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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER La A L I Ty JN f l- T fk-kn1V..5 TOWNSHIP_ ~ 0 V
SECTION- TZ_jN-R6/' W
ADDRESS_ 5((1J U &(A) ST. CROIX COUNTY, WISCONSIN
SUBDIVISION (JA- Rt( 09 if Clp~S LOT LOT SIZE_ IdT X Z
PLAN VIEW
SHOW EVE YTHIFG WITHIN 100 FEET OF SYSTEM
,eft QC~ i. p-T L N C~
G/ Xui
tA 4-6
rt PA
V61
e
0" D o
y
INDICATE NORTH ARROW
BENCHMARK:Elevation and description: -f ~ 7G~A/U~fd~~►the Aox Al r-,'axve*
Alternate benchmark_''gyp a~ huy,-f &st';"TWT C Ac of 10+63
SEPTIC TANK : Manuf acturer : S Liquid Cap. /d-n
c
Rings used:~Manhole cover elev: ?2t? -Final grade elev:
Tank inlet elev.:__ ~7(0 Tank outlet elev.:_
No. of feet from nearest road: Front7
Zl~ Side 7 zd Rear2dFt. -?0
From nearest prop. line:Front7`0I Side , Rear /Ft.
No. of feet from: Well , Building:, Z6
(Include this information in the above plot plan)
(2 reference dimensions to septic tank) 1
SEE REVERSE SIDE
PUMP CHAMBER
ManufKeev.: Liquid Capacity:
Pump Pump/Siphon Manufact.: Pump Size
Elevainlet: Bottom of tank elevation
Pump Pump off elev.: Gallons/cycle:
Alarm Switch Type: Location
Dista nearest prop. line: Front-, Side_, Rear-Ft.
Distance from: Well Building
SOIL ABSORPTION SYSTEM
Bed: Trench: Seepage Pit:
Width: -I-Length Number of Lines: Area Built T
Exist. Grade Elev. Proposed F al Grade Elev. N
Q p
Fill depth to top of pipe: !~Z'
0 S. 7 6J~ O g,~3 g 709
No. feet from nearest prop. line:Frontzl, Side, Rear,ZFt.
No. feet from well: AJA No. feet from building- ~S-Z 1
HOLDING TANK
Manufacture Capacity:
No. of rin s used: ' Elevation of bottom tank:
Elevatio of inlet:
No. feet f m nearest prop. line:Front , Side , Rear Ft.
No. feet from: Well , building_, nearest road
Alarm Manufacturer:
INSPECTOR:
DATE: _ _ / Z- PLUMBER ON JOB:
LICENSE NUMBER:-/& 4~Z~2
6/90:cj
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wj$consin Department of Industry, PRIVATE SEWAGE SYSTEM County:
'Laborarrd Human Relations INSPECTION REPORT Cf- _ ('rni x
Safety and Buildings Division
(ATTACH TO PERMIT) T.nf- {fit Sanitary Permit No.:
GENERAL INFORMATION nTTAT. Tu1,Cpr._ZC,-T7f2_R1A,u;Ii G;,lP nr_ 1aa9 U
Permit Holder's Name: ❑ City ❑ Village Town of: State Pla ID No.:
Quality Bldt. Homes Troy
CST BM Elev.: Insp. BM Elev.: BM Description: r Parcel Tax No.: R 1 F
l U W
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI 1 FS ELEV.
Septic 77 r Benchmark OZ.ZO z•zv ~lV, t
I
e
Dosin
Z/
9 7,99
41,
a_ '411
r
Aeration Bldg. Sewer
Holding St/ Inlet 13, W
TA INFORMATION St/ Outlet
6-y N K SETBACK
3,
TANK TO P/ L WELL BLDG. Ventto ROAD
et I
Air Intake _Dt
Septic -13NA Dom"UQ
Dos' NA Headertwn. r o71 99, /3 ~
Aeration NA Dist. Pipe ~ g .9S(~
Holding Bot. System 40A qi,
PUMP/ SIPHON INFORMATION Final Grade
Man n Demand, , r. /p,OD/ 1. Zd
Model Number GPM ; lPSf -d, iv,u~' ZGe
TDH Lift Friction System- TDH Ft
Forcemain Length JDia. H Dist.Towell
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length , No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
D, I DIMENSION
S (03 f DIME
fadurer:
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING
SETBACK CHAMBER
INFORMATION Type O dye, r OR UNIT Mode Number
system: 5Z 13
DISTRIBUTION SYSTEM
Header /ANa+~i#eld t tf Distribution Pipe(s) / x Hole Size x Hole Spacing Vent To Air Intake
Length 2r Dia. `F Length Dia. ~c/ 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 Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrep ncies, persons present, etc.)
