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' FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP
SECTION '7
ADDRESS ~ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT OT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
kjV1
i
j _~o se
INDICATE NORTH ARROW
BENCHMAI2K:Elevation and description:
Alternate benchmark
SEPTIC TANK:Manufacturer: Liquid Cap.
Rings used: - Manhole cover elev:~Final grade elev:
Tank inlet elev.: Tank outlet elev.: ~l
No. of feet from nearest road:Front , Side, Rear Ft.
From nearest prop. line:Front , Side )r, Rear Ft. ('J
No. of feet from: Well , Building: /
(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 /
Number of Lines:_2Area Built-Zj a
Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth to top of
P pipe: -I) -
No. feet from nearest prop. line:Front
Side , Rear/ Ft.z,?p
No. feet from well: No. feet from building
_ -5'i9 ~
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 :
6/90:cj
Wisconsin bepartmentof industry, PRIVATE SEWAGE SYSTEM County:
Libor a uman Relations
Safety and nd Buildings Division INSPECTION REPORT St. CrCl1X
(ATTACH TO PERMIT) Lot Q Sanitary Permit No.:
GENERAL INFORMATION-,. L 149084
Permit Holder's Name: City ❑ Villag EkTown of: State Plan ID No.:
Bruce Maher St. Joseph
CST BM Elev.: Insp. BM Elev.: BI V tion: Parcel Tax No.:
L U /
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic j Benchmark ~ , 38 U
~ D
Dosing
Aeration Bldg. Sewer
Holding St/ Ik t Inlet
o. ~l ,ao
TANK SETBACK INFORMATION St/ I* Outlet
Verit
ir Ito ntake ROAD Dt Inlet
TANK TO P/ L WELL BLDG. A
Air
Septic > i NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System ac S
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand M',.L °l,--'
( . 07
Model Number GPM
TDH Lift Friction System TDH Ft
oss
Forcemain Length Dia. Dis . ell
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMEN I
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING anu acturer:
SETBACK
INFORMATION CHAMBER Type O i Mode er:
System: V~t1 ~lU~J ~S OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length L_ Dia. Spacing y
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over 6 xx Depth Of xx Seeded/ Sodded xx Mulched
Bed / TfeRcb.Center r~ " Bed/ Trench Edges ps_un ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
Plan revision required? ❑ Yes ~l No
Use other side for additional information.
FT F E/Iq~ B'
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
CSANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNT
STATNIT41$1( R I
-Attach complete plans (to the county copy only) for the system, on paper not less than ~7/C!/v//Q~y
8% x 11 inches in size. ❑ CheckEif revision to p evious application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROP TY OWNER PROPERTY LOCATION
9-44ze _5,1 %4 Y4, S Q, N, R f E (Or)dV
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
,C<26 I ( 2:j~..,j &g, ~ZA
II. TYPE OF BUILDING: (Check one) CI NEAREST ROAD
❑ State Owned ❑ VILLAGE
❑ Public ®1 or 2 Fam. Dwelling-# of bedrooms-,? P EL AX NUM ER()
III. BUILDING USE: (If building type is public, check all that apply) .09 /Ea (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
40 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. VN New 2.E] Replacement 3. ❑ Replacement of 4.0 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 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 (sq. ft.) PROPOSED (sq. ft.) (Gals/d y/sq. ft.) (Min./inch) ELEVATION
Q Feet ~ Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New Plating Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation oft onsite sewage system shown on the attached plans. "
Plumber's Name Print : Plu s Si natur . (N to ) MP/MPR Business Phone Number:
4um;4*bs'jAddress (=,Is Zip Code
it. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved tary Permit Fee (Includes Groundwater a e Issued Issuing A ent Signatur Slam s
urcharge Fee) ~ ~-3 k proved El Owner Given Initial 7
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
i
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
his 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 ~lLNI.~ AeTAM
Location of Property 5 k NE k, Section , T Z9 N-R W
Township : J0 `jEV I4 ,
Nailing Address 6q 3d6
OfJT}~ ~-V 45~'"
-4t4yEYL Cgrtove IUfF~~/mil" 5o -7 s -
Address of Site r 64OLOqu OA" G40,IE
0 0 v (0
8ubdi iiion !lose Bt00g. &t,5
. Lot Number - -
Previous Owner of Property /2/f N va
Total Site of Parcel
Date Parcel was Created
Are all corners and lot lines identifiable? X Yes No .
