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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP
SECTION 3 T N-R_,~2 _W
ADDRESS ST. CROIX COUNTY, WISCONSIN
Alb 1A LL
SUBDIVISION LOT_LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
L.'~'$rijlEnr~'•Xe,~~ ' I,
!G•~,~
will
•i
INDICATE NORTH ARROW
BENCHMARK:Elevation and description: ,aa
Alternate benchmark
SEPTIC TANK:Manufacturer:_& Liquid Cap. J
Rings used: ^ Manhole cover elev: ,ZQ,2 Final grade elev._~Q ~
Tank inlet elev.:
1c?. Tank outlet elev.. _ 146
~
No. of feet from nearest road:Front , Side, Rear Ft._J-L
From nearest prop. line:Front , Side, Rear Ft.
r
No. of feet from: Well
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: 1, Length 2 Number of Lines:
_Area Built--.~~CLa
Exist. Grade Elev._ CC~ Proposed Final Grade Elev.,bV.,
Fill depth to top of pipe: ,.2
No. feet from nearest prop. line:Front-.4_, Side , Rear Ft./2
No. feet from well:- 4'
No. feet from building 7r
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: Wellbuilding, nearest road
Alarm Manufacturer:
INSPECTOR:
DATE :1L,1199f PLUMBER ON JOB :
LICENSE NUMBER:__ _
6/90:cj
o4 9/z 5 >0 /0s
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT St. Croix
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATIONSW, SW, Sec. 32, T31-R18, 149243
Permit Holder's Name: ❑ City ❑ Village R Town of: State Plan ID No.:
Greg DeRosier Star Prairie S91-40968
CST BM Elev : Insp. BM Elev.: BM Description: Parcel Tax No.. 542F
n1a 11-- -
O~ ,(Id - -11 20
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic S Benchmark
7l D
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet /07.6-7' O 6,8
TANK SETBACK INFORMATION St/ Ht Outlet 77 /a, '59'
TANK TO P/ L WELL BLDG. Ventto ROAD
Air Intake
~ NA
Septic
Dosing NA Header /Aftft B'8~Z 98-%
Aeration NA Dist. Pipe
Holding Bot. System g(o
F
PUMP/ SIPHON INFORMATION Final Grade (Dq,
Manufa Demand s `(o~ :r O jS
Model Number GPM
TDH Lift Friction System TDH Ft
oss fi ead
Forcemain Length Dia. Towell
-1 - F
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN 1 DIMENSIONS
LEACHING Manufacturer:
)XIK SYSTEM TO P BLDG WELL LAKE/STREAM
MATION Type O CHAMBER Mode Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header /Manifold Distribution Pipe(s) ~xHle Size x Hole Spacing Vent To Air e
Length Dia Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At- ra n y
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
Plan revision required? ❑ Yes No
Use other side for additional information. ( 4 1 o
SBD-6710 (R 05/91) Date Inspector's Signatu a Cert. No.
SANITARY PERMIT APPLICATION
70ILHR In accord with ILHR 83.05, Wis. Adm. Code !M.STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ / 8% X 11 inches in size. hec if rapplication
-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
%a / '/a, S Tom}' , N, R E (or) W
PROPE OWNER'S MAILING ADDRESS LOT # BLOCK #
-5/ A Z, I I -
ZIP COD PHONE NUMBE SUBDIVISI NAME OR CSM NUMBER /
CI TAT4~zl=
cJ ~
"
11. TYPE OF BUILDING: (Check one) CI NEAREST ROAD
State Owned VILLAGE
ON OF ~44
® Public ❑ l or 2 Fam. DwelIin" of bedrooms - PARCEL TAX NUMBER(S)
III. 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 /
4 ❑ Church/School 8 ❑ Mobile Home Park 120 Service Station/ ashA/o
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. ❑ 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 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 420 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.) PROP SED (sq. ft.) (Gals/da /sq. ft.) (Min./inch) ELEVATION
G 1,30 3 S 979 Feet 119d, jq Feet
VII. TANK CAPACITY Site
in gallons Total # of Prefab. Fiber- Exper.
INFORMATION New in Gall ons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App
Tanks ks structed
Septic Tank or Holding Tank S
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for instal tion of the onsite sewage s s m shown on the attached plans.
Plumb is Name (Print): Plumb is ign re: (N to ) MP/MPRSW No.: Business Phone Number:
r
S ~Sr
m 's Addr ( eet, ity State ZipCo V.
,
IX. COUNTY/DEPARTMENT USE ONLY
Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature No Stamps)
Approved El Owner Given Initial ~Surcharge Fee)
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 s Buildings Division, Owner, Plumber
-1
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_ his
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 dedd recording.
Owner of property l 2e~=,g f
Location of property_,aal/4 _e, kj 1/4, Section , T_,,1N-R_ZZ W
Township , -j z2_ ei
Mailing address
A-E,
Address of site
Subdivision name V Z- Lot no.
Other homes on property? yes No
Previous owner of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes,,r_No
Volume and Page Number c~ 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. 1-116 , and that I (we) presently
own the proposed site-' or 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.
r" .
Signatur of ap0cant Co-applicant
Da e f S na re Date of Signature
Ait*
T"1a s►ACa aslant Iea anosaws DATA
• STATZ RAW OF WISCONSIN FORK i-iffM
~ m
QUff CLAW, OM
40"0 '909,
a Lana:DaRosier....... STS
. { fted is 000"
• f pov. 13. 1987
1 o~
I 12:05 P M i
d
I
.
do fo0owhw dsseraw real estate in St.._.a-• aix County.