Cr/ Q~T f G C Ct. f
Plan revision required? ❑ Yes L'7 ryo
Use other side for additional information. 1;2_1 Cert
SBD-6710 (R 05/91) Date inspector's Signature . No.
R SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY C ~O/x
J
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ < jQ8% x 11 inches in size. Chk {f application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPE~~TY LOCATION 7 12
L CUALlr/ u! .a? E- floral d W'/a /a, S 3 T , N, R E (or)
PROPERTY OWNER'S MAILING ADDRESS LOT # LOCK #
5 (A AJ V1 6W (0 0-
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
tU CE4 W( o zz q( 5' ,s -r- R-[D6& A-L2v-S
II. TYPE OF BUILDING: (Che k one) CITY NEAREST ROAD
IV I State Owned ❑
n
O-TOWN VILLAGE : 0 (L LS
1p r- Q
❑ Public 1 or 2 am. Dwelling-# of bedrooms ~ PARCEL A B L !i
111. BUILDING USE: (If building type is public, check all that apply) _
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
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. 9_New 2.E] 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 .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
_q* ft.) PR PO D ( . ft.) (Gals/day/sq. ft.) in./inch) cE~LEVATION
RZff~s
'(s b 0 9C'6 Feet 5 ELEVATION
Feet
CAPACITY
VII. TANK Site
in allons Total # of Prefab. Fiber- Exper.
-
INFORMATION Manufacturer's Name lass Plastic App.
New istin Gallons Tanks Concrete Con Steel g Tanks Tanks
structed
Septic Tank or Holdin Tank 0'D 6J ~ S 71 1 F1
Li
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plum 'Name (Print): L,, A&j Plum ber' ignat ure: (No ) MP/MPMW l N~o.: Business Phone Number:
A_)a* ~ G P
lumber's Address (Street, City, State, Zip Code):
9-C L4 LI-) d n. r CS,- %A-) ~
IX. C TY/DEPARTMENT USE ONLY
Disapproved ry Permit Fee (Includes Groundwater Date Issued ssuing A lent Signatur Stamp
Approved ❑ Owner Given Initial u harge Fee)
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-8398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
S T C - 10 0
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 (rV5,(, k- ) T 1V_1 C!/GT
Location of propertyVWl/4 A101/4, Section 3~6, T 0 9 N-RfW
Township
Mailing address Ai J 40K
Address of site
Subdivision name )e~dti~ ~S Lot no.
51
Other homes on property? yes- No
Previous owner of property ~OC(1N6/ACS ~~/~CD~/'1 /~(~G
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? v Yes No j
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVED FOR RECORDING DATA
WARRANTY' QEED
Y% 920 BUM 9 REGISTER'S
OFFICE
ST. CROIX
~~W
CO..1
Rolling Hills Development, nc a Wi ecnnci n Recd for Record
corporation
G O)291991
at 1:45 P. M
conveys and warrants to Eugene 0 Larson, Don D. KriigAr,
and Lawrence M. Johnson, Jr doing b in as 14*wReglsteroil
as Quality guilt Homes
124 S. SECOND ST.
RIVER FALLS, W1 54022
the following described real estate In St. Crn i x County, _
State of Wisconsin:
Tax Parcel No:
Lot Sixty-Five (65), Oak Ridge Acres, to the
Town of Troy.
r'0
This is not homestead property.
(is) (is not)
Exception to Warranties:
r
ti
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER 0 k R(. &T- /Cr2u 6cc:IQ
ADDRESS:- 5u" Vl&k) 6/Z J?19M ~ t5 FIRE NO:
LOCATION : 1/4,, ~I ~cJ 1/4,, SEC. ZZ M N-R
AA L-
TOWN OF: ® ST. CROIX COUNTY
SUBDIVISION: r--5 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.
f
0
SIGNED: c K~t.~.a-
I DATE: L
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
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