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AS BUILT SANITARY SYSTEM REPORT FORM - STC - 104
OWNER-0,{o~S a, TOWNSHIP S.(-r✓1 S
S ECT I ON-~Z T_3_L_N-R_CW
ADDRESS M&A,4-ke Sf ° ST. CROIX COUNTY, WISCONSIN
M, YV Y1 6 5 j a--o
SUBDIVISION LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
A OrY7
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` v (~0a 5
za ~f
INDICATE NORTH ARROW
BENCHMARK: Elevation and description:
Alternate benchmark
SEPTIC TANK: Manufacturer: -Liquid Cap.
Rings used:0Manhole cover elev: /W Final grade elev: 40
Tank inlet elev.: --7-4--Tank outlet elev.: f g
No. of feet from nearest road:Front , Side , Rear Ft- 3 ao
r
From nearest prop. line:Front , Side, Rear Ft. 42 a
No. of feet from: Well ('4 , Building:
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
J
J
y
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump iphon Manufact.: Pump Size
Elevation of inlet: Bottom of tank elevation
Pump on elev.: Pump off elev.: Gallons/cycle:
Alarm: Man.* Switch Type: Location
Distanc from nearest prop. line: Front_, Side, Rear Ft.
Dis nce from: Well Building
SOIL ABSORPTION SYSTEM
Bed: Trench: Seepage Pit:
t-
Width: Length Number of Lines:_2Area Built r
J ~0
Exist. Grade Elev. 4720 Proposed Final Grade Elev. Z: 2
Fill depth to top of pipe: Z i
No. feet from nearest prop. line:Front Side, Rear Ft.
No. feet from we11:-4jNo. feet from building
HOLDING TANK
Manufacturer: Capacity:
No. of rings used: E vation of bottom tank:
Elevation of inlet:
No. feet from ne est prop. line:Front , Side , Rear Ft.
No. feet fro Well , building , nearest road
Alarm of acturer :
INSPECTOR:
DATE : PLUMBER ON JOB :
LICENSE NUMBER : MM L-3 Z S
7
6/90:cj
i
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
LABOR & HUMAN RELATIONS DIVISION
P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
MADISON, WI 53707
SF., NtiV, 14 , 31, l 9W State at s fined) 'Number
Town of Somerset CONVENTIONAL ❑ ALTERATIVE
# ng Tank El In-Ground Pressure E] Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPEC O DATE:' 55106 Charles Erickson
7 / / ~l
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: r 1~1 REF. PT. ELEV.:ST REF. PT. E V.:
r
Name of Plumber: MP/MPRSW No. ` County ` Sanitary Permit Number:
--149032
Gary Steel 2
SEPTIC TANK/HOLDING TAN' 7" %';v 'S, . V1 cn ~'-~tx7er= /GD•/G 7 041,
ARNING LABEL LOCKING COVER
MANUFACTURER: LIQUID CAPACITY: TANK INLET EL K OU L 7F
} OVIDED. PROVIDED:
~F' f'~ c:i-G"t_~, (~~V ~.a7 NO ❑ YES
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: kBYILDING: VENT TO SH
I r ALARM: FEET FROM LINE: I i AIR INL
❑ YES 0 L~ C GAS ❑ YES NEAREST-►
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
L_j YES ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUM S OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF ❑ YES ❑ NO
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DI RIAL AND MARKING:
or excavation. (If soil can be rolled in p a-wire, construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM.
BED/TRENCH WIDTH: LE W- NO. OF DI TR. PIPE SPA ING: COVER SIDE DIA.: # PITS: LIQUID °a
/ TRENCHES: f nneT~FOiALt~ P PIT DEPTH:
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. DISTR PIPE VA FjIIAAL: NO. ST . NUMBER OF PROPERTY BUILDING: VENT TO FRESH
BELOW PIPCE~S; ABOVE COVER: ELEV. INLET: ELEV. EPIPES: FEET FROM LINE: AIR INLET:
Q 9`21 l~ k 97,5P i _4 NEAREST
MOUND SYSTEM: !
Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW
❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED.
SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS;
❑ YES ❑ NO ❑ YES ❑ NO
DEPT ER TRENCH/BED DEPTH OVER ED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH: LENGTH: NO.OF LATERAL SPA GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
BED/TRENCH
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: ux
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT S TO
INFORMATION APPROVED PLANS
❑ YES ❑ NO ❑ YES ❑ NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
Sketch System on A;I-tain in county file for audit.
Reverse Side. SIGNAT RE: TITLE:
Zoning Administrator
SBD-6710 (R. 06/88) SSY
D'L~R SANITARY PERMIT APPLICATION
EZ , Fq 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 ly 9 0 3 :Z1
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
Charles A. Erickson SE t/4 NW S 14 T 31 N, R19 V(or) W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
1585 McAfee St. 18 n/a
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
St. Paul, Minn. 55106 612 771-1905 Rolling Meadows
II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
❑ State Owned VILLAGE Somerset 215th. St.