RatYRN -a..~
Seas of Wissania
+ Part of Sh of SWk of See. 32-31-18 described
as follows:- Commencing at the Northeasterly
i corner of Certified Survey Map, Vol. 2, pg. 503,
1
Tax Parcel No:
St. Croix County, Wisconsin, said
point being a
i one inch iron pipe located on the Westerly right-of-way of a town road; j;
+ bearings referenced along said Westerly right-of-way South 21014'29"
East (recorded as South 22-19-12 East); thence at an angle of 90 degrees
to the left, a bearing of North 68045131" East, 66.00 feet to the f
t Easterly right-of-way of said town road, also being the point of f v
beginning of this description; thence South 21014129" East along said
Easterly right-of-way, 90.09 feet; thence South 42057139" East along
said Easterly right-of-way 41.94 feet; thence South 87046100" East, 524.53 feet; thence South 02014100" West, 75.00 feet; thence South ,
87°46'00" East 372.77 feet; thence North 02014100" East 519.08 feet;
thence North 87046100" West 888.47 feet to said Easterly right-of-way i.
• of town road; thence South 22029104" West along said Easterly right-of-
t; way 149.68 feet; thence South 08059104" West along said Easterly
1 right-of-way 192.80 feet to the Point of beginnings .
EXCEPT land and easement as described in Mortgage from Steven Patrick
s Barry-->and-Jeanine Mary Barry, husband and wife, to Thorp Finance
Corporation in Vol. 647,•page 414, Document No. 377993.
} is not OWN
This . . homestead property.
(is) (is not) c
Dated this ..:..........:5.. ..day of ...~✓lo./~UK!J..... 1f..87... is .
w. }t
. (SEAL)
_ ~7~a.~....~4•....!Z....1.0440%1 . ......(SEAL)
• • . Barbara I,ynn_ DeRosier.:....
f ...................:.(SEAL) (SEAL) t~
,f
AIITBSN?ICATION ACKNOWLEDOXXXT
SiSsatnte(s) STATE OF WISCONSIN .
..D&r.1~1_ara..Lynr! DeRosier s }
x
ST. CROI.. ...............County.
tt day d....A!GG'..~ 19..87
Personally tame before me this . day
, t
s 19.01.. tho above named
• Jaiatee ,T R........ n Barbara.. L ynn DeRosier
.
MZKJ3ER STATE OF WISCONSIN s
t; (If oak astbrb" by ; 106.06. Wis. State.)
to ma known to be the person TAO esculad the s,
foregoing instrument and acknowledge the same.
:-15 INSTRUMENT WAS nRAFTFn BY
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
ADDRESS: FIRE NO:
LOCATION: 1/4, 1/4, SEC. _f~P T--g:?/ N-R_Z,9_W,
TOWN OF: ST. CROIX COUNTY-=2L SUBDIVISION: A~Z 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
INDUSTRY, DIVISION
P.0 BOX 7969
LABOR AND PERCOLATION TESTS (115
HUMAN RELATIONS 91 4 "6W'
53707
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION-.--- O UNICIPALITY: OT NO.: BLK. NO.: SUBDIVISION NAME:
COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS:
User rvr~c r, C/! oic d ~!/i ~J L
NO. BEDRMS : COMMERCIAL DES IPTION: PRTOFI OBSE SCRI TION IONS ADE
Residence pZ e2 7, ~ New ❑Replace
I
RATING: S- Site suitable for system U- Site unsuitable for system
ONV S EJU : MID: IN-GROUND ~ E. Sa ~ 1®uL TANK: RECOMMENDED SYSTEM: tional)
SS UU MS ~U S ❑
Cow✓.
DESIGN RATE:
If Percolation Tests are5 NOT required If any portion of, the tested area is in the i
under s. I L H R 83.091)Ib),indicate: Floodplain, indicate Floodplain elevation:Q
PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION _QJEIH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH ,THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN. OBSERVED ES . I HES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
i
B- Z2
~d•
7
i
B
B- 7' PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP N WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTERSWELLING INTERVAL-MIN. p I p PERIOD PER INCH
P.
( 3
P-
p_ ItS
G
P_
1 ~
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 1
of land slope. i
SYSTEM ELEVATION 9 j . _ _
A
Y! TTT~~~"`
P
-~o
Yr ; L
~ S log a ~r~~ c~~~ ► ' _ r
OF_ r,
V
log fro A"~ S A 6.07 VVe~
_ aay
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o p i
r~1// rr^~~
o
1 ~
1 41
~;f~ a--
I' the undersigned, hereby certify that the soil tests reported on this fwere mzacc ith the procedures and methods specified in the Wisconsin ,
Administrative Code, and that the data recorded and the location of th s are o the bas{ y knowledge and belief, i
NAME print TESTS WERE COMPLETED ON:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
F.
` / tin 3~{ ~ <3 v26'>~'~Gl
CST SIGNATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester,
"`4~HR-SBD-6395 (R. 10/83) -OVER - j
..ex... - - . uuur a.. ew a.a IVWFI IUW-".I ue
reverse side of this form describes most of the required plan information Further requirements may be contained in the Wisconsin Plumbing':
Code, which can be purchased from the Department of Administration, Document $ales and Distribution, 202 South Thornton Ave., P.O. Box 7840,!
