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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER___ Sep NL 1 V~"~ I c7:y TOWNSHIP G~ c~ Sa V,
SECTIONL_T-2, N-R_LC
ADDRESS 9;:> z 7,,,, ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE D, L/ PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Sc.al~ ~/V It>
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38F-23" o
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/ ?0 Wa.l I
)LL
N F. M. I I ko a 4^h ~acob 5 ~-a ~IQY
INDICATE NORTH ARROW
BENCHMARK:Elevation and description: 1 R~Ok It _U1, deruQ✓ k~ = 00, 00'
Alternate benchmark-7,P a- D. s l " i
SEPTIC TANK: Manuf acturer : Liquid Cap. 1 L~ D fr
Rings used:-3-Manhole cover elev: S':(,9 Final grade elev: 710
i
Tank inlet elev.: S 7 S,' Tank outlet elev.:
No. of feet from nearest road:Front Side, Rear Ft. 13S
d
From nearest prop. line:Front , Sides, Rear Ft. I Z 5
No. of feet from: Well Building: Z3~
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
i
I
I
~ yr
PUMP CHAMBER
Manufacturer: /V Liquid Opacity:
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: Length `lw Number of Lines:_;~ Area Built Sy ~ ~
Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth". to- t
too. feet from nearest prop. line: Front,. 1 , Side X Rear Ft. Z$ "
No. feet from well:_qL~_No feet from building ~p
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:
I
INSPECTOR:
DATE : PLUMBER ON JOB : Ze-17 44
Z
LICENSE NUMBER:A/Z- "
16e 11
6/90:cj
leg/DOJ3Q
Wiv.ronsin Deoartmentof Industry, PRIVATE SEWAGE SYSTEM Lot 24 County:
afet and Human Relations
Safety INSPECTION REPORT Jacobs St. Croix
Y and Buildings Division
Sanitary Permit No.: GENERAL INFORMATION NW4 SW4. SecT21 , 20 PERMIT) Landing arborVie 149171
Permit Holder's Name: ❑ City ❑ Village L$ Town of: State Plan ID No.:
Sam Miller Hudson
CST BM Elev.: / Insp. BM Elev.: BM Description: Parcel Tax No.:
lU~, C X57- 1 246
0, (P
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark n3 3 d G
Dosing V o)Tn- 1 U ~ S9
Aer on Bldg. Sewer
6olding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Verit
TANK TO P/ L WELL BLDG. AirIto ntake ROAD Dt Inlet
Septic 14- NA Dt Bottom
'
Dosing NA Header / Man. 0.
,
Aerati NA Dist. Pipe /0,44
Iding Bot. System -.11,Y6 91,60
PUMP/ SIPHON INFORMATION Final Grade ,0
Manufacturer Demand 71
e
Model Num GPM
TDH Lift Friction System H Ft
mead
Length Dia. Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Lengt No. Of Trenches PI Of Pits Inside Dia. Liquid Depth
DIMENSIONS IMEN I N
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHI Manufacturer:
SETBACK CHAMBER
INFORMATION Type O 1 ode Number:
System: i o~ 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/Tr nchCenter - ~Q Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, p rsons present, etc.)
10 C_ C
Plan revision required? ❑ Yes M- o
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
SANITARY PERMIT APPLICATION
1:EDILHA In accord with ILHR 83.05, Wis. Adm. Code COUNTY
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than J e-1 17 8% x 11 inches in size. 1:1 check if revision to previous
application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
L APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
S 444 Sa> %4, S z/ Tz , N, R E (or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CITY, S TAT ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
s Syo ~~b ~ctlo ~ ; k
II. TYPE OF BUILDING: Check one TY NEAREST ROAD
(Check one) ❑ State Owned ❑ V CILLAGE
Fa 4OWN OF P<4", v;,"J
76 r
PARCEL AX NUM
El Public 1 or 2 Fam. Dwelling-# of bedrooms3
BER 7a 4/~ _ S~ _ .0-10
d'au-
Ill. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo I
20 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 80 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. ~4 New 2.E] 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 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-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 12. 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) 1 ELEVATION
~sd Z O Z O 4~1` el Z S G c/ . OO Feet * 7. Z Feet
VII. TANK CAPACITY Site
in allons Total It of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New xistin Gallons Tanks Concrete structed glass App.
