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Form - S T C - 106
AS BUILT SANITARY SYSTEM REPORT
40iMER" L. Get`. OT 14' TOWNSHIP SEC. TN-R~W
2-1
ADDRESS tl t~✓ f,~ ST. CROIR COUNTY, WISCONSIN
. ; ~ . 23G12 l2, .
SUBDIVISION ~'1 LOT LOT SIZE /
PLAN VIEW
Distances and dimensions to meet requirements of ItUR 83'
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
ILI
Lt K
F13'
r ~0]
+...wr...R+n°+srn,.- •...v:,n. e .....r.:....,:..«r_..., n..wxr aFr s• ,n-..+a,w,-xw,..,....x+,!W.~n.T-SR: 15.iady-I.AeAi!•'MVa~
BENCHMARK: Describe the vertical reference point used S" 1 a ~C
Elevation of vertical reference point: /0 U Proposed slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity:
i''••f-Numbet of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front 10 Side, Rear, 0 feet
-From nearest-property line -Front to Side 0Rear, 0 feet
Number of feet from. well , building:
(Include this information of.-the above plot plan)( 2 reference dimensions to septic tank)
SFF REVERSE SIDE
PUMP CHAMBER
Manufacturer: y 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.neareat property line:'. Front, O Side, Oftar,C) Ft.
'Number of feet from well:
Number of feet from building:
(Include distances.on plot plan).
SOIL ABSORPTION•SYSTEH:
Bdd:• Trench:
Width: Length: .-Number 'of Linea: Area Built:
Fill depth to top of pipe:
Number of feet f~ m
TNumber nearest property line: Front, O Side, O Rear, O Ttof feet from well:
N 'ber of feet from building:
(Include di tances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or diet*ibution box O been used on any of the above soil
absorbtion aytems? (C}eck one).
HOLDING TANK
Manufacturer: , w e. v Capacity: ~J U
Number of '.rings used: Elevation of bottom of tank: Y- C1
Elevation of inlet: .
Number of feet from nearest property line: Front, O Side,~ear, OFt.=
Number of feet from well: G r
Number of feet from building: 2 L
Number of feet from nearest road: • o v
Alarm Manufacturer: Vt, e- C, re
Inspector:. '
Dated: Plumber .on job: 4LO14
s
License Number:
3/84:nij e
44
DEPARTMENT,OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
LABOR & HUMAN RELATIONS DIVISION
P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
MADISON, WI 53707 State Plan I.D. Number:
SW 4 , SW 4 , Sec . 27 , T29-R16 ❑ CONVENTIONAL ❑ ALTERATIVE (If assigned)
Town of Baldwin
Holding Tank ❑ In-Ground Pressure ❑ Mound
NAMIE~OF E IT H DER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
LeRoy Storley Woodville, WI f/_/ S
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: C REF. PT. ELEV.:
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Joe Stang 6646 St. Croix 135479
C/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
r PROVIDED: PROVIDED:
- - ~ ES ❑ NO ~ [ffl YES ❑ NO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL, BUILDI G: VENT TO FRESH
ALARM: FEET FROM LINE: AIR INLET:
❑ YES F)AO ` _i ❑ YES ❑ NO NEAREST
DOSING HAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF ❑ YES El NO NEAREST 00,
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING:
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
TRENCHES: MATERIAL: PIT DEPTH:
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: N0. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END. PIPES: FEET FROM LINE: AIR INLET:
NEAREST,
MOUND SYSTEM:
Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW
❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED.
SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS;
❑ YES ❑ NO ❑ YES ❑ NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.:
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑ YES ❑ NO ❑ YES ❑ NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROOPERTY WELL: BUILDING:
FEET FROM EAREST----*
❑ YES ❑ NO ❑ YES ❑ NO N
r ~
i
Sketch System on etain in county file for audit.
Reverse Side. SIGMA RE: TITLE:
SBD-6710 (R. 06/88) / ✓~i^
DILHR SANITARY PERMIT APPLICATION COUP
In accord with ILHR 83.05,.Wis. Adm. Code
E mmmommom .
