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Parcel #: 016-1062-40-100 01/11/2006 03:08 PM
PAGE 1 OF 1
Alt. Parcel#: 29.30.15.434B 016-TOWN OF GLENWOOD
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
JEFFREY A LARSON O-LARSON,JEFFREY A
2826 135TH AVE
GLENWOOD CITY WI 54013
Districts: SC=School SP=Special Property Address(es): "=Primary
Type Dist# Description '2826 135TH AVE
SC 2198 GLENWOOD CITY
SP 1700 WITC
Legal Description: Acres: 1.600 Plat: N/A-NOT AVAILABLE
SEC 29 T30N R15W NE SW LOT 1 OF C.S.M. Block/Condo Bldg:
6/1561
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
29-30N-15W
Notes: Parcel History:
Date Doc# Vol/Page Type
07/23/1997 949/167
07/23/1997 755/281
I
2005 SUMMARY Bill#: Fair Market Value: Assessed with:
89551 74,800
Valuations: Last Changed: 10/06/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.600 10,000 53,000 63,000 NO
Totals for 2005:
General Property 1.600 10,000 53,000 63,000
Woodland 0.000 0 0
Totals for 2004:
General Property 1.600 10,000 53,000 63,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch#: 216
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00
0.00
Form - S T C - 104
t
AS BUILT SANITARY SYSTEM REPORT
1
OWNER TOWNSHIP �p ��w��� SEC. `� T 37� N-R o�W
ADDRESS , ST. CROIX COUNTY, WISCONSIN
SUBDIVISION _Q0. LOT LOT SIZE
Zia
PLAN VIEW
Distances and dimensions to meet requirements of I•I.HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
14-0-35
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used l �j •a P � � ^CJ
Elevation of vertical reference point: QC-3� Proposed slope at site: 2
SEPTIC TANK: Manufacturer: Liquid Capacity:
Number of rings us Tank manhole cover elevation:
Tank Inlet E1 ation: Tank Outlet Elevation:
Number of eet from nearest Road: Front,O Side 0 Rear, O feet
rom nearest- property line - Front,0 Side,O Rear,O feet
N er of feet from: well , building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: Liquid Cap ty:
Pump Model: Pump/Siphon Ma acturer: 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,p Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench-
Width: Len " Number of Lines: Area Built:
Fill depth to top of pe:
Number of feet fr6 nearest property line: Front, O Side, O Rear,O Ft .
Number of feet from well:
Number of feet from building:
(Include distances on plotyy�lan).
SEEPAGE PIT
Size: N ber of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area B/tems?
Has either O or distribution box O been used on any of the above soil
absorbtion heck one).
HOL DING TANK
Manufacturer: Ll) Ems. Capacity: -
G d A(
Number of rings used: Elevation of bottom of tank: 76 z
G pit h � *2
Elevation of inlet: /� ,1 24 �- 9 7"
Number of feet from nearest property line: Front, O Side,Rear, 0Ft.9:: (z
Number of feet from well: �z,9
Number of feet from building: S /
Number of feet from nearest road: r
Alarm Manufacturer: � '/`� Alt,
Inspector:
Dated: l� '8-7 Plumber on job:
License Number: �nl''^1� '�S e,—"
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR N RELATIONS
7969
P.O:BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION
BUREAU OF PLUMBING
-0�AADISON,WI 53707
NEB, SW14, S29,T30N—R15W E]CONVENTIONAL MALTERNATIVE I State Plan l.D.Number:
(lf assigned)
Town of Glenwood ❑Holding Tank ❑ In-Ground Pressure ❑Mound $7-06670
Seim Road
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER INSPECTION DATE:
t
Joseph A. Hill Route 1, Glenwood City, WI 54013 /p- 7-87 ? �U
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.:
Name of Plumber: MP/MPRSW No,. Counry: Sanitary Permit Number:
Gary L. Steel 3254 St. Croix 99112
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED.