Se tic Tank or Holding Tank Tanks Tanks JOLOO (~(JrLrS G
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsits sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
, 5Tra t, (e wn ' L Z Z
Plumbe s Address (Street, City, State, Zip Code):
k
V 3 Afq~w
IX. C NTY/DEPARTMENT USE ONLY
❑ Disapproved Stary Permit Fee (Includes Groundwater a e Issued suing Ag nt Signatur o Stam s)
Approved El Owner Given initial S charge Fee)
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
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 , AZ'//ay
Location of property&&1/4 - to 1/4, Section D ! , T o19 N-R /1 W
Township &
Mailing address ~oar-Zff
Address of site •~.~~6s C,
Subdivision name Lot no. a ly
o
Other homes on property? yesNo
Previous owner of property _ V; r ...~a
Total size of parcel 3
Date parcel was created -Z , a z
Are all corners and lot lines identifiable? --,L-Yes No
Is this property being developed for (spec house)? X Yes No
Volume Z o,sand 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. 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. 4,~g5r// 7
ignatu of applicant Co-applicant
Date of Signature Date of Signature
nrr.umrPil NO WARRANTY DEED 11415 S.ME fi.SEnr.H toll 01Et.0I1111NN UAIA
STATE IIAR OF WISCONSIN FORM 2-1902 L
1:• r• REGISTER'S OFFICE
% S16143 ST. CROfX CO., V1►1 .
j
QeCed for Record
\V~ ri;inia M. Hanson. a single woman
' MAR Z2 ~9t9
« 8:00 A M
011116t•16.:I1111 1t..rra lets to Sam E. Miller, a single man
tttNltlw of D"
A
the folhlu•ine dcscrthrd real estate in St. CCVIX ~oula~,
)
Male of Wotconsin:
Tax Pnrcel No:..............
West Half (WI;) of the Southwest Quarter (SW'&) tit Section
Twenty-one (21), Township Twenty-nine (29) North, Range Nineteen (19)
West, St. Croix County, Wisconsin except that part South of the public
highway and except Lots 5, 6, 7, and 8 of Certified Survey Map n Vol. 6,
Page 1747, Doc. No. 419479.
l
That part of the West Half (W~) of the Northwest Quarter (NWt) of Section
Twenty-one (21), Township Twenty-nine (29) North, Range Nineteen (19) West,
St. Croix County, Wisconsin lying South of the right of way of the
Chicago, St. Paul, Minneapolis and Omaha Railway Company.
r-r
'aa
TR"SIUA 0
}4
i
!!A
i~
This is not hnnlr•tteatl prol,rrt;:.
} >tatk 1 is not)
F:Itrt•I,Li:n1 t,• allrrnnties: easem•-.nts of record and projective covenants and restrictions
of record, if any.
a) 4r
! 11111/•11 this dac of C
1.1 ,
88
(i1•.A1.l -C ISEA1.1 ~
Virginia M. Hanson
t
ISEALt ISEALt
f
3
1
R AUTHENTICATION ACKNOWLEDGMENT
S Signature(s) STATE OF WISCONSIN 1
j J~ \ u `k Count}'. `
authenticated this day of 19 1'ers+Inall}' came before nlr this ` day of
r
;f ty\n IL t•-- 1'J 88 the almec nanlwl
Virginia M. Hanson
TITLE;: MEMBER STATE BAR OF WISCONSIN
(If not.
authorized by 4 70•..04, Wig. Slat+.)
J to ntr Lnnten in he the pnran who exprilted tile
„ T•,' i INSTRUMENT WAS DRAFTED nY V. '
fort•r2,li,&Arn rutltent at,t1 roKnowle11rr the 4.1111(•.
Lois- A. .tlurray~. iteywppq,..Cari S t urray
l'.0.' Box 219, Hudson, W1... 54016 R'
Pt'~`~'' • y f ! ,
, i<.
(Sirnntures tiny he authenticated Hr ncknotelydgrd. Both (M 411`Ittl:lnt•111.I If not. •tatr ran ration
fire not necessary.)
flat,-: S:• 19 .l
-Name. fir r.rnan. Mltnlnr 01 any rp,a•ity .1...11'.1 1.. h1 1 , •r,1. ,1 1. w rl.• n r: • .