STATE SANITARY PER IT
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑Y
8% x 11 inches in size. ch re ision to pre sous 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
Le- S'i✓'/4S.?7 TN,R 16 E(or)W
PROPERTY WNER'S MAILING ADD ESS LOT # BLOCK #
WL1 "r 11 .11 e
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
Lt/,'s 5y~~~- 291
II. TYPE OF BUILDING: (Check one) 1:1 State Owned ❑ VILLAGE: NEAREST ROAD
fm =N : 3u 441 Us" ❑ Public ❑ 1 or 2 Fam. Dwelling- # of bedrooms - PARCEL TAX NUMBER (S)
III. BUILDING USE: (If building type is public, check all that apply) _ D f ~`OG
1 ❑ Apt/Condo i
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 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. ❑ New 2. N Replacement 3. ❑ Replacement of 4.E] Reconnection of 511 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 A Holding Tank
12 ❑ Seepage Trench 22 1:1 In-Ground 42 Pit Privy
13 ❑ Seepage Pit Pressure 430 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
Feet Feet
VII. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Se tic Tank or Holdin Tank F] 1-1 F] I
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumb 's Signature: (N mps) JAW IMPRSW No.: Business Phone Number:
Plumber's Address (Street, 'ty, State, Zip Code
OIL V,11ZC&
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued issuing A nt Signatur o Sta ps
Surcharge Fee)
Approved ❑ Owner Given initial 5 c~
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 & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A 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.
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. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed
pumper whenever 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.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and 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.
III. 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 absorption system if
required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
PLOT PLAN Page 3 of
Scale 1"= qO
of -qa
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tPSOL,t~. ►~t-tR 82.3(3 C<<) (v') 34- .
ALL w ER T71 ~IatUt
2._ `F~ P.l1J ~N 10 1 lxt Y-rub T-'R-Oti` t l~1~G PART To
3. ~~E 1~ )ul~ ~KiSTJ1uG SEl•J~: .5'~ST~'? OR lv~LL (~JV TNtS ~t~~~l"1.
Y
`i
L4 of y
HOLDING TANK CROSS-SECTION n Approved S90=40070
Vent Cap Weather Proof
Junction Box
4„ C.I. /Approved Locking Manhole Cover
With Warning Label Attached
Vent Pipe
Minimum 12
Final Grade
4" Minimum
(Approved Joint
18" Minimum
L -i
Water Tight--"
Seal ~ High Water '
Alarm Switch
SPECIFICATIONS - _ - - - - - ;
TANK New Existing
Manufacturer: Approved Joint
aw CAN ~~~_~'rsT, 1N c .
Blind C.I. Tank Size:_ Z o0 o Gallons
Plug
ALARM Manufacturer: S.S. ~L~CYR~ SYST'tS
Model Number: \O ~ H W
Switch Type
-NUMBER OF BEDROOMS: N . N .
GALLONS PER DAY: 1l O
3" of Bedding Under Tank
ONSI`I'E SEWAGE SYSTEM
azD
DCPARTF/IE N r t NLD gAAN RELATIONS
,JN OF C DfNGS
-morn
SEE CORRE" NDENCE
State of Wisconsin ` Department of Industry, Labor and Human Relations
SAFETY & BUILDINGS DIVISION
PRIVATE SEWAGE PLAN APPROVAL
Western Regional Office
2226 Rose Street
LaCrosse, Wisconsin 54603
l WEGERER SOIL TESTING & DESIGN SVC Owner: LE ROY STORLEY
P.O. BOX 74 235 JOHNSON
RIVER FALLS, WI 54022 WOODVILLE, WI 54028
RE: Plan Number: S90-40070 Date Approved: April 21, 1990
Gallons Per Day: 110 Date Received: April 21, 1990
Project Name: STORLEY, LEROY - OFFICE Location: SE,SE,27,29,16W
Town of BALDWIN County: ST CROIX
The plumbing plans and specifications for this project have been reviewed for
compliance with applicable code requirements. This approval is based on Chapter
145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are
stamped 'conditionally approved'. This approval is contingent upon compliance with
any stipulations shown on the plans. All items that are noted must be corrected.
