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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
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Ust({~
OWNER m 1" 1qV~. 4(:ow",e. SI'yj1th TOWNSHIP 5f,
SECTION 3 a T30 N-R ) 7 W
ADDRESS -Rol I ,IN ~ 1 1 LS I,ANi" ST. CROIX COUNTY, WISCONSIN
(1
SUBDIVISION ON AK- W h LOT 5 LOT SIZE ~1 . vo
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
8~ IB,~s y &v
y Ben zoo r)
1
0
INDIC TE NORT ARROW
BENCHMARK: Elevation and description: (o o•O ^ N Seel 16-sl
Alternate benchmark
SEPTIC TANK:Manufacturer: e S Liquid Cap. A)
Rings used:-LManhole cover elev:103-5 Final grade elev: -
Tank inlet elev.:101j5' -Tank outlet elev.:
No. of feet from nearest road : Front , Side , Rear Ft . 0\)m ~oo P
From nearest prop. line:Front , Side, Rear Ft.~
No. of feet from: Well 57 , Building: Q
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
1
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufact.: Pump Size
Elevation of inlet: Bottom of tank elevation
Pump on elev.: Pump off elev.: Gallons/cycle:
Alarm: Man.: Switch Type: Location
Distance from nearest prop. line: Front, Side, Rear-Ft.
Distance from: Well Building
sti.1 4.Ss ep 7,54
e%UU Q
SOIL AB: TION SYSTEM `s 6. / 7+ 3S
% s 6
Bed:_ Trench: $epage Pit:
Width: 18 Length S Number of Lines: Area Built V
Exist. Grade Elev. Proposed Final Grade Elev.
80 Ya
Fill depth to top of pipe:
1
No. feet from nearest prop. line:Front ~ Side , Rear Ft.~
~l
No. feet from well: 68 No. feet from building a
HOLDING TANK
Manufacturer: Capacity:
No. of rings used: Elevation of bottom tank:
Elevation of inlet:
No. feet from nearest prop. line:Front , Side , Rear Ft.
No. feet from: Well , building , nearest road
Alarm Manufacturer:
INSPECTOR:
DATE• U a gA PLUMBER ON JOB:
LICENSE NUMBER: 'j3 hl
6/90:cj
- J
L6~'s>','s'R#partSQndJst32.30.19,NW SW LOT 5 ROLLING HILLS LAcounty:
Labor arid Human Relations P/RIV~►TE SEWAGE SYSTEM
Safety and Buildings Division INSPECTION REPORT ST. CROIX
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION 171505
Permit Holder's Name: ❑ City ❑ Village [A Town of: State Plan ID No.:
3MITH MARC ST. JOSEPH
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
(O b I 0 6, C51 r/2- t r Sf~.~ t S
TANK INFORMATION ELEVATION DATA A9200273
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Q eft Benchmark -7, 1 c o7.
l 9
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet ~.vy 101-15-
coo ~`J
TANK SETBACK INFORMATION St / Ht Outlet &,a7
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic a-► NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System 10,7 I LA9
PUMP / SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
I Loss Friction System TDH Ft
TDH Lift
mead I
Forcemain Length Did. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Lengt 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 I I OR UNIT Model Number:
System
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 p Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed/Tr nchCenter I o Bed / Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
01 r K~ ko
i
Plan revision required? ❑ eV 'El No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH t
SANITARY PERMIT NUMBER:
3
i
QILHR SANITARY PERMIT APPLICATION `ZY COUNTY
In accord with ILHR 83.05, Wis. Adm. Code f. '
E
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. ❑ Ch Of revfalo~ 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
(VIA)L/4 S3,2 T30,N,R ~ E(or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
i 5
9 W L6 Q S j Q Nh
CI T TE ZIP CODE PHONE NUMBER SUBDIVISION NAME O SM NUMBER
q31 tjspio' o r w
S~
T AD
Rp a f LA
11. TYPE OF BUILDING: (Check one) ❑ State Owned VI LL AGE , rQ NEAR
_q WTOXJW OF: ❑ Public 1 or 2 Fam. Dwelling of bedrooms PARCEL Ax N BE K 11 f
III. BUILDING USE: (If building type is public, check all that apply) 62 6 - a6R~ &a
1 ❑ Apt/Condo WtJ
20 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 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. ❑ 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
O RE UI ED (sft. PROPOSED (sq. ft.) (Gall/day/sq. ft.) (M./inch) ELEVATION 97D, 1`Q o1S <7 9(.1s Feet W. 8 Feet
VII. TANK CAPACITY Site
INFORMATION in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
New istin Gallons Tanks Concrete strutted glass App.
