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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP
SECTION-_~~'u7 T N-R W
ADDRESS__v'`~~:a' ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE-
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
L'/.
.3~
t
41)
Q
INDICATE NORTH ARROW
BENCHMARK: Elevation and description:
t. t: ~~~z>>``,
Alternate benchmark _V5~ s` Ile
SEPTIC TANK:Manufacturer: Liquid Cap.
Rings used: Manhole cover elev: a~ Final grade elev:
Tank inlet elev.: ' , 7 Tank outlet elev.: ~ft q
No. of feet from nearest road:Front~, Side Rear Ft. clcr-- /
From nearest prop. line:Front Side l
Rear Ft.
No. of feet from: Well j', Building:
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
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_ 7 / Number of Lines: Area Built i'
Exist. Grade Elev. ~t>c ~7~-proposed Final Grade Elev. /e o-41-~
Fill depth to top of pipe: ~ ~ v-
No. feet from nearest prop. line:Front
Side >1/1, Rear Ft.c-~?,S
No. feet from well: ~0(Ioc /
No. feet from building-
!t C/ E y~
HOLDING TANK .
a
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 Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor dndH4manRelations INSPECTION REPORT St Croix
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION NE4,NW4,Se c.27,T31-R18, 149083
Permit Holder's Name: ❑ City ❑ Village EkTown of: State Plan ID No.:
Tom fUnz Star Prairie
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
Ci D q, 7-
TANK INFORMATION ELEVATION DATA✓
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ~ ~ S Q p d Benchmark 2-
Dosing
Aeration Bldg. Sewer a
Holding St/ Ht Inlet C~9 , 7
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic g 5 01 r -Z.1 NA Dt Bottom
Dosing NA Header/ Man. qz~
Aeration NA Dist. Pipe 19, G Z
Holding Bot. System %AI
PUMP / SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
oss Forcemain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 5 3 DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O oJr / CHAMBER OR UNIT Model Number:
System:
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia- Length 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 /Trench Center Bed /Trench E es Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
v~
COMMENTS; (Include code discreoh6es, persons present, etc.)
t 5
Plan revision required? ❑ Yes ❑ No -
Use other side for additional information.
SBD-6710(R 05/91) Date inspector's signature Cert. No.
r
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
,
t
~LHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code couN
E:3: . ..,,.a...~..,.~...e .
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than / Q~ (Z
8% x 11 inches in size. ❑chec 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. 56r 1~
PROPERTY.02)~R PROPERTY LOC TION
/a /,tea, S T
F4 , N, R E (oriip
PROPERTY OWNER'S MAILING ADDRESS LO # BLOCK #
CITY STATE / ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
/
II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLLLAGE NEAREST ROAD
❑ Public V~ 1 or 2 Fam. Dwelling-# of bedrooms, AR EL AX NUMBER(S) c~ ` 7
III. BUILDING USE: (If building type is public, check all that apply) 3 f~~ v ^C~~ 1
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.,gNew 2. ❑ 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/day/sq. ft.) (Min./inch) ELEVATION
o 'C`v2 Feet Feet
VII. TANK CA CITY Site
in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New istin Gallons Tanks Concrete glass App.
Tanks Tanks structed
Septic Tank or Holdin Tank G e
Lift Pump Tank/Si hon Chamber
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's ature: (No Stamps) MP/MPRSW No.: Business Phone Number:
Plum s Addre (Street, City, State, Zip Code).
O
IX. COUNTY/DEPARTMENT USE ONLY 11
❑ Disapproved Sanitary Permit Fee (includes Groundwater a e Issued Issuing Agent Si n re (No Stamps)
rfte Surcharge Fee)
Approved ❑ Owner Given Initial / ~ _
Adverse Det rmination Tk4ua".,~
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
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
3 All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (31313 6399) to be
submitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed
pumper whenever necessary, usually every 2 to 3. years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed. '
It. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested in ##1-7.
VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of
tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all
septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model. and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater, ground-
water contamination investigations and establishment of standards.
- - -
SBD-6398 (R.11/88)
APPLICATION FOR SANITARY PERMIT
9TC-100
This application form Is to be conplotad In full and signed by the ownet(s) of
the ptoperty being developed. Any lnadoquacles will only result In delays of
the pit rait issuance. -Should thla development be lntended for resale by
owner/contractor,(spoc houoe), thon a second form should be tetalned and
co.pl■ted when the property is sold and submitted to thIa office with the
appropriate deed recording.
