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AS BUILT SANITARY SYSTEM REPORT
OWNER ~~~1c,Jbs TOWNSHIP
S E CT I ON----2_T~N-R-/-~ W
ADDRESS ST. CROIX COUNTY, WISCONSIN
a
SUBDIVISION 1,4 LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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I DICATE ORTH ARROW
BENCHMARK: Elevation and description: Alternate benchmark
SEPTIC TANK: Manufacturer: Liquid, Cap.
Rings used: Manhole cover elev: Final grade elev: r
Tank inlet elev.: Tank outlet elev.:
No. of feet from nearest road:Front , Side A , Rear Ft.Y-ion
From nearest prop. line:Front , Side Rear X Ft. 2(12
No. of feet from: Well Building:
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
I 9
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufact.: Pump Size
I
Elevation of inlet: Bottom of tank elevation
Pump on elev.: Pump off elev.: Gallons/cycle:
I
Alarm: Man.: Switch Type: Location
I
Distance from nearest prop. line: Front-, Side-, Rear-Ft.
Distance from: Well Building
SOIL ABSORPTION SYSTEM
Bed: Trench: Seepage Pit:
Width:--;;.2 Length Number of Lines:,;-,2-Area Built,:
Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth to top of pipe:
No. feet from nearest prop. line:Front Side , Rear_Y-Ft.~
No. feet from well:~_No. feet from building
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 : PLUMBER ON JOB :
LICENSE NUMBER:
6/90:cj
LOCATION; SOMERSET 1.30.19.475C,SW,NE,HILLDALE DR.
Wiscon$in Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 149337
Permit Holder's Name: ❑ City ❑ VillageX] Town o : State Plan ID No.:
BERENDS, MICHAEL J & LINDA L SOMERS T
f CST BM Elev.: Insp. BM Elev. BM Description:/° Parcel Tax No.:
CJ 032200360001
A9200184
TANK INFORMATION ELEVATION DATA / O/ Z
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmar /
Aeration Bldg. Sewer
Holding St/V Inlet 2 p 9~,0
TANK SETBACK INFORMATION St/ Vf Outlet ~j, 7(o f
TANK TO P/ L WELL BLDG. Airi to ntake ROAD
Ar I
Septic ->/eZ' >1;5' lAp 41 NA Dt
Ing NA Header+fth+rr.' /o, 3s,
Aeration NA Dist. Pipe
Holding Bot. System p ~),i 113 PUMP/ SIPHON INFORMATION F~aa~Grade~
.25
toy o~ ~.T. •rz, ~
Manufa Demand a
Model Number GPM
TDH Lift Friction Syste TDH Ft
oss Head
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 ~ %7 EN I N
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHI Manufacturer:
SETBACK CHAMBER
INFORMATION Type O " + Mo er:
System:',,, 6Ld 2 t <7b' ' OR UNIT
DISTRIBUTION SYSTEM
Header ~ Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length _6~ Dia. Length ~ Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Ove Depth Ove Z , i xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench E ges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: Include~cod# discr~ ies, perso s present, et~~ )a
c, Vu Plan revision required) E] Yes o
Use other side for additional information.?
BD-6710 (R 05 l1) Da Inspector's Signature Cert. No.
cZ G"~
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
I
SANITARY PERMIT APPLICATION
70ILHFR In accord with ILHR 83.05, Wis. Adm. Code couNTY
STATE SANIT ERMIT#
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ Y1,06h 8% x 11 inches in size. c ec f rto pr wous 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
4or
24- S '/a ''/a, S T , N, R
PROPER OWNER'S MAILING ADDRESS LOT # BLOCK #
J
CITY, TATE ZIP CODE PHONE NUMBER SUBDIVISION AME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLLLAGE : NEAR ST OAD
TOWN PF: RCEL TAX NUMB dwi~ecaj
ER( b)
❑ Public El 1 or 2 Fam. Dwelling- # of bedrooms a PA
111. BUILDING USE: (If building type is public, check all that apply) DO /
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
4 ❑ Church/School 80 Mobile Home Park 120 Service Station/Car Wash
50 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. [Z New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 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 430 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.ch) ELEVATION
7 Feet Feet
VII. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks , structed
Septic Tank or Holding Tank
0 El 1 1:1 0-
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installati n of the onsite sewage system shown on the attached plans.
Plumbe 's Name (Print): / Plumber' Si natur (No Stem j MP/MPRSW-~Nyo.: Business Phone Number:
P umbe 's Address treat, City, State, Zip Code):
J 7 . J 5~
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue Issuing Agent Signature (No Stamps)
Approved El Owner Given Initial Surcharge Fee)
14 0
Adverse Determination
lal
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 da e, and at t1 ht. of renew, l any new
criteria in the Wisconsin Administrative Code will be applicable.
1 Al! revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Fore? (SBL• 6399, to be
submitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pur,,ped t y a licensed
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage systern, contact your local code adm: iist,ator or the
State of Wisconsin, Safety & Buildings Division, 60.3-266-3815.
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 nu nber(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 ['welling.
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 replacerrent, r.:connection, 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, -cumber of
tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all
septic, purnp/siphon and holding tanks for this system. Check experimental approval only it t,;nks: received
experimental product approval from DILHR.
