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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
186521 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j.
Permit Holder's Name: City Village X Township Parcel Tax No:
Miller, Brian J. & Mary Erin Prairie, Town of 012 - 1041 -80 -000
CST BM Elev: Insp. BM Elev: T Description: 'n��p Section/Town /Range /Map No:
/GYM l I 1 ti G � 18.30.17.273
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
WeQ-Q, 3 . Ve 143. Ve A Z
Dosing Alt. BM „,.� 3/
Aeration Bldg. Sewer
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing Header /Man. t
Aeration >( 1 Dist. Pipe
Holding Bot. System
PUMP /SIPHON INFORMATION Final Grade
Manufacturer Demand St Cover
GPM C4
Model Number
TDH L Loss System Head Ft
Forcemain Dia. ist. to Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liqui Depth
DIMENSIONS I*-,- *1� `_
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: ,et ✓- , r/� UNIT
� /F,i/ Model Number: d
DISTRIBUTION SYSTEM 1
Header /Manifold IDistribution Hole Size Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia Length Dia Spacing
SOIL COVER x Pre re Systems Only xx Mound Or At - Grade S y
Depth Over Depth Over xx Seeded /Sodded xx Mulched
Bed/Trench Center Bedlrrench Edges Topsoil
Yes 0 No 0 Yes � No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / /
Location: 1541 160th Av e. New ichmond WI 54017 (NE 1/4 NW 1/4 18 T30N R1 7W 5 acres Lot Parcel No: 18.30.17.273
1.) Alt BM Description = W
2. Bldg ewer length
9 9
- amount of cover
Plan revision Required? Yes €J No t _
Use other side for additional information.
Date Insepctor's Sign
SBD -6710 (R.3/97) ture Cert. No.
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uclsc riy u3 r - S -101,G prk I Y- I L tA
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In tl nt� h ap nitary rmit Application
ert 12 St. Croix County Sanitary Ordinance ST. CROIX COUNTY WISCONSIN
f Personal information you provide may be used for secondary Purposes �'ANNNG & ZONING DEPARTMENT
[privacy Law. S. 15.04(1)(m)j ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016 -7710
Attach cam ete ans for the s stem on ( Fax (715)386 -4686
County Sanitary Permit # r not le x 1 has in size.
�S'TC Check if revision to IOUs a
Ifcation Information - Please Print all Information
roperty Owner Name
2 ECEIV on:
roperiY Owner's. Mailing Address 1/4 lw 1/4, Sec
N -
R E (o W
oIt Number Block Number
ih!, State COUN -
zip Code Phone AQNMIG OFFICE
f P r Subdivision Name or CSM Number
I Type of Building: (check o (
t�+ S 3 (PS - 9 '7
1 or 2 Family Dwelling - No. of Bedrooms: 3 tJ
1L ity ❑Village
Publ ic/Commercial (describe use): Town of
❑ State -owned
t. Type of Permit: (Check on On IE r I t
n line A. Check box on fine B It Nearest Road
A 1 • ❑ Repair applicable) (oO`
1 Reconnection Non-plumbing rcel Tax Numbers)
9 • ❑Rejuvenation
Sanitation 0 /,? - /0 , // —�Q CJ(,� ( .-273
Sanitary permit was previously issued rmit Number
Date t ued
IV. Type of POWT System: (Check all that apply) P �/ Z
Non- pressurized In- ground
❑ Sand Filter El Constructed Wetland
❑ Mound z 24 in. hnd suitable soil ❑ Mounds 24 in. suitable soil 11 Mound A +0
❑ Pressurized In- ground
❑ Peat Filter ❑ Dri
❑ At- grade ❑ Holding Tank p Line
[ Aerobic Treatment Unit ❑ Single Pass 1:1 Other
' DI reatment Area Information: ❑Recirculating
1. Design Flow (gtpd) 2. Dispersal Area 3. Dispersal Area 4 Soil A
Required pplication Rate 5. Percolation Rate 6. System Elevation 7. Final Grade
Proposed
(Gets. /dayfsq.ft,) finch) (Min. �
YA Elevation
C
Tank Information G. G 7
a �
ap aic IY in Gallons Total # of
New Existing Gallons Tanks Manufacturer C l Site Con -
Steel Fiber-
Tan s Tanks Concrete structed glass
1. Responsibility Statement ❑ 0 ❑ ❑
❑ ❑ 0 ❑
the undersigned, assume responsibility for repair/ reconnenction /rejuvenationCnstagation of non - plumbing for the
f POW
TS is not re uired for terralift r it or the installation o nOn lumbi sanitation system.
