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ff 2- FORM - STC - 1-04N
4~70 AS BUILT SANITARY SYSTEM REPORT
OWNER /Vo"~ TOWNSHIP %
SECTION J;- T N-R 17 W
ADDRESS 20 ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
S.?-e rF TE GO /7- G
I
INDICATE NORTH ARROW
i y " Uc s~ y csT
BENCHMARK: Elevation and description: ~icv~io~ = /oo,
Top Of po(Oleto ~o,~c,~ a sc~+~aT wA
Alternate benchmark 9fi-o3
~vE~.t'S Co,vG,P~E
SEPTIC TANK:Manufacturer: v Liquid Cap.
Rings used: D Manhole cover elev: , 3 Final grade elev: '
Tank inlet elev.: ~7 S3 Tank outlet elev.: 77.2- -7
No. of feet from nearest road:Front Side Rear Ft.
From near prop. 1 ine : Front , Side' Rear Ft.-
No. ~i 9 9 T~ ,of feet from: Well IVBuilding: 13 z 9
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE''
l
Y Y
PUMP CHAMBER
Manufacturer: Liqu' Capacity:
Pump Model: Pump/Siphon nufact.: Pump Size
Elevation of inlet: ottom of tank elevation
Pump on elev.: Pu off elev.: Gallons/cycle:
Alarm: Man.: Switch Type: Location
Distance fro nearest prop. line: Front, Side_, Rear-Ft.
Distance; rom: Well Building
SOIL ABSORPTION SYSTEM
Bed: Trench: Seepage Pit:
Width: 5 ' Length 767 Number of Lines: Area Built
ff,' ;Pe-4 9~.a y~_ 6
Exist. Grade E1ev./0w T. Proposed Final Grade Elev. 9f! 7
Fill depth to top of pipe: 2 y0
No. feet from nearest prop. line:Front , Side , Rear Ft.
No. feet from well:/V/4- No. feet from building yZ
HOLDING TANK
Manufacturer: Capacity:
No. of rings used: Elevation of botto ank:
a
Elevation of inlet:
No. feet from nearest prop. e:Front , Side , Rear Ft.
No. feet from: Well , building , nearest road
Alarm Manufactur
INSPECTOR: Jim ~~tJ/'l/J SO.✓
DATE:- /yam f2- PLUMBER ON JOB :
LICENSE NUMBER:
6/90:cj
HOMESITE SEPTIC PLUMBING CO,
655 O'NEIL RD., HUDSON, WIS. 54016
ROBERT ULBRIGHT
~1A6. MASTER PLUMBER LIC. NO. 3307 M.P.R.S.
t,j!,N4 Itt r4LLER & DESIGNER LIC. 140. 00663
HOMESITE SEPTIC PLUMBING CO.
655 O'NEIL RD., HUDSON, WIS. 54016
ROBERT ULBRIGHT
? WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S.
i tNK INSTALLER & DESIGNER LIC. NO. 00663
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LOCATION: PLEASANT VALLEY 5.28.17.18A,W1 2,NE 60TH AVE.
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division ST. CROIX
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAWNFORMATION 175633
Permit Holder's Name: ❑ City ❑ Village EXTown of: State Plan ID No.:
MOLL, BRUCE /WEISS,JOANN' PLEASANT VAL
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
024-1003-40-000
9/0
TANK INFORMATION ELEVATION DATA A9200292
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ? Benchmark z. (P7 , CD `
Dosi
Aeration Bldg. Sewer
Holding St/ K Inlet 5,43f 9,7 01
TANK SETBACK INFORMATION St/kW Outlet
TANK TO P/ L WELL BLDG. AirI to ntake ROAD -DR-rn- ef-
rl
Septic de/ Z ~•!~L - NA flt-Bottanlr
Dosi NA Header / fan- r'y' 67r
Aeration NA Dist. Pipe
r P
Holding Bot. System 7-13
PUMP/ SIPHON INFORMATION Final Grade X13 r
40 14-1
- 77
Manuf Demand s~ 3 7~~
l_-c vex
odel Number GPM
TDH Lift Friction S stem TDH Ft
Forcemain Length Dia. Dist. To
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length I No. Of T riches PIT f Pits Inside Dia. Liquid Depth
DIMENSIONS EN I N
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHIN Manufacturer:
SETBACK _ CHAMBER
INFORMATION Type O r, Mode r:
System: .t; OR UNIT
DISTRIBUTION SYSTEM
Header IPA*R 4efd it Distribution Pipe(s) „ x Hole Size x Hole Spacing Vent To Air Intake
Length ( Dia- P Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over rr Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
~t
Bed /Trench Center - C/ Bed /Trench Edges ?vrr 7 Topsoil ❑ Yes C] No ❑j Yes_ No
COMMENTS: (Include code discrepancies, persons present, etc.)
