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Form - S XTC - 104
AS BUILT SANITARY SYSTEM REPORT
/ '
OWNER hn TOWNSHIP /1/,r 50 ~ er Q SEC. T N-R W
ADDRESS C~' 1~~h N ST. CROIX COUNTY, WISCONSIN
C4 0,71-
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of 11HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
At_~
/V
I t 11-1
31
31
1
is
V1,~ lopes
t
I ICATE NORTH ARROW
L
BENCHMARK: Describe the vertical reference point used o
w O o~
Elevation of vertical reference point: 4 Proposed slope at site: - `--K-f&Slo~~
SEPTIC TANK: Manufacturer: ~(J~QT1S Liquid Capacity: ~o-&--o A-Z
Number of rings used: Tank manhole cover elevation: 9/- 02
Tank Inlet Elevation: Tank Outlet Elevation: Cf 7"
Number of feet from nearest Road: Front 10 Side 0 Rear, O 15-0 feet
From nearest property line ' Front, Side,ORear,O feet
Number of feet from: well #0 building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
l
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, 0 Rear, Ft.
Number of feet from well:
Number of feet from building:
I'4 (Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: K Trench:
I,
Width: Len the Number of Lines: o`Z Area Built: I
iye~
Fill depth to top of pipe:
Number of feet from nearest property line: Front, (jSide, O Rear,0 it Number of feet from well: x~e`A
Number of feet from building: 4c /
(Include distances on plot pla 40, X.
G G~ r
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
I
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, OFt.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: LO' Plumber on job:
License Number:
3/84:mj
ql 00//(?
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labo*and Human Relations REPORT St.
Saf2ty and Bmildings Division INSPECTION Croix
(ATTACH TO PERMIT) Sanitary Permit N:
GENERAL INFORMATIONNE4,NE4,Sec. 8,T31-R19,230th Ave. 149202
Permit Holder's Name: ❑ City ❑ Village I@ Town of: State Plan ID No.:
John English Somerset
CST BM Ele: ( Insp. BM Elev.: BM Description: Parcel Tax No.: 96B
l/C.o , 032-1020-10-#00
TANK INFORMATION ELEVATION DATA )0/, ?
I
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic f~ Benchmark
Dosing 4Z lJ ' Z, OG .66
Aeration Bldg. Sewer
Holding St/ Inlet
TANK SETBACK INFORMATION St/ Outlet 7, 16
' f
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
/ 1
Dosing NA Header/Man. 7,:S&
Aeration NA Dist. Pipe S'
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer DemandF .a le C,
Model Number GPM
TDH Lift Lrlctl System TDH Ft
Forcemain Length Dia. -f Dist. To Well
I
SOIL ABSORPTION SYSTEM
BED / T*E - width2 Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS Z DI
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING anufacturer:
SETBACK
/ Z Mode Nu r:
INFORMATION Type o CHAMBER
System: sej;d > (50 OR UNIT
DISTRIBUTION SYSTEM
Header/Mani old Distribution Pipe(s) x Hole Size X Hole Spacing Vent To Air Intake
Length Dia. length {y Dia. `f 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 ~zdiscrep nties, persons pr nt, etc.)
E e z~rr Cq
Plan revision required? ❑ Yes P_<0- 1~11ebkqi
Use other side for additional information. k c g
SBD-6710(R 05191) Date Inspector's Signature Cert. No.
ERJ4HR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COU~ (f (-o ` X
:
mommme STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 I (?Om
8% X 11 inches in size. Check if revs ion-to previous app - tion
-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
-w,, t e_tl 6( / JdYV) t ~t/4 '/4,S g T-?IN,R ~q E(or W
PROPERTY OWNER'S MAILIN ADDRESS LOT # BLOCK
O ( (9
C
CITY ST E / Pnn ZIP CODE PH NE UMBER SUBDIVISION NAME OR CSM NUMBER`
11. TYPE OF BUILDING: (Check one) ❑ State Owned VILLLLAGE ESIROI~D/- vc
❑ Public 01 or 2 Fam. Dwelling- # of bedrooms PA EL x Nu ER( t~ '(-`'L
111. BUILDING USE. (If building type is public check all that apply)
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
50 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. ❑ 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 V1 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 220 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
~L REQUIRED<(sq. ft.) PROPOSE~sq. ft.) (Galsi/day/sq. ft.) {Min./inch) gELEVATION
41
vJ✓!.~ Feet / IS-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
Lift Pump Tank/Si hon Chamber El Fj I El 1:1
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plu er's Name (Print): Plumb ignature: (No %ps) MP PRS o.: Business Phone Number:
Plum er' ddress (Street, 'ty, State, Zip Cod
f s a
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater [Date Issued Issui Agent Signature (No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee) `
Adverse Determination qC;Q
`
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
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.