DYES ONO OYES ❑NO
BEDDING: VENT OIA.: VENT MATL: HIGH WATER NUNIOCR OF\ ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM: FEET FROM LINE: AIR INLET:
❑YES ❑NO ❑YES ❑NO NEAREST
DOSING CHAMBER:
MANUFACTURER BEDDING: LIQUID CAPACITY. PUMP MODEL. �PUMPISIPHON N UFAC7 MANUFACTURER ER. WARNING LABEL OCKING COVER
PROVIDED: ['[:]YES ROVIDED:
❑YES :EE:1 N O DYES ONO ONO
GALLONS PER CYCLE; JPUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL: BUILDING. VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET:
PUMP ON AND OFF) ❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE
the soil is dry enough to continue.) MAIM
CONVENTIONAL SYSTEM:
WIDTH: LENGTH. INO'Or JDISTR.PIPE SPACING. COVER ',INSIDE DIA.: #PITS LIQUID
BED/TRENOH TRENCHES. MATERIAL: I,1T DEPTH:
-'.`DI�tIEAt51OlUS '.
GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR N BER''.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 slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA-
❑YES NO
meets the criteria for medium sand. TIONS MEASURED.
❑
SOIL COVER ITEXTURE PERMANENT MARKERS: OBSERVATION WELLS.
DYES ❑ ❑ ❑
NO YES NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED. MULCHED:
CENTER. EDGES.
DYES ONO DYES ONO DYES ONO
PRESSUURIZED DISTRIBUTION SYSTEM:
8iEC1,TFtENH 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.:
ELEVATIO,N AND
1STRIOUTION
Iai. 011r TO HOLE SIZE HOLE SPACING: DRILLED CORRECTLY. rER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED
#'IF `ItAFA PLANS.
DYES ONO DYES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER QF'', PROPERTY WELL: BUILDING:
FEE'S FROM LINE:
1l�
DYES ❑N ❑YES 1:1 NO 1111111155 AREST
G
71 0
I
Sketch System on Retain in county file for audit.
Reverse Side.
DILHR SBD 6710 (R.01/82) SIGNATURE: TITLE:
Zoning Administrator
DILHR SANITARY PERMIT APPLICATION COUNTY
In accord with ILHR 83.05,Wis.Adm.Code St. Croix
STATE SANITARY PERMIT#
9 ra
—Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER
8%x 11 inches in size. _O &O
—See reverse side for instructions for completing this application. PETITION
1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES 5� NO
PROPERTY OWNER PROPERTY LOCATION
Joseph A. Hill NE % SW %, S 29 T 30 , N, R15 (or)W
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
R.R.4#1 n/a n/a n/a
CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK
Glenwood City, Wi. 54013 n/a O VILLAGE: Glenwood Seim Rd 0 TOWN
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family 2 OR ❑ Public(Specify):
111. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable)
1. a. ❑ New b. ❑x Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an
System System Septic Tank Only an Existing System Existing System
2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued
3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements.
4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy.
IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2)
1. a. ❑Conventional b. ®Alternative C. ❑ Experimental
2. a. ❑System- b. ® Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. ❑ seepage Bed b. ❑Seepage Trench c. ❑ See a e Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet):
n/a n/a n/a n/a Feet ®Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank
Lift Pump Tank/Siphon Chamber ❑ ❑ El 1 ❑
VII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the privates wage system shown on the attached plans.
Plumber's Name(Print): Plumbe�Sre:(No St s P/MPRSW No.: Business Phone Number:
Gary L. Steel 3254 715 246-6200
Plumber's Address(Street,City,State,Zip Co Name of Designer:
988 N. Shore Dr. , New Richmond, Wi. 54017
VIII. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name CST#
Gary L. Steel 2298
CST's ADDRESS(Street,City,State,Zip Code) Phone Number:
988 N. Shore Dr., New Richmond, Wi. 54017 f15 246-6200
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps)
Approved urcharge Fee
pp El Given Initial (�� CMG �� 116-647
Adverse Determination j�f
X. COMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION
TO THE APPLICANT:
1. This 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. A new permit may be needed
if there is a change in your building plans, system location, estimated wastewater flow (number of bed-
rooms, etc.), depth of system, or type of system;
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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
L Property owner's name and mailing address. Provide the legal description where the system is to be
installed;
Il. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat
restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling;
III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or
repair;
IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project
is in conjunction with University of Wisconsin;
V. Absorption system information: Provide all information requested in ##1-6;
VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed,
number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete
for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. 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. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only;
