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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ( r, i /V JS' A I 'L TOWNSHIP
SECTION _ _.22_ I L W
ADDRESS
ST. CROIX COUNTY WISCONSIN
SUBDIVISION LOT_/ _LOT SIZE 3 6~aq
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
7, 4-
iv
s` 1
INDICATE NORTH ARRO
BENC :Elevptip and description: y <I~,~ia7-
A All
Alternate beAhmark7 V
SEPTIC TANK:Manufacturer:_ UJA&~ ,t Liquid Cap.
Rings used:QManhole cover elev._~nal grade elev: p
® b'~'YSFi
Tank inlet elev.: F1~ 7 Tank outlet elev.
No. of feet from nearest road:Fr , Side Yom, Rear Ft
From nearest prop. line:Front , Side_,,L--, Rear Ft.___ lr,9t
No. of feet from: Well d/•~/tl , Building:: 4e
(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: y Seepage Pit:
Width: -!5'~Length kt 6 =404umber of Lines:
Area Built
9 796,7s o 96
• Sp <
! Exist. Grade Elev. Proposed Final Grade Elev. 9 96.78
Fill depth to top of pipe:_ :),sy
No. feet from nearest prop. line:Front ~
Side , Rear I~ Ft.
No. feet from well:--Z NO. feet from building-
HOLDING TANK
Manufacturer: Capacity:
No. of rings used: Elevation of bottom tank:
Elevation of inlet:
No. feet from nearest prop. line:FrontSide , Rear Ft._
No. feet from: Well building., nearest road
Alarm Manufacturer:
INSPECTOR:
DATE:- ° g PLUMBER ON JOB:- h /t/ c X V 1'J
LICENSE NUMBER:-
6/90:cj '
Wisconlin Department of Industry, PRIVATE SEWAGE SYSTEM County:
,a Human Res
S INSPECTION REPORT St. Croix
Safety and Buildings Division
NW NW, 16 , 2 9 ,18(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION' 110 - Lot #1 149251
Permit Holder's Name: ❑ City ❑ Village own of: State Plan ID No.:
John Schultz Warren
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
i - 246A2 - 0421042800)0
TANK INFORMATION ELEVATI DATA ~_/09 /g/ M1
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic &>J25 Cam, Benchmark O .G~ 3•
9
Aeration Bldg. Sewer p~
Holding St//Fit Inlet 5.671 2 7, Id
TANK SETBACK INFORMATION St/ Outlet 4.) 1' ,S9 t
TANK TO P/ L WELL BLDG. Ventto ROAD BIZA aLat_
Air Intake
Septic NA
NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System 1.7
PUMP/ SIPHON INFORMATION Final Grade ~I
anufacturer Demand T j° 5. T ' 14
Morn, e,1- S (o
Model Number GPM
TDH Lift Friction Sys TDH Ft
oss
Forcemain Length Dia. FI Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length , No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
.51 DIMENSIONS O" t D
SYSTEM TO /L BLDG WELL LAKE/STREAM LEACHIN Manufacturer:
SETBACK CHAMBER
INFORMATION Type Of c,,,n v-. , A Mode - ber: ITIII
System: 7 70 /,j4 OR UNIT
DISTRIBUTION SYSTEM
Header Distribution Pipe(s) ,f 1 ~ ~~c x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. ~ Spacing /.S"'
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only ' S:7z
Depth Over Depth Over xx Depth Of xx Seeded / Sodded xx Mulched
Bed/ Trench Center v.a Bed/ Trench Edges `~•-od Topsoil E] Yes No ❑ Yes E] No .36 COMMENTS: (Include code discrepancies, persons present, etc.) ,
n
`n Ge>✓ n u:t C.e.~ ~rer,an d b0t(=1"` d. s . 5;7
Drop CK
77AP 1 &9 16 eV 6-./Z
Plan revision required? ❑ Yes V11
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
DILHR SANITARY PERMIT APPLICATION
71
In accord with ILHR 83.05, Wis. Adm. Code COON
~.e~,.wau~a.awnn.~w.vs
STATE SANITIs PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. Ch'eck iro pre us application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
J S T,;Z , N, R 9' E (or W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
/a - I
CITY, STATE ZIP CODE PHONE NUMBER ME eR CSM NUMBER
7'y 1); 4
II. TYPE OF BUILDING: Check one CITY NEAREST ROAD
) ❑StateOwned ❑ LAGE~h-~1 I~r
❑ Public P T1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUM ERO -~7/
111. BUILDING USE: (If building type is public, check all that apply) nL~ /O</` ~~DO
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 onl a in line A. Check line B if applicable)
A) 1. ❑ New 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 Eepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 LTrench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION: A 4 4 b- ?
