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AS BUILT SANITARY SYSTEM REPORT
OWNER :::~yy% g~~ ND~ SrM d!VE TOWNSHIP d
SECTION 6 T_ZZr- N-R-W
ADDRESS Z 3 -3 ST. CROIX COUNTY, WISCONSIN
ieforzx'cwc'r e-11
SUBDIVISION p h ((D(, 176 fS LOT 7 7 LOT SIZE ft-200
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDICATE NORTH ARROW
BENCHMARK: Elevation and description: ®B~( /~d z /f~dN P/~°~ Eor c~zNC
Alternate benchmark
SEPTIC TANK: Manufacturer: lc S Liquid cap.
r
Rings used:z-Manhole cover elev: ~-Anal grade elev: q• s
Tank inlet elev.:. .7? Tank outlet elev.: /J, -/z
No. of feet from nearest road:Front7 Side , Rear Ft.
From nearest prop. line:Front 715D Side , Rear Ft. C
No. of feet from: Well Building:
Y9
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
t • r
PUMP CHAMBER
Manufacturer: ~r _Liquid Capacity:
Pump Modr.: Pump/Siphon Manufact..: Pump Size
Elevation Bottom of tank elevation
Pump on eump off elev.: Gallons/cycle:
Alarm: Ma Switch Type: Location
Distance from n arest prop. line: Front_, Side_, Rear_Ft.
Distance from: Well Building
SOIL ABSORPTION SYSTEM
Bed: Trench: Seepage Pit:
Width: ~,Length Number of Lines: Area Built Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth to top of pipe: 7~Z
/ r
No. feet from nearest prop. line:Front- L, Side', Rear Ft.
No. feet from well: N No. feet from building
HOLDING TANK
Manufacturer: Capacity:
No. of ri gs sed: Elevation of bottom tank:
Elevation inlet:
No. feet rom nearest prop. line:Front , Side Rear Ft.
No. feet f m: Well , building , nearest road
Alarm Manufacturer:
INSPECTOR:
DATE : Z PLUMBER ON JOB :
LICENSE NUMBER : _ /✓~h 3 ~~l'
6/90:cj
TRt y A3 y28.19.830 SE NW LOT 7 AST WOODRID
i i artmen o In us r` , ~RI~/AT~ SLOT SY~TEM County:
Labor and Human Relations INSPECTION REPORT
Safety and Rvildings Division ST. CROIX
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERA. INFORMATION 175677
Permit Holder's Name: ❑ City ❑ Village EiTown of: State Plan ID No.:
SIMONE JIM TROY
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
ar c t2.S 040-1188-90-017
TANK INFORMATION ELEVATION DATA A9200336 ~p
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark 2
D g
Aeration Bldg. Sewer
Holding St/0 Inlet
TANK SETBACK INFORMATION St/ I Outlet
TANKTO P/L WELL BLDG. Vent to ROAD Dt Inlet ,
Air Intake
Septic >so/ 1 NA Dt Bottom
DeSiT~ NA Headers 7~ S, 7f
Aeration NA Dist. Pipe c~? 191 '
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
L? 9
u acturer Demand Q 9, d
o Le ~✓e~- 3- ~
Model Number GPM
TDH Lift Friction tem TDH Ft
Forcemain Length Dia. .To Well
SOIL ABSORPTION SYSTEM
BED / TRENCH Width/0; / Leng No. O Trenches PIT its Inside Dia. Liquid Depth
DIMENSIONS 7 DI I N
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
.
INFORMATION Type O o,,I T Mode ber
A
System: y1r,. ~z ~'J OR UNIT
DISTRIBUTION SYSTEM
Header / momfew Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length (111 Dia Length 1-62- 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 `7 Bed/ Trench Edges a No
COMMENT (include code discrepancies, persons present,etc.)
10 uocu Plan revision required? ❑ Yes /
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH '
r
SANITARY PERMIT NUMBER:
DILHR SANITARY PERMIT APPLICATION
NTY
In accord with ILHR 83.05, Wis. Adm. Code COU4F+ C
STATE SANITARY PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ "7io s
8% x 11 inches in size. Cn ktf re Sion o prev 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
5 km * 6k 0A 57/AA o ir W/a, S TZg, N, R E (or
PROPERTY OWNER'S MAILING ADDRESSS~n ! LOT # BLOCK #
CI yST~1 ZIP CODE PHO E NUMBER SUBDIVI ION NAME OR CSM NUMBER
LL~V ~i C~( d L
aci l Off-tc 4 ~S
❑ll. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
LAGE
State Owned VIL
OWN OF
❑ Public [~;•i or 2 Fam. Dwelling-# of bedrooms PARCEL AX . NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply) CJ n O 1 ? O ^ o u
1 ❑ Apt/Condo !J
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
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. KNew 2. ❑ Replacement 3. ❑ Replacement of 4.E] 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
140 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
qS_0 1?M9 REQUIRED sq. ft.) PROPOSED (sq. ft.) (Gals/da /sq. ft.) (Min./inch) ELEVATION
v v ~~(roFeet Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holdin Tank
Li Ta mber El I Ll El El- I El El
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
PluT s Name (Print): Plumber' Signature: (No ) M No. Business Phone Number: o b-3Z2 Z 7.4 00
a
Plu ber's Address (Street, City, State, Zip Code):
V
r-ff- 00, (
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Iss Agent Sig (No Stamps)
Surcharge Fee)
Approved ❑ Owner Given Initial
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 a 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 elate, 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 fSBD 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 'c; 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 construcled 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 e'h 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 contrels; 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 foam; 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.