Omar •of ptoperty
Location of propstty x_114 .12W .1/4t Bectlon -,:;,2? T-31 it -&-V
Township /7e•rr` .5-~.ew_ 1'~.~..;,
Ha111ng addtess //0-7-4 C Ae - h _.0 t1. Z %rS(bk
Address of site Il,T C"clo41
Rubdivlslon nawej24 •
Lot number
Previous owner of property ^1.6-4d ( ,A/~,,,,`
Total sire of pstcel
I Date parcel vas created
Ate all cornets and lot lines Identlflablet r yen _ No
Is this property being developed for resale (spec house)?- as 0
YVIUMV -r co and Page Humber ~ as recorded wlth the Aaglatet of Deeds.
ter---........
I1ICLUD9 YITI1 T11I9 APPLICATION TII¢ FOLLOVIHCI
A wAARANTT DIID vhlch includes a DOCUHXHT HVHDRR, Vot,"It AND PAC[ HVxIIR, and
the BIAL OT T111t Rg0IBTRR OF DHBDD. In addition, a certified survey, (f
available, would be he)plul so an to avoid delays at the reviewing process. It
the deed deacrlptlon references to a CettlLlsd Survey Hap, the CattlLled Survey
Hap shall also be tcqulred.
PROPIRTY O "ER CERTIFICATION----
live) entity that all statements an this form are true to the best of ■y (out)
knovledgel that I (we) am (ace) the owner(s) of the property described In
this Infotmatlon form, by virtue of it warranty deed recorded In the Office of
the county Register of Deeds ae Document I(o, y(
presently own the proposed alto for the sewage d IspposaIs ysteln (ordI (weI have
obtalned an easement, to run with the above described property, [or the
conottuctlon of sold system, and the same has been dui recorded In the of lice
of the Coynty Register of Daadsj as Document No.
Ignatute o[ Ovne Signature at Co-owner (IL Applicable)
Date at Signature Data oL 819naturs
L
i
DOCUMENT No. WARRANTY DEED THIS SPA^.E RESERVED FOR RECORDING DATA
I'
STATE BAR_OF WISCONSIN FORM 2-1982
48£6 11 ivc!UaGE REGISTER'S OFFICE
I---. ST. CROIX CO., WI
Harold Olson and Barbara Olson.(...husband. and......... Recd for Record
wife. JUN G 91989
at 10:30 A.M
conveys and warrants to a
husband-and.. _wif e.,... as..mar i tal...prop~erty...with Register of Deeds
rights...of.._sllrvivoxship
• .
RETURN TO
the following described real estate in ................................................County,
St. Croix
State of Wisconsin: Tax Parcel No:
~I
Lot Six (6) of Certified Survey Map, filed May 30, 1989 in
Volume "8" of Certified Survey Maps, page 2105, as Document
No. 448270, being a part of the Northeast Quarter of the ~i
Northwest Quarter (NE4 of NW3d) and the Southeast Quarter 'I
of the Northwest Quarter (SE4 of NA) of Section Twenty-
seven (27), Township Thirty-one (31) North, of Range
Eighteen (18) West.
Together with a 66 foot strip of land for ingress and egress easement,
being the East 66 feet of the Northwest Quarter (NW4) of said
Section 27, lying North of the existing town road, except the North
660 feet thereof, as recorded in Volume 557, page 371,
Also a 66 foot wide strip of land for ingress and egress easement
being the South 66 feet of the North 693 feet of the East 330 feet
of the Northwest Quarter (NW4), and that private road, both as
shown on that Certified Survey Map recorded in Volume 3, page 708.
IRANSF
1~.Z
This i.S...ns.t........ homestead property.
(is) (is not)
t
Exception to warranties:
..89...
Dated this June - - - . . . . 19
.7..t~} day of
(SEAL) .................(SEAL)
* ..Har.01d..Q1s.On.. _
...............................................••---..(SEAL) ...Qk........ ...............(SEAL)
* Barbara Olson
.
AUTHENTICATION ACKNOWLEDGMENT
rold Olson and arbara STATE OF WISCONSIN
Signature(s) H............................................................
as.
Ol S On_./~= .County.
aut c lbday of....... iJ ne..---_-.., 19$9. Personally came before me this ................day of
19........ the above named
.
. Sc tt R. Needham
TITL MBER STATE BAR OF WISCONSIN
(If not-
authorized by § 706.06, Wis. Stats.) to me known to be the person who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Renstra,-.Van Dyk & Needham! S . C.
201 South Knowles Avenue, Box 127
New--tic-hiuoncl,.--W1-----3.40-17 Notary Public ..................County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.) date: 19.........)