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.) (M i h) -Ak- 9;2,50' E VA
vle , -t" //!/i1 /l ~ 9~2•D Feet - eet
Vlll. TANK CAPACITY 10/ Site
in alIons Total # of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank o t
Lift Pump Tank/Si hon Chamber ITT 1:1 R VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plu~^ber's Name (Print): Plumber's Signature: ( o Sta MP/ Business Phone Number:
&7 Zlw~
Plumber's Addre (Street, City, State, Zip Code
/Vezv 4" S- IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sa 'tary Permit Fee (includes Groundwater Date ssued \1 Issuing A nt Signat re (No Sta s
Approved ❑ Owner Given Initial harge Fee)
Adverse Determination (J -
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
,r 4A
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
ti
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Bar.
APPLICATA, FOR BAIIITART PERHIT
• T C - 100
This application form to to be complntddd In full and signed by the ovnet(s) of
the ptop!rty being developed. My Inadoquacles will only result In delays of
lilt ptra+lt issuance. -Should thin development be. Intended for resale by
owner/contcectoc,lspac house), thou a second tocm should be tatalnad and
completed vhan the ptapetty is sold and submitted to tills ottlce with the
apptopclate decd recording.
Omar •of property
Location of property 114 /y VI'l4t Bactlon T it
T o vn e h l p_
Halling addtet•
ci ~ S1 Y~ 3
• Address of site
lubdlvlelon nawt •
Lot nuabte _
PtevIous owner of property
Total size of parcel -
t Date parcel was created
All all cotnsts and lot 11nes Identltlablet _,Yss . _No
Is this property being developed tot resale (epee house)?- __Yes ?to
VVIU V ;:2a-1nd Page Humber as recorded with the Aeglstec of Deeds.
1NCLUOR V1711 THId APPLICATION Till POLLOVINCt
h wAARANTr DQID which includes a DOCUHaNT HUNSIR, VOLUMM AND PAOt lttntsjA, and
the BIkL Or T11L RIZOIBTHR 01' DRIM. In addition, a certified survey, It
available, would be helpful so as to avoid delays of the reviewing process. it
the deed description tetetencas to a Cet'tmod survey Hap, the Cettltied Survey
Hap shall also be tcqulted.
PROPERTY OX11ER CHRTIPICATIOH-- -
-
I(ve) cetllfy that all statements on this form ate true to the best of *y (out)
knovItdgcl that I (we) am (ace) the owner(s) of the ptoptrty described In
this Intotmatlon form, by virtue of a warranty de~a~d a orded in the ottlce of
the County Hegiatet of Deeds as Document Ho. -s'`'~?
pteaently own the proposed alto for the aewage disposal systen ,(ocdlt(ve)i have
obtained an eaae nt, to tun with Ilia above described property, Ioc t.f,e
consttuctlo of s n tam, and the same has been duly recorded In the ottlce
of t coy y no t ads, as Document No.
sl to of nor 84natute of co-Owner Ill Applicable)
Z d L~
Data of Signature Date of slgnatuce
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
/t /li{ C ~1 ce t~
ROUTE/BOX NUMBER 5k9 J 0 I FIRE NO.
CITY/STATE /~q) ZIP
PROPERTY LOCATION: A ) W 1/4 LL6 1/4, Section A, , T_2,"-~N, R W,
Town of ~t !_kKP ,72 , St. Croix County,
Subdivision 2 , 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 for a MAXIMUM of
$3000 of the cost of replacement of a failing system, which was in operation
prior to July 1, 1978. St. Croix County accepted this program in August of
1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their
systems properly maintained. ,
The property owner agrees to submit to St. Croix County Zoning a certification
form, signed by the owner and by a master plumber, journeyman plumber,
restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and (2) after
inspection and pumping (if necessary), the septic tank is less than 1/3 full of
sludge and scum. Certification form will be sent approximately 30 days prior to
three year expiration.
I/WE, the undersigned, have read the above requirements and agree to maintain
the private sewage disposal system in accordance with the standards set forth,
herein, as set by the Wisconsin Department of Natural Resources. Certification
form must be completed and returned to the St.Croix County Zonin ffice within
30 days of the three year expiration date.
SIGNED
DATE X~z
St. Croix County Zoning Office
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016
(715) 386-4680
Sign, Date, and Return to above address
-5477--RE S~~T 3 B e P R ti+ r ?