Madison, WI 53707, Telephone (608) 266-3358.
Plan R view Appointment Date Plan n is 'on Num
1:_'r PROTECT INFORMATION (Type or pr"int clearly)
Nam o ubmi ing P y laps return to same) Project Name
L V it), 0, op'li.4pi'm
d r rp~# qrF y, • 4 i'q~ a..8
4epth dr ss, P.O. ox # or Rural Route Project Address r Legal egription
M.
A.4 r
'4Cp- Al It, 1AA/_
~lage State Zip Code City ❑ 5 Coun%d
tfA -h-Mo , Village ❑ of' e No. (include area code) _
Designer Name of Owner
«t .~ov % 14" : ,1•~
Telephone No. (include area code) Telephone No. (include area code)
0 Town
Street Address, P.O. Box # or Rural Route
rt Stre Address O. Box # or Rural Route
i
tt
y' City or Village State Zip Code Cityr Village St to Zip Code
2. APPLICATION FOR. ❑ Experimental ❑ Mound System rt- " 'b 3 9, ❑ Holding Tankf i"
'fi' New Constructions ❑ Large System ii ? L` ~t«1 p [I Conventional Gravity System °'*13#3'trl s .i_a ❑ Groundwater Monitoring
Replacement , + ❑ At-Grade „ c ,loj a3 ttaO ~A ❑ System in Fill .+3a pE17o '-?r e tww i4i ❑ Petition For Variance
• s ❑ Revision ❑ Pressurized System ❑ System in Flood Plain (attach SBD-6698) ❑ OthetAlternatives .
M 3. FEE COMPUTATIONS (include existing to ks) FEE SUBMITTED k FOR OFFICE USE ' t1'
0I' -
MAKE ALL CHECKS PAYABLE TO SAFETY & BUILD N is
i~ ass >x
a 750- : 1,500 `gallon septic tank 50.00 ~ 1 ; 13 * ilr Jr ~d ^':z r~~i X11 i} " ~ t~8
a0.00tcx~ t t« k tai~~n~,~
b,(4" 1,501 2,500 'gallon septic t nk'" } ~
a t c 2 501 5,000 'gallon septic tank ; .00
d S 001 • ' 9,000 'gallon septic tank' $`10 .00 u"
c a ;
r.;
a 9,001,- 15,000 gallon septic tank $150 0 t'>}-
NOV
a' Over 15,000 gallon septic tank 5260.
500- 1,000 gallon dose chamber $ 30.00
g1l
h 2,000 gallon dose chamber`" { S 50.00 ,~ian~i u~f>4bW ` r a
z kiwi
1 2,001- 4,000 gallon dose chamber $ 70.00 F `,j't a a wr ~~f rr, ;
R+'~ ~2r,, y, ,r +Erti~:.a wt o
j. 4,001...8 8,000 "gallgn dose chamber $ °90.00
} k;~"~~ ' 8,001`12,000 ''gallon dose chamber E 110.00 °~`~1}
1 . Over 12,000 gallon dose chamber $150.00
}L
tank a ,za u1 r. s,
500 '5.000 gallon holding "s 30.00
~r
n 5,001 10,000 `gallon holding tank $ 55.00 4 b • «.r k,.~ r. t
o Over' 10,000' gallon holding tank"' b' $100.00fL
~?d'•
'l n:.p Revisions `r"u ili& E r s 20.00 =yj{i;Er 'ice i 3,'i:r !t'' t., r'trnR~ a
Groundwater Monitoring - Per Site $ 32.00 '1^ rk;vb E 3A ' A" 4 »
q
other than a proposed subdivision
r Petition For Variance 'Setback $ 25 00~~~
$Ite EVd1Udtl0n 1ls fi $ 50.00 t?7 V,,,~ .rfis;i .t ,•ia.s~ - dd, <9dy , u ,
L r
~b
s llwyrar ~d~{ dF
i~r,141
Subtotal:
is
t
(
r r Priority tij °tR d J, n '(i:3 T e hl>` Sf.a
, Plan 'Review; Enter same amount
as Subtotal
'Total Fee:
k NOTE: Appointments for plan review should be made prior to submittal. Y u may cont one of the offices listed below,
HaywarclOffice LaCrosse Office Q Madison Office o Office r° Waukesha Office_
P. O. Box 754 2226 rose Street P.O. Box 7969 P.O. Box 434 ~1~,1401 Pilot Court, Suite
209 West ayward,FWIt54843 Pho es(608)17 8 5-9334 9 MadisonaWl 31707 V e. 10 ShawanoGW1e541661treet Pho a (414) 48 8 05
H
Phone (715) 634-4870 Fax (608) 785-9330 Phone (608) 267-5119 Phone (715) 524-3626 Fax (414) 548-8614.