---------------------7--------------------------------------------------
Owner of property -
cis
Location of property &L&1/4 _AIC 1/4, section , T / N-R f W
Township
Mailing address
Address of site o23~a 'U 9
subdivision name N~ Lot no. N lf7,
Other homes on property? yes No
Previous owner of property %n!K -ycC ZlAfa
Total size of parcels /tc~2E5,
Date parcel was created
Are all corners and lot lines identifiable? Yes
Is this property being developed for (spec house)? Yes No
Volume 7~S 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 & 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. /rr/ 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.
Si ture of a licant Co-applicant
Date of S gnat re Date of Signature
INDUST OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, , 1 P.O. BOX 7969
LABOR AND PERCOLATION TESTS (115) MADISON, WI 53707
HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145)
ZON SECTION: OWNSHIP UNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME: '
/T N/R 1 me rD
MAILING ADDRESS:
Lag
s 0 7 r' d
'
USE DATES OBSERVATIONS MADE / I-
111, , E E,
NO-BEDRMS.: COMMER IALDESCRIPTION: P OFIL I NS: A TE
FResd,,c, a fi~New ❑Replace Q
RATING: S= Site suitable for system U= Site unsuitable for system
ONVENTIONAL: MOUND: IN GFiOUNDPRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
~ S ❑U S ❑U S ❑U ❑ S U❑ S le-IVe
[unpd:ercs. olation Tests are NOT required TD SIGN RATE: If any portion of the tested area is in the
I LHR 8 Tests area
1(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, OBSERVED EST- HIGHEST TO BEDROCK IF O SE VED (SEE ABBRV. ON BACK.)
B_ oz-e
-T
-3 ~s A.~
B-
115i 0,11
1 Or
1? .01
0
B-
PERCOLATION TESTS
t DROP IN WATER LEVEL-INCHES RATE MINUTES
tE WATER IN HOLE TEST TIME PER INCH
ER AFTER SWELLING INTERVAL MIN. PERIOD 1 P RIOD 2 P R G
P-
P-
I
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
00
i '
I ,
E
1
~T
1
t
7 :A
P n
0 o
E
10
• 1
aP~
5 ro
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.
TESTS WERE COMPLETED ON:
PADDRESSS: print
h r' _ CERTIFICATION NUMBER: PHONE NUMBERIoptional►:
7 /,~~6 T6l,L'
CST SIGN RE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
ST. CIM
114. / JJPASE 214
gar N
4316$1 need
Oct. 30. 19
Cosatraitt for ]"to 8:30
r i of Gash
~rttm~lY~, made and entred into this 24th day of September , by
sad betvm Prank and Joyce LiadeU, parties of the first part, and John and
Eaglisl, potties of dye socartd part,
t $$`e that the said parties of the first part, in consideration of the COVVAMU and
agreemene of seed paMes of the second part, hereinafter coat med, hereby sell and agree to comer
uW said parties of the seommd part as tomt unents and not es lemnv m common, their assigns, to
smviror of said patio,, and the hens and ws gw of do stuviwr, by a Warranty Deed
aooompanied by an abstract evidencing good titre in parties of the mat part at the date hereof, upon
the prompt and M pedfaaamem by said pettier of the second peat, of their part of this agreement,
the tract of lead lgtag and befog m the Tovnship of Somerset, County of St. Croix and in the SStiAAe ~
of Wbcomm, mmp=rq twenty erns descnbed as follovs, 0-vit :
The West one half of the NorthEast quarter of the NorthEast quarter of
Section eight, Township thirty-one North, Range Nineteen West.
Tu stuemenv of routes assessed on this property as of the dat bereof Ad be sent to
John F and Nugent A PAghsh
• 407 Sopesior 3ueet,
Saint Pool, htiaaesota 55102
And said parties of the second put, in consideration of ft premises, hereby agree b pay rid
patios of the first pan, as and for the purchase prove of z d premises, me stun of Fifteen Thonsa:d
ad MgM Htstdred Dollars ( $15,800) m manner and v times Moving, to-vu:
$800 Cash is hand paid •C4 receipt of *x hxt, z eby acknoviedged ;
515,000 Payable m msallnaents of $131 64 per month, including interest at the rate of 1096
per anmatim computed on unpaid bakneea. Ir~xrest 3hL rnr. from the dale of this Contract First
paymm a shat be due and payable on October 24tH 1987 and subsequent payments shall be doe sad
payable oa the tventSrfouM day of each 3tucceed:u month. Payments ,;,-AU be credited flM tt►
in v v P s1 and the semebAer v pzia.^~al. The ent n t.eiz n e of this Contract shall be, d ve and payable
on Sepavbez 24th 1992.