WARRANTT Dt:6D STA'rr "AR or 0.15CnKSIV KI•••n••ro 1.*r.t 1'I:I• ,
t'n1tM Flo 2 - 1.... J
SEPTIC TANK MAINTENANCE AGREE11ENT i~
St. Croix County 'J
m
n
OWNER/ BUYER~r~i~
0
•
ROUTE /BOX Numr Fire Number :J
. n
CITY/STATE ~ZIP S~d/(o c~
PROPERTY LOCATION:' .Y' ~~k, Section, T2 N, R~
Town of St. Croix County,
Subdivisiot: ~ , Lot number .
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 licens'ed' 's'e' t'ic tank pumper. What you put into
the system can affect the .unct on o, t e•septic tank as a treat-
ment-stage in the waste disposal system.
St. Croix County residents'nZ be eligible to recieve a grant for
a maximum of 604 of the cost.of replacement of a failing system,
whic was in operation prior to-July 1, 1978. St. Croix County
that
accepted this
'new, agree to keep their system properly
owners s
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. y
0
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 Depart-
ment Natural oSt. Certification
and returned to the
of the three year expiration.date. DATE
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016.
386-4680
Sign, date and return to the above address.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N W 53707
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNSH P/K&611i 6IrL'F Y: LOT NO.:BLK. NO.: nSU36_1_44 VISION NgME:
l~J~/ Z/ /T Z9N/R/4 E (o W Z4 $s Lsew~~.•i
COUNTY: OWNER'S/l3b"?`ffTrS-N'ATVlT: MAILING ADDR S: I /
STC&Ix fwm MIL.Lzk j Y 0KA4j 90hso V, s4w,K
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFI D RIPT ONS: ER L [LION TESTS:
Residence ! 1 New ❑Replace S Zo 91 ! 2f' 7
&lis SaT k
RATING: S= Site suitable for system U= Site unsuitable for system ~(-l Z is a
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(op ' nal)
S ❑U zS ❑U ZS ❑U WS ❑U ❑ S U C6AuVEnn, Aj~ tltx
D
If Percolation Tests are NOT ESIGN RATE: required I If any portion of the tested area is in the IVA
under s. ILHR 83.09(5)(b), indicate: CLASS ` Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 11.75- CN-7 S N6>V `3 75 .7 .,$/_L !O~$QvS ~L I$" $ ~jr _s
B-'Z ISO 9-7.3-7 INN > 9•56 z" 19-U 5 //'•$Qv C 4/''9,0-41116~11t
B- 3 'i9l 96. ►3 L&IF > Z-9Z 1` B4-c -t S 9`8e, _L B- A 94.Sti AI&N > 9-/7 *7 -►s /6"jL 9z" e s-~ •e
B- ,4Z 9 s z3 No tj E: > 16-41 Ts i QN L /4" N MfG,-e , Z•'$a, FS
79~6Qar ~ G'~•
B-
L~ PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER IkW54kF AFTERSWELLING INTERVAL-MIN. PERIOD 1 PE•RIOD2 PERIOD PER INCH
P_ J 4,76 KbQt! 41,16 > > Z <3
P- 7- 3.30 t4 Niif 47.3v > <3
P- LIP ,,t b.zo 3 > > ?
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of s table soil areas. Indicate scale or distances. Describe what are the hori-
>zontal and vertical elevation reference points and show their location on the plot plan. how the surface elev tion at all hprings and th direction and percent
of land slope.
ELEVATION
SYSTEM
T
ZS 60 T 5j 64~
5f Q.
L&T 61 t _ C l o M
41 tN
All,
I
,~u.lihtoe~- l •~i leorJ A
sW L~ CbtjaQ, Lk 31 7 I;p 71
J SOD c~0', .4 L '
I, the undersigned, hereby certify that the soil tests reported on this form were ade b e (Aliccord with the procedures and methods speci ied in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are co ct to hdbest of my knowledge and belief.
NAM~(print )y ~ul~Jsd~1 ~U 1 l~l/C TESTSWERAy(oS-- 2/ /99/
ADDRESS: CERTIFICATIQ N NUMBER: P ONE NU BER(optional):
vDSari) SaoI iz_:_ K-46%-6
CST SIGNAT RE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
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