST-f~ Q~ g E l~(
ADDRESS.Rf)k~
FIRE NUMBER
CITY/STATE L W R IC kW oyp to--T ZIP ly U/ 7
PROPERTY LOCATION: 5 C 1/4,1/4, SECTION ~ TOWN OF 5-10- k R k A l P, I , St. Croix County,
SUBDIVISION C. S. M , 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:
DATE:
St. Croix co. Zoning office
911 4th St.
Hudson, WI 54016
•I
I
S T C - 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 ~n delays of the pormit issuance. , Should this
development be intended for resale by owner/contractor,(spec
house), then 1a 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 Dy~ 14 S Tie o ~!5 jr- N
Location of property!: 1/4 //_1/4, section _L, T 3 l N-R W
Township
Mailing address -06.,V /z- .
Address of site C_ 5. ,E'/ 614-1 R C.~ A2>
Subdivision name Lot no.
Other homes on property? es
Y No
Previous owner of property _ Mf? ,C e, X7 F M Ue f-
Total size of parcel
Date parcel ,was created
'Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? t, Yes No
Volume fpd0 and. Page Number as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICA'T'ION 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 i the office of the County Register of
Deeds as Document No. 44 (orl; G , 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
%corded e construction of said system, and the same has been duly
in the office of County Register of deeds as Document
r~o._ gGSTGG ,
Signature of applicant Co-applicant
Date of Signature Date of Signature
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F F1LE~)D 1
Z S Ep I 1993 8
VJ6 (S viCS 0rpNNELL
R
.J Prn°to,, )1 IJOL^C$ V
St. Croix Co. WI
C ER T I FI ED S UR V E Y MAP
L ocated in the NE 1 /4 of the NE 1 /4 and the SE 1 /4 of the NE.1 /4 of Section
31, T31N, R18W, Town of Star Prairie, St. Croix County, Wisconsin.,
North line of.t1, a 16161
I,,EGEND N 1/4 N89036•F01"E I i
N890 6'01 "E _ 402 . 62 « tiY~..
t St'. Croix County'Section corner 2271.9 _ _ _ IT E COR.
NI/4 CN 89'36'01°E SEC. 31
monument
0 1"x24" Iron pipe weighing 1.68 lbs SEC. 31 402.62 T31N,R18W
per lip foot set. 33.00' 33.00'
--A Existing fenceline. RALEIGH ROAD_
East
( 344.d) Previously recorded information. line of
o~ the
• 1" Iron pipe found. A~ NE1/4.
C) m
Bearings referenced to the East ; v
line of the Northeast quarter, I * .
assumed SO0° 1.0'.39"E. ~ N
OWNER
Doug Strohbeen a~ O
Box #122 ; 2)
New Richmond, Wi:
54017 m
NOTE: "This parcel has _been IA
surveyed and drawn t conform to N gg'$4 `39"E, CU I
that deed,recorded in olume
1000, page 123 and Court _ 585.19 ` M W 21
ordered incase'#92FA53.'
V1 41
Town and county approvals are 22' North line of the N m a1
not required under County NE 1 /4 of NE1 /4, p
Ordinance 18.05(A)(1). 1 Vol p
U) W
P4 In I OD E-4
~h1/N11h/h~/ N I pond 41
~1
r i~ d~~ D' I py N p
• I W Rf ° ~ 1
HARVEY G. of >1 04 'Nn
JS NS N ~i
L ON I ; a~I ,M LO
IS ~r WI 0 1, 838, 734 Sq..Ft. (42.21 Ayes)
SURV~`~s HI o Including right-of-way.
0 1,825,448 Sq. Ft. (41.91 Ac)
ql)6 <<~ttltl~N*~~ a~ C z Excluding right-of-way.
w
Z
23'
4484.03' E 1/4 COR.
. SEC. 31
: IiIk
SEC. ' N .89*46~'11 "W 985,79" 'If (1"IRON BAR
W I/4 COR. N890461 W 45
(N 89 23 41 W 985.72')
31
(ALUMINUM CAP) I FOk1ND)
South line of the NE1/4.
T
SCALE IN FEET 1" = 300' UNPL._TED
I
LANDS_
0' 75' 150' 30 ' 600' 900'
This instrument drafted by: 4932201
T NO. isTAT>Jsa:R of wlscu..siN rU1:. 1 _ao:.1,
DOCUMENT i I
I`I QUIT CLAIM DEED It
Recd - ~
Mar ar t E Mc A for, rd
rahbeen n g g ...le'
AaiugU;z..A. I
g s-. 51993
,
i ...f1.kLa Mar ar~.~: E ro been,-
• 3 ~ w e'~•.~P~iC~l~i ~.r a ~
at r
quit-claims to Douglas A' Strchbeen~ a s3F1 he
C
c~ Datez
p~.son
~I
the following described real estate in
i:.- RETURN TOf
State of Wisconsin: "
Tax Parcel Noy
r-•~ 'R , r
the Northeast ,Quarter
East 30 ac-tes ok,,,the Southeast.Qua ter of Northeast"
and the `East `•12 ..25~acres of the Northeast Quarr~e~ o;f+ ~h~~; est.
All 'in' Sect}on 31, Township '31 Nort
Quarter,:
t..,~ 1
i ~
;R
Thisdeed is given pursuant to an.order of divorce dated'March l7,
1993,` in St. Croix County, Wisconsin. A;
j
{ This is I•omestead property. I
i
Cs) (is not) 7 March
day of
Dated this
............(SEAL) `
qq~~ - H J~"r. .
OV ~"T
-----.......(SEAL) Dou las A Strohbeen
(SEAL)
Niaz re.. E iver f.......... mcE /k
n
"".:-:::tg~_`Y++-~~a.~ x•."w_ C1ret •.rMrl-~ t.tl
1 y~CHN0WLS.I]6MF]•NT
AUTHP.NTICATION
"~a CO I
STATE OF ~V~S N N
ay
"
' Signature(s), A
r
EC2I X
•h •i~i ..C]T.ACOnnty
R
( Personally came before me this ...-17
authenticated this ........day of_________ 19 _
[aJC.Ch_ 18_~ the above n
ate;-Axahkl~erl__.and
.DC.u91~",
3
5t>~oh~~n
"-.TITLE: MEMBER STATE BAR OF WISCONSIN ~ Mar$ar~~ Fi.
J ~ I C
C - I ' - S'
u (If aot,'
authorized by § 706.06, Wis Stats) to me known to bprt~~~lekaopjk . a -who t1o t
•~,,aE fore in ►nstrte a e~6 1 it
THIS.iNS'PFtUMENT WAS ORAhE, x p. pr'ar +~tT' n i +r
I
REMINGTON LAW OFli~~••-,• iy~ a
i .-R Till ~'Qn ?G i ~T,tbm 'Pa"4 ~untv`,~W
udl
01~7 r
L t. i Notary $uby f
~54
CQ11 1.. c lr$~ h state,. expEra i
ASrl.
r ~a aIV ~.'OIItn1L4$
YG
l nth y,, a
r' (Signatures may be authentic at~iora at
are not necessarY•)-date y tT
r ~ ,Y r
` 'W ec sin L•C.1 IIl.nk Co Y)oa -
w r ~3~ '~~TATE ~ kR OF Rf~IOV 1\ 4 .:yfJ ukes. Wn _ .
'lo,a CLAM DEED
J.il. yK T r b -
a
r~s rr r ~ , ~ t
l •i ~ Z Y e ~ L u e, ~n12 1 b -S i t 1