Safet & Buiturngs Division
SOIL DESILKIPTION REPORT P.oox7969
Department of Industry,
an RPlatipry,; (Attach Soil Profile Location Map - To Scale - On A Separate, Signed Sheet) Madison, wl 53707
Page of
uitoma Hamt w ustron ate urtant Lan Usa or VeyQtauv owe Parent Mattrra t i'TTFV O V T4i
DG7~ . I Q _ Q / G--fw~ -rj•/';'~ S S• ut,~ct~:~ S~iti cw Ts
~0 SG " v~~Z sUmat! a Oweii rOU Ater Plain Elevation ~I d
ustomu at 1"~► S'T' '('2 013 ~R T'$ Gc1 $ . SYo13 > /00 •r /i
county cc !III 1161 No. y►tcm loa any Ratc rn a ns Pa q• t Per ay 1
99 6 (1
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lot leg. Detc1.I ystem eometry a Dep O ,
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Horizon Depth Dominant Color Mottles Structure
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HOMESITE SEPTIC PLWABING CO.
ebS O'NEIL RD., HUDSON, WIS. 50116 ROBERT ULBRIGHT
AS. ?RASTER PLUMBER LIC. NO. 3307 M.P.fi.S-
r ;•1N. lKTALLE1 & DESIGNER LIC. 0.0066311 ~t/C~ 1
Additional l emaj a.:
1JiP9/N 7 /f`LD EV SltOl~Lv "00
<~~5~ of 7r~e /3~4~c'D D MOel'20Ao S 401'A D%~fc~~.~,
_ STit'_ycTU.t~~S - T'U /Llrf,r/mot%ZE S/DE w~f/l 7"~°~~t-T~t~•~ i 3
4lSsoepT6 =0 o,c) 7x'~Ns Shov/-v ~t ?rS`o -~Yk D,eo~
730 IfSTRi goT/OAJ - ZlSE ~9- Fu~L 1 o F S~wf72
(J...
Pr6r6 -JAz 1"7e- W0&72 Di 5 r T73 tJ T/ oN Pep 'Aj
Other Site Features:
r
e 6w j~n e~ sf- 2.4144- o d . 3y- t/ (?/S) Limiting Factors/Dept CST Signature Date Signed Telephone No. CST M
SBO.8330IN 01190)
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PLUMBING CO-
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1S 7- - d o E5,~ O'FIF, (TNG1 IL RD., SEPTIC HUDSON PLUM, S. 54016 z Ya
ROBERT ULBRIGHT C s r
d R L /S vl0 U S "Nis. Mp ^TER PAR DE814NEp LtC~No. P 00663
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/J 655 O'NEIL RD., HUDSON, WIS. 54016
ROBERT ULBRIGHT ar # l
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Parcel 042-1042-80-000 05/24/2005 12:03 PM
PAGE 1 OF 1
Alt. Parcel 16.29.18.246A2 042 - TOWN OF WARREN
Current , X'', ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): * = Current Owner
* MELSTROM, JAMES E & KAREN E
JAMES E & KAREN E MELSTROM
998 110TH ST
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 998 110TH ST
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 3.660 Plat: N/A-NOT AVAILABLE
SEC 16 T29N R18W 3.66 A IN NW NW LOT 1 Block/Condo Bldg:
CSM 3/791 ORD
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
16-29N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1064/80 WD
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/22/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.660 44,500 76,000 120,500 NO
Totals for 2005:
General Property 3.660 44,500 76,000 120,500
Woodland 0.000 0 0
Totals for 2004:
General Property 3.660 44,500 76,000 120,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 216
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
5q S113 -5 rrRE- slk-T L 3 Be'p RA,S ? alet
Is yo& Builurngs Division
Wisconsin Department of Industry, SOIL DESLKIPTION REPORT P.0. Bx 7969
Labor and Human Relations Madison, WI 53707
(Attach Soil Profile Location Map - To Scale - On A Separate, Signed Sheet) page ~ of
?419- 3 7,?&
O U Tti ~Sy
ustomer Name i va uabon ate urrentlan Use or Vegetative Covet Pare III Meteru s -1
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ustomer rea 1~ 5 T, T2 f3 R T'S W / S , s c10.2 y An,
99f tics .
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Horizon Depth Dominant Color Mottles Structure Remarks:'da in Loading
In. Munsell u. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots o H and o GPD/ft.2
c,.
HOMESITE SEPTIC PLUMBING CO.
655 O'NEIL RD., HUDSON, WIS. 550016r # z z~BL
ROBERT ULBRiGHT 6 7
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