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AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP ~~>r~stiPi,
SECTION -2. T~J_N-R, 2 W „ -1 `1 _'j
ADDRESS ST. CROIX COUNTY, WISCONSIN
G /
SUBDIVISION 9fo l&'s~s LOT_L__LOT SIZE
i q 2.1 l V `i" +A. 5-t • PLAN VIEW
►'Y1,C1Y-~
.2W f~i C.I~I
N SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
ere
44211 1
27 16-.
1 oust
INDICATE N017H ARROW
J/
BENCHMARK:Elevation and description:
Alternate benchmark
SEPTIC TANR:Manufacturer: L,ff Liquid Cap.
Rings used:"` Manhole cover elev: Final grade elev:
Tank inlet elev.: Tank outlet elev.:
No. of feet from nearest road:Front Side , Rear_/_Ft
From nearest, prop. line:Front , Side., Rear Ft. S'f)~
No. of feet from: Well Building:
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
J
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
SOIL ABSORPTION SYSTEM
Bed: _Y Trench: Seepage Pit:
Width: 1-12 i Len th a
g _-2 Number of Lines: ~_Area Built
Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top of pipe:
No. feet from nearest prop. line:Front , Side, Rear Ft.Z
No. feet from well:_
No. feet from building. f~
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:
1
DATE:
PLUMBER ON JOB : i e
LICENSE NUMBER:
6/90:cj
y
~Aiuon~s~iigepart ernt`o ncustWIE 28.31.1-$.793 NE SW, LOT 1, 104TH County:
Labor and Human Relations PRIVATE SEWAGSYSTEM Safety and Buildings Division INSPECTION REPORT ST. CROIX
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 175637
Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.:
HARTMAN MIKE STAR PRAIRIE
CST BM Elev.: / Insp. BM Elev.: BM Description: Parcel Tax No.:
d~y0c,zr, ' 038-1166-10-000
TANK INFORMATION ELEVATION DATA A9200296 g d 92
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Aeration Bldg. Sewer
Holding St/ Inlet
TANK SETBACK INFORMATION St/ Outlet,
Vent
TANK TO P / L WELL BLDG. Airito ntake ROAD
Ar
Septic (o NA
osing NA Header,LMdkt- /p, p2'
Aeration NA Dist. Pipe /x,95' 9s 3/
Holding Bot. System x 7,8
PUMP/ SIPHON INFORMATION Final Grade 7. o 93,7 '
M cturer Demand lr/2ort,(?~~„ -7
Model Number GPM
TDH Lift Friction 5 em TDH Ft
_ ea
Forcemain Length Dia. Dist.
SOIL ABSORPTION SYSTEM
BED/TRENCH width l Length f No. Of renches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION /2- DI 1 N
LEACHING anufacturer.
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION TyPeO Coon , / CHAMBER Moe umber:
System: 30,4. Sys OR UNIT
DISTRIBUTION SYSTEM
Header /Aftrrototil It Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length _Lar Dia. Length _70' Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over f i Depth Over 1 xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center -6 Bed/ Trench Edges Z0 3 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
t
Plan revision required? ❑ Yes 2-K-0,
Use other side for additional information. 0
SBD-6710 (R 05/91) Date `r Inspector's Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
3
P e a ye
e
I
SANITARY PERMIT APPLICATION
T DILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
NEW .
STATE SANITARY IT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ /
8'/z x 11 inches in size. Check if revision to re ous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFOR ATION - PLEASE PRINT ALL INFORMATION.
PROPER OWNER PROPERTY LOCATION
. I,) '/4, IQC~12 , N, R / E(or
Z~Z& ie:~~Al 1411E
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CITY, STATE ZIP C DE PHONE NUMBER SUBDIVISIO NAME OR CSM NUMBER
l "s
II. TYPE OF BUILDING: (Check one) ❑ State owned ❑ viLTMLAGE 121 NEAREST ROAD
❑ Public ®1 or 2 Fam. Dwelling-# of bedrooms ~ PAR EL TAX. UMB ( )
III. BUILDING USE: (if building type is public, check all that apply)
1 ❑ Apt/Condo
20 Assembly Hall 6 El 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. 14 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 Im Seepage Bed 21 ❑ Mound 300 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
REQUIRED (sq. ft.) PROPOSED (Gals/day/sq. ft.) (Mi ./inch) ELEVATION
Feet Feet
-7,/ 17 A
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 strutted
Septic Tank or Holdin Tank
L42o A 72~5 1 F__I 4H
EJ L F-1 F-1
ift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for instal tion of the onsite sewage system shown on the attached plans.