1 mber's Name ( ) TS shown on the attached plans. A
Plu is ignatu no
k ` tamps): MP PRS
lumber's Address {Street, City )
State, Zip Cade Business Phone Number
i^
1. Cou Use On S O !
gpproved Disapproved Sanit Permit Fee 1
Owner Given Initial Adverse ^ let u Issuing A nt g ture
Determination ` 0, T tamps)
X Conditions of Approvat/Reasons for Disa
AProval: p
SYSTEM OWNER: sGfiyviQ. l D�i�c, "� X12/ I'Ip't`Jyt/.IR,. f� GGr�t�G
1 Septic tank, effluent filter and
dispersal cell must all be serviced / maintained
as per management plan provided by plumbil tr�ht f 771
9. R
II setback requirements must be maintained 1
as per a t_R r .
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'Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code Coun
• H ST. CROIX
Attach complete site plan on paper not less than 8 12 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference -mint (BM), direction and Parcel I. D. ,r� , /,� /�_ ' G , `Il
percent slope, scale or dimensions, north arrow, and locatfo rd nc o n St f QOM" V U U
road. Reviewed by Date
Please print all information.
Persons information you provide y w r Dees ( CU� -- � �/
Property Owner Property Location �•
BRAIN MILLER 08 Govt. Lot NE 1/4 NW 1/4 S 18 T 30 N R 17 E (or) W
Property Owner's Mailing Addres Lot # I Block # Subd. Name or CSM#
816 MOONBEAM W T. CROIX COUNTY — 73 ACRES
City State ip Codq_ONI (' City (' Village (o Town Nearest Road
HUDSON WI 5 715 386 - 6532 ERIN PRAIRIE 150th & 160th
(: New Construction Use: (i Residential ! Number of bedrooms 3 Code derived design flow rate 450 GPD
Replacement Public or commercial - Describe:
Parent material TILL Flood Plain elevation if applicable N
General comments and recommendations: � y cce
SYSTEM EL 92 n ?�
�'
F 1-1 Boring # Boring
g Pit Ground surface elev. 96.5 ft Depth to limiting factor } 96 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDKb
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -10 10YR3/2 L 2fsbk mfr gw 2co .6 .8
2 10 -32 10YR5/6 _ sl 2fsbk mvfr gw 2co .6 1.0
3 32 -96 10YR6/8 _ s omsg ml - .7 1.6
i - T F
Comments:
Boring # C Boring
Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDI%
in. "" Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
tj
Comments:
* Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg * Effluent #2 = BOD 5 <_30 mg/L and TSS <_ 30 mg/L
CST Name (Please Print) Signat a CST Number
CALVIN POWERS 220537
Address Date Ev anon Conducted Telephone Number
1969 185th AVE, NEW RICHMOND, WI 54017 Apr 16, 2008 715- 246 -5135
SBD - 8330 7
C-Y1 /(o r ` vim
Q � _
S
�a
05/03/06 WED 07:28 FAX 715 986 4686 ST cRx cb ZONING a 001
s
ST. CROIX COUNTY ZONING OFFICE
CERTIFICADON STATEMENT
POR UTILIZATION AN EXISTING SEPTIC TANK
This is to certify Qiat I have ins ied the 4qptiic tank presently serving the
n ` ast - residence located at:
_ Jam_ ` /�, N `/4, Stction - , Town 3c) N, Range W, Town
of Ek-I n Vrl aL % ri`Ile- , St. Croix County Wisconsin. Upon
inspection, I certify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of Comm. 84.25, and it (they)
appear(s) to be functioning Properly- ,
Most recent date of service
Did flow back occur from absorption system? 'Yes No
(if no, skip next line.)
Approximate Volu or length of time: gallons minutes
Capacity:
Construction: Prefab Concrete Steel Other
Manufacturer (if known): d/ I /,/;1p��
Age of Tank (if know l y' y 2.