Is this property being developed for resale (spec house) Z Yes No
Volume - R and 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, and 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 refer-
ences to a Certified Survey Hap, the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
I W10 cVLU6y that d U s tdtemen,t~s on tha onm cute tAue to Vie best o6 my (oun)
hnowtedge; that I (we) am (she) .the owneA.k i o6 the pnopeAty deAcAi.bed in .tW
.in6onmaAon down, by viAtue 06 a waA.anty deed keemded in the 06 ice o6 the
Count RegiAteh o6 Deeds all Document No. X44 ; and that I (We) pteeenCty
avn The pRoposed site 6oh .the sewage diApoe bye em (oh 1 (we) have obtained an
taAement, to Ruh with the above de cAibed phopeeAty, bon the eone•thuetion o6 6did
ayatem, and the eame has been duty n¢eond¢d .tn the 066tee o6 the County Reg.ca•teA o6
Veeda, ae Voeeument No. _g(o ( .
SIGNATURE 01? OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED
DATE SIGNED_ .
N} CORNER NE CORNER
SECTION 7 SECTION 7
T29N; R19W o i 1i T29N R19W north line of the NU 1310.521
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8.51 SCALE IN FEET ,
40 20 0 40 o
0B
OWNERS Jao ro
o O c~
Rudolph E Kathleen Blakeman AREA OF LOT 1 ro o\m`~o
1222 Golden Oaks Lane o o' f`'~ .
dson, Wi. 54016 2,400 square feet 0\
0.06 acres `ten `~s m
~~~~\o \°y ~o
o
LEGEND °
County Section Corner Monument o
LOT 1
0 1" iron pipe found. y \ a oo
~`.rf ~~.1060 ~ ~
of o
O 1" x 24" iron pipe weighing 1.68 lbs per linear foot, set.
Co
to
NOTE
This parcel is to be deeded to an adjoining owner.
this instrument was drafted by Douglas Zahler job no. 86-54 \
VO/JUr?!1 10; VU /15 JaP
DO _UMEM1R NO- - WARRANTY 'DEED Ymt 3r^= RESERVED FOR RECORDING DATA
STATE RAR OF WISCONSaT FOPM 2 xs82
a
469864
REGISTER'S oma
i
Brian j.--5m ST. CROIXC4., W!
yth_andCheryI L. _Smth----------------------_---------- Recd for Record
MAY 3 0 191
2'45 PA-0
conveys and warrants to 's
V i'~~
....Ma.It~.1<}--J~.us.b~v.~__~.z~.d_ zz~.~e_---as-s•~~g~~s~ip-----........_.. Registerof D"
_ m$Itil`k,~--gQ~_ety-----------------------------------
i
r-
R__MR i TO
'
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• . 1•-•----
- - -
the folIotwint de<crUed real a3tate tti --Gl 9 X-- ty,
State of fsconsi r
Part of 5 of NEY; of Section 7-29•-19 described as follows: Tag Parcel o:.-
Commencing at the Northeast corner of said Section 7;'thence South 39 391 50" West (true
bearing) 330.46 feet; thence South 01' Q61 West 1174.86 feet along the centerline of an
existing Town Road; thence South $$0 551 30° West 595.0211feet to the POINT OF BEGINNING;
thence South 88° 551 3011 West 416.03 feet; thence North 290 191 West 504.49 feet; thence
Northeasterly 68.43 feet along the Easterly right of way.; line of a proposed Town Road on
an 85.00 foot radius curve concave Northwesterly whose chord bears North 370 351 10"-East
66.60 feet; thence South 750 261 4011 East 647.41 feet; thence South 0° 461 West 322.15
feet to the POINT OF BEGINNING. Except Lot 1 of Certified Survey M6 in Vol. "6", page
1753. A parcel of land [mown as Parcel n8 located in SE% of NET/d of Section 7-29-19
described as follows. Commencing at the Northeast corner of said Section 7; thence South
30 391 501! West (true bearing) 330.46 feet; thence South!00 461 West 1174.86 feet-along
the centerline of an existing Town Road; thence South 880 551 30" West 595.02 feet to the
POINT OF BEGINNING; thence South 00 461 West 441.62 feet; thence South 780 36, West 354.09
feet along the Northerly right of way line of a proposedlTown Road;,thence Westerly along
said Northerly right of way line 110.71 feet on a 683.201foot radius curve concave
Northerly whose chord bears South 830 141 QOII West 110.59 feet; thence North 00 461 East
516.07 feet; thence North-88 0 551 30" East 456.00 feet to the POINT OF BEGINNING. Except
part to Larry J. and Patricia L. better in Vol. 11549", page 105. TOGETHER WITH an
easement for access road as described in Affidavit in Vol. 1149111, page 207.
' i
I
homestead property.
