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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 1 _m
TOWNSHIP__ #&i6z
SECTION -T~N-R-jLe'W
ADDRESSW fiidr Al ST. CROIX COUNTY, WISCONSIN
SUBDIVISION_ LOT A 01 LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
II .
i
7i
5y
i
2
~r
•~•e w
INDICATE NORTH ARROW
BENCHMARK:Elevation and description:_
Alternate benchmark
SEPTIC TAHK:Manufacturer: Ld oib Liquid Cap. iaba
Rings used: 1 Manhole cover elev:_Final grade elev:
Tank inlet elev.: Tank outlet elev.:
No. of feet from nearest road:FrontSide , Rear Ft.
From nearest prop. line:Front , Side , Rear Ft.
No. of feet from: Well , Building:
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
J
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:--:L-Length Z Number of Lines: Area Built 730
Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth to top of pipe:
No. feet from nearest prop. line~:Front Side Rear X Ft. 16"'
No. feet from well:
No. fee from building
HOLDING TANK
Manufacturer:.
Capacity:
No. of rings used: Elevation o
f bottom tank:
Elevation of inlet:
No. feet from nearest -prop. line:Front_, Side
Rear_Ft._
No. feet from: Wellbuilding
nearest road
Alarm Manufacturer:
2 INSPECTOR: l
DATE : PLUMBER ON JOB :
LICENSE NUMBER:-
6/90:cj
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
11abor and Human Relations St. Croix
Safety and Buildings Division INSPECTION REPORT
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATIONNW,SE,Sec. 28,T29-R19, Lot 42 149248
Permit Holder's Name: ❑ City ❑ Village bd Town of: State Plan ID No.:
Tim McClosky Hudson
CST BM Elev.: Insp. BM Elev.: lBM Description: Parcel Tax No.:
i Of Zi , tJl
(0 /
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 4< ~ Benchmark ' 40 X, Gb~
Aeration Bldg. Sewer
ds
Holding St/IWInlet
TANK SETBACK INFORMATION St/Outlet jd" 4.02
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
NA Heacler4WWL
Aeration NA Dist. Pipe
Holding Bot. System ~~z SS 6/ y /0-Z
PUMP/ SIPHON INFORMATION Final Grade a;
anu ac Demand TA ° S"T, ~~~%y
Model Number GPM
TDH Lift Friction stem T Ft
oss
Forcemain Length Dia. Dist. To I ZZ~
SOIL ABSORPTION SYSTEM
BED/TRENCH Width r Length r No. Of Trenches No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS S 3 DIMEN I N
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHIN Manufacturer:
SETBACK CHAMBER Mo a er:
INFORMATION Type Of Lpalty. /D f~ 59 ] OR UNIT
System:
DISTRIBUTION SYSTEM
Header/ fd ( Distribution Pipe(s) r x Hole Size x Hole Spacing Vent To Air Inta C1 . Length Dia. Length Dia. Spacing _Z~1_
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 CG`S Bed/Trench Edges Topsoil ❑ Yes C] No ❑ Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.) (T 5 T
64,
~~i l e o'®r~ fa;2' ff7A ,7 J" 0
f, /oaf
vlslo o
Use other side for additional information. , MA
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
~~ILHR SANITARY PERMIT APPLICATION couNr
In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than El /i / Q/ IV
8% x 11 inches in size. c eck re ision to pr sous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPE TY OWNER PROPERTY LOCATION
/ Ity► ~~l .S I~'J % ,17 t/4, S Z T Z~, N, R / (Or)
PROPERTY OWNER'S MAILING ADD ESS LOT # BLOCK #
CITY, STATE ZIP CODE PHONE NUMB~E SUBDIVISION NAME OR CSM_ NUMBER
II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
ILLAGE :
❑ State Owned ~ V
JQWW OF:
❑ Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms PARCEL AX NUMBER(s)
111. BUILDING USE: (If building type is public, check all that apply) ~aa 6 - fZ/~
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. ~ New 2.E] Replacement 3.E1 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 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) 14Z. icy ELEVATION
Q -,o Z, 5;; Cj-~I G
00 FO 7 y4) , 7 , Feet Feet
CAPACITY Site
VII. TANK in allons Total #of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
,AP ~ Septic Tank or Holdin Tank 0 C'
Lift Pump Tank/Si hon Chamber
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plum:;,, ' Name (Print): Plumbe~ ignature: (No Stam s) MP17- o.: Business Phone Number:
01~ 7 7 Z 3Z
Plumber' Address (Street, City, State, Zip Code):
'Z -7
IX. CO NTY/DEPARTMENT USE ONLY
❑ Disapproved SanitaryPermit Fee (Includes Groundwater Date Issue Issuing A ent nature (No S ps)
Surcharge Fee)
Approved E3 Owner Given Initial I c
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
APPLICATION FOR SANITARY PERMIT
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'develo.pment be intended for resale by owner/contracts-c,("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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
~ Go liLDS ~ L
Owner of Property 1r'1
Location of Property /lru) k SC Section Z y , T Z:! N R J W
r
Township
Mailing Address 75' o9/ ef&
ee
Subdivision Name Cea(4r-✓ 911/! 46
Lot Number 7-
Previous Owner of Property
Total Size of Parcel
Date Parcel was Created
Are all corners and lot lines 'identifiable? Yes
is this property being developed for resale (spec house) ? Yes_ No
Volume 01 oz, and Page Number as.recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed
2. Land Contract
3. Other recordings filed with the Register-of Deeds Office
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 the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) eeA,tiSy that aU .6tatemenar6 on athiA 6oam age tAue to the but o6 my (ouA)
k.nowZedge; that I (we) am (aAe) the owner (4) o6 the pnope, ty de4eA,ibed .i,n th.i6 .
