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AS BUILT SANITARY SYSTEM REPORT
OWNER +l 04 N U V-Alk TOWNSHIP S .2rse,-f
SECTION-3 TAN-R_,L __W
ADDRESS 702 2 14c,)x 4 ST. CROIX COUNTY, WISCONSIN
..Se m~ r L J.4 ,55/ o..2- -S
SUBDIVISION NZA LOT_.LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
aP ~~t
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INDICATE NORTH ARROW
BENCHMARK: Elevation and description:
Alternate benchmark n -
SEPTIC TANK:Manufacturer: t'ec~ar;4 FnC Liquid Cap. /JZ7D
Rings used: anhole cover elev: 9Z ,,a Final grade elev:
Tank inlot elev.: .5~ Tank outlet "elev.: 95.55
No. of feet from nearest road:FrontSide Rear Ft./o2Q
From nearest prop. line:Front , Side, Rear Ft. ~U
i
No. of feet from: Well 546 Building: a?a
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
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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
SOIL ABSORPTION SYSTEM
Bed: Trench: Seepage Pit:
Width: /2 Length Number of Lines:
-.2-Area Built Exist. Grade Elev. 9 7, 7 Proposed Final Grade Elev. 9,7,R
Fill depth to top of pipe:
No. feet from nearest prop. line:Front , Side, Rear Ft.-Lv/-
No. feet from well:-2lL_No. feet from building -Re'
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: 3
6/90:cj
r
LOCATION: SOMERSET 3.30.19.506A NE NE STATE HWY 116411
Wisc nsinDepartmentofIndustry, PRIVOE SEWAGE SYSTEM County:
Labor Human Relations
S INSPECTION REPORT ST. CROIX
Safety fety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION 180277
Permit Holder's Name: ❑ City ❑ Village [XTown of: State Plan ID No.:
LOURDE, ROY C SOMERSET
CST BM Elev.: Insp. BM Elev.: BM Description. Parcel Tax No.:
,D / 032-2010-10-000
TANK INFORMATION ELEVATION DATA A9200356
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet CfS,
TANK SETBACK INFORMATION St/ Ht Outlet 2 ~3 9S,3~
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic $v 6 r a' NA Dt Bottom
Dosing NA Header / Man. 0 9 q 1/• 2 7
Aeration NA Dist. Pipe g, a 9 y, 7 3
Holding Bot. System q.aV q?, 7V
PUMP/ SIPHON INFORMATION Final Grade ~G
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
oss Fi
Forcemain Length Dia. Dist. Toweu
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS /O'~.< DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O CHAMBER r / Mode Number:
System: ITO 5-61 OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold / Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length i ~ Dia. L/ Length ~2__ 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 E] Yes C] No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: SOMERSET 3.30.19.506A,NE,NE,STATE HWY 116411
Plan revision required? ❑ Yes No a
Use other side for additional information. (a &
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
z
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
DiLHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code CoUN
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than `1?0 a 7 9
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 OWP PROPERTY LOCATION
d Llk r 44 L126 t/a '/4, S 3 T54, N, R or) W
PROPERIfY OWNER'S MAILING ADDRESS LOT# BLOCK#
7 a w G $1 AJCITY, STATE ZIP CODE PHONE NUMBER SUBDIVISI N NAME OR CSM NUMBER
so w 5y62.s N
II. TYPE OF BUILDING: (Check one) StateOwned CITY NEAREST ROAD
O VILLAGE gr m r gtwhm 6(w se
❑ Public 4 1 or 2 Fam. Dwelling of bedrooms a PARCEL TNUM ER( )
o3a-ao~o- (o
III. BUILDING USE: (If building type is public, check all that apply) s d
1 El 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. ❑ New 2. N Replacement 3.E1 Replacement of 4. ❑ Reconnection of 51:1 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 N 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-ln-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PE RC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
Zj 5o REQUIRE (s . ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) eE~LEVATION
650 i~ 9 N 7 Feet / 7 )-Feet
--Immmmk!W V_ VII. TANK CAPACITY Site
in allons 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 Hold! n Tank /0= i, F-1- 11 F]
Lift Pump Tank/Si hon Chamber 1:1 1 El
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 Sigtt: (No Stamps) /MPRSW No.: Business Phone Number:
C CJ Ll L h D W e-5
,r
Plumber's Address (Street, City, State, Zip Code): ,
174 9 / 8s 1~*, o-p--
IX. COUNTY/DEPARTMENT USE ONLY
Groundwater ate Issued Issuing Agent Signature (No tamps)
❑ Disapproved Sanitary Permit Fee (Includes Surcharge Fee) Ecj
Approved El Owner Given Initial , 60,
0 • p?9 9z '
Adverse Determination l/ Ina
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
f
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
sub" ad~to the counkpriortp installation.