'Names of persons signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE, BAR OF WISCONSIN Wimeonsin f.enni Blank Co. lne..
FORM No. 2- 1982 Atilwbukee. Wis.
SEPTIC TANK MAINTENANCE AGREEHENT
St. Croix County ~
. W
rt
014NER/BUYER o
17 Fire Number :j
Il~l~o~
ROUTE/ BOX NUMBER
W
72' -
CITY/STATE ,~1 U 4 1 C
PROPERTY LOCATION: _ k, Section,12 Ti , Rj_W.
Town of St. Croix County,
Subdivision Lot number
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes.- Prover maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licen's'ed" 's'e tic tank pumper. What you put into
the system can affect theFunet on o, t e-septic tank as a treat-
ment-stage in the waste disposal system.
St. Croix County residents'-may be eligible to recieve a grant for
a maximum of 604 of the cost.of replacement of a failing system,
whici 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 *sys't'ems agree to keep their system properly
maintained.
The property owner agrees to.submit to St. Croix County Zoning a
certification form, signed by the owner and by a mater 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).after 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.
0
I/WE, the undersigned have read the above requirements and agree 0
to maintain the private sewage disposal system in accordance with
the standards set forth, herein, as.set by the Wisconsin Depart- r
merit of Natural Resources. Certification form must be completed •o
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration.date.
SIGNED
DATE
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
DIVISION
ON
LAB611 AND P.O. BOX 769
HUMAN RELATIONS PERCOLATION TESTS; (115) MADISON WI 53707
sw~ OLHR 83.09(1) & Chapter 145)
LOCATI N:~ SECTION: j OWNSHIP MUNICIPALITY: OT NO.:BLK. NO.: SUBDIVISION NAME:
Nt- Y N/R/ (or ,r, e_ -4g 02! C U T/Y: a MAILING ADDRESS:
USE DATES OBSERVATIONS MADE?/7;.24( 7.21
NO. BEDRMS.: CO M AL E RI TION: TS:
Residence New ❑Replace
Q..0- 7'
RATING: S- Site suitable for system U- Site unsuitable for system
ONVENTIONAL: MOUND: IN-GR ND-PRESSURE]EISSU SYS EM-IN-FILL OLDING TANK: RECOMMEENNDED SYSTEM: (optional)
®S EJU S ~U S EJU EIS /
DESIGN RATE:
If Percolation Tests are NOT required
If any portion of the tested area is in the O
under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL -DER H T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED E TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- l 4 aw /'Ia f G
13- .5 .fie{';V
o-/a i h :5111A _ ye%~,s,• ay 57 r
13.3 O -ia h s is a t_ s~` 2V 0-00 Syr
B" Uo n /o~ / 3 /az ,3a~ ~vZ Sfr
13-
PERCOLATION TESTS
}t EST D TH WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES
t NUMBER AFTER SWELLING INTERVAL-MIN. PERIOD 1 P RI D 2 PERIOD3 PER INCH
P_ / 14, tbr' of,16 a- o it S
P- .tip 7
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.
SYS EM ELEVATION J •
~,/Ga I i I I l i ~ I
t d r ( P
40.
I
V
Yt?
i
I
(
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.
NAME print TESTS WERE COMPLETED ON:
1 44
ADDRESS: CERTIFICATION NUMBER: jPH`ONE NUMBERIoptional):
c A / 7 ~aZ6 6
CST SIGNATURE:
Ar" e~~
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
- DII HR .RRDF3U5 IR in/Ail nvcQ
PLOT PLAN
'P;ROJECT ADDRESS
A/-1/4 1/4/S,?-7ff3~ N/R/-~(W TOWN COUNT 7~Cr®ii~S~o~7
MPRS Byron Bird Jr. 3318 DATE t-1,2
BEDROOCLASS PERC~CONVENTIONAL~ IN-GROU PRESS RE
CONVENTIONAL LIFT- MOUND_ HOLDING TANK
SEPTIC TANK SIZE TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
A
11116 BSORPTION AREA o - _ PERC RATE God BED SIZE X 5
Benchmark V.R.P. Assume Elevation 100'
Location of Benchmark
* H.R.P. /~i . Go.-"
O Borehole Q Well Scale = Feet
0 Perc Hole System Elevation
Uent
12"
Grade
TYPAR COVERING
12" 3' 4 g' O 3' 3' O 3'
I " Sewer Rock
s
1 2' 18'
v
27r 1 r 'w
' ~ LB ~'31 i 1 ~
33o a Uo'