X. Comment area for use by county or resaon given when application is disapproved.
Complete plans and specifications not smaller than 8'/2 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; dosing or pumping chambers; 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.
------------------------------------------------------------------------------------------------------------------------------------------------------------
GROUNDWATER SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more
commonly known as the groundwater protection law. This change in statutes was the
result of over 2 years of steady negotiation and public debate. The groundwater bill Ground Ater
included the creation of surcharges (fees) for a number of regulated practices which Wisco in..$r,, °
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasure'
is used in your building is returned to the groundwater through your soil absorption u
system or the disposal site used by your holding tank pumper.
0
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground- t
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
SBD-6398(R.03/86)
Holding Tank
for
Joseph A. Hill
NE4-SW'4S29-T30N-R15W
Town of Glenwood
two (2) bedroom home
pages 8 706 S
g O
#1---------------------------plan approval application
#2---------------------------holding tank agreement
#3---------------------------holding tank servicing agreemaent
#4---------------------------plot plan
#5---------------------------115
#6---------------------------work sheet
#7---------------------------holding tank profile
a y L. Steel
C""� X- &-4
988 N. Shore Dr.
New Richmond, Wi. 54017
MPRSW 3254
8-25-87
=::Muni STATE OF WISCONSIN DILHR
R PRIVATE SEWAGE SYSTEMS DIVISION OF SAFETY&BUILDINGS
BUREAU OF PLUMBING
r 201 E.Washington Avenue,Rm 141
PLAN APPROVAL APPLICATION P.O.Box 7969,Madison,WI 53707
608-266-3915
INSTRUCTIONS: Please fill in all applicable data and submit this form with plans. Plans will not be reviewed until all fees are received. The
back side of this form describes required plan information. Plumbing codes can be purchased from the Department of Administration,
Document Sales,202 South Thornton Ave.,P.O.Box 7840,Madison,Wisconsin 53707,Telephone(608)266-3358.
1. PROJECT INFORMATION(Type or print clearly) Revision To Plan Number: M
holding tank
Name of Submitting Party(Plans returned to same) Project Name
Gary L. Steel holding tank
Street&No.or Rural Route Project Location-Street&No.or Legal Description
988 N. Shone Dr. '- -
City or Village State Zip City ❑ County
New Richmond Wi. 54017 Village OF: Glenwood St. Croix
Town
Telephone No.(Include area code)
715-246-6200
Designer Telephone No.(Include area code) Owners Name Telephone No.(Include area code)
Street&No. Street&No.
R.R.#1
City or Village State Zip City or Village State Zip
Glenwood City, Wi. 54013
2. APPLICATION FOR: ❑New Mound System(3a) ❑Groundwater Monitorinig(7)
❑Conventional System-Public Building(1) ❑Replacement Mound(4a) Holding Tank(2)
❑Replacement Pressurized System(4b) ❑System in Fill(1) Petition For Variance(6)
❑New Pressurized System(3b) ❑System in Flood Fringe(1) ❑Other Alternatives(5)
3. FEE COMPUTATIONS(Include existing tanks) 4. FEE SUBMITTED FOR OFFICE USE
MAKE ALL CHECKS PAYABLE TO DILHR
3a. 750- 1,500 gallon septic tank - 50.00 4a.
3b. 1,501- 2,500 gallon septic tank - 60.00 4b.
3c. 2,501- 5,000 gallon septic tank - 80.00 4c.
