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Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
LabprandHuman Relations INSPECTION REPORT St. Croix
Safety and Buildings Division
NE NW, 16 f 29, 19~TTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION Lot #22, Glover Station 149212
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
Ron Shimon Troy
CST BM Elev.: Insp. BM Elev.: B escription: Parcel Tax No.:
160,CSID~ " y 040-1207-20
_410 t~" j
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic c/ AC S <J Benchmark 6-L' eo '66
Aeration Bldg. Sewer ( jnVIC~ C. Gf -
Holding St/0 Inlet
TANK SETBACK INFORMATION St/V Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic 1 99 NA Dt Bottom
NA Headep4VIa1a. 2, 3/
r 79
Aeration NA Dist. Pipe /O 8
Holding Bot. System
PUMP/ SIPHON INFORMATION al Grad
ufacturer Demand
Model Number GPM Wrd.
TDH Lift Friction System DH Ft
Fi
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width/ Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS D-/Z g~ IMEN I
adurer:
LEACHING
SYSTEM TO P / L BLDG WELL LAKE / STREAM
SETBACK CHAM
INFORMATION Type O % . OR UNIT R model Number:
System:
DISTRIBUTION SYSTEM
Header-),- +i4eld Distribution Pipe(s) / x Hole Size x Hole Spacing Vent To Air Intake
Length _t Dia. Length ~Z Dia. ~ Spacing 6
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over t Depth Over xx Depth Of xx Seeded /Sodded xx Mulched
49
Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
Bed /Trench Center Bed /Trench Edges -
COMMENTS: (Include code discrepancies, persons present, etc..)) 'XA 5
r ~z WX ~r✓~~~
/
9t7
r
77-
6
Plan revision required? ❑ Yes ❑ No p
Use other side for additional information.
SBD-6710 (R 05/91) ` Date Inspector's Signature Cert. No.
t I
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: `
16L C-M
i
D1LHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code couN
'tom ai wo~w,wwrnar .
STATE SAN RY PER T #
-Attach complete plans (to the county copy only) for the system, on paper not less than 10? l
8% x 11 inches in size. ❑ Check if revision to prew us application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
.-'/a %,S TvI N,R / E(or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVI ION NAME OR CSM NUMBER
s-ds e j v I-,),, -s T , m.cJ
II. TYPE OF BUILDING: (Check One) El State Owned 0 VILLAGE NEAREST ROAD
Q/y1d~o~
❑ Public 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMBER(S)
111. BUILDING USE: (If building type is public, check all that apply) it
1 ❑ Apt/Condo ~'G V
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service station/Car Wash
5 ❑ Hotel/Motel 90 Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. 0 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 9 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) O ELEVATION
zell'od ~ era 40 Q Q eells 3 Feet SD 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
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system show on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) PRSW No.: Business Phone Number:
14, A "Ot .5~ _ 4 &L A- A A6- I - ~ rel._~
Plumber's Address (Street, City, State, Zip Code):
le 70 s`077"" /V4 ,--1 e S YO t
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved S nitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signatu (No Stamps)
Surcharge Fee)
Approved ❑ Owner Given Initial
Adverse Determination q
CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
X.
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
DEPARTMENT OF REPORT ON SOIL BORINGS AN REM AFET. , BUILDINGS
INZ)USTRY, ,1~~ DIVISION
LABdR • ~
AND PERCOLATION TESTS (115) BOX 7969
HUMAN RELATIONS \ / cc; MAR ~ DIS WI 53707
(H63.09(1) & Chapter 145.045) ZONING
t~
LOCATION: SECTION: TOWNSH UNICIPALITY: LOT NO.: BL : SUB N NA
~►~-n►w1/ 1/ 16 IT z6 N/R 19E (o -(-ROY zZ % ,~~ov ~oiv
COUNTY: WNER'S BUYER'S NAME: MAILING ADDRESS: L-t T- 16- ST•
S"S, CRU1x 7:Z7v vs R E1 s PRESCA~'r W Z
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: O New PROFILE DESCRIPTIONS: PCOLATION TESTS:
~•Residence I v L✓SINew ❑Replace $7
RATING: S= Site suitable for system U= Site unsuitable for system
ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
l~S ❑U ❑s ~u [s ❑U ❑Sou ❑S ~U x-OAJUEND0AjAL BEb
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the ` A
under s.H63.09(5) (b), indicate: Floodplain, indicate Floodplain elevation: 1 v ` `
