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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER CRAIG HANSe TOWNSHIP 1Lt"1 ;ICI~ii0T1D
SECTION Z0 T __]o N-R 18 W 'j
ADDRESS 1445 Co' d. A ST. CROIX COUNTY, WISCONSIN
New Richmond, 'I 54017
SUBDIVISION N/A LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
a ~f
Y~y1
C
C9
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INDICATE NORTH ARROW
14-
BENCHMARK:Elevation and description: j -
c4 f~ 15 /tom
Alternate benchmark
SEPTIC TANK:Manufacturer: weeks Concr. PrLiquid Cap. Q~'1lq fj -
Rings used:-C-,Manhole cover elev: Final grade elev:
Tank inlet elev.: Tank outlet elev.:
No. of feet from nearest road:Front4-, Side , Rear Ft. r
i
From nearest prop. line:Front_, Side , Rear_X_Ft.
No. of feet from: Well Building: zod
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
~I
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: -Length < t Number of Lines: 7 Area Built
~C
Exist. Grade Elev._ 4~~k ' Proposed Final Grade Elev.
Fill depth to top of pipe: y`
No. feet from nearest prop. line:Front , Side , Rear Ft.
No. feet from well: ~ t' No. feet from building J
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: 0
6/90:cj
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
• Labo;andHu%an Relations INSPECTION REPORT St. Croix
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION SE, NW, Sec. 20,T30-R18,Co. Rd. A 149146
Permit Holder's Name: ❑ City ❑ Village [jt Town of: State Plan ID No.: 303A-10
Craig Hansen Richmond n?.6-1o61-20-110
CST BM Elev.: Insp. BM Elev.: BM Description: C-. Q, Parcel Tax No.:
TANK INFORMATION LEVATION DATA a w
~f CAPACITY STATION BS HI FS ELEV.
TYPE MANUFACTURER
Septic ojef ,~5 Len!C. l~' d-tY J~ .a , Benchmark o ~l/O~ G~ p
Dos'
Aeration Bldg. Sewer
r
Holding St/ IZtt Inlet 9? Z~
TANK SETBACK INFORMATION St/Outlet 97, TANK TO P/ L WELL BLDG. Ventto Air Intake ROAD Dt Inlet
Septic 7_0I -x-90 7 NA Dt Bottom
r
Do ' NA Header HV6w . g , S 's 16
III
Aeration NA Dist. Pipe S_ 5' l
Holding Bot. System -~j' SOS
PUMP/ SIPHON INFORMATION Final Grade S.SD 9,?, ,100
Manufacturer Demand
Model Number GPM
TDH Lift Friction System Ft
oss Forcemain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM S'
BED / TRENCH Width / Length No. Of Trenches P No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS Z- d DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING anufacturer:
SETBACK CHAMBER
INFORMATION Type O CO,,,L~-. i r Model Num e .
System: i~AA a), 7 ~ /d?J OR UNIT
DISTRIBUTION SYSTEM
Header-; MoMFoW , Distribution Pipe(s) / i x Hole Size x Hole Spacing Vent To Air Intake
Length LP Dia. Length _:~L 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 - Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc-)
l~ 1
Plan revision required? ❑ Yes D-1-0-
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert No.
DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
St. Croix
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than
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
Craig I-Ianson SE '/4 NW '/4, S20 T30 , N, R 18 E (or) W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
1445 Co. Rd. A N/A N/A
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
New Richmond Gd 54017 715 346-4105 N/A
II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
❑StateOwned M VILLAGE: Richmon Co. Rd. "A"
❑ Public 01 or 2 Fam. Dwelling-# of bedrooms ? PARCEL TAX NUMBER(b) 0a~ ^ /0(0 ~ - QO / 1
III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 3031+-16
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. 1 Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repairof 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) ELEVATION
3 00 4 901 0 .sue c/X ,.72 . &.2 1 94.5 Feet 98.8 Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name concrete Con- Steel glass Plastic App
Tanks Tanks structed
Se tic Tank or Holdin Tank X 1 1 Weeks Cor1Cr. dr47] El F1
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): PI is Signature: (No mps) MP/MPRSW No.: Business Phone Number:
Byron R. Bird ~ 1309 715 268-8317
Plumber's Address (Street, Ci State, Zip Code):
Rt. 1 - Box 2. 8 - Amer , 1111 54001
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued issuing Ag t Signature (No Stamps
Approved El Owner Given Initial Surcharge Fee) I
Adverse Determination ~ * I a/ /
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
~ a
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 C R A 1(r .4 t pE U-A T. AN S E &J
Location of property $ E 1/4 t 4W 1/4, Section AO T 30 N-R_La_W
Township K i C 11 w, o h d
Mailing address ly4S Counfy Road A New Rin•ond hI= St(o17
Address of site Sa m f
Subdivision name A Lot no.
Other homes on property? yes ✓ No
Previous owner of property SfcveN M d Nq#vc 0 W rick
Total size of parcel (Le-res
Date parcel was created D y/ 07/89
Are all corners and lot lines identifiable? ✓ Yes No
Is this property being developed for (spec house)? Yes '--~No
Volume 63 7 and Page Number 362 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 . 06 73 1 , 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. 446 73 1
r
Sig ature of applicant Co-applicant
Q,~. 14,
1 aq
Date of Signature Date of Signature
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER LQA l6 A It DEBRA -T- 14an se r
ADDRESS : 14q!;- G+X Rd. A FIRE NO: ON 5-
LOCATION: S E 1/4, N W 1/4, SEC. 2 0 T 30 N-R ( y W,
TOWN OF:. R a m o nd ST. CROIX COUNTY
SUBDIVISION: LOT NO.
