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Form - STC - 1
AS BUILT SANITARY SYSTEM REPORT
OWNER � � � � TOWNSHIP /��? ��/�-1 SEC. T _::�N-R
ADDRESS �A?T J ST. CROIX COUNTY, WISCONSIN
A yo_l
SUBDIVISION ro LOT LOT SIZE 5-
PLAN VIEW
Distances and dimensions to meet requirements of I1HR 83 '
SHOW EVERYTHING WITHIN 100 FEET OF SYS M
> S�
e
des"
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2
� ` lea.<Y•
INDICATE NORTH ARROW
it
BENCHMARK: Describe the vertical reference point used ;� i,� Ity
Elevation of vertical reference point: /®p f
,�,� d Proposed slope at site: /1 �d
SEPTIC TANK: Manufacturer: UlO� 4�r" Liquid Capacity:
Number of rings used: r ' Tank manhole cover elevation:
Tank Inlet Elevation:_� �, �6 Tank Outlet Elevation:/0 7. y
Number of feet from nearest Road: Front,O SidejaRear, 0 -?d® r feet
From nearest- property line Front,O Side,O Rear, feet
Number of feet from: well >/OQ 'r , building: _21? r
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE STD
4 PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
W
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,0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: L-� Trench:
Width: / Lendth: Number of Lines: .2. Area Built
Fill depth to top of pipe: 2 `
Number of feet from nearest property line: Front, O Side, &Rear,O Pt .�_
Number of feet from well: '- �/oo v
Number of feet from building:
(Include distances 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 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, O Side, O Rear, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: Plumber on job:
License Number:
3/84:mj
r
r, INSPECTION REPORT FOR SAFETY&BUILDING
DIVISION
.,cLATIONS ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION
,o
SL`ISON,WI 53707 State Plan LD.Number:
SE 4,SE 4 i Sec. 23 , 29-R18 [CONVENTIONAL ❑ ALTERATIVE (If assigned)
Town of Hudson Lot[ Holding Tank ❑ In-Ground Pressure ❑ Mound
E RMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Tom Hanson Rt . BOX 168 River Falls GII5402 REF.PT.ELEV.: 7REF.PT.ELEV.:
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN:
Name of Plumber: MP/MPRSW No.: ��County � Sanitary Permit Number:
David Fo ert 3289 1
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WAKNIDNEU pROVIDED:O�JR
❑YES ❑NO ❑YES BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO F
ALARM: FEET FROM LINE: AIR INLET
❑YES ❑NO ❑YES ❑NO NEAREST
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING
PROVIDED: PROVIDED:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
GALLONS PER CYCLE: FEET FROM LINE: AIR INLET:
(DIFFERENCE BETWEEN ❑YES ❑NO NEAREST�♦
PUMP ON AND OFF
LENGTH: DIAMETER: MATERIAL AND MARKING:
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE
or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH: LENGTH: NO.OF �PIPESPACING: COVER IEDIA.: PITS: LIQUID
MATERIA L: DEPTH:
BED/TRENCH RENCHES: PIT DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF WELL: BUILDINGBELOW PIPES: ABOVE COVER: ELEV.INLET: ELEV.END:
PIPES: FEET FROM 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: PRKERS: OBSERVATION WELLS;❑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: TRENCHES: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING:
ELEV: ELEV.: DIA.: ELEV.: PIPES: DIA.:
ELEVATION AND
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑YES ❑NO ❑YES ❑NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
❑YES ❑NO ❑YES ❑NO NEAREST_to
Retain in county file for audit.
Sketch System on TITLE:
Reverse Side. SIGNATURE:
SBD-6710(R.06/88)
�-' • SANITARY PERMIT APPLICATION
PILHR In accord with ILHR 83.05,Wis.Adm.Code COUN
-.�.�,...v.....,...,_...� =-
STATE SANITARY PERMIT#
–Attach complete plans(to the county copy only)for the system,on paper not less than ❑ ���
8%x 11 inches in size. C/ if revision to previous application
—See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER
I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION.