Fax (715) 634-5150 i1y,it we: u3 .a • l_a . f,,. , f nt r.,r„ ..Fax (608) 267-0592 , j Fax(715)524-3633,
a ay, !x 43KP~ -
tc
i SBD 6748(R.07/91) ,F NOTE: Fees are pursuant to Wis. Adm Code, Chapter Ind 69, and AVER
are subject to change annual)
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1 fifth Alf Inish And Obtsivallon Pipe
Applovid Veal Cor j
s''~j/O/l - 4Mlmuw U"Above
i
20. 42' Above Plpp 4- Cool iron
•r:
To fled Good* VoA1 Pipe
Low oft lieu Of Srntt.etk Co••iM~_ .t Wn T- Ayyi•polo
Ovol PIP0
' - 01•Ul~rllon
qIP° 0 0 0 - Teo
` P
6e nssib Pipe ipe P•llo•sled P1Ya bdov
°
o ~C•.pllnI Twminoltns AI
solism Of $16140
Ann "o
-
rac~t _
P~u(1o~tp►~•-1 9
SOIL FILL;
DISTRIBUTIOI.1 PIPE
• APPROVED S`JMTHETIC COV
° MATIMIN- OR OF STRA
i 2" OF AGGRE&AIE Ofi. MARSO "Al
{ LEY. O f."OP'lt-P-,/ AGGRCGATE
DISTRIbUTIlOM PIPE TO DC AT LEh%*T IMCHES BELOW ORIGIWAL GRADE
i I AUU AT LEASTtO IMCHES BUT 1.10 MORE THAW 42. INCHES OE.LOW FINAL GRADE
MAXIMUM DaMi OF FXCAVATIOP rKOM OR16V AL 6RADF- WIL 5E ~ IMCHES
111NIf M (EP1 l1 of EXCAVATION r-~oM CAK160JAt_
A f- WILL BC INCHC s
' GR P
jItiona
„ ,nom
' LIGCUSC uLIMBEIt:
I '
DATE. 2
A
o r~~,1ft`t ~.ABQR Q Ow*
00P~1Lf IMS. t~ F S
5 CIO ,C~---- - - -
Form-STC- 104
AS BUILT SANITARY SYSTEM REPORT
w
&re,6 oa r^ 5 / e 7 TOWNSHIP SYGC/ ~Gt / e SEC T,~L/ N-RX~ W
OWNER
ADDRESS CROIX COUNTY, WISCONSIN
42r`5G ,40/7
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I•T.HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
. ~ `J I1~ ~ /1 t 4~- ly
h
W Q 1 ~p~l ~a~. Janr ~ 318
-Ira
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used &S
Elevation cf vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer: 141-ee f_15 Liquid Capacity:
Number of rings u e -1 Tank manhole cover elevation: q~, G
/IV O'u,5,e, Z01 -
Tank I,Ilet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front, Side o Rear, O feet
.6rom nearest property line Front,~Side,O Rear, O feet
Number of feet from: well , building: 3l$
(Include Viis information of the abolre plot plnT,) ( 2 reference dimensions rn Rentic )
SEE RFVFP"
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, O Rear, Ft.
i
Number of feet from well:
Number of feet from building:
b
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: /
Len ~th:
~ h v? Number of Lines: v2 Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, 0 Side, O Rear,0 Pt.~~O /
Number of feet from well:
Number of feet from building: 6
(Include distances on plot plan).~u o
SEEPAGE PIT 9~, 97~ aZ✓~ 9a.c~
Size: Number of pits: Diameter: r
Liquid depth: Bottom of seepage pit elevation:
Area Built:
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, Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
rr y~ Inspector:
Dated: Plumber on job:
License Number:
/l~lj'
3/84:mj
DEPARTMWT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LAIBOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
BUREAU OF PLUMBING
P.O. BOX 7969
MgDISON WI 53707
ssigne I.D. Number.
SW4, SW-4, S32,T31N-R18W CONVENTIONAL ❑ALTERNATIVE Saate Fit
(1f1 assienedl
town of Star Prairie ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
Palmer Road
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Greg Derosier Route 1, New Richmond, Wl 54017
BENCH MARK (Permanent reference po,ntl DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV..
Name of Plumber. MP/MPH SW No.: ICo"n,y: Samtary Permit Number:
Byron Bird Jr. I3318 St. Croix 102803
SEPTIC TANK/HOLDING TANK:
MANUFACTURER . LIQUID CAPACITY. TANK INLET ELE V.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
PROVIDED . PROVIDED
~bCf ~q aq BYES ❑NO ❑YES SNO
BEDDING. VENT CIA IVINTMATL. HIGH WATER NUMBER OF ROAD: LINE PROPERTY WELL: BUILDING. JVENTTOFRESH
AIR INLET
ALARM. .
FEET FROM
❑YES WO ❑YES ❑NO NEAREST
DOSING CHAMBER:
MANUFACTURER BEDDING'. LIOUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROV I DED. PROVIDED:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING VENT TO FHE SH
LINE AIR INLET
(DIFFERENCE BETWEEN FEET FROM
PUMP ON AND OFF) ❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING
or excavation. (if soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH'. ILENGTH. NO. OF DISTR. PIPE SPACING. COVER IN SIDE DIA -PITS LIQUID
BED/TRENCH 9~ C~ TRENCHES ` MATERIAL: PIT DEPTH
DIMENSIONS / J
GRAVEL DEPTH FILL DEPTH JOISTH PIPF DISTR. PIPE DISTR. PIPE MATERIAL. NO. D TR. NUMBER OF PROPERTY WELL BUILDING VENT TO FHE SF
BELOW PIPES ABOVE COVER ELEV. INLET ELEV. END'. PIPE" FEET FROM L+NE AIR/INLET
~D IT ~.'SO q~,~5 51 & NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
❑YES ❑NO
SOIL COVER TEXTURE PERMANENT MARKERS OHSEH NATION WELLS
❑YES ❑NO ❑YES ❑NO
E,-E R TRENC H/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
EDGES.