3d. 5,001- 9,000 gallon septic tank -100.00 4d.
3e. 9,001- 15,000 gallon septic tank -150.00 4e.
3f. Over 15,000 gallon septic tank -250.00 4f.
3g. 500- 1,000 gallon dose chamber - 30.00 4g.
3h. 1,001- 2,000 gallon dose chamber - 50.00 4h.
31. 2,001- 4,000 gallon dose chamber - 70.00 41.
3j. 4,001- 8,000 gallon dose chamber - 90.00 4j.
3k. 8,001- 12,000 gallon dose chamber -110.00 4k.
31. Over 12,000 gallon dose chamber -150.00 41.
3m. 500- 5,000 gallon holding tank - 30.00 4m. 300
3n. 5,001-10,000 gallon holding tank - 55.00 4n.
3o. Over 10,000 gallon holding tank -100.00 4o.
3p. Revisions - 20.00 4p.
3q. Groundwater Monitoring Per Lot - 32.00 4q.
(other than a proposed subdivision) Subtotal 30.00
3r. Priority plan review:walk through 4r.
Submittal of plans in person,
by appointment,with double fee
3s. Petition for variance
Setback - 25.00 4s.
Site evaluation - 50.00
Total Fee 30.00
NOTE:Fees pursuant to Wis.Adm.Code,Chapter Ind.69
may be subject to change annually
SBD-6748(R.8/85) Effective July 1,1984 -OVER
�1
REGISTERS OFFICE
423 761 f 97PAGE P05 ST. CROIX CO., WIS.
Rec'd. for Reco,cl this 3rd
day of Aug. A.D. 198°7
of 12:30 P t&
James O'Connell
HOLDING TANK AGREEMENT N JaAo� Deputy
This Agreement is made and entered into this day of c 19 ;?V 67
by and between the hereinafter called the "municipality"
and 0!z�j -2 hereinafter called the "owner."
We hereby acknowledge that application is being made for the installation of (a)
holding tank(s) on the following described property:
.L6 -r c s M .4 VOL 0 PH 6� /s� J'706670
_� 2q - --
P7, N F� - S w' �7 ( 3 � 5
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. We also acknowledge that said
property cannot now be served by a municipal sewer, any other type of private sewage system
as permitted under ch. ILHR 83, Wis. Adn. Code, or ch. 145, Stats. , and that the property
does not contain an area of soil suitable for any other type of private sewage system as
permitted by ch. ILHR 83, Wis. Aam. Code.
Therefore, as an inducement to the County of .Cit..v^.y to issue a
sanitary permit for the above described premises, we hereby ag ee and bind ourselves as
follows.
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. and 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 • +mer within
thirty (30) days from the date of notice. In the event the owner does not pay tie costs
within thirty (30) days, the owner hereby specifically agrees that all of the co is and -
charges may be placed on the tax roll as a special assessment for the abatement if a
nuisance, and the tax shall be collected as provided by Wisconsin Statute.
3. The owner, except as provided by s. 146.20 (3) (d), Stats., agrees to contract with
a person who is licensed under ch. HR113. Wis. Adm. Code to have the holding tank serviced
and to file a copy of the contract or their 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
ti
days from the date of change to the service contract.
- EXAMPLE 7 -
r y M�0/�
' •`` ' 87 20i
4. The owner agrees to contract with a person licensed under ch. NR113, 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
ter, registration under s. 146.20 (3) (d), Stats., the owner shall submit the report to the
municipality and the county.
S. This agreement will remain in effect only until the local governmental unit
responsible for the regulation of private sewage systems certifies that the property is
served by either a municipal sewer or a soil absorption system that complies with ch. ILHR
83, Wis. Adm. Code. In addition, this agreement may be cancelled by executing and recording
9
said certification with reference to this agreement in such manner which will permit 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 shall file the agreement with the register of deeds which
shall be recorded by the register of deeds in a manner which will permit the existence of the
agreement to be determined by reference to the property where the holding tank is installed.