Pages of me record part shah! not perform am corowrmn on the premises pear to the payoff of
this Coauact if said construction creases a lien or oler third party claim to the title.
Shoctid defeak be mode in t9a pasc;xnt of prmcipai er it t?rest Cue }inetunder or should the parties
of the 3eccad part Earl 1D perform any or enther of fL& co-. emats, a;mements, terms or condition
hevem conamed, io be by said second partm kept or performed. the said parties of the. first part
may at their option, by vdv n nowe declwe this contract cancelled and termwed, and all rights,
titre aM iris m aogvmd tberewader by sand parses, shall thereupon cease and lerminate, and an
tmpravemeale made upon the premises, and all payment r&,Ae hereinunder shell bebnd to said
parties of the Em pat as bgmdated damsges for breach of this contract by the second parses, said
notice to to m accordance with the statute in such case made and provided. Neither the exlermn
of the tome of pepm m, nor avy veiver by the parr. s of the first part of their rights v decline this
co=w fotierted by reason of any breech tiienof s tali in any menr er affect the right of said parties
to ceoeel thu contract bemuse of defaults subsegtiern$y nAnunng, and no extension of time shall be
ttW miess evidenced by duty mcmd =meat.
f 1Coatirmed
Ftu er, dw service of none and failure ti remove vAbm the perad albved by kv, the defiolt
of the second pen beseby spwfrallY Wye, upon demand of seed
of ' pW, gtet Y erd peweeW b swender tq tham posseson of sand premises
;
4r-. pw the~ceof, it belt mydersaood that un>sl such default, said pasties of the second pan On 'D
blue possession of said Premises.
3
by uA between eye parw hereto to the tees of
e:ants and s~reerrnents team
pomm shall be an esses►ail pen 01 t m Cony ut and that all the cav
Conlod shtwli exVVA' stm VI& the 1a>ad, and bind the anus, execuroors adrrunistic xo and &#JWns ,
of the respective Pestles beseto-
sy
~e~tt11(p ~1 the poxw have here anti set their hands the day and
tA 3w fiW above written y
Frank L~adelt
,y
*tau
Y
county of
Tlhe► ! ~slrrvment tnef sr~tn®~~ledgPd bPfnrP me this 241A dsy
IN7, Erb' LlndW! end JvyrP Linde/L AusDend ~/n/l1~.
of Stpte~
stltl doAa NOTAW end Margei tl English, y
lay
°iir'.@ C` GS•r5vfi r.,a4egee
i1TE
~IbtNIrtAM~~+
N cow' t 11 0-jre of piwson ackruvte0gee
r, T,+'.4 or RtM+k 1 ~'3
. t r met, Ps d. Y-L S5102
'111 t Val Qtafl~.'d by .tL ar4 ` , r .
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
ADDRESS: FIRE NO:c~~i+/(r l2
LOCATION: 1/4, 1/4, SEC. T 3/ NN--R' (LW,
1
TOWN OF: 5,g f&-R S',_-o- ST. CROIX COUNTY IV/
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
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
PLOT AN
PROJECT 7~70A/1 LCA LSA ADDRESS
IV~ ti-14 NF- 1/4/Sg /T,31 IR 19 ® TOWN COUNTY MPRS Byron Bird Jr. 3318 DATE q'
BEDROOM CLASS PERC__L__ CONVENTIONAL IN-GROU ESSURE
CONVENTIONAL LIFT_ MOUND- HOLDING TANK
SEPTIC TANK SIZE Cam./ LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA PERC RATE _BED SIZE / v2 WS -X
1116 Benchmark V.R.P. Assume Elevation 100' /
Location of Benchmark e- wit, C' ~e 0CA42 ~~`~ddn
M Borehole Q Well Scale = Feet
0 Perc Hole System Elevation ~J
Uent
12"
2 Grade
T
TYPAR COVERING
2"
12" 3' 4 g' O 3'
" Sewer Rock
6
12'
~ 3S
I
/fl
I fr ~ O G"
Y V^
~Jr,