This ---5---}=
(is) (is hot)
113 00
E.cceptiott to w=Taatics: None rur 10
19.41. .
Dated this -------------------------23-•----------------- day of flay.......
i
(SEA G) (SEAL)
(SELL) (SEAN.)
i •
` ----Chary - .Smyth
i
AUTHENTICATION A.CSNOWLBDGMSN'T
* rnI hn
Sigaatare(s) _ _s . STAFF OF.
._._.,day of
authenticated this day of 18----. Fe:sonaLh` c-sale before me this - !q
n_~ L the above named
i
Y'J 4-`-~--- --gym . -
TITLE : MEMMRSTATE BA$ OF W ISCO1_16TST_*T - - .1-- -
(If AO -
authorized by $ 706.06, Wis. Stats)
to me known to be the person ..T who executed the
forE®oiae ins i eat and ac]asoaeledge the same-
THIS INSTRUMENT-WAS DRAFTEo 6Y -
Brian, J. Smyth
Soulton., Wi. 540.82 rJ_'`_---'►~1_---•----......--•-••------
hot"r= Public!---------county, I
(Signatures may be aAtheutic vted..ae.aCkXgz9Cd d. Both NF Cmnmicsio is vermanerM(If not, state expiration
are not aeeassary.)
-
W91 F 19-17.)
~1- c Mr's CM as
1X_ e X___ 8%=-Tnw in Bra eoddty LilIlDB! AQ ;
~L _ - , KAEiEN F_
l J I
SEPTIC '"ANK MALNTEMANCE AGREEMENT
Sr_. Croix Cuuncy
OWNER/BUYER ~8/L ce /`~L1rL
ROUTE/BOY NUMBER (093$ c~ 4ve- Fire Number
CITY/STATE NVEX CvzovG L4-i(*qa_ /KIV ZIP 55c-7
P^OPERTY LOCATION: Z, RIO- `t, Section - T Zg N, R W,
Town of S7: 5S4q6! St. Croix County,
Subdivisio 4A:. CA.~ Loc number.
Improper use Xnd maintenance of your septic system could result in
its premature Eailure 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 Euncciun of the septic tank as a treat-
ment stage in the waste disposal system.
St. Croix County residents.mav be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operaci.on 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) af't'er 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.
I/W E, the undersigned, have read the above requirements and agree
to maintain.the private sewage disposal system in accordance with
the standards sec forth; herein, as sec by the Wisconsin Depart-
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date.
I
SICKED L' 22 /
GATE
St. Croix County Zoning Office
P.U. Box 2':7
Hammond. :JI 54015
7L5-796-_Z39
SI.;%n. 0ar7.• ;rnd ro,-!:itr'n !'ct ahove address.
RINGS AND SAFETY & BUILbU•
FAE T OF REPORT ON SOI ; O RINGS P.O. BOX 7009
10 0 qHULA PERCOL.ATIOI I-ESTS (115) MADISON, WI 63707
ATION S S H63.091f1 & i liter 145.045)
~NO.! LK.
SURD I rHIPUNICII n1TY: QR ~ICIS
!~N COUNTY' '/4 ~ l / z9 /R1 01 Jos~5 - i [J4 1`Ft s- AT3A r'- Mali. f14
_ _
CQdIX-~141.'QM►~^~_-- _ DATES08SERVATIONBMAO!
USE , pc
is CO-ISM@~II~CLi1=~ ffiliTl~3iV: A<New UReplaca I ,]Ui.Y 24 ~"I o~ JU-2_'
14 N Amtl!y
_ ~otcc >gop PA 501.5 ^1 r~
S
~ Site piiteble For system U+ Bite unsuitable for system
RATING: 8 0'--
FJTFDI ~L: nnn11 1()LDIFG(TAK: RECOMMENDED SYSTEM:loptl son z 17
$ C~U~_[S C1.....
- Oi:yIGN RATr. II any bullion of the lolled area it In the N
~ 11 Percolation losts aie NOf roqui~ttil flnuclploin, indicate flourfplaln elevation:
under r.1403.(1H1511bl. mdicale: (
PROFILE DESCRIPTIONS
b LC -"-j p A' :R INCFIES ian~nCi •R S I W T TN SS, LOR, ACK.)
ELFVA T , AN E TH
BORING toinL RE 2 1l) I.IEDROCK IF gjERVED ISEE ABBFIV. ON B BR~
NUMBER nEPltl t!i TIUN 311S liV r •-•Sr
3" &e~15t lE G re. 2
z N g LL,-s s'' B e.v G r 'g, L.