C 1 0 1 V,
(Licensed Plumber Signature) (Print Name)
f il P S as a S 3 7
0 (License Number) MP/MPRS
a ? Do g
(D)
Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes)
or licensed disposer (NR 113 Wisconsin Administrative Code)
I
ST. CROIX COUNTY
SEPTIC TANK MAIl+t'TENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer t
Mailing Address ( Mno h 0 w. G0 u- lsOVA tol S D 1 to
Property Address S 4 (400' k "Q)
(verincation required from Planning & Zoning Department for new construction)
City /State Aj p a , , YS lrI1Yr:1w a ( T Parcel Identification Number
LEGAL DESCRIPTION
Property Location N C %. , ti tj '/ , Sec. T AN R W, Town of POCL4 hl �.
Subdivision Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # =�-� , Volume q"T ( , Page # �_ _
Spec house yes Lot lines identifiable O no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
ma aiumance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into
the system can atrect the function of the septic tank as a treatment stage m the waste disposal system- Owner penance
responsibilities are specified in § Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Crain County Planning & Zoning Department a certification form, signed by the
owner and by a master phuraw, journeyman plumber, restricted phmrbe r or a licensed pumper verifying that (1) the on -site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
Uwe, the undawgned have read the above requirements and agree to — nitain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Commerce and the Department of Natrural Resources, State of Wisconsin.
Certification stating that your septic system has been maiumme d mast be completed and returned to the St. Croix County Planning &
Zoning Department within 30 days of the three year expiration date.
Uwe certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the
Property descntied above, by virtue of a warranty treed recorded is Register of Deeds Office.
Number of bedrooms
Si ATURE O PLICANT(S) DATE
—*Any information that is mi may result m the sanitary pernat being revoked by the Planning & Zomng Department. * **
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 08105)
LV.Oc_- ume�-r:r N4D STATE BAR OF WISCONSIN FORM J- 16'+x3
QUFr CLAIM DEED
489035 W7
REGISTER'S OFFICE
Brian J. Miller. F3 nuare — led T7CTSOn C.R sT°
.... .. ._ -. ..., _. .._ ._...__. _. ... .._. __. - - a Im Record
quit - claims t Brian J, Miller land Mary lien Miller, SEP ;.;5 1 992
husband and wile, as marital property with rights
of _au!rvXxa rah tp _ _
Qt 2.45 P • tJ{
tl:e following described real estate in ... Bt ClS91..._ ._ .. County. OOK13
State of Wisconsin:
T Parcel No: , _ . - . _
The Lust Halt of the Northwest Quarter (E} of NWO of Section Eighteen (18),
Township Thirty (30) North, of Range Seventeen (17) West. ?i
1
1
it
ii
iP
i
This ... si:.F?Qt........... homestead property. !
(is) (is �nn ot) j
Dated this ....... c'23 ............. ... ..- day of Sept.emb.er
I - ---- -- ...- ... ..... .... .......,. .(SEAT) �� �.. ?....,... .,(`+EAL) I!
I�
--•----- ----- -.-- . Brian 3, i11er
......... ....... .... ...... _ -... 1.
._ ._.. .(SEAL) _ _. __ (SEAL) II
{ li
AUTHENTICATION ACHNOWLEDGMENT I
SPATE OF WISCONSIN ,
ss. i
St Croix
it ---••'------- ----• --
authenticated this __.. "___day of ........................... 19 ...... Personally came before me this ---- - Any of
� September -:c Q7 .. o...
--------- - - - - --
---- -- - --- ...........................
I! - • - • - - Brian J. Miller
ii "
E! ' - - - - - - _..... ....... ., -
li TITLE: -- - - - - -- - - - - -- • -- - - - - -- - - - - - -. - - -- - -- --- - - - - -- -- - hfEirlIs'EIi STAT BAI2 OF i� ISCONSIN - ai r_
(If not.
-------------------
,__
��
, thor zed by i a 708 ^ `.i
II . to be ....e t;,. :. v.:
£oreg i g :nstrumen nn • cicno�c c$� •{,]'(+
i jjl THIS +NSTRUMENT WAS DRAFTED O� ,
4 Bain &zx fan nyk &• Needham, S.C.
Ruth A. Johnson 'y ?
201 South Knowles Avenue, Box 127 '- - - -- 4 QW --
�I New'Rinhmand; 'Wf 51+fl17 Notary 1 ubli:. . t. Croix - . it
�`; 5 .
