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Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM county:
Labor and Human Relations INSPECTION REPORT Sundance St. Croix
Saletg and $uildings Division Sanitary Permit No.:
(ATTACH TO PERMIT)Estates
GENERAL INFORMATIONSW;,NW%,Sec. 4,T29-R19,River Dr.,Lot 10 149103
Permit Holder's Name: ❑ City ❑ Village JZ] Town of: State Plan ID No.:
Mark $ Julie Larson St. Joseph
CST BM Elev.: Insp BM Elev : BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark / a0- D
Dosing
Aeration Bldg. Sewer
/S
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet LfS`S 1 ~~5
Vent
TANK TO P/L WELL BLDG. Air Ito ROAD Dt Inlet
ntake
Septic 7-col y 0 l5 / /~`t NA Dt Bottom
Dosing NA Header/Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP / SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Loss mead
Forcemain Length Dia. f Dist. To well
SOIL ABSORPTION SYSTEM
No. Of Pits Inside Dia. Liquid Depth
1 1 ELLeengthngth~~ No. Of Tyenches DIMENSIONS
BED/TRENCH width a
DIMENSIONS Manufacturer:
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING
SETBACK CHAMBER Moe Number:
INFORMATION Type O >101 s o ' A Jrk OR UNIT
System:
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipee(s)~ x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length r7~J Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded /SMulched
Yes ❑ No
Bed /Trenh Center /Trench Edges T psoil E] Yes ❑
COMMENTS: (Include code discrepancies, persons pres netc.)
A
• J)
Plan re~ision required? ❑ Yes ❑ No (a
Use other side for additional information.,
Date Inspector's Signature Cert. No.
SBD-6710 (R 05191)
DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
~.~.O,,.e, ,..,..,~,..e.
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than /qfl 3
8 % x 11 inches in size. Ch k v sion o previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPER WNE PROPERTY LOCATION
e2 S D Y) 5'li 1 '/a %4, s T N, R 19 E (or)O
PROPERTY OWNER'S nkiLINGSDDRESS LOT # BLOCK #
CITY, TATEC`/ ZIPCODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
5yv1b Joy
II. TYPE OF BUILDING: (Check one) CITY NEAREST ROA
❑ State Owned ❑ VILLAGE : Ci2eic P ~OWW OF: ❑ Public 9 1 or 2 Fam. Dwelling-~# of bedrooms ~ PARCEL AX NUMBER( )
111. BUILDING USE: (If building type is public, check all that apply) J( O d /~'jI
1 ❑ Apt/Condo (r 6 (1(JC/
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 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. [N New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 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 19)1(b 11 r 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 q. ft.) PROPOSED (sq. ft.) (Gals/day/q. ft.) (Min./ h) ~ ELEVATION
~1456 1 ~~10/1 /i eetV i 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 9 F1 I F1 1 1:1 -F
Lift Pump Tank/Si hon Chamber F-1 Ij F-1 I El 1:1
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumb Xignature: (No Sta ps MP/MPRSW No.: Business Phone Number:
4 un I hj
7AA6 5
lum r'sAd r (Street, City, State, ip Code): I
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing gent Signatur No Stam
Surch
Approved El Owner Given Initial arge Fee
Adverse Do rmin i n 42,
X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
LHR SANITARY PERMIT APPLICATION
accord with ILHR 83.05, Wis. Adm. Code COUN
In
=:aR=L-Mmmmmmo
STATE SANITARY PERM #
-Attach complete plans (to the county copy only) for the system, on paper not less than Cf / QJ
8% x 11 inches in size. ❑ c~eck.f revisioM., o us application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROP TY WNER PROPERTY LOCATION c~
Qr` t° ~"SD ~'a S T N, R E (or W
PR PERTY OWNER'S MAILI AD ESS LOT # BLOCK #
p
CITY, STAT ZIP ODE PHONE NUMBER SUBDIVISION NAME OR C M NUMBER ) d4
C7- 14
II. TYPE OF BUILDING: (Check one CITY f NEAREST ROAD `
) ❑ State Owned VILLAGE * G
❑ Public L1~91 or 2 Fam. Dwelling-# of bedrooms ~ PAR LTAX NUM ER
III. BUILDING USE: (If building type is public, check Z11 that apply)
1 ❑ Apt/Condo v ( v V
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. N New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.E1 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 1-4 /Y5d 21 El Mound 30 El Specify Type 41 El Holding Tank
12 ri 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.) PROPO ED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
Cl~ a ) 7- ~ Feet , J P Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank a o S
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plu s Signature: (No to ps) MP/MPRSW No.: Business Phone Number:
7
Pu r'9,Address reet, City, State, gip Code).
(J~
7XV
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e sue issuing Agent ' a re (No Stamps)
Approved E] Owner Given Initial Surcharge Fee) /1/5- hill
Advers 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 T lcie,,,d X w Lc /7-7-
Location of property SG✓1/4 A,,&_-,114, Section, T 19 N-R_jj_W
Township S"f
Mailing address
g dress 191 ye.l lZv
Address of site P /t,,-7o1
Subdivision name Sic cc. Z--:5 -Lot no. _/0
Other homes on property? yes X No
Previous owner of property r,e % e Yr. cSCr✓
Total size of parcel 3.