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
i
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.
SIGNED: "z u
A-
I:
DATE: I~ , a a
St. Croix County Zoning office
911 4th St.
Hudson, WI 54016
r
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY,- DIVISION
LASOR-AND PERCOLATION TESTS (115) MADISON W X 7969
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNSHIP UNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
5E'/ NW'/ 20 /130N/R18to t= P- lc cA),D AM Ab
COUNTY: MAILING ADDRESS:
Sic,oix CRAIG 11,0J_50A) 1y4i5 Cakes NFw 9fc//0e,0-o wx 5vo/
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: ICOMME_ IAL DE R T O :1 O O TESTS:
FIResidence~ • / /T ❑New Replace -7 7191
RATING: S= Site suitable for system U= Site unsuitable for system
ONVENTIONAL: M UND: IN-GROUND-PRESS E: SYSTEM-IN-FILL HOLDING TANK: IRECOMMENDED SYSTEM: ( optional)
~S ❑ U S ❑ U ~S ❑S [JS ~:o~uvE/(JTioNAL OF f /z,x 35
If Percolation Tests are NOT required ESIGN RATE:
NA I If any portion of the tested area is in the ~ a
under s. ILHR 83.09(5)(b), indicate: Il Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED ES HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
Al 7 T-7
B-' 8rJ 70,.[s, 'V0AAE / 9.,4 w~Y •j`?i0 5- ,`8n cl/r~y N1VJ-;' 3~5 -4!5 vi,_ ve,
o-/ 0
B- 2 9,$_6 A 0 S-3 3._7 !3 n - v h d /rt~r 5 W~ I Br, ~5 . t U ~,,cf
-4 -7 n
BO"
B 3 s go 9,3 3.
N r ~ o~~ss
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUM_B_ER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH
P_ ' < 1
P_ 2/ Nit 2 - < 1
P-
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 the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION 9,y.S h h - •__1..e._ 4ys : eleva
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CC,G: a on, ~Ble,
Ma }eke _I/a, o ✓ci v,'. a ~ r - _ _
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I, the undersigned, hereby certify that the soil tests rdported 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 717 PLETED ON:
R Ic/~ w _ 1E25 7 9/
ADDRESS: CERTIFICA ON NUMBER: PHONE NUMBER (optional):
- 30 ~A~S ~1 LAKE t-vz s- p 31/33 `/9-57-336.9
CST NATU E:
-
O-1 / t•Gi
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
July 29, 1991
Cia,g,llanson ,
144,5 Co. Rd. A
New Richmond, WI 54017 ca
I
SE4, 141444, S 20, T 30 N, z 1,13 4d i
Township of New Richinond
St. Croix County WI
2 - Bedroom
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 7969
N WI 53707
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNSHIP UNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
5E'/aMW'/a zo 1130N/R18t. L P-1c, ONZ A)h AJ A AM
COUNTY: MAILING ADDRESS: ,
SL C oix A /G fE, AJ-5oAl 1 yy5 ca Ra Nrw 9 ?C9mo/vD wX SVb/
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFIDESCR PTIONS: R LATION TESTS:
Residence 2 r ! /1 ❑ New Replace '77171 77~ 7191
303k 0
RATING: S= Site suitable for system U= Site unsuitable for system Lt 7-- 3 Lo 1L)
OENTIONAL: M~ D: ~ IN-GROU ~ P RE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
rZS oUU S ❑ S U [IS Ii~Q`IU G o~tlVE1/T-ioNAL ,3F_Z) /Z I X 3 S/
If Percolation Tests are NOT required DESIGN RATE: iFloodplain, If any portion of the tested area is in the under s. ILHR 83.09(5)(b), iIV /T indicate Floodplain
elevation: /V 0 IV AE
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- Al0VE 17 ~,''Y ~►8 S,'B» d arty 7~S- 5 DfcY,0n S'
>l all 5: ILA7
C-f
.2.y
/ / O l o ' 8/k %tf• ~,r/te` /.o y`8K all
13 7 n -oK~ ~cl,rtysw/ rff//an srs.t ba.,o~
B ,Z 8+3 9~_l0 NoI)E S-3 3..7;
Blk
B- 3 8.3 9017 A)0A/E > 8 3 ,3 n d „-ty s w/~ .y - 8.3 Ak vl3,, - Ya/. s vats
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 PER PER INCH
P_ 2 do 2 - < I
P- Z
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 the surface elevation at all borings and the direction and percent
of land slope.
lever
9y5'
SYSTEM ELEVATION fP_._Q
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I, the undersign, hereby certify that the sgiI tests r orted on phis form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative de, and that the 'data record Id and t4h locati of the tests are corr~ to the best of my knowledge and belief.
77
NAME (print): TESTS WERE PLETED ON:
7 9/
ADDRESS: CERTIFICA ON N MBER: PHONE NUMBER (optional):
3oX _ ~ s 3133 `roS-336$
GH~j„ f~ CST NA,TU E:
SCOUh~~ o-/ Kim
10.
DISTRIBUTION: Original and one copy to Local Authority, e~ d So4Tster.
1 Yti
DILHR-SBD-6395 (R. 10/83) --LIVER -