in6o4mati.on 6onm, by vixtue o6 a wakAanaty deed necokded in the 06jice o6 the
County Regizlten o6 Deed4 ab Document No. and that 1 (we)
pne4ent2y own .the pnopme.r s4 to bon. the 4ewage knob s ys t. ,n (on 1 (we) . have
obtained an eabement, to hun w:i:th the above de,6cA bed plcopmty, jo,% tte
con4ttA.uction ;o6 6aid 4 .6tem, a,nd the dame ha4 been duty teco&ded in the 066ice
1
06 the Coun-ty _R o eds, a4 Document-No.
l
'IG T RE OWNER SIGNATURE OF CO-OWNER (IF APPL CABLE)
rig
DATE SIGNED DATE SIGNED
DOCUMENT No. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
' STATE BAR OF WISCONSIN FORM 2-1982
4`7 5`788 V 922PAGE 5'75 OF
REGISTER "S Cpl TICE
-Cedar Hills Develo mennc . ST CROIX CO. W1
- t..---- I-------.................................. Recd for Record
a~ N0V15) 1991
11:15 A... qM
conveys and warrants to ......Timothy H. McCloskey and ~p
Margaret-:M..,Wetli„_ husband__and__wife:, szrvivorhip V ,,eed~...s.
Register of D
Maxita~..Pxox
RETURN TO
the following described real estate in ............St.....C.roi-x ..............County, -
State of Wisconsin:
Tax Parcel No
Lot 42, Cedar Hills Estates II, according to
the recorded plat thereof, St. Croix County, Wisconsin.
i
I
I ~
I,
s.
~i
i
This S_ nOt homestead property.
(is) (is not)
Exception to warranties: easements, restrictions and rights-of-way
i
of record, if any.
I
Dated this day of Q'c.?e.... - 19-.. 91.
Cedar Hills Deve pment, Inc., by:j
j
. . (SEAL)
.--•--•-------------------•-•--•----•----......-•--•-------.........(SEAL)
* Dean R. Larson , President
*
(SEAL). (SEAL)
* * William C. HAzwell, Secretary-Treasurer
ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
.
ss.
County. )
authenticated this --------day of..... ct9ber...... 19_.91 Personally ame before me his day of
. . 19 the above named
hax~on. sue. [^?~L~.~ . C _ - lj,L ell. b tj
* Kristina Ogland Lundeen R'
of .Ced -ir lii] 1s_D.eveloprent-----------------------•----
TITLE: MEMBER STATE BAR OF WISCONSIN . _
(If not, T-C-
authorized by $ 706.06, Wis. State.) to me known to be the per ted the
<C.
~Qa
f oing instrum and a the s % THIS INSTRUMENT W DRAFTY BY
Kristina Og1anC Luneen V Y ARY
tt-or-itey --a t--mow
Notary Public 9r Y, W is.
ra n
n , . If~?izo
(Signatures may be authenticated or acknowledged. Both My Commission is permane
are not necessary.) date:
~ 1 )
1------.
eXames of persons signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank.Co., Inc.
FORM No. 2- 1982 Milwaukee, Wisconsin
4 r
4~ r
'
S T C 105 ,y
y
SEPTIC TANK MAINT'ENANCE AGREEMENT o
St. Croix County t
o
9
OWNER/BUYER 'rlM f10- l 1 _1 -
ItOUTE/BOX NUMBER Dire Number 7y
C I TY / ST AT li~~~ _L t 1'_
PItONIiIt''1'Y LUCATION:_~/~ %o. SECt:ican 25 i 2-Y N~ R__ ..W
'town of q~~fLCciClwl St. Croix County,
Subdivision ftl~ ~~5 Lot n•utnber~-
Improper use and maintenance of your septic system could result in
its premature"failure to handle wastes. Proper maintenance'cun-
sists of pumping out the. septic tank every three years or sooner,
if needed, by a licensed jj.epLic tank puwper. What you ptit into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St.•Cruix County residents mal be eligible to receive a grant for.
a maximum of 60% of the cost of replacement of a failing syst,dm,
which was in.operation prior to duly 1, 1978. St Croix County
accepted this program in August of 1980, witli the require ment,chat
owners of all new systems agree to keep their:systems properly
maintained.