Tanks Tanks
Septic Tank or Holdin Tank
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.: TTS usiness Phone Number: Ir" _r e 8~-g4~U
Plumber's Address (Street, City, Stat , Zip Code
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Saplary Permit Fee (Includes Groundwater Date seas ent Sig ture (No S ps
'~Surcharge Fee)
Approved ❑ Owner Given Initial n1
Adverse Determination U~ X. X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
i
i
SBD-6398 (formerly Plb-67) (R. 11/88) 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 renew.il 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 (SBI) 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,-608-266-3.815.
.
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 31/2 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; close 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)
APPLICATION FOR SANITARY PERMIT
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.
Owner of property
i
Location of property 1/4 1/4, Section , T e>J N-R \`1 WW
Township
Mailing address
Address of site -
Subdivision name-
Lot number
ti
Previous owner of property
Total size of parcel _ j
Date parcel was created _ j
Are all corners and lot lines identifiable? --X-Yes No
Is this property being developed for resale (spec house)? `Yes No
Volume and Page Number 3 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, 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 Map, the Certified Survey
Map shall also be required.
PROPERTY OWNER. CERTIFICATION
I(We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described in
this information form, by virtue of a warranty deed recorded in the Office of
the County Register of Deeds as Document No. y
LI y (o ; and that I (We)
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 Register,of Deeds, as Document No.
Signature of Owner / Signature of Co-Owner (If Applicable)
~L
Date of Signature Date of Signature
I~
DOCUMENT NO. WARRANTY DEED THIS sPAC[ R[8[RV[D FOR R[CORDIND DATA
STATE OF WISCONSIN - FORM 2
REGISTERS OFFICE
.VOL U, 3
ST. CROIX CO., wl
This indenture, Made this 5 day of .......-July a Rectd for Record
A. D., 19....•..9.? between ....J & L Land Developers , Inc . J U L 15 19'92
a Corporation duly Horganized udson and existing under and by
virtue of the laws of the State of Wisconsin located at.._ ...1H at 12:50 P. M
Wisconsin party of the first pert and ~ _ ...rC......D.......Sm. _ .i. _ CAnn] e S .
pror~erhy~
as survivorship marita
Sm.ith.,...husband_.and..w1.?e,
_ $4-W (J („~>•'aM,RiCX,.
_ Re9i3ter of Deeds
said art.
part o Witnesseth, That the second
party of he first part for and in considerationof the sum
Sixty-one Thousand and no 100 Dol~ars ~f}
of..._.... _
R[T4 b' -weir mer, .
to it paid by the said part...... _ leS of the second part, the receipt whereof is hereby confessed and I Second St. P, 0, BOX 106
acknowledged, has given, granted, bargained, sold, remised, released, aliened, conveyed and con- HUd8on, WI 54016
ain, sell, remise, alien convey , and con rm unto
firmed, and by these presents does give, grant, bar es Y I _
the said ParL..y..... ,t.-Qf tthrsecond part l heirs and assigns forever, the following described real estate, situated in
(XO
the County of.......... State of Wisconsin, to-wit,
See legal description on reverse side.
06 I
I
I
i
(IF NECESSARY, CONTINUE DESCRIPTION ON REVERSE SIDE)
Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining; and all the
estate, right, title, interest, claim or demand whatsoever, of the said party of the first part, either in law or equity, either in possession or
expectancy of, in and to the above bargained premises, and their hereditaments and appurtenances.
To have and to hold the snid prremises as above described with the hereditaments and appurtenances, unto the said part ..leS
I tCle1
Of the second part, and to..._...... heirs and assigns FOREVER.
And the said _ J...&~_Z ..i?..DeveS23r~...Inc.........._........_..............................................
I
Party of the first p t, fpr itself and its successors, does covenant, grant, bargain and agree to and with the said part of the
second part, ~lZ heirs and assigns, that at the time of the ensealing and delivery of these presents it is well
seized of the premises above described, as of a good, sure, perfect, absolute and indefeasible estate of inheritance in the law, in fee simple,
and that the same are free and clear from all encumbrances whatever
_
and that the above bargained premises in the quiet and peaceable possession of the said part.. eS........ of the second part, ._~e1r....... l
heirs, and assigns, against all and every person or persons lawfully claiming the whole or any part thereof, it will forever WARRANT and
DEFEND.
In Witness Whereof' the said J.... L.I~nd..Developers., ...Inc... I
party of the first part, has caused these presents to o bdnda e signed b ...igned by. Gerald ..A....Johnson
its President, and countersigned by . T................................_............................_................. its Secretary, 11'
.-.--Hudson Wisconsin, and-el~-eerrporaerxa~to-$r-Ftereanle-+~i+ted, this
1 day of......... JL1.1V................................... , A. D., 1992..... SIGNED AND SEALED IN PRESENCE OF J & L Land Developers, Inc.
i3 Corporate Name
I
Gerald A. Jo n President
I
COUNTERSI/G~NEEDI1:
D. Jo son -Secret Y........
nda
STATE OF WISCONSIN
ss.
t~..... md.X.................. County. J~- ............Personail came before me, this ...............9 t)1........................ day of......n. ...n .•.........J.....or..