(Signatures cony he authenticated or ac!:no:clen,r_a,. D.Ab 1T:• C� e e is•.irn pe anera. i if :ot. sta.o
{) • 1s - - --)
are not necessary.)
date: -- -- --- -- _' - ---
t!
nut^.• fa.9'... .._;,_'
Parcel #: 012 - 1041 -80 -000 10/23/20 PAGE 04:56 OF 1
PAGE 1 OF 1
Alt. Parcel #: 18.30.17.273 012 - TOWN OF ERIN PRAIRIE
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner
O - MILLER BRIAN J & MARY ELLEN
BRIAN J & MARY ELLEN MILLER
816 MOON BEAM W
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 36.000 Plat: N/A -NOT AVAILABLE
SEC 18 T30N R1 7W NE NW 36AC Block /Condo Bldg:
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
18- 30N -17W
Notes: Parcel History:
Date Doc # Vol /Page Type
07/23/1997 971/120
2007 SUMMARY Bill #: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 11/07/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 4.000 49,000 48,800 97,800 NO
MFL BEFORE '05 CLOSED W8 32.000 102,400 0 102,400 NO
Totals for 2007:
General Property 4.000 49,000 48,800 97,800
Woodland 32.000 102,400 102,400
Totals for 2006:
General Property 4.000 49,000 48,800 97,800
Woodland 32.000 102,400 102,400
Lottery Credit: Claim Count: 0 Certification Date: Batch #:
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
AS BUILT SANITARY SYSTEM REPORT
OWNER h Ct l� �}'] � p Y' TOWNSHIP h F ✓� n�i r• !
SECTION Z9 T _,3 4 N -R -- L2 W
ADDRESS e"'O aoL 4 ST. CROIX COUNTY, WISCONSIN
W r S
SUBDIVISION_ LOT vOT SIZE
4J Z14
PLAN VIEW
N .
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
75 .
INDICATE NORTH ARROW
BENCHMARK:Elevation and description:
Alternate benchmark
SEPTIC TANK: Manufacturer: IA),_,!-� Liquid Cap.
Rings used: Manhole cover elev: Final grade elev: 9L'3
Tank inlet elev.: � - Tank outlet elev.:
No. of feet from nearest road:Front4, Side , Rear Ft. /S =
From nearest prop. line:Front-,Y-, Side , Rear Ft. l
No. of feet from: Well - (7 (5, " -' 3 , 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: ?2 Length 7.S Number of Lines: 42�a Area Built 9da
Exist. Grade Elev. y Proposed Final Grade Elev. 96 -v
Fill depth to top of pipe:
No. feet from nearest prop. line:Front-K Side , Rear Fts +-
No. feet from well: feet from building c�
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: Well , building nearest road
Alarm Manufacturer:
INSPECTOR:
DATE: J� �oZ PLUMBER ON JOB:
LICENSE NUMBER:
6 /90:cj
. TC6Mirt art in�'u IE 18. 30 p &A) S'EW�►GE county:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division — ST. CROIX
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION 186521
Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.:
ERIN PRAIRIE
ST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
14 • b 100, I Cc ._r_ => 012- 1041 -80 -000
TANK INFORMATION ELEVATION DATA A9200406
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic, O Benchmark
Dosi ng
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet g, , $ C/ a S
TANK TO P/ L WELL BLDG. Air I ntake ROAD Dt Inlet
Air
Septic /g ®t 9 , 6,3 S/ 7' NA Dt Bottom
Dosing NA Header / Man. 1�1 0 2.
Aeration NA Dist. Pipe 1 9, 10 >
Holding Bot. System , 5 I 9.) `S
PUMP/ SIPHON INFORMATION Final Grade n - 9
Manufacturer Demand
Model Number GPM
TDH Lift Friction Syestem TDH Ft
Forcemain Length Dia. Ilff Dist. To well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION ! � "� DIMEN 1 N
SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type Of Model Number:
System: 6) 04 3 OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) 1 x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. 7 Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over �1 Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed/Tr nch Center Bed /Trench Edgesa Topsoil El Yes ❑ No ❑ Yes ❑ No
COMMENTS (Include code discrepancies, persons present, etc.)
LOCATION: ERIN PRARIE 18.30.1 "273,NE,NW, 160TH
✓ .0 � j5A Y
, t
Plan revision required? ❑ Yes No
Use other side for additional information.
SBD -6710 (R 05/91) Date = Inspector's Signature Cert. No.