/ ('eAC-2 + n end bath. • ~ Z J
I Jr.4:9' ~Sr 9,d fit' 5.zy`
hr Plan revisionrequired? ❑ Yes o
Use other side for additional information. S--r~
SBD-6710 (R 05/91) Date Inspectors Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
LILHR SANITARY PERMIT APPLICATION
COUNTY
In accord with ILHR 83.05, Wis. Adm. Code ST. C/PQ~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. LZ vis nt pre application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNI ~ PROPERTY LOCATION
RUCKD/~ cJ0 ANA ~L~SS 3f~/VE/a, S S T IX,N, R/ 7 E (or) W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
240--1 460A *AR- I
CITY, STATE P CODE PHO E NUMBER O SUBDIVISION NAME OR CSM NUMBER
(&ooil)
II. TYPE OF BUILDING: Check one CITY NEAREST ROAD
( ) ❑ State Owned VILLAGE
:,P/E',f ff ,T Cpl Q GtR--
OF:
❑ Public 1 or 2 Fam. Dwelling- # of bedrooms PARCEL AX NUMBER ! V
III. BUILDING USE: (If building type is public, check all that apply) fj l if f ~b 4/0 00 C2
1 ❑ Apt/Condo
Assembly Hall 6 El Medical Facility/Nursing Home 10 El 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, ICJ New 2. ❑ Replacement 3. ❑ Replacement of 4.E:1 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 ❑ S stem-In-Fill a N
Y Z 7VE' a,$ ~ fGt 7, j
VI. ABSORPTION SYSTEM INFORMATION: f,~. Jr'Ci • 0
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
I'' REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
7, O 17-re) 6 s ~Ilf Feet 7e' 7 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 Holdin Tank
Lift Pump Tank/Si hon Chamber U-z-, /V
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) MPRSW No.: Business Phone Number:
o x~`~ 3 0 7 71f ~6 AVS
3
r- ,C T
Plunper's Address (Streyt, City, State, Zip C de
CpS S O EiG fj~'1Jj~,sO.•~ CJ /-S• ~~lfl `i
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps)_
Surcharge Fee)
Approved ❑ Owner Given Initial _
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety a 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 115.1orm; 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.
S13 D-6398 (R.11/88)
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 in delays of the permit issuance. Should this
development be intended for resale by owner/contractor,(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.
M AAg of property t' V t p L ~o LO ti X5
Location of propertyu% Y ~ NE 1/4, Section 5 T d8 N-R I") W
Township ~CC 5C& yc" ~1•<
Mailing' address P. Cd 13CX ~A~~ H~,~~„w•oL.~ Vui 5
Address of site _ ;7- 0 ~nw.aL,~l
subdivision, name Lot no. -
Other homes'. on property? yes X- No
Previous owner of property CU c_ e to c N t v In d dt f
Total size of parcel C, C res
Date parcel was created
Are all ',corners and lot lines identifiable? ye5 No
is this iprcgperty being developed for (spec house) ? Yes )<No
Volume 9!&O and Page Number ova Lg 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 he office of the County Register of
Deeds as, Document No. _ q $ 1 79 , 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
7,7 . )b
Signature of applicant Co- pplicant
Date of Signature Date f Signature
' I
•I, DOCUMENT No. WARRANTY DEED T.I. SPACE RESE RVED FOR RECORDING DATA
STATE BAR OF WISCONSIN FORM 2-1982
486178
v n 960
Eugene F. Neuendorf and Joyce Neuendorf, REGISTER'S OFFICE
'h_ii6band -and---wife---as---- 3oirit.._tenants----------------- ST. CROIX CO., WI
ec' or Record
. JUL. 2 21992
conveys and warrants to $Zll-C~_-_J_.._1`bola -a-nd--- JoAnn....We_is.s_' ---.._as-- J-oint._.tenants------ - Dt 1:30 P. M
- -
LAryL
ro Deeds
-
RETURN T
. S 54
-1
the following described real estate in _ - St . Cro iX County, S U` 1-5.
State of Wisconsin:
Tax Parcel No-
j~ That part of the West Half (Wz) of Northeast Quarter (NE4) of
Section,Five (5), Township Twenty-Eight North (T28N), Range
Seventeen West (R17W), lying Northerly of Interstate Highway
1111 11I-9411, EXCEPT the East 400 feet thereof.
I
ICI i~~F~i! Iii
A
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it
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This homestead property. ~I
~I *.0q (is not)
I;
j Exception to warranties:
Easements and exceptions of record.
I
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Dated this t-- day of 19.92
v
- - - ---.--(SEAL)
- -
..._...(SEAL) E?oc F. eu ndorf !
II (SEAL) ( (SEAL)
JNeuendorf
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN I,
ss
ST. CROIX III
v` ------------_------------County.
authenticated this day of 19.....- Personally came before me this _ ....-.__..-day of
, 19__92.- the above named -13
Eu ene F Neuendorf and
* Jo ce Neuendorf i
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by § 706.06, Wis. Stats.)
to me kn e. t11-,person S. w o executed the
foregoi and -acknowl ge e same.
T ~
THIS INSTRUMENT WAS DRAFTED BY
f ♦ S.