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH: LENGTH. NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPF. FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD • DISTR. PIPE MANIFOLD MATERIAL NO DISTH JD~STRPIPE DISTRIBUTION PIPE AELEVELEV.DIAELEVPIPES DA.'.
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS ❑YES ❑NO ❑YES ❑NO
gER TION WELLS. NUMBER OF LIRNE ER7V WELL: ]BUILDING
COMMENTS: PERMANENT MARKERS: JOBS
FEET FROM
3.0 ❑YES ❑NO ❑YES ❑NO NEAREST
112`1
Sketch System on Retain in county file for audit.
Reverse Side.
J URE ~ TITLE
Zoning Administrator i
DILHR SBD 6710 (R. 01/82)
SANITARY PERMIT APPLICATION COUNTY
fl DILHR
In accord with ILHR 83.05, Wis. Adm. Code GPO X
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER
8% x 11 inches in size.
i
-See reverse side for instructions for completing this application. PETITION ((171
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YESNO
PROPERTY OWNER PROPERTY LOCATION
6 Y .G ,Ql" D 5 <'e1^ '/4 r✓'/4; S T , N, R E (or
PROPERTY OWNER'S MAIL 414G ADDRESS OT NUMBER BLOCK NUMBE SUBDIVISION NAME
CITY, STATE ZIP CODE PHONE NUMBER CITY -NEAR KE OR LANDMARK
VILLAGE : I" 4e I d .03
3r -101 A _4_ - Ili TOWN OF
II. TYPE OF BUILDING OR USE SERVED: - 03 D 11aff O -Q
ms if 1 or 2 Family- OR Public (Specify):
Number of Bedrooms
III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable)
1. a. ~ New b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an
System System Septic Tank Only an Existing System Existing System
2. ❑ A Sanitary Permit was previously issued. Permit # Date Issued
3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements.
4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy.
IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2)
1. a. ~Eonventional b. ❑ Alternative c. ❑ Experimental
2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. See a e Bed b. ❑ seepage Trench c. ❑ See a e Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
Private El Joint ❑ Public
G 61 J~- 9iLs Feet
VI. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank a0~ -C' r
Lift Pump Tank/Si hon Chamber ❑ ❑ ❑
VII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Name (Print): / Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
l .•26~7s
r®~'! fed l 2r 1
Plumber's ddress (Street, City, State, Zip Code): Name of Designer:
.e r' GYl
VIII. SOIL TEST INFORMATION
Certified Soil Tester (CST) Name CST #
® opO Z
40
CST's ADD SS (Street, City, State, Zip Code) Phone Number:
--G
IX. COUNTY/DEPARTME T USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Date Issuin gent Signature (No Stamps)
® Approved I ❑ Owner Given Initial `t S rchar a Fee y
( C~~ 8
Adverse Determination r aoo X.
X. COMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION
TO THE APPLICANT: ,
I
1. This 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. A new permit may be needed
if there is a change in your building plans, system location, estimated wastewater flow (number of bed-
rooms, etc.), depth of system, or type of system;
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation;
5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 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 where the system is to be
installed;
II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat
restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling;
III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or
repair;
IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project
is in conjunction with University of Wisconsin;
V. Absorption system information: Provide all information requested in ##1-6;
VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed,
number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete
for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. 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. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only;
X. Comment area for use by county or resaon given when application is disapproved.
Complete plans and specifications not smaller than W/2 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; dosing or pumping chambers; 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.
GROUNDWATER SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more
commonly known as the groundwater protection law. This change in statutes was the
result of over 2 years of steady negotiation and public debate.-The groundwater bill Groundwater
included the creation of surcharges (fees) for a number of regulated practices which WiscoriC,in's-
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried treasure
is used in your building is.returned to the groundwater through your soil absorption o
c
system-or the disposal site used by your holding tank pumper.
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground- t
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
SBD-6398 (R.03/86)
APPLICATION FOR SANITARY PERMIT
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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Amer of Property
y
Location of Property C ~fP > _h;, Section T ? N-R W
Township
Nailing Address
Address of Site
Subdivision Name
Lot Number
Previous Owner of Property
Total Site of Parcel
Date Parcel was Created F~ GY/'3~ 7
Are all corners and lot lines identifiable?_ Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume .:Z(p 7 ~ 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 Map, the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
t "00 eehti.6y that a.ff. 6tatemewt5 on .tlu's ahe true to .the but o6 my (OUA)
hncwtedge; that 1 (we) am (ahe) .the owneh.(bfor the phopenty ducAi.bed in this
.in6onmation 604m, by viAtue 06 a waAAanty deed neeo,nded in the O66ice o6 the
Coiutty R¢geAzen 06 Deeds ah Voeument Na. S ; and that i (We) phesen,tfy
aun th¢ pnoposed Aite 6oft the sewage di,spos s ysTe_m_ (ox I (we) have obtained an
eseemen.-t, to nun with the above deseh,ibed pnoper+,ty, bon the eonatnucti.on o6 said
system, and the same haA been tt n.econded .in the 066tce o6 the County Reg.ieteA o6
Heeds, as Poemnent No. )
SIGNATURE Op OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
4;_1
L DATE SI D DATE SIGNED
a
4021WS ' BOOK PACE. 5 03
STATE OF WISCONSIN CIRCUIT COURT ST. CROIX COUNTY
RUSSELL L. FLANDRICK Jand. -
GEORGENE M. FLANDR CKI---'
Plaintiffs,
VS. SHERIFF'S DEED
Case No. 86 CV 432
STEVEN PATRICK BARRY,
THORP FINANCE CORPORATION,
RICKARD ELECTRIC, INC.,
AMHOIST CREDIT UNION,
REINSTRA, VAN DYK & NEEDHAM,
STATE OF WISCONSIN - T,;7~
DEPARTMENT OF REVENUE,
=u
WARREN W. WOOD, LTD., TOLL COMPANY,
DR. PETER MIELKE,
MOTORALA, INC., ?