1 _ 77. 53 r~ecN ~ GR 3( F•/MS•V4.C = Y 60 )llrf
B' 98-66 . _._.i oNL.__r _ -4.rB~l_-t's ?0 6Y&r1 7 m Y.(6vc0 17 A
13.Z -1•33 _91.14 ftJ&Nt ~ 7~ 33 _gs►_Q,L.!~-4~ ~ a~ S1 Z $Rr~M
- 4~B~LTS l7 GRYBRNSt /4~~Ri$ , ]S ~~NS 7 ~R~~Ob
8.1 8~ 9~ Iq No~_ > 7. Q3~f:NSC 'oY RSGez I+T~N
- - 6 Bu_TSF►S' BR gem F 5
CUTS, c 6vB~N 1 IZ%rgSf 33 Its >rFDEoA
S" I
7.qZ s F~~ 23" Y G 6814 0 F S DENSi*
13- -7.42 90
PERCOLATION TESTS
D A V PER INCH
DEP 1 WA ER I HOLE 1 ES I TIME ,
N BER I A y AFTEHSWELLING INSET MA.I_MIN. R.1.______ NGR10
P. I x'11 f~0 41 3 C> _ - 7~
r. x 3.33 odd. g_3 30 _
91-7.1
all t►o 1 ns ~and the ldirection and peheerlI areas. Indicate
3--____ it9hift 10 LOT PLAN: Sltow loretlons of pnrctilation nAls, %oil b dnil nandio the oil di the nsions of st'5ltow tho
l surlata elevation e scale
plot vian. nntel and vertical 11111V11111011 reference points and and slope.
9 s .oo
'S PI
RK- , . C IK
i Qdst*.':t ► B- 8&NC1•I MA KE JN.
ELENA? IDN ,/ptj•4~
. ` Y
' IN
UJ
BE~SG tK• v4k14TION S IN 'SOIL.
flPoru ~PF; 'czo~• /•1oRlioNS So1~ T+s<s-r~2 Rtco,~t~r< >~S
4L-TA- RNA \a~' /3'{ r SYSTEVh
4S T ot16R5►2FN4 -rNE
I ~ ~ ~ I ~ SYSTL /1'1 ~ A~ ` ,
IN
3 scALt
~ 3 ITT ~ / 30
OV _
Zo /q
601,
8 slid le y me Its I
i, the undersign+rl, hernhy cerlily that ilia loll 'fists reporwil on this 101 M wOll Ill tests are corrscnto the bestcol mVlkntov,rieelon anurbelief. rrietltaft specified In the
Wisconsin
11
4dminiurailar Cotle, and that ilia data recorded and the Ioentiun of live t
T STSWERE, yMp7~~/N
~USC~ CERTIFICATI NNUMBER Te&NUMBER
A-0? T Sl URE:
DI3TRIBt)TIONe Onglinal and ono craPY IP I.ocail Awurnny. Pinnarty Ownw 'flat $r,il 1"5141.
7j
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PAGE OF
Crv S S S 0c 10 f, o f 1 t S, s ~et-
fresh Alf Inlets And ODsefrallon Plp•
Appro.bd Vent Cap
Mlnlmum 12•Abo.o
.J" Final Grad.
~V V 76-
20 - {2' Above Plpr _ 4• Coet lion
10 final Grade V.n1 PIP.
Z-. Noy Or Srme.lk Co+orlny
Wn 2' Aaareyals .
O,of Plpa
01e111b.lldn
Ptpa o 0 0 - Tea -
ti Apar a gala
BeneUll Plpa ° Perloroted Pipe bolo.
o -Coupllny T•r minallny At
8ollom 01 Syel•m
Pru o~ e p ~1~e`~ 9 rf, ~1<
P
SOIL FILL
DISTRIBUTIOLI PIPE
• APPROVED $yu-jHETIc covcR
` '9121 ^'PIATERIN- OR ol" OF STRAW
2"OF hGGREG, AIF- OK BARS" ltAy
0Fli -21/z AGGREGATE
OFa~.uFEET,
ELEV. °P tt S Vii/ DISTRIWJTIOM PIPE TO BE AT LEAST _ INCHES BELOW ORIGIIJAL GRADE
AMU AT LCASTLO WCHES BUT 1.10 MORE THAM 42. IMCHES BELOW FINAL GRADE
MAXIMUM DSPrvj OF EXCAVAT1,00 FKOM ORIGINAL 61 P\D~ WILL BE Iuc11Es
nNIMvm A£Pr'tt of EACAVATION rl~O/A 0~I64NAL (3RADI: WILL BE INCHES
51GIJCO:
LIGE►JSE AIUMBER:
DATE: X9-1
1 t o .