The property owner agrees to submit CO St. Croix County Zoning a
certification form, signed by the owner and by a master 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 (it 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.
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with, M
the standards set forth, he'rei.n, as set by the Wisconsin Ueparr `d
ment of Natural Resources. Cert•ificatiOn form must be completed r
and returned to the St. Croix County Zoning OffkC-e_wit30.days
of the three year expiration date. i
S I,-G N
St. C.•oix County Zoning 'Office
P.O. 11ox 95.
klammo-pd; WI 54015
715-7.16-2239 or 715-425-8363
Sign, date and return to above address.
LDINGS
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
JNDIlSTRY, P.O. BOX 7969
LABOR AND PERCOLATION TESTS (115) MADISON, WI 53707
HUMAN RELATIONS (ILHR 83.0911) & Chapter 145)
LECATION, ' SECTION: TOWNSHIP/~ly UNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
E /a Z9 / r- 9 N/R i9 E (or) W Hc~DSo~ 41 CEaa>e IL:
0OWNER'S/UYER'S NAME: MAILING ADDRESS:
!x l r Me
Cwsr-E
MADE
USE PROFILESE OBSERVATIONS
NO.BEDR7: COMMERCIAL DESCRIPTION: DATES OBSERVATIONS n PERCOLATION
*Residence - IL~Cew [Replace 1 T'/9'
u>v~, ~z - ~QKT
6b Sa
RATING: S= Site suitable for system U= Site unsuitable for system Jh>k~RY
rOMNVENTIONAL: MOUND•❑U 11, -G URE:SYSTs I❑uLHO❑LDING A K:REC ONJINTIDU/~2pt'
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: eLASS Floodplain, indicate Floodplain elevation:
c~r PROFILE DESCRIPTIONS
rB- ING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
BER DEPTH W ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 1 lb-4Z /off 09 Na L ~io.gz IALSL-rs N"'R&,9#rJAS4A& T0"8#.jVN64K,e-
$"gl.LT~ /6 L BRnJ S, L 2~ d Qlv 4+2
B- z 11.1-7 109,46 N&4r } 11.1? io"RdBe",1hs4l_ -74 "L-r8a&, MS416k
~o zT~ 7 ,8,2,,► ~C /1" A aNSIL
B- 3 10.-3 1o3.'50 NONE .~S z-7"RAa&,jM5 6>Q 7s" LTA N mS44h. 0a 1:-~ 40
S$ ~o nJ > .67 3z"+QA$1tu n~S 4c.,Ie -S-6 L-r I -a,v MS 41.
B dC /0.67 104
9 " 8u io e&, L iV l& cs
B- 5 .`63 99.40 t4oN w >8-63 28'Sa►.► R.e, ~'~s~Gl2 !6" R>DB,aN MS ~41~ 27 "Bie>J wt $
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER MM01'1~ AFTERSWELLING INTERVAL-MIN. PERIOD1 PERI002 P R PERINCH
P_ 3.So Nomm o mc 3 ~Z >-Z <3
P- 4.90 aemlE 10%4o <3
P_ _313,-10 o /04.60 > >Z <3
P-
P_ ELv T ERC
P_
PLOT PLAN: Show locations percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation ref ence points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATIO
€ 7 ~
J 7
E
-TaE^W_N 0 - , /61.46.
E
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E
~ 3 E
y
' ,P ,`QT S W
- -
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1, the undersigned, hereby certify that the soil tests reported on this fo wer m e by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the to s correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON:
140 JON say, 'Suv y m Sc pr i9 /99/
ADO. RESS: CERTIFICATION NUMBER: PHONE NU BER(optional):
O. $dx 91 asaw Sq0 b 3qg 3196-
CST SIGNA RE:
2
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
- JOB I ooi //c CLo S JAI
TIMM EXCAVATING
' Route 1 BOX 192 SHEET NO. OF
WILSON, WISCONSIN 54027 CALCULATED BY~ ~ Y DATE
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
SCALE
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PRODUCT 205-1 /mss Inc, Groton, Mass. 01471. To Order PHONE TOLL FREE 140o-225.6380
Illeclasiex
. TIMM EXCAVATING
Route 1 BOX 192 SHEET NO. OF
WILSON, WISCONSIN 54027 CALCULATED BY-~+i'i s~JFY~fv~- DATE- ~i ~r ~ Sy P
MPRS #3 24 WI MPCA3# 96 MN
CHECKED BY DATE
SCALE
d 1
.
6 4>
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01
-
PRODUCT 2051 s Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE 1-80D-225-M