Vill. 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 r::'f 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; replac(-+ment 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
reguiated 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)
•
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.
7
I
Owner of property MchaP~ ~ Be-j-e-A s
Location of property(L 1/4 _1/4, Section T 30 N-R q W
Township s Q C - -s..,A
Mailing address
Address of site
Subdivision name Lot no.
Other homes on property? yes No
Previous owner of property v2` re.
Total size of parcel IL
rj
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being develop//e//d for (spec house)? Yes -4No
Volume -5 and Page Number /gf'4 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 the office of the county Register of
Deeds as Document No. , 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.
iSignature of applicant Co-applicant
Date of Signature` /
Date of Signature
y DOCUMENT NO. THIS SPACE RESERVED FOR RECORDING DATA
y WARRANTY DEED
' STATE BAR OF WISCONSIN FORM 2 - 1982
460541 "
-VOL 876PAGE2
REGISTER'S OFFICE
ST. CROIX CO., WI
Joseph R. LafAi rande and Emma Lahti rande, Recd for Record
JUL171990
husband and wife as joint tenants I
conveys and warrants to M i c h a e l J . B e r e n d s and of 9-00 A. M
Linda 1. Rerends hushand
a n d w i f e As s I i r i v n r s h i n Register of Deeds
marital nrnnarty
RETURN TO
the following described real estate in St. C r o i x County,
State of Wisconsin:
Tax Parcel No:
Part of the Northeast Quarter of Section 1, T 30 N - R 19 W,
described as follows: Lot 1 of Certified Survey map filed
August 13, 1984 in Volume s.-of Certified Survey Maps as
Document # 395560, page 1452.
I
This i S n 0 thomestead property.
(is) (is not)
Exception to warranties: recorded easements and rights of way.
1 ~
Dated this day of J u l y '19 90
(SEAL) (SEAL)
* Joseph R. LaMirande * Emma LaMirande
(SEAL) J~ (SEAL)
* ~ *10
AUTHENTICATION ACKNOWLEDGEMENT
Signature(s) STATE OF WISCONSIN
ss.
S t C r o i X County.
Personal[ came before me this / day of
authenticated this day of , 19 J U l y 19 9 0 the above named
Joseph R. LaMirande and
Emma LaMirande .n.
* ~ H. Sf'•
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the person S ..rvho gertgdAhg
authorized by § 706.06, Wis. Slats.) foregoing instrument and acknowledge the V ~1 1
THIS INSTRUMENT WAS DRAFTED BY
z
M
Ci
John D. W a l s h Notary Public S t . C r o i x (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (if not, state"Affifffi
are not necessary.) date: G~ 2 -19 :2 3
• Names of persons signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN WISCONSIN REALTORS® ASSOCIATION
FORM No. 2 - 1982 4801 Hayes Road, Madison, Wisconsin 53704
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
ADDRESS. hh 'F~ X 7) FIRE NO:
LOCATION: N L 1/4, 1/4, SEC. T30 N-R_12_W,
TOWN OF: o S
ST. CROIX COUNTY--
V
SUBDIVISION: LOT NO. 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 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.
SIGNED:
DATE : -`~--C-,
St. Croix County Zoning office
911 4th St. "
Hudson, WI 54016
fticomvn Deoa-tmrrt of Industry.
~UIL Ut~~nlr l tvt• ttt.t vn t
000!, and human Relations -U ice
(Attach Soil Profile Location Map • To Scale -On A Separate, Signed Sheet) madtson.:•t z3:C'
Page J_
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LOT BLOCK SUBDIVISION wtw _ atrtaet
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In Munsell u. St. Cont. Color Texture Gr. $t. $h. Consistence Root Boundary Depth Trench B•d A,1114- s +2
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Additional ~Remarki:~~/ /y 61 //A RECOMMENDED SYSTEM TYPE: /'yt/i1i>nr
Other Stte FtJlures:
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Sysfcin Elevation T rgn re oats t9ned Telephone No. CSt •
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CST Name (Print) City State Lip
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PAGE OF
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will 2' Ayprepele
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OIS'I'RIBUTIOU PIPE To K AT L.CAYT INCHES BELOW ORiGIMAI. •.,.;AOC
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RAPE WILL Sr- _ INCHES
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SIGIJCO: -
LICCUSC WUMBEIZ:
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DATE:
1 1 O
REPT131 SOMERSET ST. CROIX COUNTY ZONING PAGE 1
.10/01/92 19002;? EQUESTS FOR INSPECTION WORK SHEETS FOR: 10/ 1/92 AREA: JT
Activity: A9200184 10/ 1/92 Type: CONVSEPT Status: PENDING Constr:
Address: SOMERSET 1.30.19.475C,SW,NE,HILLDALE DR.
Parcel: 032-2003-60-001 Occ: Use:
Description: 149337
Applicant: BERENDS, MICHAEL J & LINDA L Phone:
Owner: BERENDS, MICHAEL J & LINDA L Phone:
Contractor: O'CONNELL, KIM A. Phone:
Inspection Request Information.....
Requestor: KIM O'CONNELL Phone:
Req Time: 14:10 Comments:
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION
Inspection History.....
Item: 00012 FINAL INSPECTION