PROPER OWNER PR'O,PIjRTYLOCATION
jam '46)VIM Se�V% %4,S ,2 3 T , N, R E(or)o
PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK#
CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
�t Yo 2-z s 11�o'k t,,
II. TYPE OF BUILDING: (Check one) ❑State Owned ❑ CITY LL GE NEAREST ROAD
DY! //
❑ Public LJ 1 or 2 Fam. Dwelling–#of bedrooms PARCEL TAX NUMBER(S)
III. BUILDING USE: (If building type is public,check all that apply) d 36
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. IJ 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 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-ln-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1.GALLONS PER DAY 12.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE
yl,o REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION
S 7 D .3 /D Feet lo Feet
VII. TANK CAPACITY Site
in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New istin Gallons Tanks Concrete structed glass App'
Tanks 1 Tanks
Septic Tank or Holding Tank DD
Lift Pump Tank/Siphon Chamber
VIII. RESPONSIBILITY STATEMENT
1,the undersigned,assume responsibility for installation of the onsit sewage system shown on the attached plans.
Plu ber's Name(Print): PI is Sign o St ps) MP/MPRSW No.: Business Phone Number:
7 �S
Plumber's Address(Street,City,State,Z1p Cod W-.
11. COUNWIDEPUTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee(Includes Groundwater ate Issued Issuing Agent Signature(No Stamps)
Approved ❑ Owner Given Initial i j�p 6 Surcharge Fee) �
`�► Adverse Determination `�
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(formerly Pib-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber
s ,
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:
I. 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 farm; and F) all sizing informations"__
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.
S8D-6398(R.11/88)
1
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
Location of Property 1 t. / f > , Section , T LN-R W
Township ' f
Mailing Address
Address of Site 1 / r' , �? p" / /-.2 4'
Subdivision Name
- ,Lot Number
Previous Owner .of Property
Total Size of'. parcel
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes _ No
Volume _f and Page Number as recorded with the Register of Deeds.
k N,
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
I (We) ee ti.by that aP.e .6tatement6 on thivs botm axe-t uz to the beat ob my (out)
knowledge; that I (we) am (ate) the owv . (a) ob the pupe-tty desehibed in thi6
inbohmati,on bosun, by vi tue o6 a wa&xaanty deed neeonded in e 0 b b.%ee o6 the
County Regusten ab Deeds az DaeumentffNa. 1. and at I (We) pnuentey
own the ptopobed 6 to bon the z_ewage`t .poz � stem (we) have obtained an
easement, to nun with the above d cti:bed pnopetcty, bon the constnucti.on ob said
dystem, and the.same has been duty neean d in the Obbice ob the County Reg.usten ab
Deeds, as Do ent No. 3q )
e
SIGNATURE OF OWIJER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
DOCUMENT NO. THIS SPACE RESERVED FOR RECORDING DATA
STATE BAR OF WISCONSIN FORM 1 - 1982
452939 WARRANTY DEED
My 855PAOEJJS REGISTER'S OFFICE
Norman C. Mears and ST. CROIX CO., WI
Thick f ee mad betty en Recd for Record
r ran a lame, etenan s in common, and each in
is own right, OCT 2 61989
_ Grantor, G1 11:05 A. M
and Thomas W. Hanson ,and Linda L. Hanson, Husband and
.wife, Survivorship Marital Property
16�111R0�13tOf of iDeed�
Grantee,
Witnesseth, That the said Grantor,for a valuable consideration
RETURN TO
conveys to Grantee the following described real estate in St. Croix
County,State of Wisconsin:
Tax Parcel No:
Lot # 2 .'Plat of Fox Valley in. the Town of Hudson
I'RANSE$
s33 .—
This is not homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And
warrants that the title is good,indefeasible in fee simple and free and clear of encumbrances except
and will warrant and defend the same. yq
Dated this �C� day of ' 19
(SEAL) (SEAL)
* *Norman C. Mears.-)-
(SEAL) (SEAL)
* *Frank La 4ante
AUTHENTICATION ACKNOWLEDGEMENT
Minnesota
Signature(s) STATE OFUNICOUSM
Washington SS.