SANITARY PERMIT APPLICATION
7b1LHR I n accord with ILHR 83.05, Wis. Adm. Code COUN 5f, 02
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ lh 8N x 11 iriches in size. 01961 41ous 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
arg, !_' NP, %a %a,S T N,R /7 or)W
PROPERTY OWNER'S MAIL ADDRESS LOT # BLOCK #
? * 51 „ y
CI] Y, STATE ZIP CODE PHONE NUMBER SUBDIVISIO NAME OR CSM NUMBER
/ j�� o^ All*
II. TYPE OF BUILDING (Check one CITY NEAREST ROAD
State Owned ❑ VILLAGE Eht •
❑ Public 1� 1 or 2 Fam. Dwelling -# of bedrooms -3 PARCEL TAX NU ERO IA" P73
III. BUILDING USE: (If building type is public, check all that apply)
_ v 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 E 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 X 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
p
T / Do 950 ' s is C 1 3 Feet 9,64 Feet
VII. TANK CAPACITY
Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION -New istin Gallons Tanks Manufacturer's Name oncrete Con- $teal glace Plastic App
Tanks Tanks strutted
Se tic Tank orHoldin Tank/
Lift Pump Tank/Siphon Chamber , __ Ej Fj :1 0 I R 71 E] 171
VIII. 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 Sign : (No Stamps) MP /MPRSW No.: Business Phone Number:
t� orw�n We r5 C� _ 1.51.3 7Jr y6 51
Plumber's Address (Street, City, State, Zip Code):
19
r ` - 5
IX. COUNTY /DEPARTMENT USE ONLY
❑ Disapproved Sa tary Permit Fee (Includes Groundwater a e ssue Issuing gent Sig
Surcharge Fee)
Approved ❑Owner Given Initial 4flf // /
Adverse Determination (
� 5�
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. Four- .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 (SBD 6399) to be
subnutted to the county prior to installation. -
S ,.
5. Onsft' sewage systems must `b2 properly maintained. The septic tank(s) must be pumped by a licensed
pumper whene�ver 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
Al
` To be comb lets an¢,accurate th'; sanitary yermit application must include:
1. Property owner's -riame And y mailing address. Provide the legal description and parcel tax number(s) of
where the system.,is to be installed.
II. Type of building being served: Check only'one and complete ## of bedrooms if 1 or 2 Family Dwelling.
IIL 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 adsorption system if.
j required by iQ`County; E) soil test data on a 1 form; and F) all sizi4 information. - -'
` GROUNDWATER SURCHARGE A '
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies collected through thesg LrCharges are used for m
oniWiN groundwater, ground3`
- water contamination investigations and establishment of standards.
SBD -6398 (R.11/88)
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
Location of propertyA 6�1114, Section /!r , T W
Township 1' E -Q,V, L"JQ.
Mailing address _ / (/ j '- OA �T
1
Address of site
Subdivision name Lot no.
Other homes on property? yes No
Previous owner of property -
Total size of parcel
Date parcel was created s— /
Are all corners and lot lines identifiable? _ Yes No
Is this property being developed for (spec house)? Yes X No
Volume 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.
Signature o applicant Co- applicant
1 �
Date o Signature Date of Signature
i
DOCUMENT NO.
STATE BA2C OF WISCONSIN FORM 5-1982 THIS SPACE RESERVED FOR RECORDING DATA
PERSONAL REPRESENTATIVE'S DEED
48903 VOL. t1PAGE
-� REGISTER'S OFFI E
._ X a--- I Mttter ----------------------------------------
-------------- -------------- - - ---- ST. CROIX CQ., WI �
----- - - - -- ----------------------------------------- - - - - -- 4 Redd For Record i
--------------------------------------------------- as Personal Representative of the estate of
M �hael, E: Kane------------------------------------------------------------------------ - - - - -- SEP 251992
---•----------------------------------------------------------------------•----------------- •-------------- -• - - -- Gf
( "Decedent "), 2:45 P • M
for a valuable consideration conveys, without warranty, to •-- .__.._- _••_________________ ro
. _Brian_J. Miller V L�
Re tster of Deeds
- - --
------------------------------------------ ------------------------------------------------------- Grantee, TO �
St
the following described real estate in .__.___e Croix
-- --- Coulityt I�
State of Wisconsin (hereinafter called the "Propertyll :
Tax Parcel No- ------------------------ - - - -•-
The East Half of the Northwest Quarter (Ej of NWj) of Section Eighteen (18) , Township
Thirty (30) North of Range Seventeen (17) West, St. Croix County, Wisconsin;
AND
Vendor's interest in Land Contract to Gerald J. Kimlinger and Janice L. Kimlinger,
husband and wife, dated April 8, 1969 and recorded April 9, 1969 in Volume "450 ", page !'