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-I CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH Lft ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
'-t>1z.4 st TS;
Z Ci rvu~►0- en-s' olte>nsl'S Z ~'B►~s1 ~.s y 6~►s'1 • .3'Bn>~o s
3 1\.b' tioo•b' 1V01~1 E > ll. 6 ' o• 6' Uk$n'lS Ts; \XBr,si; y.~'Bh ls; y.W rTlh tmeAS
B- vb 8n ~S -
\\_~I!_. OtV~__. l).y' 0.8'U~'brISTS;3.)'8nIS;a,)'$nh'LekS Y.V'Ph~S
B- S ' g8•$' )von» > >).o' o.g'7i~e~t 1s Ts •z.~'8rL is -~.s' 3rtfs
6_..... _.98.6' ivp,~►E 9.2' o.~ 'o1t$nlsTs;p.~8'$nS[; ►•9'Bn1S;S-8' h s---
B- `7 11.6' h (j, 8' N3wd V > 11. 0-2 ' Utz n l IS -2,•S' Qn is •3• $ R:1-0 ' 81+
B_---- 11,41gyp). ' N-AgA S • t•o'$h ~s; \.6' 'l3n riea S
N01Ue 2 11.y o.Z S~ $ ISTS Gw\S • 3-V 13)1 htv S L V/ 4_ 6
` --8n `Its
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER I-Pdftil!~ AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERT D 2 P PER INCH
P_ 1 5_8' SAS P lL~}IZ $3.O S of C~ `toF U.'P fEp_ S < 3
G Z MI v < 3
P- Z 6-V AwN- J~j
P- 3 3.46, < 3
IRM 1RL COf'1~'JE'fU O 8 V T! LL -
P-_ \Z'XSZ' BeJ IS M1/UtMt1 Q1 b 1Z'r-1
P_ t~tc RUAL~A l GZAVI LAw
p_ ~ 4
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. 1NLlllrll ff~El~(-~tCL`~~1VT ~~G~ aZ pUZ2~t~{'1~'IL~~'- SZ~TR~'
SYSTEM ELEVATION q S • o
0
a R ~l - oo~o' I "x7.~"w flS'1~1>: ~ ~ ~ m_._ ► S L Z
' - ~ O w 7~'1'~►lam- ~1
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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:
~RTN-vR. L. w~GCR~h 3-ZO-8~
ADDRESS: 1;,-QQ TS L4 aVU Z.2, (6 CERTIFICATION NUMBER: PHONE NUMBER (optional):
1=L-L-SwOR l s of S-)b Is- 14 25-o16y
CST SIGNATUR
e i
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) -OVER-
"NNW
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 this
development be intended for resale by owner/contractor,(spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property G'i I
Location of property /.'X1/4 !1,11ti~i/4, Section T ZN-R_)Lj 4j
T
Township
ti
Mailing address
Address of site
Subdivision name_ Lot no.
Other homes on property? yes X No
Previous owner of property _ ~_a5 ~fy;,,k
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 X No
Volume ~2 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. 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. - C
slwn'
signature of•applicant Co-applicant
Date of Signature Date of Signature
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYE l r1 /l , C~ 1 1 l J-0 i'
ADDRESS: FIRE NO:
LOCATION: 1/4, 1/4, SEC. T , ' W,
TOWN OF: ST. CROIX COUNTY
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:-
i.
; :az
DATE:
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
_
DOCUMENT NO. I j
WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
• I
STATE BAR OF WISCONSIN FORM 2 -1982
459620 REGISTER'S OFFICE
ST. CROIX CO., WI
Russell J. Hanke and Cynthia D Hanke, husband Rec or Record
~I
and wife, as survivorship marital property
JUN 181990
at
8:00 A. M
conveys and warrants to .Ronald J. Shimon and Cathleen
. ~rw
F.---Shimo---,---husband_-arld_-wife., __as._survivorship Regtaterofp s
m ar i t a l_._p rop e r tx_____
Ij ' RETURN TO
the following described real estate in .........................County,
j State of Wisconsin:
ii
Tax Parcel No:
I'
LOT TWENTY-TWO (22), GLOVER STATION IN THE TOWN OF TROY, St. Croix
County, Wisconsin.
i
TRANS
FEE
ii
is
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s'
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This i s not homestead property.
i ;i~ (is not)
I
Exception to warranties: subject to easements and restrictions of record.
i
I
Dated this - day of ...June......................... 1990
I
(SEAL) ......................(SEAL)
)....,7~ anke `
I!
1t/.•- • - ------.(SEAL) (SEAL)
~I
nthia D. Hanke „
`,`ttµ11111171/N
NTICATION ACKNOWLEDGMENT
Sismat zg(s) _ R a s s 111 J. Hanke STATE OF WISCONSIN
ss.
- County.
u
a nticated this sy of. rf~^ ~ 19 ( Personally came before me this day of
'~1+ 19------.. the above named
- ' a -
I
•
TITLE: MEMBER 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 `
Gwen Kuchevar, RODLI, BESKAR & BOLES `I
!1 l~ o'r'£li"..N a i ri; o X- r 3 g-----------•----------- . I
Rives_..EA1_Ls.,_..W_L..... 54.0.22 Notary Public .
I ______________County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration II
i are not necessary.) date: 19._.......) II
•Names of persons signing in any capacity should be typed or printed below their signatures.
a STATR BAR OF WISCONSIN nn
~FUCfI~m► FORM No. 2 - 1982 Stock No. 13002
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