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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER CZL TOWNSHIP sic
SECTION _T-? N-R W'
ADDRESS
ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT SOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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0 NDICATE NORTH ARROW
BENCHMARK:Elevation and description: o
Alternate benchmark
SEPTIC TANK:Manufacturer: Liquid cap.
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Rings used:-/-Manhole cover elev: r ah Tinal grade elev: /Qtr -
Tank inlet elev.: ,103 e6 Tank outlet elev.: /403, !jf
No. of feet from nearest road:Front-4 , Side , Rear Ft.
From nearest prop.. line:Front , Side, Rear Ft.
a A
No. of feet from: Well Building. /
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE "
! 4"'41
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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: eepage Pit:
Width: Length 4o Number of Lines:_,,/ Area Built-ffoj--e~
Exist. Grade Ele _ 2ij Proposed Final Grade Elev.~r, ~f;
Fill depth to top of pipe: `0
No. feet from nearest prop. line:Front Side, Rear-
Ft./o";-No. feet from well: ~•_.-.__,R
No. feet from building
HOLDING TANK
c~~~ / •S.-~.~ ~ i.
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 :
4gw-"4:Z~-
LICENSE NUMBER: /.%/'~l~ 3 3l S!
,a
b/90:cj
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Aurgan Relations INSPECTION REPORT St. Croix
Safety and Buildings Division
NE,SW,3,30,18W (ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 175th Ave. 149145
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
Jeff Lauck Richmond
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
026-1008-40
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 7~~ . 7 Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet 163,E
TANK SETBACK INFORMATION St/ Ht Outlet ltd L V
Vent
ir Ito ntake ROAD Dt Inlet
TANK TO P/ L WELL BLDG. A
Septic NA Dt Bottom
Dosing NA Header / Man. q, 3 s
N S3
• a y
Aeration NA Dist. Pipe lOQ
ry t.
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade cn~3
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Len h. No.Of,T)renches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O CHAMBER Model Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header/Mani old 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 discr ancies rsons resent, etc.)
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Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
~d
_ SANITARY PERMIT APPLICATION
ILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY n
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than A 1?/ 4y5
8% x 11 inches in size. ❑ Check if revision to 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
-~G GC (,c,C '/a '/a, S T C5, N, R (ol~
PROPERTY OWNER'S MAILING ADDRE LOT # BLOCK #
~aa
CITY, STATE, ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
0~.7
11. TYPE OF BUILDING: (Check one CITY NEAREST ROAD
) 1:1 State Owned VILLAGE:
❑ Public 01 or 2 Fam. Dwelling-# of bedrooms A CEL TAX NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply) L
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) 1.0 New 2. eplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5-E] Repair of an
System Pystem 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 eepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ?Seepage eepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 Pit Pressure 43 ❑ Vault Privy
14 ❑ System-in-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLON 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. tt.) (Gals/day/sq. ft.) (Min./inch) _0 _ _J Feet
7--e5toll -7 O L Feet Feet
VII. TANK CAPACITY Site
INFORMATION in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
New istin Gallons Tanks Concrete structed glass App.
Tanks Tanks
Se tic Tank or Holdin Tank
Lift Pump Tank/Si hon Chamber
Vill. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): T Plumber's Si tune: (No Stamps) MP/MPRSW No.: Business Phone Number:
Plumber' Address (Street, City, State, Zip Code):
Da
90 A~LVA~
IX. UNTY/DEPARTM NT USE ONLY
❑ Disapproved San' ary Permit Fee (includes Groundwater ate slue Issuing A ent Signature (No Sta p
Approved E] Owner Given Initial rcharge Fee) r.
Adverse Determination ZZI-01 L,/~~d
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
I
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety a 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 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
Location of Property, Section, T N - R W
0
Township ( LEI 4A
Nailing Address
Subdivision Name
Lot Number
Previous Owner of Property Ctt~1 ZJG~
Total Size of Parcel d0
X ~
Date Parcel was Created cc p
I
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
V 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) eenti.6y that aU a.tatementa on thiA 6onm ace tAue to the but o6 my (ouh)
knowledge; that I (we) am (ate) the owner (a) o6 the pnopeh ty dee eh i bed in ,th i a
in 6onma ti.on 6onm, by vi4 tue o6 a wahAa.nty deed heeonded in the 06 6ice o6 the
County RegiAten o6 Deedd as Document No. S' and that I (we)
pneaentey own the pnopoaed 6 to bon the sewage poa ayatem (an I (we) have
obtained an eaaement, to nun with the above deaehi.bed pnopenty, bon the
conatAu.cti.on o6 said aya.tem, and the name had been duty %eco&ded in the 066ice
o6 the County e ' .t o6 Deeds, ad Document No.
S TU F 0 ER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
~ Y' J i~1Qr - ry - ~►MA MMICF ~ il_ ~ _
AT8 C!P ##8i701~t1~ POVA
~kd• 4
WILOS
"Er3aiL.L..- nde#jon,._alta known. as Brian .-Lea -
4. _A IAL Cinft X...Andersaa,. also.. known MAY
F y.
-04
" YI
n •-1flra'Y.-Anderam` his.. Wife, as
snm :+vo~aki alwic al.. 11:00
p- praPert3►
deverrga sod WsrMts to.7tfC.. Lauck.-.and Brenda_ K..
t auclt -Atimbal".aad•-Wife, -az marital property.... .
k-
355 south Eeo~rl~rM;
tbo following described real state in now"_Aisl!• NA. .