427, as Document No. 295894, on the following described premises:
I'
A parcel of land located in the Northwest Quarter of the Northeast Quarter (NWJ of j
NE3), Section Eighteen (18), Township Thirty (30) North, Range Seventeen (17)
West, Town of Erin Prairie, St. Croix County, Wisconsin, more fully described as
follows: Commencing at the North quarter corner of said Section 18 as the point
of beginning for parcel to be described; thence proceed North 87D 04' East along
centerline of Town Road a distance of 987.50 feet; thence South 1 22' East, a
distance of 404 feet to an iron pipe; thence South 85 44' West a distance of j
261.60 feet to an iron pipe; thence North 5D 05' West a distance of 103 feet to an
iron pipe; thence South 88 26' West a distance of 726.11 feet to an iron pipe and
the North and South quarter line of said Section 18; thence North along said
quarter line a distance of 290 feet to point of beginning. Said parcel containing l
7.43 acres, including Town Road right of way.
This conveyance is a distribution under the Michael E. Kane Estate.
Personal Representative by this deed does convey to Grantee all of the estate and interest in the Property which
the Decedent had immediately prior to Decedent's death, and all of the estate and interest in the Property which the
Personal Representative has since acquired.
Dated this -- - - - - -- Nth--------- - - - - --
day of
�I
A
TAPrO
(SEAL)
- - -------------------
...................................................
r-------- - - - - --
Personal Representative Personal Representative
i
AUTHENTICATION ACKNOWLEDGMENT
Signature (s) ..._•_.•________ ---------------------------------- ........ STATE OF WISCONSIN
- --- ---- --- -- ---- ..........
_ $ _t_a - . CX_ --------- - - - - -- ---County. sa.
authenticated this -------- day of___ ___ ___ ___ ___ ________ 19 ...... Personally came before me this -27th ------- day of
.... August ------------------------ P 19_22 ... the above named
* .._Brian J. Miller
------------------------ - - - - ----- - - - - -- -
-----------------------------
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not- --------------------------------
authorized b -- -- ------ ------ ----- --- -- -- - - -- -----•-••----------------------------•---•---
y § 706.06, Wis. State.)
to me k_ Awn to be the person ............ who execyted the
forego• instrumen and acknowl ge the satii.
THIS INSTRUMENT WAS DRAFTED BY
Reinstra, Van Dyk & Needham, S.C. - - -- - -- - - -- _ - -- ____ _ :�
y
201 South Knowles Avenue; Box I27 " * Ruth A. Johns ''''
Ne�z-- llichmand, WL 54017 - - - - -- St. Croix ( s ,: • W A
: --
Notary Public . - -•- -• -- --•• - - - - --
y �t§:.• f '
(Sign ot ecessary )e authenticated or acknowledged. Both My Commission is permanent. If no?J ti� ti �f,�lo�i '
i1 !?
date. ----- - - - - - 1 21 . 1 $ / 94 � _�,,., j# +ti : •) + i
- - -- _ 4
•Names of persons signing in any capacity should be typed or printed below their signatures. T_ TAt�
!
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER /BUYER J31-0 Y`
ROUTE /BOX NUMBER d 12 .2 -''0 - FIRE NO.
CITY /STATE Ig L11- - k ZIP 5 I b
PROPERTY LOCATION: N5 1/4 A) 1AJ 1/4, Section / , T _�b N, R ___Z2_ W,
Town of Pr ----� , St. Croix County,
Subdivision k , 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 Zoning Office within
30 days of the three year expiration date. `
SIGNED
DATE
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
Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Pag ) of 3
Labor are Human Relations g —
Division of Safety Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but -5-f ` G r ° k X
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # a 7.3
dimensioned, north arrow, and location and distance to nearest road. Q / a _ p y ► — �p
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
P OPERTY OWNER: PROPERTY LOCATION
bV 4v-, " 1 `Q. Y-. GOVT. LOT Aj 1 /4IVW 1 /4,S ) 9 T ,36 ,N,R 1 7 Jffln W
PROPERTY OWNER':S MA D RESS LOT # BLOCK # SUBD. NAME OR GSM #
/Z9aa a I 0.
