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AS BUILT SANITARY SYSTEM REPORT
~ I
OWNER TOWNSHIP
SECTION--Z,:5--_T N-R ' W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION_ ,yh LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM - tip-`J"
f- .
INDICATE NORTH ARROW
BENCHMARK: Elevation and description: 140 e ?s~ - .~/f r~"J,G
Alternate benchmark
SEPTIC TANK:Manufacturer: ~ Liquid Cap. -10M Qz%
Rings used: _ Manhole cover elev:,.S' -Final grade elev:
Tank inlet elev.: Tank outlet elev.: 'S
No. of feet from nearest road:Front , Side, Rear Ft.,/.i~S-
From nearest prop. line:Front , Side, Rear Ft. S,/_ f
No. of feet from: Well , Building:_ --2V
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
i
s
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: X Trench: Seepage Pit:
Width: /-2, Length Number of Lines:_,--2_Area Built ZS%~
Exist. Grade Elev. 1 Proposed Final Grade Elev.
Fill depth to top of pipe:
No. feet from nearest prop. line:Front , Side, Rear-j_Ft,,~
No. feet from well: No. feet from building S~y
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
It9®rT1lgepartm1WnMndus' A -IE 15.31 P $ r EO E'WAOCiE NSffhh LOT 2 County:
Labor and Human Relations INSPECTION REPORT
tSbfety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary9rnitlekOIX
Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State Plaf M.4 3
X
CSR , C f,r,~M Elev.: BM DescriptiongTA~Rr ~PRAIRIE Parcel Tax No.:
~ ~lf . O~ ~'.CS C.>c
TANK INFORMATION ELEVATION DATA 038-1061-95-000
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic n7nC. Benchmark Gd I
Dos' d Lf ..d ~'(yL
Aeration Bldg. Sewer 10 11
Holding St// Inlet " ,&5,
TANK SETBACK INFORMATION St/0 Outlet , G r
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic o? NA Dt Bottom ~yQ
Do ' NA Header440km Ok',
Aeration NA Dist. Pipe '2 11P
Holding Bot. System 7 Z~a
PUMP/ SIPHON INFORMATION Final Grade
Demand M p
Model Number GPM
TDH Lift Friction stem TDH Ft
oss He
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH width i Length / No. Of T enches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS /v~ -3 DI I N
SETBACK SYSTEM TO P/ L BLDG WELL LAKE/ STREAM LEACHING facturer: INFORMATION Type O IA, CHAMBER ~ 7 r Model Num er:
System: d ~ OR UNIT
DISTRIBUTION SYSTEM
HeaderfMnft4Q1r. Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia if Length /6A Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade stems Only
Depth Over it Depth Over o xx Depth Of xx Seeded d xx Mulched
Bed/ Trench Center Bed /Trench Edges z / Topsoil ❑ Yes El No No
Z
9
COMMENTS: (Include code discrepancies, persons present, etc.)
Plan revision required? ❑ Yes ~Use o
ther side for additional information. p P I
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH r
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION
DILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
memo
' STATE SANITARY PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than 7 R(~?
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
C'/a ' t/4,S j T_ T_S/ ,N,R E(or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
C
CI , STAT ZIP CODE PHONE NUMBER SUBDIVISI NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one) CI NEAREST ROAD
❑ State Owned ❑ VILLAGE
[Z =NOFL:LL d--&,2g
NUMBER(S)
❑ Public ®1 or 2 Fam. Dwelling- # of bedrooms - PARCEL TAX
111. BUILDING USE: (If building type is public, check all that
1 ❑ Apt/Condo
2 ❑ Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 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. ~z New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.E1 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 ~j~-Seepage Bed 21 ❑ Mound 30 El Specify Type 41 ❑ Holding Tank
12 LJ 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
,4 Feet / Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New listing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Hoidin Tank
Lift Pump Tank/Si hon Chamber 1:1 El Ej El I El 11
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installati n of the onsite sewage system shown on the attached plans.
Plumber' Name (Print): Plumb 's Si nat re: No ps) MP/MPRSW No.: Business Phone Number:
S~
-34
Plumb s Ad s treat, City,- State, ip Code)"_
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issu' Agent Signature (No tamps)
Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination l
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 sanhary permit may be renewed before the expiration date, and at the time of reneAal any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revision; to th1 s permit must be approved by the permit issuing authority.
4. Changes in ownersh;p 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, 6013-266-3815.
To be complete and accurate this sanitary'p"ermit 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.