All permits required by the city, village, township or county shall be obtained
prior to construction. The licensed plumber responsible for this installation
shall keep one set of plans with the department's approval stamp at the
construction site. The installer shall notify the appropriate inspector when
inspections can be made.
This approval will expire two years from the date approved or if a sanitary
permit is obtained, it will expire the day the initial sanitary permit expires.
The Section of Private Sewage has reviewed these plans for private sewage system code
requirements only. These plans have not been reviewed for the code requirements
set forth in Section ILHR 82 for general plumbing or in Chapters 50-64 of the
Wisconsin Administrative code.
This approval is for the following components only:
I
- NEW HOLDING TANK
Inquiries concerning this approval may be made by calling (608) 785-9348.
Sincerely,
GERARD M. SWIM
Section of Private Sewage
Division of Safety and Buildings
4PP039/0009n/62
cc: LE ROY STORLEY X Private Sewage Consultant
SBD-6423 (R. 08/88)
S90_40070
CALCULATIONS Page 2 of~
This building is to be used as office space with
a maximum of 3 employees.A future floor drain is
included in the calculations.
3 employees at 20 GPD = 60 GPD
i floor drain at 50 GPD = 50 GPD
Maximum anticipated wastewater =110 GPD
A 2000 gallon precast concrete holding tank will be installed.
S90-40070
HOLDING TANK
Page 1 of
LOCATED IN . THE S~ 1/4 OF THE SW 1/4 OF SECTION , T .9 N, R It. W,
TOWN OF, ST. c- Zj)( COUNTY, WISCONSIN.
INDEX
PAGE 1 of 4 TITLE SHEET
PAGE 2 of 4 CALCULATIONS
PAGE 3 of 4 PLOT PLAN
PAGE 4 of 4 HOLDING TANK SECTION
PREPARED FOR
w~o~v1~~.~ w~ sy~Z~3 p 199
PREPARED- BY
r>- 6
- Flo v~ *yV ~ ~by
AR''H!)R L. r
WEG:iiER
0-en p
RTH.
W EGEI ER S.Q = TEST I V AP
KY i
AND V_"
I3 ES E(l q S E= F:Z V I G E a~®® y, A
Pit F Pea 31 G-14
4 421 K. tAIN ST.. ~
RIVER FALLS, YI, 56022 fe715- n-0165 A d
JOB NO. 6)Q - 6/
_
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
• INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 7969
N WI 53707
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: OWNSHIP UNICIPALITY: LOT NO.:BLK NO.: SUBDIVISION NAME:
sw sw z~ /T N/R)~ E to ~3PtL-1~w1N l \Jnl.k4 C!3 H 100-7
COUNTY: t.le_=- IRZ4 15"1C.Z1..t= MAILIN ADDR SS:
voopQlLU~, w! S 0
ST-CtZ1X w- yu ZS
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL S R TION: ~r
❑Residence
dFFlc~ 1INew ❑Replace 70F11LLE tvow V r -xis1'• 4~~ a c s s sR S YS r»I
RATING: S= Site suitable for system U= Site unsuitable for system OUND
)o (oTptional)
NG TAN C EONVEN l ST U IONAL: MEl S IZU IN-GEl S ll E: S❑T J -IN-FILL O rS EJU : ENDED SYSTE
k
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the - IN
under s. ILHR 83.09(5) (b), indicate: N Floodplain, indicate Floodplain elevation: N
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGRTsf- TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 1 z g N tv ~ g SEz=.- G C Z, o F 7-
B- Z 3 0 A. ~o~ t
B-
B-
B-
B-
PERCOLATION TESTS
it
TEST. DEPTH , WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RAT MINUTE
NUMBER INCHES AFTERSWELLING INTERVAL-MIN.. PERIOD 7 PERIOD 2 Pr; PERINCH
P-
P-
P-
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. E S}L'fgf=jZG 5
SYSTEM ELEVATION
I_, ej Ts r~ L-C C*e so'~
o
t-11- Tie -%W
40
-
j tN
AT0014 S
I r' ~A A)
0
~I
12
salt LE I'c =60'
I, the undersigned, hereby certify that the soil tests reported on this form were made by mein 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.