A.R.V.M. HOSPITAL, +z,:
EVENSON PLUMBING & HEATING,
STENEMAN CONCRETE PRODUCTS, INC., S SCE
INTER COUNTY CO-OP PUB. ASSN., ► ST. CROIX 00.9 WM
FORMAN FORD PLANT, _ ~0 Reed. for Record fhb 2nd BLUE PAGE, AND ' day of Feb A. D. 19 8V
UNITED STATES OF AMERICA,
f 11.5 Mw
Defendants.
N&Wa of ON/s
This indenture, made F~-a~~vua-y auk , 1987, between
Ralph Bader, Sheriff of St. Croix County, party of the
first part, and Gregory Joseph DeRosier and Barbara Lynn
DeRosier, parties of the second part.
WHEREAS, at a term of the Circuit Court held in and for
St. Croix County, Wisconsin, at the Courthouse in the City
of Hudson in said County, on November 3, 1986, it was among
other things ordered and adjudged by said Court, in a
6110 IPAG~ rangy
certain action then pending in said Court, between the
plaintiffs and defendants above named that:
All and singular the mortgaged premises mentioned in
the complaint in said action, and in said judgment described
or so much thereof as might be sufficient to raise the
amount due the plaintiffs for principal, interest and costs
in said action and which might not be sold separately
without material injury to the parties interested, be sold
at public auction by or under the direction of the Sheriff
of St. Croix County, at any time after sixty days from the
date of said judgment, unless, previous to such sale said
premises and said judgment shall be redeemed in the manner
provided by law, that said sale be made in St. Croix County
where the premises are situated.
Said Sheriff shall give public notice of the time and
place of such sale, in the manner provided by law; any of
the parties in said action might purchase said premises at
such sale; said Sheriff, upon compliance by the purchaser
with the terms of such sale, execute and deliver to the
Clerk of Court, a deed to the purchaser of such premises so
sold, setting forth each tract or parcel sold and the sum
paid therefor; the Clerk of Court, upon compliance of the
parties of the second part with all the requirements of WIS.
STATS. Section 846.17, as amended, deliver to the purchaser
or purchasers said deed.
Said Sheriff, pursuant to said judgment of said Court,
did on January 20, 1987, sell at public auction at the front
►r
' 67PArf
BOOK
steps of the St. Croix County Courthouse in Hudson, St.
Croix County, Wisconsin, at 10:00 a.m., all the premises in
said judgment mentioned, due notice of the time and place of
such sale being first given, agreeable to said judgment at
which sale the premises hereinafter described were struck
off to said parties of the second part for the sum of Ten
Thousand Two Hundred and No/100 Dollars ($10,200.00), said
parties of the second part being the highest and best
bidders therefor, and that being the, highest sum bid for
same.
Now, this indenture witnesseth, that said Sheriff, by
virtue of said judgment, and of the statute in such case
made and provided, and in consideration of said sum of money
so bid as aforesaid, being first duly paid by said parties
of the second part, receipt thereof being hereby
acknowledged, has granted, bargained, sold, aliened and
conveyed, and by these presents does grant, bargain, sell,
alien and convey unto said parties of the second part, and
to their heirs and assigns forever, all the following
described land situated in St. Croix County, Wisconsin, to
wit:
A parcel of land situated in the South Half
of the Southwest Quarter (S 1/2 of SW 1/4) ,
Section Thirty-Two (32), Township Thirty-One
(31) North, Range Eighteen (18) West, further
described as follows: Commencing at the
Northeasterly corner of Certified Survey Map,
Volume "2"1 page 503, St. Croix County,
Wisconsin, said point being a one inch iron
pipe located on the Westerly right-of-way of
a town road; bearings referenced along said
Westerly right-of-way South 21014'29" East
(recorded as South 22-19-12 East); thence at
Pn !.)7PAGE 50 j
an angle of 90 degrees to the left, a bearing
of North 68°45'31 East, 66.00 feet to the
Easterly right-of-way of said town road, also
being the point of beginning of this
description; thence South 21°14'29" East
along said Easterl~ right-of-way, 90.09 feet;
thence South 42 57'39" East along said
Easterly right-of-way 41.94 feet; thence
South 87°46'00" East, 524.53 feet; thence
South 02°14'00" West, 75.0 feet; thence South
87°46'00" East, 372.77 feet; thence North
02°14'00" East 519.08 feet; thence North
87°46'00" West, 888.47 feet to said Easterly
right-of-way of a town road; thence South
22 29'04" West along said Easterly right-of-
way, 149.68 feet; thence South 08°59'04" West
along said Easterly right-of-way 192.80 feet
to the point of beginning.
To have and to hold all and singular the premises above
mentioned and described, and hereby conveyed or intended so
to be unto said parties of the second part, their
successors, heirs and assigns, to their only proper use,
benefit and behold, forever.
IN WITNESS WHEREOF, said party of the first part,
Ralph Bader, Sheriff as aforesaid, hath hereunto set his
hand and seal the day and year first above written.