Ill. 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 ga"ons, 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 muss: sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than E1% 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 (8.11/88)
STC-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 propertxS1/4 L;,) 1/4, Section TAI N-R-,~g_W
.Township
Hailing address
f j
Address of site
Subdivision name_ Lot no._
Other homes on property? ~ye8x'.__No
Previous owner of property
Total size of parcel Date parcel was created
J _
Are all corners and lot lines identifiable? - ~ Yes NO
Is this property being developed for (spec house)? Yes No
volume` and Page Number as recorded. with the Register
of Deeds .
114CLUDE WITH THIS APPLICATION THE rOLLOWING:
A WARIUUITY DEED which includes a DOCUMENT NUIiDER, VOLUME AND PAGE,
NURDI R & THE SEAL OF THE ILEGISTGit 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(wc) certify that all statements on this form are true to the
best of ny (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. .>7 , and that I (we) presently
oo:n 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.
signature of ap~1icant Co-applicant
i
Date Sig ature Date of Signature
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 3-1982 THIS SPACE RESERVED FOR RECORDING DATA
QUIT CLAIM DEED
48343`
VOL 950PAGE 51'18 REGISTER'S OFFICE
ST. cROfx co , w~
Robert H. Soderquist and Lorraine B. Soderquist, s
4 hedforRecord
husband and wife as joint tenants MAY151992
quit-claims to Qt
Curtis Daniel Bulman and Diane Marie Bulmant husband M
P.
and wife, as marital property with rights of 1 : 45
survivorship
..1.
RegWer of Deeds
the following described real estate in St. Croix County,
State of Wisconsin:
RETURN TO
Tax Parcel No:U3o- 1Oto
Lot Two (2) of Certified Survey Map, filed August 12, 1983 in Volume "5" of
Certified Survey Maps, page 1327, as Document No. 386915, located in the
Southwest Quarter of the Southwest Quarter (SWJ of SWJ) of Section Fifteen
(15), and the Southeast Quarter of the Southeast Quarter (SEJ of SEJ) of
Section Sixteen (16), Township Thirty-one (31) North, of Range Eighteen (18)
West.
FW
F P,
This is not homestead property.
(is) (is not)
Dated this 14t-In day of May 19 92
(SEAL) (SEAL)
(SEAL) (SEAL)
.Lorraine B. Soderquist
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
SS.
St. Croix County.
authenticated this day of 19 Personally came before me this 14th day of
May 19 92 the above named
Rnhert H. Snderguist and Lorraine B.
~~rler~iii cr
TITLE: MEMBERSTATE BAR OF WISCONSIN
(If not, to me known to be the person I'fL~►e'.
authorized by § 706.06, Wis. Stats.) fore ng instrum t d ack wl¢d th ~x t
THIS INSTRUMENT WAS DRAFTED BY
Robert H. Soderquist O J
Ruth A. Johnson y
New Richmond, WI 54017 Notary Public St. Croix V Gounty, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.) date: 12/ 18/94 19 )
'Names of persons signing in any capacity should be typed or printed below their signatures. SB3 NTF 0023
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
ADDRESS: FIRE NO: c
LOCATION: <
_1/4 SEC. J=►1+ - N-R-,Z
TOWN OF: A ST. • CROIX COUNTY
SUBDIVISION: ti 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.
SIGNED: C c
} I.
DATE: iM
z.g
St. Croix County Zoning Office
911 4th St. _
Hudson, WI 54016
06/"03/92 12:13 1 715 425 2962 WILLIAMS & GILL P.02
"}''P.IiTMI Irt Or REPORT ON SOIL 5Q CgGS AND uOC11 ?r II .r Ij. PERCOLATION TESTS (x.15)
~ ',r
IUMAN ki: i:A1 IONS MADISON, Wl 1-37 is
(H63,09(1) & Chapter 145,045) l~cSt ` . .1'; , f'I>P1' 0Vft L
i.nC`.AYii IJ SE .11~iNi _ _••W _ TUW~I f~ l~TiAUNICIPA1.lT'Y: ~iY41i• UT NU. KLK.NU.ifSUBDIV IZiKNA~A~i-~~_.' -
-'w• 1 ~s /T 3l N R~ f o W ..,.,•..5 r h' 1.,.,.