TESTS WERE COMPLETED ON:
NAME (print)
AND
ADDRESS: DESIGN SERVICE CERTIFICATION NUMBER: PHONE NUMBERIoptional):
C,%-r ooo S7(~ 7IS-q25-o16s
P.O, BOX 74 421 N, MAIN , CST SIGNA URE:
RIVER FALLS; W154022
. 715-425-0165 ` f
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. 2
DILHR-SBO$395 (R• 10/83) - OVER -
4
SOIL DESCRIPTION FORM
ttach o 1 Pr I L CaLio Ma On a Su amts Shoot)
LINEAR LOADING
PuRPOS :F-UAWflmw FOB SOIL t~a3so Sys SLOPE
L.J EG IV o2TN
DErRiPT ION BY Q?- L-~ G)ztT ASPECT '
v ~T• l B9 CURRENT LAND USE, I~w
OATf.:
COLINTY/STATE: ST' c9-41Lx C wort u-j 1 VEGETATIVE COVER;
l`1 - ` 'UORI-Y D l~~
1 1/ 2'7, TZ4 N I R l d w DRAINAGE CLASS: eA3
LOT DESCRIPTION ~ToT=S)") /y'SW y 3
LOCATION* ~~I~iJ n~- L.D►~~11J GALLONS-PER S .'FT. PER DAYt
S\z.Y (3 s
PARENT MATER AL(s)/DEPTI L~ ~tS S / T( LL SOIL SERIESt
so T1 ClAss
HORIZON DEPI11 MATRIX COLORS MOTTLES TEXTURE STRUCTURE CONSISTENCE CLAYSKINS/ PORES ROOTS PH •BOLWOARY REMARKS
(moist) C St. Sh COATINGS
in.
rJ ~ l
o- 1u'IR Z/2 S't rk wtfv~ Gs
z $_2p o" l y/`~ mZP S ~ 1 I ~ QI m-~t- `Cw -7.S'iRSJLi ho7-
•t
3 28 yr -l tL. y/ m Z C' S~~ O >n
p- ` 07 tZ 2„/Z - S 1 S bk wL t T
c:
Lj/ VX
)6-3o bilk yh/ ~YT ZP sc.l O w. ►►1'Qt-
C> WGS G Lam`-
vyv ~tN Iy V~ G
O CoV Sol L, Sv C ill
Sh S- itvOl G G U D
soi L,
L 00 at_ I: and L
1 R.~L
_ 8oR.1 n~ o~ c- c.. of v 1
OTHER SITE FEATURES/NOTES:
~n6e?~ of Z
Signature Date CST A
LIMIT,I~IG FAC10R5/DEPTH: t '
WEC-3 EfF EL F7< E3C3 I TEST I IVC-,,
• AND
F.U. BOX 74 421 N. MAIN ST.
RIVER FALLS, NI 54022
715-425-0165
ATTN: DATE
CC:
SUBJECT:
WE ARE ENCLOSING THE FOLLOWING ITEMS:
NO. OF
COPIES DESCRIPTION
. 1 `~.ICO~- i ,ru 6
SENT TO YOU FOR THE FOLLOWING REASONS:
❑ FOR APPROVAL ❑ APPROVED AS SUBMITTED ❑ INFORMATION DESIRED
[-FOR YOUR USE ❑ APPROVED AS NOTED ❑ RETURN COPIES
❑ NOT APPROVED ❑ FOR REVIEW AND COMMENT I]
WEGERER SOIL TESTING
AND
DESIGN SERVICE
ve: S6SPatt 39
Document No. This space reserved for recording data
457507 HOLDING TANK AGREEMENT
Agreement Date
April 16 ,19 9 0 - - This agreement is made between the '
ISTER OFFICE
G
County or Local Governmental Unit I Holding Tank(s) Owner(s) ST. CROIX CO., W1
Town of Baldwin LeRoy Storley Rec1d for Record
(Called Municipalitybelow) I APR 171990
We acknowledge that application is being made for the installation of (a) holding 1:00 P M
tank(s) on the following property, (Provide legal land description:)
Lot 1 of Volume 4 of Certified Survey Maps, Ceefb
_ Page_ 10.07 being part_ of the SW1/4 of the SW1/_4_
of Section 27, T29N, Rl6W, Town of Baldwin,
St:Crox County, Wisconsin.