Signed, sealed and delivered
in the presence of:
Ralp~ Bader, Sheriff
167 FAGF 50'7
Y
STATE OF WISCONSIN
ss.
ST. CROIX COUNTY )
fe e.Pu.s o~e
Personally came before me this o?,vd day of
1987, the above named Ralph Bader, Sheriff of St. Croix
County, Wisconsin, to me known to be the person and officer
described in, and who executed the above conveyance, as such
officer, and acknowledged the same.
~ s
Notary/"Public o .
State of Wisconsin
My Commission ekll' V-iy Z.
v
REMINGTON LAW OFFICES
150 West First Street
New Richmond, WI 54017
TELEPHONE: 715/246-3422
H
z
H
STC - 105 r
• a
H
SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
OWNER/BUYER C H
ROUTE/BOX NUMBER L Fire Number
CITY/STATE ZIP'/J %
PROPERTY LOCATION: Section r T 71 N, R 1 W,
14,
Town of jam- /v./ St. Croix County,
Subdivision Lot number
Improper use and maintenance of your septic system could result in
its premature failure 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 function of the septic tank as a treat-
ment stage in the waste disposal system.
St. Croix.County residents may be eligible to receive a grant for
a maximum of 60% 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 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
E
I/WE, the undersigned, have read the above requirements and agree N
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- 10
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.
SIGNED
DATE s~
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 ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 53707
HUMAN RELATIONS
(ILHR 83.0911) & Chapter 145)
LOCATION: SECTION: TOWNSHI /MUNICIPALITY: LOT NO.:BLK. NO. SUBDIVISION NAME:
t~1/bra 1/ /T3 N/R/ E (or ` '
COUNTY: ER'S BUYER'S NAME: MAIL G ADDRESS:
G~^oi ' c r t l Q m o^ r ~e o
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence _ New ❑Replace I 9F -%121
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
®S ❑U WS ❑U S ❑U ❑S ❑S 5dU
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s. ILHR 83.09(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.)
c,
B- / JJ- On.-e :>gd
B a a 95. no
tic 7 ~o
B- file
B- 5' er^
B-
.e.c PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER tIMML AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3_ PER INCH
P- I L
P- r t,
P- /L
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.
SYSTEM ELEVATION
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3
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1, 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:
o f
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
-12 Zj!f
CST SIGNATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
/PLOT PLAN
PROJECT 4rcja0e-05r ~r ADDRESS " l e-V X c~ on~,, "q/ B=
1/4 5-1 1/4/S,3k.1T,3/ N/R/.O'W TOWN-S7-g,, COUNTY , Gro~X
PRS Byron Bird Jr. 3318 DATE e- c'£
BEDROOM CLASS PERC- CONVENTIONAL elN-GROUND PRESSURE
CONVENTIONAL LIFT_ MOUND_ HO ING TANK
SEPTIC TANK SIZE LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA PERC RATE BED SIZE
Benchmark V.R.P. Assume Elevation 100'
Location of Benchmark _ --A o r _ Ca rr7 e r^ a -5:: Cam--~ K
* H.R.P. i - acct, Jyj
D Borehole Well Scale = Feet
O Perc Hole 42 System Elevation
a` TYPAR COVERING
12" 3' 4 6, 0 3'
6 Sewer Rock
12'
-
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5411
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AS BUILT PLAN OF SANITARY SYSTEM
iX i=W COUNTY
SEPTIC TANK PERMIT # ~7ZAB
OtVNER~~ - - - ADDRESS . d _ ZIPS X0.17
LOCATION OF SYSTEM P 6, of Section 3 .::_'Town N RANGE JR W
Gov. Lot # - Lot # Subdivision- PLAN VIEW
? Distances & Dimensions to meet Requirements of H62.20(1)(d)(2)
SHOW EVE&TTHING WITHIN 100 FEET OF SYSTEM
067r----------------
0 u C'
67
a
sz--
S ~ c, PFl c 6C,4
SEPTIC TANK: Concrete 1_Steel RMfgr.f Depth to manhole z
SOIL ABSORPTION SYSTEM: Drywell_Depth Inside Dia. Depth Below Inlet
TRENCHES, No. of Width Lenpth Area Depth to Pipe
BED, No. of Lines Z 11idth /Z-Length -5-2 -Area
Z Depth to Pipe
AGGREGATE, Inches Area Required' AREA AS BUilt
DISCLAIMER: The inspection of this system by Polk County does not imply complete
compliance with State Administrative Codes. There are other areas that it is not
possible to inspect at this point of construction. Polk County assumes no liabil-
ity for system operation. However, if failure is noted, the county will make
every effort to determine cause of failure. GREASES AND SHOULD NOT BE DIS-
POSED OF THROUGH THIS S TERM!!!
PLUMBER ON JO _ LICENSE%~~~
INSPECTOR _ DATED
z '
°REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
San.itahy
Permit- State Septic %2-7
NAME Towndh.ip St. Cna.ix County
Locations % a~ Sectianj~',T_N,R W
SEPTIC TANK
Size/&VO gattons. Numbers a~ Compantmen.t.6
Distance Ft om: Wett !2% on g&eaten stope it
Bu.itd.ingjr/_6t. Wettands ~ .
DISPOSAL SYSTEM Highwaten
Distance Fnom: Wett it. 12% on greaten ztope it.
Bu.itd.ing it. W ettands Ft.
i
/
H.ighwaten St.
