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Form S T C 104
AS BUILT SANITARY SYSTEM REPORT
OWNER e a r' G Le r TOWNSHIP SEC. / 7 T -?F N-R /S W
ADDRESS ~rC I/V I S o &J ST. CROIX COUNTY, WISCONSIN
it S
SUBDIVISION LOT LOT SIZE '~6 44C /':~9rAA,
PLAN VIEW
Distances and dimensions to meet requirements of II-HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
b
b
b
G y~ ~Q~T
v ~
~ r Z/
~g I )(70 Hob5e_
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used ~Ca V y~cy" ~T
Elevation of vertical reference point: L~lOo,cl► Proposed slope at site:
SEPTIC TANK: Manufacturer: ~ WAt'°T ?ft-(fl-St-Liquid Capacity: 12-00
y!f'L.•
Number of rings used: ® Tank manhole cover elevation: q, 4(p
Tank Inlet Elevation: C13q _ Tank Outlet Elevation: 7
3:$b ,
Number of feet from nearest Road: Front,O Side,o Rear, O feet
From nearest property line Front, 0Side 10Rear, 0 - feet
Number of feet from: well jpi , building: '72. 4
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
I '
PUMP CHAMBER
Manufacturer: 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 nearest property line: Front, O Side, O Rear,Q Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: Lenith: Number of Lines: Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear,0 Ft.
Number of feet from well: ::j 'qC0
Number of feet from building: . 72,{
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter: r
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer:- Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, 0 Bide, O Rear, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
foe- A& 1
Dated : l ~~b Plumber on job: VUe- & 7-e r
License Number: i
3/84:mj
~z 7 -,9s
DEPARANT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
LABOR & HUMAN RELATIONS DIVISION
p~P...O. bOX 7969 D, ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
,"SP9 4y"SY A, T28r1-~1lSl State sPlan I. Number:
TOWn Of Cady M CONVENTIONAL El ALTERATIVE (If Count Road N ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
George Henter Route 1, Wilson, WT 54027
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Joe Menter 5658 St. Croix 119479
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
'16200 / J %J ? . / PROVIDED: PROVIDED:
' ❑ YES ❑ NO ❑ YES ❑ NO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM. FEET FROM > LINE, AIR INLET:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST 7Z
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
E:1 YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL, BUILDING: I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF ❑ YES ❑ NO NEAREST 11111~
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: ERIAL: PIT DEPTH:
DIMENSIONS J _
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. ISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES FEET O
: LINE: / AIR INLET:
' (g $ •,~itJ 2 22-2 NEAREST-~ 0 T `2_ 72
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: DA.:
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 PROPERTY WELL: BUILDING:
FEET FROM LINE:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
~ l 3
Sketch System on r~ U e aln unty file for audit.
Reverse Side. sIGNAT TITLE:
SBD-6710 (R. 06/88) Zoning Administrator
flILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY-
57,
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than J 1 Or// *7 9
8'% x 11 inches in size. ❑ Check If revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
P~QPERTY OWNER PROPERTY LOCATION
l~eo r e, /qeATe f' k) %Z5 S / T,, N, R /rG E (or W
PRQ Er,RWN~R'S MAILING ADDRESS LOT # BLOCK #
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVI$IpN NAME OR CSM NUMBER
► s o A1, bll s 6y0(:;? (7/6 172 a 8 ® Ze- P*rc,e4
L-i CITY
II. TYPE OF BUILDING: (Check one) F-1 State Owned O
VILLAGE ; NEAREST RO~AD/
:9-TOWN OF:
❑ Public & or 2 Fam. Dwelling-# of bedrooms y~ PARCEL TAX NUMBER( )
Ill. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 80 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. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit # Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 Seepage Pit Pressure 43 ❑ Vault Privy
14 System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 14. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQU RE (sq. ft,) PROPOSED (sq. n.) (GaAMID- ls/day/sq. ft.) (Min./inch) 1%2-7-S-Feet ELEVATION
o0 / z 9~~. DO Feet
VII. TANK CAPACITY
in allons Total # of Manufacturer' Site
INFORMATION Prefab. Fiber- Exper.
New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank / 2.06 Mjd&1 os r ~fC 0ST I [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): mber's Sign cure: (No Stamps) M PRSW No.: Business Phone Number:
e Ake-ru Te.c- ~T a,:Z" I 7/~ d3S 73 7f
Plumber's Address (Street City, State, Zip C de):
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No S mps)
Approved El Owner Given Initial Surcharge Fee)
Adverse Determination 09 410fil n l AA_ L A__/
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
l
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.
'a. 7
Owner of property (-~S;~i~oP o 92aY1alDP4 '6„ 1e_77
Location of property -)ZjJl19 S1/4, Section l *7 , T_,-:~ &N-R r W
Township ----Q-`/
r
Mailing address
Address of site Subdivision name
Lot number ZZ
Previous owner of property ~~C~ h ry)
5®7U
Total size of parcel 'Z~
Date parcel was created
Are all corners and lot lines identifiable? _2~_Yes No
Is this property being developed for resale (spec house)? Yes _ X o
Volume and Page Number (5( 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 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 (wg) 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. 3~ a ; and that I (fW
tig)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of a County Register of Deeds, as Document No.
,Q )
ignat re of Owner Signature of Co-Owner (If Applicable)
3~ ~ Z~)' `~-f
Date of Signature Date of Signature
STC 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
9'e, OWNER/B 0h-Lue
0
ROUTE/BOX NUMBER FIRE NO. 1
CITY/STATE ZIP 6LIO a
PROPERTY LOCATION: 1/4 1/9, Section T,_~LN, R__L,:L_W,
Town of q"q} St. Croix County,
Subdivision , Lot No.
