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AS BUILT SANITARY SYSTEM REPORT
OWNER-/ .'GLc TOWNSHIP l )~rili ~.c~
SECTION ~S- T-,LLN-R /r W
ADDRESS % `lG J Q S` f~Gb~Y T. CROIX COUNTY, WISCONSIN
l ~`7~0 ~D~~S`fii
ol~aq"i V
SUBDIVISION__ C s lYl LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
3 - SX
,
r J
A
t
INDICATE NORTH ARROW
BENCHMARK: Elevation and description:
Alternate benchmark
SEPTIC TANK:Manufacturer: 29 -..-~4- Liquid cap.
Rings.used:, Manhole cover elev: Final grade elev:
Tank inlet elev.: Tank outlet elev.:
No. of feet from nearest road:Front-,I-l Side , Rear Ft.'zjIJ~
From nearest prop. line: Front-L.., Side , Rear Ft. /,Old, v4
No. of feet from: Well, Building:
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
t.
~a
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: S Length Number of Lines
Area Built-i~6;1
Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth to top of pipe:
No. feet from nearest prop. line:Front X
Side ! Rear Ft.?,,7'
No. feet from well:
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: ~Y1 2
6/90:cj
i
ii~c3rt~st~i5. 29.18.7IVEWA'GE ~YSTEMT. LOT County:
Labor qro Hum' n Relations INSPECTION REPORT
'Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarygyn.it"ekoIX
Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State Plafi N-48
CS BM Elev.: BM Descriptio Parcel Tax No.:
1131:11 RIC 19"WARREN
044 '~&e
TANK INFORMATION ELEVATION DATA 042-1011-40-200
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic. Benchmark /oa
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet 1y•8I $.5-. a-!
TANK SETBACK INFORMATION St/ Ht Outlet
Ventto
TANK TO P/ L WELL BLDG. Air Intake ROAD Dt Inlet
Septic yin o ' `n,a 7'5 NA Dt Bottom
&rat
Dosing NA Header/Man. ~19 C.2 ai
~j
Aeration NA Dist. Pipe ,4.3~ 8o.7s
-7 -7
Holding Bot. System 'aoa
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand ' /d~f7
Model Number GPM
TDH Lift Friction System TDH Ft
mead
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width , Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ` 3 DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type O7 / Moe Number:
System: ~le.• 0 ' N OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes No
COMMENTS: ((Include code discrepancies, persons pr? ~ nt, etc.) ICU L2
~ N
Q `/v a31 f t I$
-2it
I
aa.
Plan revision required? ❑ Yes ❑ No ` r
Use other side for additional information. P6 tea'' i i A'
r---r
SBD-6710 (R 05/91) Date / Inspector's Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: .
I
70ILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code couNTr
STATE SANITA PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than El ~~C.~ 9
8% X 11 inches in size. Ch k if revision o 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
Q o^ Q~ 90 W aS`'J Y4, S,! T :Z O, N, R J~- E (orw
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
11+,K l o' S 7`.C ~71_
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
c T G✓ .4-' 02f1 , S'am
ITY
LLAGE : NEAREST ROAD
II. TYPE OF BUILDING: (Check one) ❑ State Owned VI
n : dddY~G.~/ d 6- 7-X
❑ Public 1 or 2 Fam. Dwelling,# of bedrooms PAR EL AX NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply) l ®l l ^ ~O ~o d
1 ❑ 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. XNeW 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ 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
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) ??.61e ELEVATJON
,{sd ?P sa .
6~ fro a 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 Holdin Tank t~r
Lift Pump Tank/Si hon Chamber El I El n
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Signature: (No S ps) /MPRSW No.: Business Phone Number:
Plumber's Name (Print):
7 - eo 1
-W-oo. 5:dA * 'e~ Z:,~ 8X ) 312C
Plumber's Address (Street, City, State, Zip Code): J
Id, 7 5<:- d f%r5 Q.r/ GlJ/ f
IX. C NTY/DEPARTMENT USE ONLY
❑ Disapproved Sagjtary Permit Fee (Includes Groundwater Date ssue Issuing gent Signature (No Sta s)
''/P¢ Surcharge Fee)
AApproved ❑ Owner Given Initial //c~~ ! O
Averse Determinati n t0 r 0000F
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 SaWf~airy Oermit 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
§ubmitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by i 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.
Vlll. 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 soil absorption system if
_."required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNUWATEW"CHARGE
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)
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 /R C~6-rya
Location of property.-a/4 S4d1/4, Section Jt- , T 7N-R /7W
Township 6,j a"'
Mailing address 1 4lG /D,S 7 / a,l e,.- r.%- Lam' <
Address of site el" 1~1l
Subdivision name <-"3A? a Lot no.