❑ Public ®1 or 2 Fam. Dwelling-~# of bedrooms 3 PARCEL TAX
_NUMBER(S) ~i 6
III. BUILDING USE: (If building type is public, check all that apply) b 3.~ _ 163R(
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. ® New 2. ❑ Replacement 3. ❑ Replacement of 4.E] Reconnection of 5. ❑ 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 300 Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 ❑ In-Ground 420 Pit Privy
13 ❑ Seepage Pit Pressure 430 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/day/sq. ft.) (Min./inch) ELEVATION
450 900 900 .50 34 96.99 Feet 100.72 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 strutted
Se tic Tank or Holdin Tank x 1000 1 Weeks C . P .
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installati n of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber' nature: (N m MPRSW No.: Business Phone Number:
Gary L. Steel 3254 715 46-6200
Plumber's Address (Street, City, State, Zip C
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater [ate Issued issuing gent Signat 7NO S ps
Surcharge Fee)
Approved ❑ Owner Given Initial S 9
Adverse 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
APPLICATION FOR SANITARY PERMIT
STC - 100
I
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/contractpr,("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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
t ,rte ~
Owner of Property X0.11' S R ~lr \Z~50~
Location of Property Section T "31 N - R W
Township
Mailing Address S A-. k~'C~V 1I Y 1►~d 5 6 ~U ~Q
V
Subdivision Name R0L,2, WIC A- oW
Lot Number 0 .
Previous Owner of Property
Total Size of Parcel
s
Date Parcel was Created 4-18-75
Are all corners and lot lines identifiable? xxx Yes No
Is this property being developed for resale (spec house) ? Yes 'A, No
Volume 899 and Page Number 235 as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
i
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 revtowing 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) eeAti.6y that att statements on this 6onm a,%e true to the beat o6 my (oun)
hnowtedge; that I (we) am (an.e) the owneA(d) o6 the pnopehty deaeni.bed in thia
in6onmation 6onm, by vi tue o6 a wanh.a.nty deed n.eeon.ded in the 066ice o6 the
County RegiAteh o6 Deeds as Document No. 468446 ; and that I (we)
pn.esenti'y own the pnopoaed 6 to bon the sewage diapozat system (on I (we) have
obtained an easement, to nun with the above de4cti.bed pnopv ty, bon the
conatwcti.on o6 said 6yatem, and the aame has been duty xecokded in the 066iee
o6 the County Reg.i,aten o6 Deeds, ab Document No.
SIGNATURE OF OWNER SIGNATURE OF C -0 ER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
J
DOCUMENT NO. THIS SPACE RESERVED FOR RECORDING DATA
WARRANTY DEED
^ ~ .w c STATE BAR OFA§jNSIN,F2&M2 - 1982
Cj "fiV vol
REGISTER'S OFFICE
Mark D. Klink and Roxanne K Klink- husband and wi fee ST. CROIX CO., WI
as survivorship marital (L Pry Recd for Record
of APR191991 °
M
conveys and warrants to Charles A. Erickson and Donna J 4:10 P, g
Etickson, husband and wife, as survivorship marital i
property Register of Deeds
R CE C
1811 Weir or.
the following described real estate in St. Croi x County, fluke 170 WWdw% MN 66126
State of Wisconsin:
Tax Parcel No: O"ba-10 Al-3Q ( 199
Part of the Southwest Quarter (SWI) of the Northeast Quarter (NEI) and
Southeast Quarter (SEa) of the Northwest Quarter (NWI) of Section Fourteen
(14), Township Thirty-one, Range Nineteen (19) described as follows:
Lot 18 of certified survey map filed April 18, 1975 in Volume 1, Page 115,
St. Croix County, Wisconsin.
TRAN.WO
$38 -
This is not homestead property.
(is not)
Exception to warranties:
Dated this 18th day of April , 19 91
(SEAL) (SEAL)
-*Mark D_ Klink v * Charles A. Erickson
00 (SEAL)
(SEAL)
* Roxanne K. Klink Donna J. Erickson
AUTHENTICATION ACKNOWLEDGEMENT
Signature(s) STATE OF WISCONSIN
ss.
St. Croix County.