Cl y, STA T ZIP CODE PHONE NUMBER ❑CITY ❑VIL ®TOWN NEAREST ROAD
[ j New Construction Use Residential / Number of bedrooms Addition to existing building
QQ Replacement [ ] Public or commercial describe
Code derived daily flow .5Q gpd Recommended design loading rate r bed, gpd/ft , G trench, gpd/ft
Absorption area required 900 bed, ft trench, ft Maximum design loading rate 1 5 bed, gpd /ft , L trench, gpd/ft
Recommended infiltration surface elevation(s) 1 73 1 6 ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable � ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL I HOLDING TANK
U= Unsuitable fors stem E o u Jo S D U I ®S 1711.1 El S [9U ❑ S (gLU ❑ S IM11
SOIL DESCRIPTION REPORT a 3� TP,,�
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouxlary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed TT-w&
:- ' x 6 - 10 io R 3/ .= - ;L — s/ a M a s rn , SI' lo s
Ground C 6 - /D q (S n'1 v C W 5
elev. C 57`8') /O (,Iv
m C W l 5 to
Depth to
limiting
factor
4p-
Remarks:
Boring #
O t-. 4 "5 m 2 s
kill
Ground 6 -8 5
W 3' l v L
elev.
C& L / ft.
Depth to
limiting
factor
Remarks:
CST Name:—Please Print Phone: 71-C
Address:
Signature n Date: � �a CST Number.
PROPERTYOWNER m� ��� ►� SOIL DESCRIPTION REPORT
Page of_
PARCEL I.D. #
Depth Dominant Color Mottles Structure G -PD /ft
Boring # Horizon Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tree&
13 V -24 16 /s a ty) sbk m er Au& a ►•. /� ,S
Ground C �O` (,8 Q S M A ►- h1 J -F / , S
elev.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
y.iiti iii: iii:•:
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
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-- - _. -
Cro S•/5���1
frslh Air Inlet► And OD►uvotlon Pips
� ' s Yo�•G
v`^���- ^ — �•" Appro.id vent Cop
►rintmu 12 Above
ilnal Grade
20 42' Above Plpp _ 4" Cost from
To Final 0rede Vent Pipe
' eearen }ley Or SrnlMlk Ceveriny
4rn 2* Aggregate
Over Pipe
DlelrlEvllon •
Pipe 0 0 0 — Tee ►
V Aggregate
Beneath Ptpe ° Perforated PIPS ffetor
o `Ca•gling Ter- Inaling At
'• flollom Of System
p
P ru ��CD
Pin- I �rac�t ��• l _.
P �
�I��•.�' Ion `% / .
"0,.
SOIL FILL
DI.STRIBU PIPE
y + APPROVED syl P4cTIC COVER
OR 9 OF STRAW
2" OF hGGREGAZE —� OR M Ay
MARSH H
OF
Q ?
�LEV. O !J ' F �•Yj�' ��z-2 /z AGGREGATE �P ° th' •
F EET —.-
D15 rRIWJTI(DW PIFE TU BE AT LEAST _ _ INCHES BELOW ORIGIIJAL GRADE
A►JU AT LEAST LO 11JCH[S BUT 1.10 MoP C THAIJ 4Z IIJCHES OELOW FINAL GRADE
rOLMU DEPrVi OF FXCAVATIOO FKom ORIGWAL 6R)'\DR WILL BE � INCHES
MHIMVM OCPni of EXCAVATION FA Ci,"G►NAL GRADF- WILL BE S
SIGIJCO: Z
LICEuSC ►.1UMBE12:
DAT E : l0 ''7�' 'Z"
REPT131 ERIN PRAIRIE ST. CROIX COUNTY ZONING PAGE 1
11/13/92 10:03 REQUESTS FOR INSPECTION WORK SHEETS FOR 11//92 AREA: TN
-------------------------------
Activity: A9200406 11/13/92 Type: CONVSEPT Status: PENDING Constr:
Address: ERIN PRARIE 18.30.17.273,NE,NW, 160TH
Parcel: 012 - 1041 -80 -000 Occ: Use:
Description: 186521
Applicant: MILLER, BRIAN Phone:
Owner: MILLER, BRIAN Phone:
Contractor: POWERS, CALVIN Phone:
--------------------------------------------------------------------------------
Inspection Request Information.....
Requestor: POWERS, CAL Phone:
Req Time: 16:11 Comments4
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION
- - -- -------------------------------------------------------------------------
Ins . I "oh History.....
I is , 00012 FINAL INSPECTION