Other homes on property? yes No
Previous owner of property
Total size of parcel -r ~~.E/'-e- ,9
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes _D~_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 in the office of the County Register of
Deeds as Document No. 4/ t l ~7 2 j"- , 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.
I
8
Signature of applicant Co-applicant
Date( of S gnature Date of Signature
II
jj
•DOCUMENT No. S OE BAR OF WISCONSIN FORM 1 - 1980 THIS SPACE RESERVED FOR RECORDING DATA
WARRANTY DEED
4819'76 1:
J5PAG 1
L -ICE
REGISTER'S OFF
T WS D dO, so ade bettyanca $T. CRO~X CO- WI
yrforna bison
j oo -n n . Recd for Record
as survivorship marital Propert
.
y
APR 1 1992
Grantor,
and.......... Richard..A..-. Olson.. and. Roxanne J___ Olson of 3:15 P. M
_..a-s survivorship marital_.propetty
mm a nn
v%
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration..-... R@9131@f of D@@ds
RETURN TO
j. conveys to Grantee the following described real estate in -St_._ Croix
County, State of Wisconsin:
Tax Parcel o-
Lot 2 of Certified Survey. Maps recorded in Volume
of Certified Survey Maps at Page .71171 as
Document No. q?190S Located in the Northeast
Quarter of the Southwest Quarter of Section 5, T29N,
R18W, Town of Warren
This _ is not :-F': homestead property.
.
(is(is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;'
And................................................................................
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
and will warrant and defend the same.
day of April 19.92....
Dated this 74
~J
~----.4% SEAL) (SEAL)
Myron K. Olson
=7}-+- !"~!'.--(SEAL)
......L-~ (SEAL)
* orna • E.. Olson.---••-•••----•----•••--•• `
i
AUTHENTICATION ACKNOWLEDGMENT
I'~ N~lnn~::~
Signature (s) STATE OF WL%CO- SIN
SS.
45h1 ~ivn
n County.
T
authenticated this ........day of..._... 19...... Personally came before me this day of
Av.Y1.t 19y2-... the above named
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not-
authorized by § 706.06, Wis. Stats.) to me known to be the person who executed the j
!I foregoing instrument and acknowledge the same. I~
II
' THIS INSTRUMENT WAS DRAFTED BY I
Ij
akkeNorm:~
Notary ~1~1J LEE ~UI`ID unty, Wis
(Signatures may be authenticated or. acknowledged. Both My Co m' Is Per e t. (I£ of state expiration r
are not necessary.) date: . CTARY.PUBUG TAINNESOTA, 19 'i.) d, Y
__WASHINGTON..COUNTY_ -
- -
My OW 4944M Vq*W 3-18 68 r ~q
-Names of persons signing in any capacity should be typed or printed below their signs rea
STATE BAR OF WISCONSIN Wisconsin Leval Black Co. 1;t y~rs
i
C ER T I F- I ED S UR V E Y MA P
Located in the NE1 /4 of the SW 1/4 of, Section 5, T29N, R 18W , Town of
Warren, St. Croix County, Wisconsin.
Surveyed for: Myron Olson NOTE: North
1146 105th St. quarter corner,
Roberts, Wi. 54023 falls in lake.
2097.40' _ UNPLATT-ED LANDS
N89°54'41"E " " (N89°54'23"E 510.00') 2608_85'_ _
1 - - -tT S9~5-4'7P"- 509.98'-
_ S 89.44'04"W 47,6.21' I
3292 (477.00) l I E1/4 Cor.
W 1/4 Corner
Section 5 l I Sec. 5
T29N, R 18W. 0
-co . 6 6'1
Bearings referenced to the East- N 1 1
West 1/4 Section line of Section 5,
assumed N89054'41"E. N I X11
~ ~ I I
LEGEND 2i 1-4 434, 767 Sq. Ft.
~-1 cry (9.98 Ac.)
t N
Section Corner monument. i CU Including R -O -W.
N m 1
390,770 S l Q
v
° 1 "X24" Iron pipe weighing N 00 (8.97 Ac.) Ft co ail N
1.68 lbs. Ain. ft, set. Excluding R-O-W. N NI ~i
• 1" Iron pipe found. W
b owl =
o=
-0- Fendline 41 ~ ~ml LO
W ~ ~ 01 ty
(47700') Previously recorded infor- EH+i Nt N
mation. a o
1 O ol O QI
z N 89'56'07"E 509.26' ZI Hi
NOTE: This map has been done a' Z 475.82' 3344,-~ N 91
to revise and replace that 2 I j wl
Certified Survey Map recorded 217, 878 Sq. Ft. l I
in Volume 8, page 2283. No (5..00 Ac.) I
new lots have been created'.