Personally came before me this 18th day of
authenticated this day of '19 April , 1991 the above named
Mark D. Klink, Roxanne K. Klink,
Charles A. Erickson, Donna J .Erickson
*
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the person who exec t
authorized by § 706.06, Wis. Slats.) f going instrument and e
THIS INSTRUMENT WAS DRAFTED BYE' tiOFFMEYER
NGTr,.<'t v~.lR. - ~IL.+E;UIP
Garv H_ Raillargenn
` ' my commission expires 1-31-96
-
Notary Public . St, %OTIF17707
County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.) date: Septmber 18 1994 )
Names of persons signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN WISCONSIN REALTORSO ASSOCIATION
FORM No. 2 - 1982 4801 Hayes Road, Madison, Wisconsin 53704
I
1
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/R Charles A. Erickson
ROUTE/BOX NUMBER 1585 McAfee St. FIRE NO.
CITY/STATE St. Paul, Minn. 55106 ZIP
PROPERTY LOCATION: SE 1/4 NW 1/4, Section 14 T 31 N, R 19 W,
Somerset
Town of , St. Croix County,
Subdivision Rolling Meadows Lot No. 18
,
cSwL //S
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 for a MAXIMUM of
$3000 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 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 form 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 Department 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.
SIGNED-
DATE G} i
_ t~
St. Croix County Zoning Office
P.O. Box 98
Hammond, WI 54015
(715) 796-2239 or (715) 425-8363
Sign, Date, and Return to above address
DEPARTMENT OF REPORT OIL SOIL BORINGS AND 5A t-t I Y 19 t3V t_U DIVISION '
INDUSTRY,
LABOR AND P.O. BOX 7969
LA
LA OR RELATIONS PERCOLATION TESTS (115) MADISON, WI 53707
HLAVrAN (H63.090) & Chapter 145.045)
LOCATION: ECT O : TOWNS HIP/N91NN)U4=TY: =18n/ja O.: SUBDIVISION NAME:
SE 1/4NO/4 14 /T31 N/R191 (or) W Somerset Rolling Meado ws
COUNTY: S E: MAILING ADDRESS:
St. Croix Mark D. Klink... 15617 Ozark Ave. N., Oak Park Htgs. Minn. 55082
USE DATES OBSERVATIONS MADE
B DESCRIPTION QNew PROFILE TS:
❑Replece I 9-11-87 9-12-87
Residence 3 n/a
RATING: S- Site suitable for system. U- Site unsuitable for system
CONVENT L: MOUND: IN-GROUND: S T - N-FILLOLDING TANK: RECOMMENDED SYSTEM: (optional)
S ❑U Ms ❑U Q S ❑u ❑ S ®U ❑ S QU conventional
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.1-163.09(5)(b), indicate: n/a Floodplain, Indicate Floodplain elevation: n/a
decimal' PROFILE DESCRIPTIONS page 10 AIC2
BORING TOTAL.., PTH TO GR UNDWATER-INCHEH CHARACTER OF SOIL WITH TH)CKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ELEVATION ggSERVED ES - GHE TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B_1 7.25 100.72 none >7.25 ..67 bn.sil. 5.083bri.s.1.
13.2 6,91 100.32 none >6.91 .75b1.1. 1.33bn.sil. 4.83bn.s.1.
6.3 6.91 100.42 none >6.91 .83bl.1. .83bn.sil. 5.25 bn.s.l.
B-4 6.50 100.51 none >6.50 .83bl.1. .50bn.sil. 5.17 bn.s. 1.
B-5 6.75 99.72 none >6.75 .75bl.1. 1.00bn.sil. 5.00bn.s.1.
B_ I vrr v`a' < <
decimal' PERCOLATION TESTS d 10 0, ! !e_ 14 s r-3
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INIC]KERS AFTERSWELLING INTERVAL-MIN. P R 1 P Rl D PER INCH
P. 3.73 none 30 1 7/8 7/8 34
P.2 3.33 none 30 Uk 1 1 30
P. 3 3.43 none 30 2-2 2 2 15
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
. o „S rnd rort!c-! e!Bv^tipn referen-n points and shoe., the!- !^cat!o:1 on t! a pint elan. ghaw tho eurfnee elevation er all horings and the direction and Percent
of land slope. • \-W, - C i
SYSTEM ELEVATION 96.99
5. N 1 G``
F _1
51
! Br ,
-
_ - 4
IN
111--__ -
[F~4~t 4, 1
!
0
- 1
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:
NAME print
Gary L. Steel 9-12-87
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
988 N. Shore Dr. New Ric-tunond Wi. 54017 I2248 715,-246-6200
CST SIGNA E:
0
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
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STEEL'S SOIL SERVICE
Gary L. Steel 988 N. Shore Drive
C.S.T. 2298 Charles A. Erickson New Richmond, WI 54017
MPRSW-3254 SE4NW%,, S14-T31N-R19W (715) 246-6200
Somerset, township A QiRai. 6W
lptf- ~
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. ~~v1 r l
` ' S mil/ ~ 32~
INiC,r r'k//t y~S
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14d Z----
Af
,Cr ~ mac- G~T/'T/ fir ~ ~?J
7 z S
Gary L. Steel
5-6-91