SIGNATURE OF OWNER(S): ( /'� '
SIGNATURE OF MUNICIPAL OFFICIAL (Include Tit W: c-vi
�`'
Jose,ph A. Hill
State of Wisconsin )came before me this 8 thday of July A.D., 198 ,
)to me known to be the person ho executed the foregoing
County of St' Croix )instrument and acknowledged same.
1
Subscribed and sworn to before Jam s O'Conn 11
�/'da of 19� No ry, My". Commimsion expires
Me this y Apyil 29, 1989
Notary
My commission expires !17L � 19 LL
RECEIVED FOR RECORD
day of A.D., 19 _, at o'clock M.
and recorded in Volume of page
Register of Deeds
i County
This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human
Relations, Bureau of Plumbing.
EXAMPLE 8 -
J!
(y) r � Sr e e [�
HOLDING TANK SERVICING CONTRACT
r
This Agreement is made an! entered into this -,,7— day of l��
/J c
by and between ,Ayfit / hereinafter called the "owner"
and ,�j�N� t- � '_�c +_ hereinafter called the "pumper."
We hereby acknowledge the installation of (a) holding tank(s) on the foll�n O
described property: 6 7 0
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 r Grc,; 1t
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
submit a report which shall include:
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 of _K r. C poi f within ten (10) business days from the date of change to
this service contract.
EXAMPLE 9 -
i
'7066 '70
R
SIGNATURE OF OWNER(S): i
Tn {Ph 1II
SIGNATURE OF PUMPER (Include License Number):
State of Wisconsin )came before me this 8 day of July A.O., 198 , the above Hind
)to me known to be the person who executed the foregoing
County of Stw Croix )instrument and acknowledged the same.
Subscribed and sworn to before
e this $_ day of July 19 17
N Lary
ames O'Connell
commission expires April 30; 19 ,9
This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human
Relations, Bureau of Plumbing.
�'� - EXAMPLE 10 -
plot plan
FRo�S7 PRoor AS PfA A41IR *a, 30 (//) C-�
4706670
I
c — — — — 0"roo3 ,'�_ s I s4k wD
44
I � �
30 '
l
000 TrA I
o go Ic1 a ny ✓►K
a
loco
�rG
)4o)&t v)
b
I
i
�Vo� 740
holding tank for a two bedroom home
site meets all requirements of I.L.H.R. 83.10
bm=top of n.e. corner of cement slab at 100' .
holding tank mfg. by Weeks Concrete Pdts. two 1000 gal. tanks for a total of 20000 gal. ,
approved septic tanks with baffles removed, will be used for holding tanks
alarm mounted inside of house
lot size 3 acres PRIVATE SEWAGE SYSTEM
�o�iEiona[it�
APPROVED
DEPARIMffT 11 INOU . LABOR AND HUMAN RELATIINS
VISION SAFETY AND 111LDINGS
CORRESPONDENCE
_. Q
J OPT•ION&L WORKSHEET
1. MOUND SYSTEM 11. IN-GROUND PRESSURE SYSTEM-Continued-
1. Wastewater Load,Total Daily Flown gal. 10. Force Main:
Use S. ILHR 83. 15 (3) (C) Minimum Dosing Rate= Rpm.
in.
Adm.Code and PROVIDE A DETAILED Diameter
LIST OF SIZING ON PLANS. 11. Total Dynamic Head:
ft System Head= 2.5 ft.
.
2. Depth to Limiting Factor= Vertical Lift= ft.
3. Landslope= % ft.
4. Distance from Dose Chamber to Friction Loss=
Distribution System=
ft. TDH= ft.
S. Elevation Difference Between 12. Pump Selection:
Pump and Distribution System ft. Pump will discharge at least - tlpm
6. Absorption Area Sizing: at..__._--ft.total dynamic head.
Area Required= sq.ft. Pump model and manufacturer:
Bed or Trench Length(B): ft.