Date parcel was created
Are all corners and lot lines identifiable? _ Yes No
Is this property being developed for (spec house)? Yes K-No
Volume and Page NumbeV Z/X 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. S? -/,S 9-,5'3 , 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. 394' s.~.3
Signature of applicant Co-applicant
-7> '
Date of Signature Date of Signature
DOCUMENT NO. STATE BAR.bF WISCONSIN FORM 2-1982 THIS SPACE RESERVED FOR RECORDING DATA
WARRANTY DEED
462210 wo: 880 PAGE 612
REGISTER'S OFFICE
5-a ratt -rig eetsei+ a S c~►~ ST. CROIX CO., WI
T 1- Recd for Record"..-_ S C P 101990
at 11:40
conveys and warrants to A' M;
Mat L 1. J d V- SD N I.t f Q ,I7 BYi1 V
Reglste►of Deeds
142
Ma I, i a PCQjp 42 r4
RETURN TO
the following described real estate in + C. 1,0 IX County,
State of Wisconsin:
of 5~~etai, tr - cQescir I
717, y cam- y-oA)It s 41o Sq: r1 e sPp 10 o f
It
v~~• :.2 4A rJey
P I Iq 9q
t46 c Ct -to -T kip ~ If-04 'e CT ~ C p t/ e4a it is G~ ~ ~cOF o1 q~
I`1 V Et ( u sKQ 6 G 7 ! pe, 3-III Uoc ►fc a -Z~ P/0. .3 9 6 F5 S31
1 c c t ~Q tot ~I < ct~'f ►c-t: o-r QFryfo fs o l -
Cx %A 1,
f TR
This j s WCI i' r.Tr
homestead property.
(is) (is not)
Exception to Warranties:
.Sw bJ v -r o p t,,;,. Q ~✓1 S rLo; e M" 04 t Ok S, a ir'es ' " ` f b~f o
Dated this ~ q day of ' ` V_ LC ,19 A
(SEAL) (SEAL)
(SEAL) (SEAL)
♦ w
TH TI I N ACKNOWLEDGMENT
Signature( STATE OF WISCONSIN IV SS.
& County.
authenticated this day of , 19 Personally came before me this---yC-day of
19~1Z the above named
TITLE: MEMBER STATE BAR OF WISCONSIN
(if not, to me known to be the person who executed the
authorized by § 706.06, Wis. Stats.) foregoing instrument and a0~ndryiaQge.the same.
THIS INSTRUMENT WAS DRAFTED BYY +a►.(
lo- 1101 C- I f ~ t Y 12 L
?
1 1"71
K h Gt Ct ►LC.(~ ~t7 S l`*t iil~ SL~s7 ~A/~ S NO - w
y ublic Cou ty, Wis.
;iT
(Signatures may be authenticated or ack owledged. Belh M~' Commission ' Der sUegt.. • not;, state expiration
are not necessary.)
date: ~
O•. 1tf`=JJ
'Names of persons signing in any capacity should be typed or printed below their signatures. NTF 2280
WARRANTY DEED STATE BAR OF WISCONSIN Nelco Forms. P.O. Box 10268, Green Bay. WI 54307-0208
Form No.2 - 1982
=NJ
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER A on l 6<-1, /9 j-- So
ADDRESS: S 2 _n ,'vim Y of FIRE NO : S a
LOCATION:ci 1/4, SEC. _T N-RAW,
TOWN OF: ST. CROIX COUNTY
SUBDIVISION: LOT NO. /0
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
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:
DATE :
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
0EPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, , 1 c DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 7969
N WI 53707
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION- OWNSHIP UNICIPAy►TY: LOT NO.:BLK. NO.: SUBDIVIS ON NAME:
w 1/a Ta9N/0E W o s e D .510 4c if F 7
COUNTY: BUYEJB'S NAME: MAILI G ADDRESS:
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: ICOMMERCIAL DESCRIPTION: PROFIL E R PTIONS: ER TIO TESTS:
Residence V New ❑ Replace
RATING: S= Site suitable for system U= Site unsuitable for system
C )MMEN ED SYSTEM: optional)
ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDINGTANK: IRECI
CAS ❑U S ❑U S ❑U ❑S ®U ❑S 0U ayTd' ed
If Percolation Tests are NOT required DESIGN RATE: any portion of the tested area is in the
under s.H63.09(5)(b), indicate: 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 EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 1 9~ b ,66 6 ~~S'b 1.~a6 s b 3.5~ Dose d r
B-~ .~a 6 s t ~o~ s~ ~DOg sc~~b
B-3 Svc .ob I'Dos
to ►S~D S . D0 h kooS,P
B- ~ ~b t~0 ~~o ~ s b.oo B~ Dose ~G~
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERtOlp 1 PER 2 PERIOD PER I H
P t
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.
Q
SYSTEM ELEVATION ?3,
d7 yt1_ _ _m 8 C lv r
1 s i j
n
r
IN
T
I, the undersigned, hereby certify that the soil tests reported on this form wer made by me in accord with the procedures n 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 (p int): TESTS WERE C MPI/EED ON:
JAR CERTIFIC I NGGNUMBER: ]PHONE NUI)QBE5RItional):
X, X00 9
CST SI RE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
1F`~~~n eovev' L►J/
S i`1 e ~"c C t`4W y )C
~n 13 r~
Sta~~e
. lov,a
jq7
Chu bb3 ~
Ik) C.
frepase
10b0 ~rt
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l~l
Fad r ~e
3, C) 0 fef
r,Gn I n l a Pk
~ feu. ~3
3 Bed.
l~or,e
Q~ooO ~a~ i~S ,e
30Q 66~ d
)on,b
bas e ~"re~
A (fir
b~► D n g
~a