Return To
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of
sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under
Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, Stat
c
As an inducement to the County of 0120 I to issue a sanitary permit for the above described property,
we agree to the following:
1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the
holding tank properly serviced in response to orders issued by the municipality to prevent or abate a nuisance as described in ss. 146.13 and
146.14, Stats. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner by
placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by
s. 66.60, Stats.
2. Owner agrees to pay all charges and costs incurred by the municipality for inspection, pumping, hauling or otherwise servicing and maintaining
the holding tank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify
the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the
costs within thirty (30) days, the owner specifically agrees that all of the costs and charges may be placed on the tax roll as a special assess-
ment for the abatement of a nuisance, and the tax shall be collected as provided by law.
3. The owner, except as provided by s. 146.20 (30) (d), Slats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to
have the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality and with the county. The owner
further agrees to file a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within
ten (10) business days from the date of change to the service contract.
4. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code who shall submit to the municipality and to the county a
report in accord with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under
s. 146.20 (3) (d), Slats., the owner shall submit the report to the municipality and the county.
5. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage~~sygenm! ' i s that
the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adry2`~od'e. Iri'- dd NP41his
agreement may be cancelled by executing and recording said certification with reference to this agreement in suchZ-hnpt' whicfi`*jI`geAVitr
the existence of the certification to be determined by reference to the property.
t
6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner stwibmit.the,agr-eemenf tq
the register of deeds and the agreement shall be recorded by the register of deeds in a manner which will permit the=exis4 ncWlof 1:6 agrersrnerit
to be determined by reference to the property where the holding tank is installed. ? 4' , -
Owner(s) Name(s) (Print) I Owner(s) Signature(s)
Subscribed and sworn to before me on this date:
I
20 41-16 -'fo
Municipal Official Name (Print) I Municipal Official Signature Ka".L b o u Notary Public
A L 7ro A N k-L Q k S 4 I My commission expires:
Municipal Official Title (Print)
oW C A)RMA I
SBD-6123 (R. 10/85) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations, Bureau of Plumbing.
ve; S6$Att 39
Document No. This space reserved for recording data
457%`5"07 HOLDING TANK AGREEMENT
Agreement Date p~~ A
April 16,19 9 0 This agreement is made - - between - the - - - 16GVM~tC'S OFFICE
- - - - - - - - -
County or Local Governmental Unit ( Holding Tank(s) Owner(s) ST CROIX CO.' W)
Town of Baldwin LeRoy Storley Reed for Record
(Called Municipality below I APR171990 M
We acknowledge that application is being made for the installation of (a) holding cit 1:00 P _
tank(s) on the following property, (Provide legal land description:)
of Deeds
Lot 1 of Volume 4 of Certified Survey Maps,
Page 10.07 being- part_ of the ,SW1/4 of the _SW1/4
of Section 27, T29N, R16W, Town of Baldwin,
St-Croix-County, Wisconsin. Return To
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of
sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under
Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, SSttat .
As an inducement to the County of ca y F t to issue a sanitary permit for the above described property,
we agree to the following:
1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the
holding tank properly serviced in response to orders issued by the municipality to prevent or abate a nuisance as described in ss. 146.13 and
146.14, Stats. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner by
placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by
s. 66.60, Stats.
2. Owner agrees to pay all charges and costs incurred by the municipality for inspection, pumping, hauling or otherwise servicing and maintaining
the holding tank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify
the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the
costs within thirty (30) days, the owner specifically agrees that all of the costs and charges may be placed on the tax roll as a special assess-
ment for the abatement of a nuisance, and the tax shall be collected as provided by law.
3. The owner, except as provided by s. 146.20 (30) (d), Slats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to
have the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality and with the county. The owner
further agrees to file a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within
ten (10) business days from the date of change to the service contract.
4. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code who shall submit to the municipality and to the county a
report in accord with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under
s. 146.20 (3) (d), Stats., the owner shall submit the report to the municipality and the county.
5. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage~ ~ym~ s that
the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adrt sewage.