5. Onsite sewage systems must be properl'y'mainta ned: The septic tank(s) must be pumped by is licensed '
pumper-whenever necessary, usually-every 2 to .3 years.
6. If you hive questions concerning your' enkite sewage system, contact your local code administrator&the
State of Wisconsin, Safety & Buildings Division, 608-266-3815. ,
To be`Lomplete and curate this Aqg itary permit application must include:
1. Property„bwner's heme.;and-j.nigilia8 address. Provide the legal description and parcel tax number(s) of
where the system is to be insta4d.,
II. Type of building being served. Gthe6k 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. 6omplete 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 'I.gbsorption systemdf-z ,
required by,the county; E)_e4dIl lest data oW aAM form; and F) alt4iziog infeirf6ati
YRd6N16WATER SURCHAR13E
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies tlected through these surcharges are used form nitori r
_ pa 9_9_9,"dwater, ground-s`..,
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.
Owner of property
Location of property 711V/44 _41J5114, Section, T -36 N-R__~2W
Township
Mailing address
to ~
Address of site
Subdivision name AJlfi Lot no.
;
Other homes on property? yes_ No
Previous owner of property r^►'~E 17C 1 S
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? /1 Yes No
Is this property being developed for (spec house)? Yes No
Volume and Page Number 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 theU ~ fice of the County Register of
Deeds as Document No. !b , 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.
Sig . ure of applicant Co-applicant
Date of Signature Date of Signature
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STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER R13w
ROUTE/BOX NUMBER ~c _ Fire Nu'>>bcr
CITY/STATE LArk ' IP
PROPERTY LOCATION:`j& ~4, 4i Section_5 T_30 N, R W,
St. Croix County,
Town of _ -
Subdivision _ Lot number. I
Improper use and maintenance of your septic system could result in
its premature"failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank pu iiLer. What you put into
the system can affect the futlctiui If the 5~~,~LC Lank as a treat-
ment stage in the waste disposal system.
St. Croix.County residents maw 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'l, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master 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 icum.
Certification form will be sent approximately 30 days prior to
three year expiration. yo
E
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- w
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. C -oix County Zoning Office
P.O. 'lox 96
Nammo id, W1 54015
715-7)6-22:9 or 715-425-8363
Sign, date and return to above address.
.Isconsln Department of Industry, SOIL AND SITE EVALUATION REPORT Page of
Labor and Human Relations I
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code _
COUNTY
Attach complete site plan oq paper not loss than 81/2 x 11 inches in size. Plan must include, but
not limited to vbhical and hiorizontal.reference point (BM), direction and % of slope, scale or PARCEL`hD. #
dimensioned, north arrow,, and location and distance to nearest road. ,
AE E' D BY DATE
APPLICANT INFO RMATION-PL'EA~ PWtNT-AL'L INFORI AtION
PROP RTY OWNER: PROPERTY LOCATION
GOVT. LOT IV15 1/4 f l f 1/4,S 3 T 3d N,R 2r,W,
PROPER WNER':S MAILING ADDR SS LOT # BLOCK # SUBD. NAME OR CS # j
cO N 151
CITY, STATE " ZIP CODE PHONE NUMBER []CITY []VILLAGE OWN NEAREST ROAD
S me r Lot OL6 aS ( ) o m trs e.
New Construction Use P4 Residential / Number of bedrooms 3 Addition to existing building
Replacement Public or commercial describe
Code derived daily low, 5Q_ gpd Recommended design loading rate *7 bed, gpd/ft2 Irench, gpd/ft2
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate _L2_bed, gpd/ft2 trench, gpolft2
Recommended infiltration surface elevation(s) 93 .*7 ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material C9 aLA3 CXS Flood plain elevation, if applicable N A ft
OU
S =Suitable for system CONVENTIONAL MOUND 7VNGSR
ND PRESSURE 7AT-GRAII SYSTEM IN FlLL HOLDING Unsuitable for s stem I$ S[] S❑ U U S [RU 0S U 0S
jr 1
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure jG DYft
oring # Horizon Texture Consistence Boundary Roots in. Munsell Qu. Sz. ConL Color Gr. Sz. Sh. D-10 7,5 sl 1 C W 1
13 C N 1. Ground C a9-88 p R S S C i c'~ r M) C W *7
elev.
~,3fL
Depth to I
limiting 1
fact
Remarks:
Boring #
10-11 S a 5 1 irr CW J n.
o~ . 1130 d / f Mir C(Z I
Ground
elev.
q.74-& it.
Depth to
limiting
facto
Remarks:
CST Name:-Pleaso Print nn Phone!,-/,
. a yL - sf.3s
Address: /n9' 8s.'t% v~. 2~.J c, nc~ W t x
Signature: ~SCST -r j bey.