$tab of Wisconsin:
Tax Parcel No:
22m West 100 feet of the East 272 feet of the North 233 feet ~
of the East Half of the Northeast Quarter of the Southwest
0owt4w (M of 10% of SNh) of Section Three (3), Township
ThLrty (30) North, of Range Eighteen (18) West.
-
T homestead property.
~ lie •ot)
Facaptton to w'wntks: Easements and restrictions of record.
ltd
elated this day of May 1s9.Q. r_b
r`a (SEAI.1
a _ Brian L. Anderson ~ s
. ,V
Cin M. Anderson
AUTURNTICATION ACHNOWLRD(}lsNUT "
STATE. OF WIS4,ONSIN
L: 5~
- - - St. Croix County. ss
tlti• day of
19. Personally came before me this
n: 99~
Brian L. Andes.. at
. Anderson., And.Cindya
.
r t"vkV ftzIR STATC BAR OF WISCONSIN a/k/ Cynthia Mar AAd tt
.
at106orised b7' X46,66. Wis. Stats.)~
' to me n u71 the person rloiteried
f"tTRUMENT *A14 DRArMt) By
-
s
Ul1laham, s.C.
µ
A-South, M%Qwl*s Avenue, Box 127 A.
`Nr - ...-54017 - r +►,r~ _ r ~E
rat6NttiCated or acknowl d rrl. Roti, 1+ a ion is. pe i I f
4
r date. July 7,,-1991S''
x 9 0* ary.dty .k.1d t.• -tst • : „ S. :i. -1 b,!.
. • b^:r . r ¢ ~
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STC - 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
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OWNER/BUYER .1c L att. Il( X47,-'fi P~ l ~tG~~ can
ROUTE/BOX NUMBER 1 Lj Fire Number
.CITY/STATE ZIP
PROPERTY LOCATION: a t,' k, 14, Section , T N, R W,
Town of St. Croix County,
Subdivision 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 licensed septic tank pumper. What you put into
the system can affect the function of the septic tank as a treat-
ment 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 systems properly
maintained.
The property owner agrees to submit to 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 (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
• E
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- b
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning P£f e~within 30 days
of the three year expiration date.
SIGNED
Vr
DATE
St. Croix County Zoning Office
P.0 Box 98=
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, 1 C DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 76
N WI 3707
HUMAN RELATIONS
ILHR 83.0911) & Chapter 145)
LOCATION: SECTION: O NSHI MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
/L-30N/R/,E (or) W r L~II~'!P~/I
COUNTY: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE G .Z
:
Residence NO. BEDRMS.: COMMERCIAL DESCRIPTION: ❑New Replace PROFILE DESCRIPTIONS: PERCOLATION TESTS
1
RATING: S= Site suitable for system U= Site unsuitable for system o? Z^ Ca C -71-0
CONVENTIONAL: MC'1ND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEf":1nnrional)
S' 'U 10 S❑U XS 'U ❑SZU ❑S®~ eh~i~5
If Percolation Tests are NOT required DESIGN RATE: If an
y portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
_71
PROFILE DESCRIPTIONS ,2 '6 ~dQ-d-- qa
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOI WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHE T TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B
54
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B- jt2
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P- 0 3 5 S
P. ' x 7 3
P- ZI
P_
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable 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. Show t/hp surface elevation at all borings and the direction and percent
of land slope. i^ y 3 ~~~rG//J[ , /
SYSTEM ELEVATION
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I, the undersigned, hereby certify that the soil tests reported on this form were made 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 tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON:
s^
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ADDRESS: CERTIFICAT13-N-NOWSR: PHONE NUMBER (optional):
7 / 76
CST SIGNA E:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) -OVER -
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, 1 1 C DIVISION
LABOR AND' PERCOLATION TESTS (115) MADISOP.O. BOX N WI 539069
HUMAN RELATIONS
I LHR 83.09(1) & Chapter 145)
LOCATION: SECTION: T~ u r W O NSH MUNICIPALIT LOT NO.: BLK. NO.: SUBDI VISION NAME:
,/4 / o N/I1/,# (or) n , [
r G/!I?'!P?
COUNTY: MAILING ADDRESS: off
~Y'b J G EL ~Sp~ `~l riC. ~ , il'~6Iz Ol
USE DATES OBSERVATIONS MADE Ci ~Z
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: IFERCOLATION TESTS:
Residence El New Replace
RATING: S= Site suitable for system U= Site unsuitable for system ® fig Z^ 7 0
rxs ONVENT1IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTErl:1 -tional)
r S ❑U S r ~U ❑ S ~U F_] S FA U/~cs-rcf~~5 s-X
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: Floodplain, indicate Floodplain elevation: ~/r V
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B
54
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B Z/ SCI- 704;0.
oo. xo Q /
B- K ~Qa.~ ~ ~ D ✓ °2 y/~ ~ ~ -~aZ /x%11 ~e~ 0 ~ ,sr
p Doll
/01
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH
5r
P- Ive-up /0
P- 7 3
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable 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. Show th surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION
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-VIA
10
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1 of
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I, the undersigned, hereby certify that the soil tests reported on this form were made 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 tests are correct to the best of my knowledge and belief.
NAME (print):
TESTS WERE COMPLETED ON: 06, r/ - -I ADDRESS: CERTIFICATI N NU. R H NE NUMBER (optional):
Av, C) A r ~J r. 2 - tZ
"fox 0002!!i~ e 7 / a6 76
CST SIGNA E:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R, 10/83) - OVER -
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