Plumber' Name (Print)s Plum er' ignat e: (NO)S s) MP/MPRSW No.: Business Phone Number:
P umber's A dress Street, City, State, Zip Cod :
se
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater 'ate Issued issuing Agent Sign Stamps)
Approved ❑ Owner Given Initial Surcharge Fee) _1Z '9L
~
V
T 4>
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 & 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'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; replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; (Jose 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
9TC-100
This application form Is to be conplatod in full and signed by the owner(s) of
the property being developed. Any lnadoquacles will only result in delays of
the parmlt issuance. -Should this development be intended for resale by
owner/contractor,(spec houoe), 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 _.k~E_114 S /4, Section Tom! s-R/9y
Tovns h l p
Malling address 1>
i
Address of site
Subdivision naos
Lot nue►ber
Previous owner of property ~yw/"Op'-Ae
Total size of parcel _ ~Z~~ ✓C i~'~
Date parcel was created
At* all corners and lot lines Identifiable? an yo
Is this property being developed for resale ('spec house)?, as
No
Volume and Page Number as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A VARRANTY DYtD which Includes a DOCUNRHT NUHBYR, VOLUHS AND PAOZ KUHatR, and
the SISAL OF THE RROISTER OF DEEDS. In addition, a certIfled survey, if
available, would be helpful so as to avoid delays of the reviewing process. It
the deed description references to a Ceitifled Survey Nap, the Certified Survey
Hap shall also be required.
---------------------------------------------------------7---------------------
PROP UTY OWNER CERTIFICATION
I(Vs) certify that all statements on this form are true to the best of my (our)
knovledgel that I (we) am (are) the owner(a) 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 dlaposal•ayaten► (or I (we) have
obtained an easement, to run with the above described property, tot the
construction of said system, an the same has been duly recorded In the Office
Of the County ql e o ad , as Document No.
>f gnatur-so f Ow r Signature of Co-Owner (If Applicable)
Data of Signature Date of Signature
DOCUMENT No. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
STATE BAR OF WISCONSIN FORM 2 -1982
i
486988
t'OL 93PAGE 129
Richard J. Wier and Diane M. Wier.,..husband-and. wife- SREGISTER'S OFFICE
- - T.CROIX
CO" WI
as joint. tenants - A Recd for Record
AUG 10 1992
conveys and warrants to M?-chael__J.__Hartrw________________________--___-__--_ it
2:15 P M
- -
RegistercfDeeds
II.
i' RETURN TO
ICI I:
it - - - 'i
X
1
the following described real estate in
County, _
~I
State of Wisconsin:
Tax Parcel No:
I
Lot 1, Red Pine Estates in the Town of Star Prairie, St. Croix County, Wisconsin.
~I
i
I
FEE
I
II .
j
This .--is--not homestead property.
(is) (is not)
Exception to warranties: easements, restrictions and rights-of-way of record, if any
Dated thi - day of .August
7- . ------•----r F--------------------(SEAL) X (SEAL)
Richard J. W' r * Diane M. Wier
- - - (SEALI) t8"~ a Ks .>o~cr ?Yr~ w,.wro~v~vw~.v --(SEAL)
.offW4A fWAN
* ex?i'. ;?F f'i361X: - iRYrKr°X?TA
i
- - - - - - ~~x;a,,..tit I r.,iFY COUNTY 4
+'i t t k 54, It`kYd tXPIRE3
67
AUTHENTICATION +t;A~•KAi:EIE.aTsl6d$~ITa~:a
Minnesota
Signature(s) X STATE OF =00001
ss.
Ramsey
County
. jj
authenticated this .-._..--day of--------------------------- 19...... Personally came before me this .`A_V.Y.\._day of
19.':ia: the above named
E2
--------1__hard wiex---------------------------------------_
Diane._M_.__Wier..................
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not- authorized by § 706.06, Wis. Stats.) to me known to be the person who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
hristina Ogland - -
Attorney at Law
County, Wis.