-4~
FIELD DIMENSIONS:
Width o6 tnen ch_Z..E' it. Depth o j na ck b etow t ite t12-in.
Length o6 each tine ~.2- ~
it. Depth o6 nacFi oven t.ite .in.
Numbers, a6 tines 2 Depth ob tite betow grade /'El in.
Totat .length a6 tines f it. Stope ob trench in pen 100 it.
it. Depth to bednacfz
Distance between tines
Totat abeonbtion anea76(-2 Depth to gnaundwaten b .
Requited area b .
SIT DIMENSIONS:
Number o6 pits Gnavet nd pits ye.a no
Outside d.iamete Depth betow .intet it.
2
Totat a sanbti a ea it z
A
Area nequi i2 rn
INSPECTED BY✓"`'~~ TIT
APPROVED , DATE Z Z 19 7,6.
REJECTED ;DATE 197
Ifz
2, C
~EH 11-5
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
~`rr►R i ~A 1 E
LOCATION: sE '/a,: WW Section ~Z, T31 N, R t8 '(or)ccW, Township or Municipality
Lot No. , Block No. 7 4osEDLEiL-rlFit ,e;TLVV MA.l' County ST• Gzo IX
STEV F N AQiZ~( Subdivision Name RVS,SF_%_'.. ok%ulkICK PROPERTY
Owner's Name: (1 y~
Mailing Address: )73 ~aKN1GV1~T 0 VL. ~`I h) •~1
TYPE OF OCCUPANCY: Residenceat N GL1= No.. of Bedrooms 3 Other
EFFLUENT DISPOSAL SYSTEM: NEW V"ADDITION REPLACEMENT
MA6!
DATES OBSERVATIONS MADE: SOILBORINGS M4-y 1ST 118 PERCOLATION TESTS
SOIL MAP SHEET BSA- 3FF-~'Z- SOIL YPE
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P-) 3 0 ~~'~s ~i ,~S L Z 8 L 7 O N o 1 S Z ~ T4 ) S
P- Z 'To Z
s o L Z3 SL Z v N o 33~ 3 3 ~I. 9
5T
P 3 48 Ts Lo„L z3~~sL_ Z° NO S Z~Z
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATAINCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMAT(DEPTH TO BEDROCK IF OBSERVED)
B_ Z o N Ts L 1S o N S T 'Lo It L 511 s L
B_ 3 A 1-570 E sr-r;, 2D L 59 SL
4- 7 z m 169 44 if s L_
B- s 7Z. 111*14E ) L8 "
~S Ts ao L 44 s L
PLAN VIEW (Locate perco lat ion tests,soi I bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of ui able are s. Indicate number of square feet of absorption area
needed for building type and occupancy. I it able Q , F'T. Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope,
.-QR T
o -~o~g
I IT
•-s, _
A - . 1 T t~l 114
Pt iZ t' 01;F_ 4 * P 25
ttiw '
Sut
u N N 1Z $T 3
Gu I> Can E tE CA -To 'T
pr _ 1 0 # I*
IPIW
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090-0
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1
8?- b 5 j
8,5 0
,
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I, the undersigned, hereby certify that the soil tests reported on his form were made by me i accord with the procedures
n'~
and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct 3L
to the best of my knowledge and belief. 1--31-N
Name (print)GENV. C.Z.FIRFFEZ -Certification No. 1'4Z0
Address '10 ) Z-R' ST` V D SO t . S4 O l 6
Name of installer if known
CST Signature .r.'~ C. 14-
COPY A -LOCAL AUTHORITY
# -
State and County State Permit
Permit Application County Permit
PLB67
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
~Te vim. , ~g rf / 9"y-C-
B. LOCA ION: ~i4 , Sect' n T_3 J _3 R K E (or) W Lot# City _
Subdivision Name, nearest road, lake or landmark Blk# Village
Township 5&&
C. TYPE OF- OCCUPANCY: *Commercial 'Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons
D. TYPE OF APPLIANCES: Dishwasher AYES NO Food Waste Grinder _ YES t►PQO # of Bathrooms
Automatic Washer 1/'VES NO Other (specify)
E. SEPTIC TANK CAPACITY f Q'~7 Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation Addition Replacement _ Prefab Concrete
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2)~3)_Total Absorb Area sq. ft.
New-A<" Addition Replacement 'Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches _
Seepage Bed: Length _,f,;ZLWidth Depth 3L 'Tile Depth :OL y,. No. of Lines ;Z_
Seepage Pit: Inside diameter Liquid Depth Tile Size y
Percent slope of land 3% Distance from critical slope
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certified Soil Tester,
NAME & c'. s, ~e e .5~ /2 9 C.S.T. # O and other information
obtained from (owner/builder).
Plumber's Signature MP/MPRSW# le S 7 Phone *AV a-S -V-27
Plumber's Address
or 1, /
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
r~ A
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~~st
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00,
Do Not Write in Space Be w FOR DEPARTMENT USE ONLY
Date of Application 10 ? Fees Paid: State Jln-0 County *1*" Date -7110178
Permit Issued/Rejected ( ate) -711 O -Issuing Agent Name
Inspection Yesk-'N o Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy)
Revised Date 6/1 /76 ~
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VOL.-,-PA,GE633,_ G ~,f r a lit
CERTIFIED SURVEY MAPS ?.o
ST. CROIX COUNTY, WI.
?OS •~Fa
Volume 3 Page 633~~~pp
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