- MIMA N AM t! MAILING ADDRESS;
a~~.•1~U~ T`
l•ISE " GATES USE RVATIONS MADE
j" - lt4 ('1,_ G0 EFI 7~rDUM'P t~ PROFFLT-IiUM(P
New ❑kcPleCa cJ ~J • 14 .
r
HATING: S" Site sultsble for system U- Sita unsuitable for system --.1
r.FYST € N FIL H LDIN A REC M [i$YSTEMr(Optipna
)f`GNVEIV`Ift)fJL1l, N1pUNCr IN- ZS-Uwcp*gM101 t
L$ CCU F] $ y 79
ZjN
'i'u..u.'~ b[SI RATE;
ed Y P
It n Tests are NOT, f Illy of the tHstwl area is in the - u 1
~.(t5i5}Ib), indit:~le ~°i~••k!a S FloodPlaln, Indicate FIOOCIpIa,n Clcveti0n; ~ • A
PROFILE DESCRIPTIONS
_
tiirvG '12TAl Clly' PTHTO R 11V WAT R•W S C1~{AF~A~TER~bT-mil WIT}i 1H1G1(NL S,~G (~f 7EXT'UH~, ANU'OEPTH
a.AJIBEI4 DEPTH E_.L._.CYVl..,1 101v V 1 1:U $EDR()CK lF E§gFiVED ISEE ABBRV.,UN BACK.)
- ! ~t.S•a~~ay,. S/.."1'S. j /.5 ~Lt 13A a1 d.2 o~r•,S
A)O/~ ~J ~s,i';• Z.2's~:.:..l~.j.C-c 1 er
I e• ! _ lV
_ A - }O V6' i~KC7~•-3iry-_~ ~...~,t7' Tns1 j 0.% • t3^ asi~r'
I _ ~ t2a7 • LY ~n'8~ 7'S ' D.~' Is•r ~r ~ ~•.S:a -tPr-
Py t
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P' 1,6.0' '91-s
PERCOLATION TESTS
r •
N '1 E L L-i-:-7l1" - A IN
-A A (-'fESI (icPTk EST Tllvi T) IR
it q rr,~• i PER INCH
~•_IMBUi INC.►fE. AFT. ,,l':F::!h. ird1tNVAL-MIN. Rl l5'i ..("1•x3r'~
_ 1.
r
P1.01 PLAN, Snain• locations of percolation tests, Soli bonogs and the dnromsions of suitable soil ksrbbi. hrdicbti• stale ter distances. beseribe what are tr,r. nori-
-'rrnh' anG verrtiwi elevaLron refvrencc poinu and show their Iot:ellon on the plot plan. Show the surfacv Pvvation at all borings and the dlremlon and ueroem
r. ~ ar,rt slUl•rt. ~ 7s *-C 'f t, C~aC...1tt N AR4 T S
/NI71,94 fdofic"-r of at.d-gs.aD
SYSTEM ELEVATION ^~~f2i:rf~Ls ~ 94.so'
ex"
. .ti~,.~~......... m. ~e+ti' .....--r.._.... ..lit r't_?.~1~?~'~.. ~~%Y%,?~is41/ti,•/
~t,~,-~,
a S•
,ate _S ..r 1.
$ x . ~..9. ' .d,f~'P. •L
It N
7: 1
jll
Sclzr. J :'40
1, the undersiped, hereby certify thht the soil tests reported on this form were rnede t,y nit In accord with the proceduins and mothods specified In the Wisconsin
Adrninistrat,vv Code, eh(1 111til Via data rooortibd and the 4otal4on of tl:e'lasls ors goirect to the best of my knomedpe and tyoiiel, r
~1d;~ yIE (siriiil~?'• . PESTS
l / } -tbMPLFTED ON;
I~Iif~F1rSS CEHTIFIi.AIiONNUMBER PHbN$~►UM~RTapiloriel)}
N?- y_... 10___.... SyoiJ
ST*PTWiAtA`tU
1F 1 liilit I lON; Original and onr c ouv +n 1 arr. Aulhoi:tt•, P-nperty Owner and Sol] Tester,- • .
~y~'~S" x:JU~/r/~9✓ ~jSe~ ~j..-Si«~5~~..5/~lS/~~i%~
yG ~14
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REPT131 STAR PRAIRIE ST. CROIX COUNTY ZONING PAGE 1
09/23/92 11:38 REQUESTS FOR INSPECTION WORK SHEETS FOR: 9/23/92 AREA: JT
Activity: A9200208 9/23/92 Type: CONVSEPT Status: PENDING Constr:
Address: STAR PRARIE 15.31.18.270C, CO. RD CC, LOT 2
Parcel: 038-1061-95-000 Occ: Use:
Description: 171443
Applicant: BULMAN, CURTIS Phone:
Phone:
Owner: BULMAN, CURTIS
Contractor: O'CONNELL, KIM A. Phone:
Inspection Request Information.....
Requestor: O'CONNELL, KIM Phone:
Req Time: 13:09 Comments: /i36
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION
Inspection History.....
Item: 00012 FINAL INSPECTION