N ar - -
y Public- -
(Signatures may be authenticated or acknowledged. Both - y Commission is perman . (If not, state expiration
are not necessary.) date: 19.~
.Names of persons signing in any capacity should be typed or printed below their signatures.
SEPTIC TANK MAINTENANCE AGREEMENT
w
St. Croix County
OWNER/BUYER
o
ROUTE/'$OX NUMBER" Fire Number
tzi
r
S` el
CITY/STATE Z IP (0
PROPERTY LOCATION;'.'Section T N, R W,
Town of /t• Croix County,
Subdivision2~Vol .~.s/l.S Lot number
;r .
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 1'icbnbed" 'a'e'pt'i~,..tank um er. What you put into
the system can a ect Cre functionn of the 'i1pp:tic tank as a treat-
ment-stage in the waste disposal system.
St. Croix County residents''ma~'be eligible to recieve a grant for
a maximum of 60% of the cost.of 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 's sy t'ems agree to keep their system properly
maintained.
The property owner agrees to.submit to St.. Croix County Zoning a
certification form, signed by the owner and by a mater 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 :scum.
Certification form will be sent approximately 30 days prior to
three year•expiration.
H
I/WE, the undersigned have read the above requirements and agree 0
to maintain the private sewage disposal system in accordance with
the standards set forth, herein, as..set by the Wisconsin Depart- a'
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Office ithin 3 d ys
of the three year expiration.date.
SIGNE /
DATE'/
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
Wiscdnsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page / of
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY ~
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. 0_79- -
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROP TY OWNER: PROPERTY LO ATION
GOVT. LOT 1/4 1/4 8 T N,R !Y(or G
PROP RTY OWNER'S MAILING ADDRESS L # BLO # SUBD NAME R CSM #
CITY STATE ZIP CODE PHONE NUMBER []CITY ❑ ILLAGE MOWN NEAREST R0
( )
pQ New Construction Use[ ] Residential /Number of bedrooms [ ] Addition to existing building
j J Replacement [ ] Public or commercial describe
Code derived daily flow. /t1, ,,9c; gpd Recommended design loading rate bed, gpd/ft2 -trench, gpd/ft2
Absorption area required bed, ft2 7, /n trench, ft2 Maximum design loading rate , ~bed, gpd/ft2_,_e _trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material Apod plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem ®S ❑ U ®S El U ®S ❑ U ®S ❑ U ❑ S ®U ❑ S U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Bounclary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed TmrK:h
,
j:t
/7
19 Lj
Ground _
elev.
9L~~ ft. -
Depth to
limiting
factor
Remarks:
Boring #
r
Ground
elev. Z" SZ
Depth to
limiting
factor
Remarks:
CST Name:-Please Print / Phone:
Address:
_ -1
Signature: Date: CST Number:
9-
PROPERTY OWNER - Zr,49,AZ SOIL DESCRIPTION REPORT
Page of
PARCEL 1.134
# c'73R/ill -f
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
Bed Trench
-z -
:
Ground 3, Sv /V
elev.
-st -
A4Z Depth to
limiting
factor
2'104
Remarks:
Boring #
v '14
/ •:ti" JIB ~
4.~•.•..•. - V
Ground
elev. ,
77, Z 7 9w
Depth to - - - 7 _2
limiting
factor
Remarks:
Boring #
-119 J,~Z-v
l
Ground
elev. _
Depth to -
limiting
factor
/d 9
Remarks:
Boring #
4l:
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
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DATE :
REPT131 STAR PRAIRIE ST. CROIX COUNTY ZONING PAGE 1
09/03/92 08:59 REQUESTS FOR INSPECTION WORK SHEETS FOR: 9/ 4/92 AREA: JT
'Activity: A9200296 9/ 4/92 Type: CONVSEPT Status: PENDING Constr:
'Address: STAR PRARIE 28.31.18.793,NE,SW, LOT 1, 104TH ST.
Parcel: 038-1166-10-000 Occ: Use:
Description: 175637
Applicant: HARTMAN, MIKE Phone:
Owner: HARTMAN, MIKE Phone:
Contractor: O'CONNELL, KIM A. Phone:
Inspection Request Information.....
Requestor: O'CONNELL, KIM Phone:
Req Time: 11:09 Comments:
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION
Inspection History.....
Item: 00012 FINAL INSPECTION