Fhe monies collected through thez;e surcharges are usec' for monitoring grorrodwater, gi, ound-
water contarnination investigations and establishment of standards.
SBD-6398 (8.11/88)
STC-100
7'h is application form is to be
completed
, in
the oc~nc full and sign
r(,, of tIIe ed b
Y
property being develo ed.
will only result in delays of the p Any inadequacies
development be intended f permit issuance. Should this
hour or resale by owner/contractor,spec
e), then a second form should be retained and completed(when
the property is sold and submitted appropriate deed recording. to this office with the
owner of property K,,v0a ~i1ilA/
Location of propert -
Yf g l/4 _ ~ Zl/4 Section
'
-3i~ , T_2~5N-Rjc~ W
Township 4 V
Hailing address
I A GS ( tJ 6 Z Z
Address of site ~ ~ (,vvaQ D 6E
L`-
Subdivision name- OA- 1 re- k2e-S
Lot no.
Other homes on property? es
y --K_N No
Previous owner of property ~~ClN6 ~flccs tip &-t
Total size of parcel V -7
Date parcel was created
Are all corners and lot lines identifiable?_
Yes No
Is this property being developed for (spec house)? Yes _kNo
Volume &and page Number - as recorded. with the
of Deeds. Register
INCLUDE WITH THIS APPLICATION THE FOLLOWING: -
A IIARI UITY DEED which includes a DOCUMENT NUIiDER, VOLUME AND PAGE,
NUMBER & TILT SEAL OF THE R.EGISTGR OF DEEDS.
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
10,!0) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner() f
the property described in this information form, by virtue sofoa
warranty deed recorded th ffice of the Count Re
Deed; as Document No, o Y gister of
and tha I (we
own the proposed site for the sewage di
sp salt system) orr Ie(we)
obtained an easement, to run the above described property, for
the construction of said system, and the same has been duly
rec r lie office of County Register of deeds as Document
No.
Signature of aplicant
Co-appl cant
IS 9 ~ Date gnature
. Date of s gnature
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVED FOR RECORDING DATA
,,"R A(?NTY DEED
VOL ~U8PAGE193
488304 REGISTER'S OFFICE
Rolling Hills Development, Inc., a Wisconsin ST.CROIXCo',W1
_ corporation 4 Redd for Rewrd
S E P 0 91992
conveys and warrants to James E. Simone and Brenda L. tt 12:15 P. M
Simone, husband and wife, as survivorship
marital property ewry+M~
Register of Deeds
RETURN TO
the following described real estate in St. Croix County, i
State of Wisconsin:
Tax Parcel No:
Lot Seventy Seven (77), Oak Ridge Acres,
to the Town of Troy.
fRp
-7. 00
This is not homestead property.
(is) (is not)
Exception to Warranties:
easements, restrictions, and rights-of-way of record, if any.
Dated this 8 ..day of September 1s
ROLL S D
(SEAL)
-By: Richar N. Fox, Pr sident
I/ nn
(SEAL) .~C c.-C_ eJ _ (SEAL)
-By: Frances J. Fox, Secretary
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) Richard N. Fox and STATE OF WISCONSIN
ss.
Frances J. Fox County.
authenticated this da of -September o92 Personally came before me this day of
19 the above named
. C. L. Gaylord
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the person who executed the
authorized by § 706.06, Wis. Stats.) foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
C. L. Gaylord, Attorney
River Falls, WI 54022 Notary Public County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission Is permanent. (If not, state expiration
are not necessary.) 15 )
date:
'Names of persons signing in any capacity should be typed or printed below their signatures. 7B2 NTF 0021
WARRANTY DEED STATE BAR OF WISCONSIN Nelco Tax Forms, P.O. Box 10208, Green Bay, WI 54307-0208
Form No.2 - 1982
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER_
ADDRESS: Z'3 N6~ L-J~M C.~ FIRE NO:
y-wo47-
LOCATION: C- 1/4, /`f (N 1/4, SECT -R_LJW,
TOWN OF: 1~Q Ly ST.•CROIX COUNTY
SUBDIVISION : n mQ u6P LOT NO. 2.
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.
GNED:
SI mz
DATE
St. Croix County Zoning office
911 4th St.
Hudson, WI 54016
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REPT131 TROY S ST. CROIX COUNTY ZONING PAGE 1
09/3A/92 0 3y REQUESTS FOR INSPECTION WORK SHEETS FOR: 9/30/92 AREA: JT
Activity: A9200336 9/30/92 Type: CONVSEPT Status: PENDING Constr:
Ad'dress: TROY 36.28.19.830,SE,NW, LOT 77, EAST WOODRIDGE DR.
Parcel: 040-1188-90-017 Occ: Use:
Description: 175677
Applicant: SIMONE, JIM Phone:
Owner: SIMONE, JIM Phone:
Contractor: NELSON, ROGER Phone: 273-4444
Inspection Request Information.....
Requestor: ROGER NELSON Phone:
Req Time: 15:09 Comments:
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION
Inspection History.....
Item: 00012 FINAL INSPECTION
i