Iri'I&Oin Phis
agreement may be cancelled by executing and recording said certification with reference to this agreement in such,4"npr which*ill-'Qeit.
the existence of the certification to be determined by reference to the property. ,
F.
.
6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner s6l~"bmit he'agIfeemen+, to
the register of deeds and the agreement shall be recorded by the register of deeds in a manner which will permit the_existgnctgof the agrecmerit
to be determined by reference to the property where the holding tank is installed.
Owner(s) Name(s) (Print) I Owner(s) Signature(s)
Subscribed and sworn to before me on this date:
41-16
J.Ot2oi _S4
Municipal Official Name (Print) I Municipal Official Signature ~QU Do or n y Notary Public
A L fro ~ 1 )r k s a I Q~ 1 My commission expires:
Municipal Official Title (Print)
I
0\.Q c, AIRMA I
SBD-6123 (R. 10/85) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations, Bureau of Plumbing.
S6SPOA 39
Document No. This space reserved for recording data
457 r&0 HOLDING TANK AGREEMENT
Agreement Date
April 16 ,19 9 0 - - This agreement is made between the - (EJ'NS 1 C YOR'S OFFICE
County or Local Governmental Unit I Holding Tank(s) Owner(s) ST. CROIX CO., WI
Town of Baldwin LeRoy Storley Rec'd for Record
(Called Municipality below) I of APR171990 M
We acknowledge that application is being made for the installation of (a) holding 1:00 P
tank(s) on the following property, (Provide legal land description:)
Lot 1 of Volume 4 of Certified Survey Maps, a
_Page__10,07__being part of the SW1/4 of _the, SWl/4.._
of Section 27, T29N, R16W, Town of Baldwin,
St CYD1X" County, Wisconsin. Return To
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of
sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under
Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, SSttat .
As an inducement to the County of d e y I to issue a sanitary permit for the above described property,
we agree to the following:
1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the
holding tank properly serviced in response to orders issued by the municipality to prevent or abate a nuisance as described in ss. 146.13 and
146.14, Slats. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner by
placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by
s. 66.60, Stats.
2. Owner agrees to pay all charges and costs incurred by the municipality for inspection, pumping, hauling or otherwise servicing and maintaining
the holding tank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify
the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the
costs within thirty (30) days, the owner specifically agrees that all of the costs and charges may be placed on the tax roll as a special assess-
ment for the abatement of a nuisance, and the tax shall be collected as provided by law.
3. The owner, except as provided by s. 146.20 (30) (d), Stats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to
have the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality and with the county. The owner
further agrees to file a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within
ten (10) business days from the date of change to the service contract.
4. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code who shall submit to the municipality and to the county a
report in accord with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under
s. 146.20 (3) (d), Stats., the owner shall submit the report to the municipality and the county.
5. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewag !syi5'C rn,'411fi s that
the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adrpt~`Kcre, Iq'dclca io his
agreement may be cancelled by executing and recording said certification with reference to this agreement in suctt~hnor"which trRill°erl~itze
the existence of the certification to be determined by reference to the property.
6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner st#aIrAybmikthe'ag'feemenf to
the register of deeds and the agreement shall be recorded by the register of deeds in a manner which will permit theFexrs' nd of tlhe agreement
to be determined by reference to the property where the holding tank is installed. . `
Owner(s) Name(s) (Print) I Owner(s) Signature(s) a~4*,
- I - Subscribed and sworn to before me on this date:
Municipal Official Name (Print) I Municipal Official (Signature o L).'- r h ~G Notary Public
A LT, A lq k z c, 14 I ~ 1J~ My commission expires:
Municipal Official Title (Print)
oW C_ !t►RNA
SBD-6123 (R. 10/85) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations, Bureau of Plumbing.
HOLDING TANK SERVICING CONTRACT
Contract Date
This contract is made between the
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Holding Tank Owner(s) Name(s) and i Pumper's Name
Leroy Storley G iS lG,l JI-SS
We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:)
Lot 1 of Volume 4 of Certified Surye__MaPage 1007 beinq part of
-
t e of the S1411 _4o f Section 27, T29N, R16W, Town of Baldwin,
1. The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality", which has
signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and
with the County of St. Croix
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to
enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all-weather access
road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay
the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper.