Thomas A. McCormack
Baldwin, WI 54002 ~,✓u - - -
Notaf ~r0 --County, Wis.
(Signatures may be authenticated or acknowledged. Both My Cor Sri ss n S.. e-nt (If not, state expiration
are not necessary.)
date: •-----4-- 19--•-----•)
t F t'1 ~ '
*Names of persons signing in any capacity should be typed or printed below their signatures.
WARRANTY DF,ED STATE RAR OF WTSCONSTN Wisconsin Legal Blank Co.. Inc.
i
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER 0 Viol C'-C- M~ Jo Ahn Wea"S S
A.DDRESS_C AU-p-~ FIRE NUMBER c -1
CITY/STATE' Y+ O"d W~ ZIP-
PROPERTY LOCATION: V/Z , 04- 1/4, SECTION- T N-R-1 _7W
TOWN OF. P'fec~skwr UGl'eA , St. Croix County,
SUBDIVISION LOT NUMBER
i
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
ou 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
~s:ystem, 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.
,'fl I/We,.., the undersigned have read the above requirements and
'agree to maintain the private' sewage disposal system in accordance
with th;e 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
130 days of,the three year expiration date.
SIGNED: i ,
DATE: R-,2 -q2
'St. Croix co. Zoning Office A
911 4th' St
Hudson,; WI 54016
i
yz dIG~S ,v~~ co.v s`r;~'ve Tro.~
Wisconsin Uapartmentof Industry, SOIL DESLKIPTION REPORT Safety 3 8uiiurngs Division
Labor and Human Relations P.O. Box 7969
(Attach Soil ile Location Map - To Scale - On A Separate, Signed Sheet) Madison, w1 53707
74r!p ZG / $GS 77 Page of L
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ustomer Nemi r va ustion D urrent Lan Use or vegetative over arent arena t
z P~+s7d~PE - 9,P, S. 1 H~+y ef-l
st.mate Shallowest Groundwater am Elevation
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County at ara o. 7b~,v D F ystem Loa mq Rate ina onnt Per Sgjt Per Day D~
I 5-1• yZ .firms Ales 0 ~t , ~ -[0 P- f ~tJ ?,4 s ( tot Legal nptron ystem eometry an Dept Slope an Aspect
ii SW Nf SRc, S Pit W, T- 2'? _ see p . Z
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In. Munsell u. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Boundary ores 'W And other GPD/1t.2
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It mESIT E SEPTIC PLUMBING CO.
6b5 O'NEIL RD., HUDSON, WIS. 54016
ROBERT ULBRIGHT e s r # y
4S. MASTER PLUbtBER LIC. NO. 3307 M.R ft
r .!N1N. INSTALLE'i & DESIGNER LIC.14O. 00__0
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HOMESITE SEPTIC PLUMBING CO.
655 O'NEIL RD., HUDSON, WIS. 54016
ROBERT ULBRIGHT SCALE = 30
WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S.
MINN. WALLER & DESIGNER LIC. NO. 00663 .lam',
t.
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Fresh Air Inlets And Observation Pipe Tip-vac
Approved vent cap
~ Minimum 12".Above
Final Grade
4" Cast Iron
Above Pipe
si 3o
Vent 'Pipe'
-to Final Grade '
t
Marsh Hay Or Synthetic Covering
Min. 2" Aggregate
t Over Pipe
Distribution ~~L9 Yee
0 0 0 0 011
I~ Po
a
" Aggregate
Beneath Pipe ° PertOraled Pipe Below
0 Coupling Terminating At
Bottom Of System
F L ~ .
Ile) lu~,k
Fresh Air Inlets And Observation Pipe
Approved Vent Cap
Minimum 12" Above
Final Grade,
4" Cast Iron
• Above Pipe
`to Final Grade Vent Pipe'
Marsh Hay Or Synthetic Covering
Min. 2" Aggregate
Over Pipe
Distribution } z9z f Tee
Pipe 0 0 0 0 0 ,
" Aggregate o Perforated Pipe Below
J~Beneath Plpa •
0 Coupling Terminating At
9,/,,~ - Bottom Of System
REPT131 PLEASANT VAL ST. CROIX COUNTY ZONING PAGE 1
~99/fA/92 11:07 REQUESTS FOR INSPECTION WORK SHEETS FOR: 9/15/92 AREA: JT
Activity: A9200292 9/15/92 Type: CONVSEPT Status: PENDING Constr:
Address: PLEASANT VALLEY 5.28.17.18A,W1/2,NE, 60TH AVE.
Paedel: 024-1003-40-000 Occ: Use:
Description: 175633
Applicant: MOLL, BRUCE /WEISS,JOANN' Phone:
Owner: MOLL, BRUCE/WEISS, JOANN Phone:
Contractor: ULBRECHT, BOB Phone:
Inspection Request Information.....
Requestor: UBRICHT, ROBERT Phone:
Req Time: 15:09 Comments:
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION
Inspection History.....
Item: 00012 FINAL INSPECTION
I.