PRDPERlrOWNER rid SOIL DESCRIPTION REPORT Page ~of
PARCEL I.D. f
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourdary Roots GPD/ft
In, Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tn3nch i
3. 6 --g 74 S 3 C LO M
i.-Sbk w. B g• aG 16 YR. 9/4/
t x w w / y
Ground C b -qd /D Ce Sb •e O e I C W
elev.
,
%
Depth to
limiting .F
factor
Remarks: '
Boring #
off
Ground
elev. i
Depth to
biting
factor j
-
Remarks: '
1 Boring # ,
i s, Wit? ~
"E,3
Ground
elev.
It.
f '1
Depth to '
Smiting
factor
Remarks:
Boring # 11•
Jry
13'
Ground
elev.
IL
Depth to
timiting
factor
Remarks-
SB D-8330('?.05/92)
0Sf' ; -
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 3-1982 THIS SPACE RESERVED FOR RECORDING DATA
QUIT CLAIM DEED
211)72 ,PAb1:
BOOK301 - REG45MRS OFHCE
ST. CROIX Mr WIS.
Francis W. Plourde and Marceline R. Plourde, 2nd
Rec d. for Record this
his wife, Jan.
y of D. 0. 19
at 2:10 P.
to .------R~y C. Plourde .
2"MW . o..
the following described real estate in CrOlX____________________ County,
State of Wisconsin: RETURN TO
A 57.81% interest in:
The East 152 feet of the North 333 feet of
the East 1133 feet of the Northeast Quarter of the Northeast Quarter of Section 3, !
Township 30 North, Range 19 West Tax Parcel No:
S.JiJ!
I
I
I
i
This __.__.1 . not
. homestead property.
1010 (is not)
.
Dated this 2nd day of
1987
g.................................................
-----•-•-----••----•------•-------------•--_--------------------•----(SEAL) (SEAL)
Francis W. Plourde
~7~ - EAL)
----------------------------•--------••--------------•--------------(SEAL) <tr.c~_..
Marceline R. Plourde
ii
j AUTHENTICATION ACKNOWLEDGMENT
Signature (s) -Francis W. Plourde and STATE OF WISCONSIN
Marceline R. Plourde ss.
County.
! authenticated this ..day of.__Januarx....... ig• .7 Personally came before me this ................day of
19 the above named
hn_-D._-.Hey-wood---------•------------------------
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by § 706.06, Wis. Stats.) -
to me known to be the person who executed the s
~ foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
John D. Heywood
Heywood; 17at-1-11 --MU'rray---&°Sherb-arne
..5.Q.16__ Notary Public County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.)
date : 19--------•)
Z `a
QUIT CLAIM DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc.
FORM No. 3 - 1982 Milwaukee, Wis.
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0181#11a 116A
Ptpa e e e Tae t f
C' A~areoela If
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Pru~o)tD ~1~e~I qrr.~~{
SOIL FILL
DISTRIBUTI6F.1 PIPE
APPROVED $y1JPACTIC COVCRI
"AMERI&t. OR 9", OF STRAW
2 OF AGGREGATE
llp: OP
a
~L.EV. OF--[.r+_1FE1; !`OP%L•2t~t AGGRCISATC ~Pwv?
• - : ion j' I
DISTRI51LITIOM PIPE TO BC AT LEAST 1ti1GNES BCLOW ORIGIMAL GRADE
AIJU AT LEASTLO IIJCHES• BUT 1,10 MORC THAW 42. IIJCNES BELOW FINAL GRADE I
t`WIMUM DFptH OF EXCAVAT100 ROM otWWAL 6AAoF WILL BE 111licHeS
t~NIMUM CKFni ofEACAVAT100 r-P0A G~i(WAL GR^Ck WILL Bc I"cHcs
SIGMEOF.
I
LIGCUSC LIUMBE11: 15 C,~ }
DATE:
1 10 I
REPT,131 SOMERSET ST. CROIX COUNTY ZONING PAGE 1
09/29/92_C3 d0 REQUESTS FOR INSPECTION WORK SHEETS FOR: 9/29/92 AREA: MJ
Activity: A9200356 9/29/92 Type: CONVSEPT Status: PENDING Constr:
Address: SOMERSET 3.30.19.506A,NE,NE,STATE HWY 116411
Parcel: 032-2010-10-000 Occ: Use:
Description: 180277
Applicant: PLOURDE, ROY C Phone:
Owner: PLOURDE, ROY C Phone:
Contractor: POWERS, CALVIN Phone:
Inspection Request Information.....
Requestor: CALVIN POWERS I~ Phone:
Req Time: Comments : h-~
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION
Inspection History.....
Item: 00012 FINAL INSPECTION