Improper use and maintenance of your septic system could result in its premature
failbre 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 restricted plumber or a licensed pumper verifying that plumber,
(l the
wastewater disposal system is in proper operating condition and on-site
inspection and pumping (if necessary), the septic tank is less than 1/3)full tof
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.
SIGNEDs
DATE l
St. Croix County Zoning Office
St. Croix County Courthouse
911 9th Street
Hudson, WI 59016
(715) 386-4680
Sign, Date, and Return to above address
DEP,ARTM'ENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, C DIVISION
P.O. BOX 76
LABOR AND PERCOLATION TESTS (115) MADISO
N WI 53707
HUMAN RELATIONS
(H63.0911) & Chapter 145.045)
LOC N: SECTION: i /V8 N111/6E ( ) W TOW SHIP/!FTY: LOT NO.: BLK. NO.: SUBDI VISION NAME:
COUNT : OWNER'S BUYER'S NAME: MAI N ADDRESSWz
977 ClViy, It, M&A/7-c~~ yt USE DATES OBSERVATIONS MA IA
NO. BE RMS.: COMMERCIAL DESCRIPTION: PROFI E DES PTI NS: PER ATION TESTS:
esidence ❑New Replace I .C Q~ ~".~/®~8
RATING: S= Site suitable for system U= Site unsuitable for system O
CON ENTIONAL: MOUND: IN-GROUNDPRESSURE:S STEM-IN-FILL HOLDING TANK:RECOMMENDEDSYSTEM:(optional)
S ❑U ❑S U ❑S NU ❑S 5ij ❑S 911 15C411
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.1-163.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH T GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED ES . HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- / 72 9'5.25 AJo 72 /o r . T, 5.2o S, Z, / C S, 3S e- sy,vd
B- 2 72 gS.dS AJ o 72 /o ez , 2~S Js'&L, 2 ti 7~'_ sg,vd
B-3 72 95.ds Vo 7;~, 12- 'i /,Piz, 210 S4444
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD3 PER INCH
P_ o N'O o 3 &
P- 2 3 o At# .0 . s
P- O / /
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.
SYSTEM ELEVATION
Lsr~T.VAJ , 11A/LeT /JUV:
i
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a 13
Ma-
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7-7 I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAM rmt): TESTS WERE COMPL ED ON:
A RESS: CERTIFICATION NUMBER: PHONE NUMBER (option I):
l 102 ,0 ~~d gal w a a/lo Aj 49 `e s ~s--ss 7i S-73 el
C S AT
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
UILHR-SBU-6395 (R. 02/82) - OVER -
'J
INSTRUCTIONS . COMPLETING FORM 115 - SPCA - 6395
To be to and accurate soil test, your report must include:
1. COrnplete ascription;
2. The use sr ust clearly ,hetl is a residence or commercial project;
3, MAXIMU !~er of bedroom con-,m- se planned;
4, Is this a Aacement syst-n;
5. Cornpl- rty rating boxes. A ; SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER.E RULED 01 J SOIL CONDITIONS;
6, PLEASE eviations sh{ ~ ing profile descriptions and complel ~ plan;
7. MAKE A LEGIBLE diagram ac your test locations. Drawing to seal ~ferred. A
separate sheet may be, used if c,>
8, M sure your benchmark and yr i . Terence point are clearly shown, ~ ~rrnanent;
9. all appropriate boxes as t• addresses, flood plaint st exernp-
opropriate;
10 information {such flood plain, oes not apply, place N.A. it -e box;
11. 10,31 acrd f* ' (anent a-i. your certification number;
2 IistribUte as d. ALL SOIL TESTS MU-T r THE
L(1AL 1 HORIT T`IIN 30 DAY rF COMPLETION,
NATIONS FOR CERTIFIED SOIL TESTEI_
Soil T ;tares Other Symbols
St S° BR - Bedrock
cob - k. I SS - Sandstone
gr - Gi 3") LS - Li stone
s
c; HGVV - I Gi )Lmdwater
cs C Perc - F' is on Rate
is - Bid( - F r,
Is > - C r Than
sl l _ L n
l - Pan
sil - t Loam BI <
si Silt Gy
. L=ram Y
Clay Loam R - ,
Clay Loam mot - Mt : les
Clay W/ - with
sic - Clay fff f,fine, faint
c cc n, coarse
}7I _ rnrn medium
er - ` h d - (I tinct
p - ,r Iment
HVVL - F! water level,
reral soil textures dace water
It ;tfid waste disposal BM - ,lark
VRP iical Reference Point
TO THF OVV
a c..-,.anty or the C_ y r :guest
~rmplete set of r r.ivate
t.. r= appropriate loc I order to
)sted pi im to the start of a- .tion.
pip
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Parcel 004-1040-90-000 02/08/2007 10:41 AM
PAGE 1 OF 1
Alt. Parcel 17.28.15.273 004 - TOWN OF CADY
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
0 - MENTER, GEORGE E & BERNADENE
GEORGE E & BERNADENE MENTER
2851 CTY RD N
WILSON WI 54027
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 2851 CTY RD N
SC 0231 BALDWIN-WOODVILLE AREA
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 17 T28N R1 5W 40A SW SE Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
17-28N-15W
Notes: Parcel History:
Date Doc # Vol/Page Type
2007 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 04/17/2006
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.000 14,000 80,400 94,400 NO
AGRICULTURAL G4 30.000 4,300 0 4,300 NO
UNDEVELOPED G5 9.000 5,800 0 5,800 NO
Totals for 2007:
General Property 40.000 24,100 80,400 104,500
Woodland 0.000 0 0
Totals for 2006:
General Property 40.000 24,100 80,400 104,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch 511
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00