3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis.
Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees
to include the following in the semiannual report:
a. The name and address of the person responsible for servicing the holding tank;
b. The name of the owner of the holding tank;
c. The location of the property on which the holding tank is installed;
d. The sanitary permit number issued for the holding tank;
e. The dates on which the holding tank was serviced;
f. The volumes in gallons of the contents pumped from the holding tank for each servicing;
g. The disposal sites to which the contents from the holding tank were delivered.
4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract,
the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality
and the County named above within ten (10) business days from the date of change to this service contract.
Owner(s) Name(s) (Print) I O nature(s) .
Subscribed and sworn to before me on this date:
B~ t
Reuben Doornink
Pumper's Name (Print) I Pumper's Signature Notary Public
My commission expires:
L lfr CAL -Aug. 22, 1993
Pumper's Registration Number
SBD-7574 (N. 11/85) This instrument was drafted by the State of Wisconsin Department
of Industry, Labor and Human Relations, Bureau of Plumbing.
. U
CERTIFIED SURVEY MAP
Located in the NW 1/4 of the NW 1 /4 of Section 25, T30N,R 15W , Town of
Glenwood, St. Croix County, Wisconsin. ,
Surveyed for: ' Joseph Draxler
Glenwood ity
Wi. 54013
N 1/4 COR.
SEC. 25 3
to
N
tV In
(00 LEGEND
Z
so°39'50"E SECTION CORNER MONUMENT
IS 2i' 41.76 (BERNTSEN CAP)
I
23.97' O 1 °X 24" IRON PIPE WEIGHING
I 1.65LBS./LIN. FT. SET.
I 17.79
6 'I \G
to X2,0
~ SCALE IN FEET I" = 200'
NOW
0' so' loo' 200' 400' 600'
\
Bearings referenced to the West line
\o
o s ~z'y of the NW 1 /4 of Section 25, assumed
4 w (P ~O, N00°14'20"W .
I 101 i • a• -
~ w
H I ~ Q _
1
~ I wl
U. iD o
N p► W
rfl Z S 00'14'20'E 531.35'
W
N
Z r1 I N J
m)
Z N' I Z
W
V LOT I
613,314 SO. FT. (14.08 AC.) oI
r I INCLUDING RIGHT-OF-WAY 0 ZI
I~ N 1030' 07 "W 592,075 SQ. FT. ( 13.59 AC.) I
124.54' EXCLUDING RIGHT-OF-WAY = c~
6.68 ( ~I
96.22' W al
126.32' to ,N4 a1
Q ' ZI
O sp m ~1
r 2
C4 Z
N
FENCE N O6' 15' 44'E 712. 13' N 00° 14 X20°W
884.40 _ _ _
S 00.14' 20' E= 1788.33
NW CORNER WEST LINE OF THE NWI/4 WI/4 COR.
SECTION 25 "PL ~T'j.&NQS SEC. 25
T3ON,R15W
Lift HARVEY G.'
• JOHNSON
S-1899 =
HUDSON i
L W IS
< ~o o• q o
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NOSIM ' 066T `Aaenuier ;o f%-ep qj8 still pal-eQ
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(saaoe 80 • ~1) ;9a; aaEnbs V1 £ T 9 8uiuye4uoo ' $utuut8ag ;o lutod aq4
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NOI.LcIIIIOSaG
I.. 4 0
i
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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property za C
Location of Property S 16 Su/ 14, Section 7 , T N-R W
Township !Ju l~ w , ~t
!tailing Address ~le_
r--
Address of Site l✓. d G,/, 'S
Subdivision Name L1
.Lot Number I
Previous Owner of Property
Total Size of Parcel
Date Parcel was Created 1 q 7~_
Are all corners and lot lines identifiable? I/ Yes No
Is this property being developed for resale (spec house) ? Yes L._- No
Volume and Page Number 10c)-7 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
1 (We) eenti.6y that att Atatement6 on thi6 oAm eAe thue to the but o6 my (ouh)
knowledge; that I (we) am (*re) the owneA (,s f o6 the pnopeAty dens ch i.b ed in .thiA
.i.n6oAmati.on 6onm, by viAtue o6 a WaAAa.nty deed Aeeonded in the 066.iee o6 .the
County Reg id ten o6 Veedh ah Voeumen t No. 1,2 ; and that I (We) phuently
own the pnopod ed .6 to bon the z ewage dispo.d .d ys em (on I (we) have obtained an
easement, to nun with the above dedcA bed pnopehty, bon the con6tkuctc:on 06 chid
dydtem, and the came had been duty neconded in the 066.ice o6 the County Reg-idten o6
Veedb, ab Voeument No. 2_6 I.