Bed or Trench Width(A)= ft. 13. Dose Volume:
Trench Spacing(C)= ft. 10 Times Void Volume of
7. Mound Height: Distribution Lines= Rai•
Fill Depth(D)= ft. Daily Wastewater Volume+
Fill Depth Downslope(E)= ft. 4 Doses In 24 gal.
hrs._
g
Bed or Trench Depth(F)= ft. Bac _kflow= 0 6 6 0
Cap and Topsoil Depth(G)= ft. Minimum OS R al.
Cap and Topsoil Depth(H)= ft. 14. Dose Chamber:
8. Mound Length:
Volume= gal.
End Slope(K)= ft.
Total Mound Length(L)_ ....__. ft. 111. CONVENTIONAL PRIVATE SEWAGE SYSTEM
9. Mound Width: 1. Wastewater Load,Total Daily Flow= Sal.
Correction Factor= -� Use s. ILHR 83. 15 (3) (e) , Wis.
Upslope = ft. Adm.Code and PROVIDE DETAILED
Upslope Width do
LIST OF SIZING ON PLANS.
Downslope Correction Factor=
Downslope Width(I)_
ft, 2. Required Septic Tank Capacity= Rai•
Total Mound Width(W)= ft. 3, Percolation Rate= min./In.
10. Basal Area: 4. Absorption Area Sizing:
Refer to Table 2 in ch. ILHR 83
Infiltrative Capacity of
Natural Soil= gal./sq.ft./day and PROVIDE A DETAILED LIST OF
Basal Area Required= sq.ft. SIZING ON PLANS.
Basal Area Available= sq.ft. Required Area sq.ft.
=
Length ft.
11. If Standard Tables from Chapter ILHR 83 =
are`! Width ft.
used, Indicate Table #
=
12. For the Distribution Network,Use Numbers 5-14 in Section 11. Number of Trenches=
Trench Spacing= ft.
11. IN-GROUND PRESSURE SYSTEM, S. Distribution System:
ft.
1. Depth to Limiting Factor= ft. Lateral Length= _
= Number of Laterals=
2. Landslope %
3. Percolation Rate=
min./in. Lateral Spacing= In.
4. Proposed System Elevation= ft. Distance from Sidewall to Pipe= in.
5. Wastewater Load,Total Daily Flow: ___ gal.
System Elevation= ft.
Use s. ILHR 83. 15 (3) (c) , Wis.
Adm.Code and PROVIDE A DETAILED IV. SYSTEM-IN-FILL
LIST OF SIZING ONTLANS. Fill in All Items from Section 111
Required Septic Tank Capacity= gal.
6. Absorption Area Sizing: V. SEPTIC TANK
Percolation Rate= min./in. 1. Capacity= gal.
2. Manufacturer:
Area Required= sq.ft.
= 3. Show Site Constructed Tank Details on Plan
System Length ft.
System Width= ft.
7. Distribution Pipe Sizing: VI. DOSING TANK gal
Hole Size= in. 1. Capacity=
Hole Spacing= ft. 2. Manufacturer:
Lateral Length - fl. .1. Pump Manulacturer:
Lateral Siic in. 4. Pump Model:
Laler.tl Spacing ft.
S. Operating Head= ft.
Dislaime Irons Sidewall.141 Pipe in. G, flow Rate= Rpm.
3 K. Distribution Pipe Discharge Rate: 7. Show Site Constructed Tank Details on Plans
Number of Iloles Per Pipc �S /p(XJbjQ� F/+I? h
1 low 1'ur Pipe gpm, VII. HOLDING TANK G-4N! 2040
i 1. Capacity= rr gal.
i 9'. Manifold Sizing: Felkc
j Type(center or und) 2. Mrnulaclurer: �
Length= ft. 3. Show Site Constructed Tank Details on Plans
Diameter= in.