..LTl..s........n........................................................_., A.
D-.-, > 19.22-
C. President, and.........---..... Secretary
of the above named Corporation, to me known to be the persons who executed t fore ' ing i rum t, and to me known to be such
President and Secretary of said Corporation, and acknowledged that they e::ecu the f r go' finer ent as such officers as the deed of
said Corporation, by its authority.
THIS INSTRUMENT WAS DRAFTED BY Hu H. O win
NOTARY Notary Pu ic, ......St. Croix County, Wis.
Attorney Hugh H. G IAn TA
My commission IcK)dxxX (is) ~rlTlallent.
(Section 59.51 (1) of the Wisconsin Statutes provides that all instruments to be recorded shall have plainly' printed or typewritten thereon
the names of the grantors, grantees, witnesses and notary. Section 59.513 similarly requires that the name of the person who, or govern.
mental agency which, drafted such instrument, shall be printed, tvpewritten, stamped or written thereon in a legible manner.)
--'Y' jV1grv,va7v
vol_ 959 m,,; AT 4
A. parcel of land.located in the N~ of the SO.s of Section 32, T30N, R19W, Town of
10 St. Joseph, 'St. Croix County, Wisconsin, described as follows: Lot 5 of
Jolinson Parkway.
!Together with :
A 66 foot wide Private Road Easement for ingress mid egress over a private road named
Rolling Hills Lane, from the Town Road now named Rolling Hills Trail to the easterly
bound'ary' 'of the 'Pldt of Johnson Parkway. The southerly 33 feet of said Private Roa•.i
Easement is as shown on Certified Survey Maps recorded at Volume 0 of Certified Survey
Maps, at page 1514, as Document No. 401074; and Volume 6 of Ccrl.ified Survey Maps, at page
1652, as Document No. 412061; and Volume 8 of Certified Survey Maps, at page 2233, as
Document No. 459864; and Volume 7 of Certified Survey Maps, at page 2060, as Document No.
444406; and the northerly 33 feet of said Private Road Easement is as described in a Wart ,►nty
Deed dated December 29, 1987 and recorded December 30, 1987 in Volume 800, at page 98, as
Document No. 433351, and as shown on a Certified Survey Map recorded at Volume 7, Certified
Survey Maps, at page 2060 as Document No. 444406, all in the office of the Register of Deeds
for St. Croix County, Wisconsin.
I
Exceptions to warranties: TOUR WITH AND SUBJECT To any other easements, covenants,
reservations or restrictions of record, if any, but this shall not be deemed to extend
any such other recorded encumbrances beyond the term established by law therefor.
~L
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
r
OWNER/BUYER
ADDRESS : I _ FIRE NO :
LOCATION: 1/4,1/4, SEC. T N-RW, VJ
TOWN OF: k\ ST. CROIX COUNTY
SUBDIVISION: A~ 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.
• SIGN
DATE: f
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
K'-Hont-A Dtoa-ImertofIrduttry' 5VILUCbI.hIrIlVte nt.f vnt
LAW and human RelaUOns : U got . d
(Attach Soil Profile Location Map - To Scale - On A Separate, Signed Sheet) ' Madison. :.t WC,
Page 'r
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LOT BLOCK SUBDIVISION 11,16re _ tttelada
(3 - Nortton Death Oorrtinant Color Mottles Structure Llrttltlttg Faltor/ Loaang VP0 sa M.
In Mansell St. ont. Col r Ttxture Gr, t. h. Consuten a Root o n ar Depth Ttanch Dad
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Elev to
Additional Remarks:
RECOMMENDED SYSTEM TYPE: 2
Other Site Features:
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loo lien ath Pi a e~ Coupling Terminating 7%
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REPT131 ST. JOSEPH ST. CROIX COUNTY ZONING PAGE 1
10/22/92-08:57---REQUESTS -FOR-INSPECTION -WORK -SHEETS -FOR: -10/22/92----AREA: -MJ--
Activity: A9200273 10/22/92 Type: CONVSEPT Status: PENDING Constr:
Address: HUDSON,32.30.19,NW,SW, LOT 5, ROLLING HILLS LANE
Parcel: - - - Occ: Use:
Description: 171505
Applicant: SMITH, MARC Phone:
Owner: SMITH, MARC Phone:
Contractor: BOUMEESTER, JIM Phone: 386-9020
Inspection Request Information.....
Requestor: BOUMEESTER, JIM Phone:
Req Time: 15:10 Comments: 0 00
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION
Inspection History.....
Item: 00012 FINAL INSPECTION