W o Including R -O -W . of Town and County approvals ? 0 203, 605 Sq. Ft. 0 6 6'1
are not required. N (4.67 Ac.) N) I
Excluding R -O -W . cl =1i
1
(477.00') 33.26' 1 1
d1011iP4l9m 475.63'
V Gp S 89' 56' 07"W 508.89'1 l
V
S/Az(S89°54'23"W 510.00') '6 31
UNPLATTED LANDS p' ,I
a HARVEY G. - o - - - - - - - M N
a JOHNSON °
5-1 0
899
HUDSO
o WIS o S1/4 Corner
< Section 5
moo q No
T29N, R 18W
0I~- loll!
This instrument drafted by 492-2007
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uostntpgnS Alunoo xtoz0 •IS agj Isagn4,egS utsuoostM aq4;o {,£'9£Z uot40 as
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satz,epunoq zotzajxa oql ;o uot4-ejuasazdaz joazzoo pine anal -e st I-eld Bons
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NOIJ dIUOS3Q
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER iy~J~ r d 01 3?
ADDRESS FIRE NUMBER
CITY/STATE 2CeZer'-es° ZIP
PROPERTY LOCATION: 1/4, SECTION , T ,Q? N-R ~T W
TOWN OF St. Croix County,
SUBDIVISION e S m , LOT NUMBER 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
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 systems agree to keep their
system properly maintained.
The property owner agrees to submit to St. Croix Zoning a
certification form, signed by the owner and by a mater 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.
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 stating that your septic has been maintained must be
completed and returned to the St. Croix Co. Zoning Officer within
30 days of the three year expiration ate.
c
SIGNED'
DATE'
St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
Wisconsin Department of Industry, SOIL DESCKIPTION REPORT Safetyy b euiiumgs Division
! tabor and"Human "lations P.O.BOx 7969
{ (Attach Soil Profile Location Map - To Scale - On A Separate, Signed Sheet) Madison, WI 53707
10 - Ce 3 8 7 Page of
Customer Name ~n r Evaluation oat* i Currant Lan use or Veyetauve over Parent Materias
I / f - 2 C,PO~a//INv - ft~ Fij~f~- ~(uE~tTti a~ -sA~OSTO v~
IPiCL~'w'q 6/50'J ,11V64- V
Customer 4MICIA s dk - 2 O (~!2 7-S 60/S S Yd 2 --z- sumac /DOst 1roun water flow Pam Elevation
I'~ ~ TLC ~ r
County D_ as arcs No. ystem Loading tom • m Per Sq. Ft. Per ay
5f CXW/ X GSM 46--
lot leya Descrrptron ystent tometry an Depth Slope an Aspect
NE, S6v, S,ee. S, 7 ~,tJ /P/~~[J , ~u ,P,fEv TdlvrJ . SEA 'w'01- '01'1"j /,7.190 5 k) .
Horizon Depth Dominant Color Mottles Structure Remarks: clayskips Loading
in. Munsell u. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Boundary ores Hand other GPD/h.2
/AYR 41y ~s 6) , ye iyn-e 2'w` G$
-3o /oYR-r~ ,e,.~ !f cS . G
39 i
- 9G /o ye s 8 fs , f vf/z of S /o>9,K v • S
14 0
Remarks: cla kips Loading
{ Horizon Depth Dominant Color Mottles Structure ys I In. Munsell u. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Boundary
ores H and other GPD/ft.?
2 ~-rz YK 5/G S vim, sic 40
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REPT131 WARREN ST. CROIX COUNTY ZONING PAGE 1
06/19/92 10:40 REQUESTS FOR INSPECTION WORK SHEETS FOR: 6/22/92 AREA: MJ
-Activity: A9200213 6/22/92 Type: CONVSEPT Status: PENDING Constr:
Address: WARREN 05.29.18.73B-20,NE,SW, 105TH ST., LOT 2
Parcel: 042-1011-40-200 Occ: Use:
Description: 171448
Applicant: OLSON, RICHARD Phone:
Owner: OLSON, RICHRD Phone:
Contractor: SCHUMACHER WILLIAM C. Phone: 386-3121
Inspection Request Information.....
Requestor: WM. SCHUMAKER Phone:
Req Time: 10:06 Comments:
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION
Inspection History.....
Item: 00012 FINAL INSPECTION