J
SIGNATURE h OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
`7"- o -
DATE SIGNED DATE SIGNED
6 ff(
+w..,'ix fYk°~Y`~4tF ~Fa+•"w.'h ~ F~.,~s~1~~ ,
y"' q
Uf
P '
%N
ft
mi. "9 g t. +r : Si: •!t .::t s.x,. :at• Yf'~:nk 6
;k a i• 'F ,
p.
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tAU
14
4 , FORM NO. 98SA
MGMnMeCmpq® ~
36 255 CERTIFIED SURVEY NO. 1007
Part of the SWk of the SW)4- of Section 27, Town 29 North, Range 16 West, Town of Baldwin,
N County of St. Croix, State of Wisconsin, described in Volume li of Certified Survey
Maps, page 1007 as Certified Survey No. 1007
60 SET 3/4" x 30" IRON ROD SCALE: = 60' BRG. REF. TO THE WEST
WEIGHING 1.502 LB./L.F. LINE OF THE SW 1/4
02550' 100 SE,C.27, T29N, R16W
ASSUMED BRG.
N 00° 02' 00" W
UNPL A T TED
LANDS
S 016
34" E
327.40'
0~4 2i+ a
Q•
• 0o de Q ;
0 OFFICE
Q; m BLDG. a
~I• ti co
W• 8 e p;
LOT I.
Q : ; 1.31 ACRES,
F10 D .
N
MAN a41980 o Q:
0
J . 0 4ounn er ~ N
q2u AS ~9r
. . . X3'4
'v N 870 16' 34" W 44
.
p 315.51
U. S. HWY "12"
S 87° 16'34° E Z
656.49
SW COR., SEC.27,
T29N, R16W
3/4" IRON ROD
SURVEYOR'S CERTIFICATE
I, THOMAS G. KUESTER, Registered Land Surveyor, hereby certify that I have surveyed,
divided and mapped a part of the Southwest 1/4 of the Southwest 1/4 of Section 27,
Town 29 North, Range 16 West, Town of Baldwin, County of St. Croix, State of Wisconsin,
more particularly described as follows:
Commencing at the Southwest corner of said Section;
Thence S. 870 16' 34" E., 656.49 feet;
Thence N. 000 02' 13" W., 33.04 feet, to the point of beginning;
Thence continuing N. 000 02' 13" W., 178.00 feet;
Thenc S. 87 16' 34" E., 327.40 feet;
Thence S. 030 47' 20" W., 177.82 feet;
Thence N. 870 16' 34" W., 315.51 feet, to the point of beginning;
Said parcel contains 1.31 acres, more or less.
That I have made such survey, land division and plat by the direction of Leroy
Storley.
That such plat is a correct representation of the exterior boundaries of the land
surveyed and the subdivision thereof made.
That I have fully complied with the provisions of Chapter 236 of the Wisconsin Statutues
and the subdivision regulations of the Town of Baldwin and the County of St. Croix in
surveying, dividing and mapping the saple. -7~4~
DATED THIS DAY OF 1980.
THOMAS G. KUESTER, Registered Land Surveyor
,~~gttaaanaaa~~,
GQNWA APPROVED
4
mom
A
s -tx S-Ins 0 0 T 15 1980
:.c 11100monif4 W,
Volume 4 Page 1007 ST. CROIX COUNTY
compitE Ms" PARKS nAW04
~~''~O,S U R ;o~•`'~ ,wee zoeSINe COMMITIMI
aaasaa