County. �/�
P al y ame before me this day of
e Z_authenticated this day of , 19 19 the ve n ed
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the person who executed the
authorized by§706.06,Wis.Stats.) foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Jv kn ;t, i r-
DE
d 9r1 i� 2 County,Wis.
of I U
(Signatures may be authenticated or acknowledged. Bot
Wcommls�_ion is per a n. (If not,state expiration
are not necessary.) date: , 19 )
'Names of persons signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN WISCONSIN Rt_ALTORS®ASSOCIATION
FORM No.1 -1982 4801 Hayes Road,Madison,Wisconsin 53704
• H
. z
STC - 105 r
a
H
SEPTIC TANK MAINTENANCE AGREEMENT Of
St . Croix County z
d
a
OWNER/BUYER
ROUTE/BOX NUMBER Fire Number
.CITY/STATE �y4 : ;(s. a ' , ZIP ,r�ryG 2
PROPERTY LOCATION : Ski 's, SA !4, Section, T N, R W,
Town of ! r`�`- �`� St . Croix County,
Subdivision 4, . +� � `" 4 Lot number
.--
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes . Proper maintenance con-
sists 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 treat-
ment stage in the waste disposal system.
St . Croix. County residents m_ y be eligible to receive a grant for
a maximum of 60% 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 veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary) , 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. H
0
E
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with H
the standards set forth, herein, as set by the Wisconsin Depart- 'b
ment 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 LN
DATE (/ 2 r Z64
St . Croix County Zoning Office
P.O. Box 9&=
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address .
L
r DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
DIVISION
INDUSTRY,
LABOR AND PERCOLATION TESTS (115) MADISON WI 53707
HUMAN RELATIONS
(H63.09(1)&Chapter 145.045) 0.
LOCATION: SECTION: TOWNSHI /W4lifdi£YP�XCYTY: OT NO.:BLK.NO. SS V NAME:
1/4�'I /T N/R/1 E to rox
COUNTY- OWNER'S MAILING ADDRESS:
USE a DATES OBSERVATIONS MADE
Orx�� NO.BEDRMS.:1COMMERCIAL DESCRIPTION: PROFILE D S R PT ONS: R A ON TESTS:
ISGResidence 3 �lew ❑Replace
RATING:S=Site suitable for system U=Site unsuitable for system
CON.VENTIO❑NAL: MOUND: _` IN-GROUN Pa URE: SYSTEM-aILLHOLDIN aNK:RECOMMEND SYSTEM:(option 1)
If Percolation Tests area NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: �^ Floodplain,indicate Floodplain elevation: x/
PROFILE DESCRIPTIONS
BORING TOTAL H TQ QRQU NDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- ( c• oar O e- > 103 !' s ' w S w IVI ' e ,d e
B-2— o Y. S ?.kf Ir to �.:r
B- 3 �e3,y- / ' 2.
B- y' lot+,sr r'6 ,1' / 7 '6 s / ;OA ,rrs
B-
B-
PERCOLATION TESTS
LTEST DEPTH WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES
INCHES AFTER SWELLING INTERVAL-MIN. p RIOD 1 PERT D P PER INCH
3 17
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 horn
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
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1,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.DA— FOGEM PLUMBING
NAME(print): UCenSed Perk Tester & P1Umber TESTS WERE COMPLETED ON:
#3233 #3289 0
ADDRESS: CERTIFICAT ON NUMBER: PHONE NUMBER(optional):
ROBE S, WISCONSIN 54023
CST ZATURE,
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395(R.02/82) —OVER —
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