-SHOW ALL INFORMATION ON PLANS-
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
PNDUSTRY, c DIVISION
'LABOR ANb- - PERCOLATION TESTS (115) MADISON WI 53707
HUMAN RELATIONS
(H63.090) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/MU�Y: LOT NO.:BLK.NO.: SUBDIVISION NAME:
NE t/4 SW/ 29 /T 30 N/R151 (or)W Glenwood n/a n/a n/a
COUNTY: OWNER'S SD30EK CNAME: MAILING ADDRESS:
St. Croix Joseph A. HIll R.R.fl, Glenwood City, Wi. 54013
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
[®Re sidence 2 n/a ❑New Q Replace 6-109 /
RATING:S=Site suitable for system U=Site unsuitable for system
IF-IS ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM:(optional)
E EIS FX S ®U S EA 2 S ❑U holding tank
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: n/a Floodplain,indicate Floodplain elevation: n/a
PROFILE DESCRIPTIONS a e 48 AW2
BORINGI TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE, AND DEPTH
NUMBER IDEPTHIM ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- 1 4.25 n/a none .67 .67bl.1. .58 mot. sil. 3.00mot. s.l.
B_ 2 4.50 96.30 none .75 .75bl.1. 1.50bn.mot. sil. 2.25bn.mot s.l.
B_ 3-q all h ve mot. at .75 or le s, on site onducted by Thomas Nelson, St. Croix county
B- 3 ace lot.
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
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.
SYSTEM ELEVATION n/a
m`4�
Ing
i
fi
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I_ .9- r7l
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1 '
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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.
NAME(print): TESTS WERE COMPLETED ON:
Gary L. Steel 6-10-87
ADDRESS: CERTIFICATION NUMBER: IPHONE NUMBER(optional):
988 N. Shore Dr. , New Richmond, Wi. 54017 2298 P15-Z46-6200
CST SIGNA E: n
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) - OVER
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ST C - 105 r"
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SEPTIC TANK MAINTENANCE AGREEMENT o
St . Croix County z
d
a
H
xkBUYER Joseph A Hill
ROUTE/BOX NUMBER R.R.#1 Fire Number
CITY/STATEGlenwood City, Wi. ZIP 54013
PROPERTY LOCATION : NE ;4, SW 14, Section 29 T30 N , R 15 W,
Town of Glenwood St . Croix County,
Subdivision n/a Lot number n/a _.
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 may 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
H
three year expiration . o
z
I/WE, the undersigned , have read the above requirements and agree W
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 � �'G1,
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 .
ff
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APPLICATION FOR SANITARY PERMIT
STC - 100
his application form is to be completed in. full and signed by the owner(s) of the
roperty 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 Joseph A. Hill
Location of Property NE ti SW h;, Section 29 , 130 N-R 15 W
Township Glenwood
!tailing Address R.R.#1
Glenwood,City. Wi. 54013
Address of Site same
Subdivision Name n/a
Lot Number . n/a
Previous Owner of Property Tgenn Nh,r,dt
Total Size of Parcel 3 acres
Date Parcel was Created 9-26-86
Are all corners and lot lines identifiable? x Yes No
Is this property being developed for resale (spec house) ? Yes x No
V01UNe ASS and Page Number 9.51 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
I (Wel cekti.6y that att a.tatementz on .this �vhm ane hue to the be�s.t o6 my (oun.)
hnowtedge; that I (we) am (cute) .tile owneA(a o6 the pnopenty de�scAibed in .thiA
in6onmati.on 6o4m, by viAtue 06 a waAAanty deed kecokded in the 066ice o6 the
Countyy Reg usteh o6 De¢d�sah Document No. ; and that I (We) pneden.tey
aun .the pnopoaed aite bon the -sewage d APoa aya em (ok I (we) have obtained an
ea.aement, to hun with the above deisckibed phopehty, bon the conAtthuc ion o6 acid
aya.t", and the acme haA been duty Aecohded .in the 066.ice 06 the County Reg.i.a.teh o6
Vetch, ab Uoemen t No. ) .
7rf
SIGNATUA 09 OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
C! cd- - (e-
DATE SIGNED DATE SIGNED