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Form- ST C- 104
AS BUILT SANITARY SYSTEM REPORT
OWNER (fie. QS TOWNSHIP m :2:t,7fi C. e77 T e_N-R AN
ADDRESS B ff ST. CROIX COUNTY, WISCONSIN
,5b er Se/-
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I•hHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
J i
a 3 ~ 0
-t-
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used %O a A'- .~tJs Go rA c.Y v
~ c~s
an ~sc
Elevation of vertical reference point: AC Z) Proposed slope at site: - , _ .
~
SEPTIC TANK: Manufacturer: Aj ge-k2 Liquid Capacity:
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation:
26 Tank Outlet Elevation: .
7
Number of feet from nearest Road: Front, Side,Q Rear, O 1:20 feet
From nearest property line : Front 10 Side, Rear, O feet
Number of feet from: well building: f
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SRR RRVR.RSR. STnR
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, 0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION"SYSTEM
Bed:,/ Trench:
Width: AX Length: Number of Lines: _ Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, Side, O Rear,O A JJ 5-
Number of feet from well:
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, a Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
/ Inspector:
Dated: Y^ g'-(O Plumber on job: G%
License Number : m--~
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7,989 BUREAU OF PLUMBING
MADISON, WI 63707
UCONVENTIONAL ❑ALTERNATIVE State Plan 10. Number:
Ilt assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE
Joe Osvatic Box 98J, Somerset, WI 54025 q-14_ e3d
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: JCST REF. PT. ELEV
NE NE, Section 21, T31N-R19W, Town of Somerset
Name of Plumber. IMPIMPRSW No TS-1. Sanitary Permit Number:
B ron Bird, Jr. 3318 Croix 83852
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY TANK INLET ELEV. TANK OUTLET ELEV. W NG LABEL LOCKING COVER
/ ~ ,.>•L r~~ ~,rs 77 PR IDE D. PROVIDED.
Q I//( / YES ❑NO ❑YES NO
BEDDING. VENT DIA. VENT MATT HIGH WATER NUMBE OF. D-mss O JPROPERTV WELL BUILDING VEN TOFRESH
ALARM FEET FROM ROAD LAIR INLET:
❑YES NO ❑YES O NEAREST
DOSING CH BER:
MANUFACTUR R JBEDDING. LIQUID CAPACI TY PUMP M()UEI PL7MP.SIPHUN MANUI ACT(JHLR PRO WARNING LOCKINGOCOVER
DYES ❑NO YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: P UMP AND CONTROLS OPERATIONAL MOPE RTY IW,LL BUILDING IV ENT TO FRESH
(DIFFERENCE BETWEEN
rEETF! OM INE AIR INLETPUMP ON AND OFF) ❑YES ❑NO A ST----
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowin N(, 1 DI a1f TE 1+ 111AII HIA( AND MARKING
or excavation, (if soil can be rolled into a wire, construction shall cease until L FO
the soil is dry enough to continue.) MA
CONVENTIONAL SYSTEM:
` w1DrH LENGTH IN101 UISIH PIPE SPM:IN(, COVER NSIDE Din -PITS LIQUID
5 THE NC11E5 IIA IIAL' PIT DE
BED/TRENCH PTH
DIMENSIONS'
G AV L DEPTH FILL OE lf'T~Ilv H PIPE UISTH PIPE DISTR. PIPE°~MATENO NUMBER OF PRPERTV WLL
l//') BUILDING V NT TO FRESH
BE LOW PIPES VER INLI1 ELEV '.NIp I s(f PIPES FEET FROM LIJ y ~ A NyE
/Jf -Ijl-- / NEAREST
MOUND SYSTEM: _
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
❑YES ❑NO
SOILCOVER TEXTURE PE IIAtANf NI 41 AHKf HS OBSEHVATION WE LLS
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH BED IDEPTH OVFH TRENCH HfU UE VT1+(ri TOPSOIL SODUf D 5EF OF U MULCHED
CENTER EDGES
❑YES. CJ NO ❑YES ❑NO [DYES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH NO. OF LATERAL SPACING (TRAVEL. DEPTH HE LUW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES.
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE IMAN11OLD MAT EHIAL V( OISTH UISTH PIPE UISTIIIBl/IION PIPE MATERIAL & MARKING
ELEV. ELEV DIA ELEV. PIPES DIA
ELEVATION AN
DISTRIBUTION
INFORMATION HOLE 512E HOLE SPACING DRILLED COHiiFCily COVER MATERIAL PLAN'S VERTICAL LIFT CORRESPONDS TO APPROVED
❑YES ❑NO ❑YES ❑NO
JPERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE
❑ YES ❑ NO ❑ YES ❑ NO NEAREST "
a_ (,,d
~l
Sketch System on all county file for audit.
Reverse Side.
IGNA E TITLE lr -
L
DI LHR SBD 6710 (R. 01 /82)
conssn APPLICATION FOR SANITARY PERMIT .y~
r:7 L H R crN,A COUNTY
(PLB 67) UNIFtjRIVI 6ANITARY PERMIT #
-RI LRIF war A -
USTRV,LRBOR 6MUTHrIRELGiTlOrlS 1//~
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
30'e 7 C- p)( : e~ S T Z/CSC
PROPERTY LOCATION CITY:
,,yV~~
P 1/4/`1/4, S , T,3/, N, R/ E (or AGE:
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME EAR EST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms: -Z ❑ Public (Specify):
THIS PERMIT IS FOR A:
X New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
ED Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued
❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity /
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
~3'r~ ~130 6: 34~ Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): Signatur • i MP/MPRSW No.: Phone Number:
&1 11 f-) /'Z all
Plumber Address: Name o esigner: r
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
❑ Owner Given Initial
~~J ~a D Approved Adverse Determination
Reaso DT ppro 0111:
Alternate course(s) of Action Available:
i
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
INWRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION PLB 7 - ~
6 SBD 6398
To be complete and a0curate the permit application must include:
1. ,Property owner's name and complete #egal description, please circle the appropriate municipal government unit, (whether this is in
- ?city,`villa o'town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.);
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
` 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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
V }
Owner of Property a S r1 it- 15,41 014a
Location of Property 4/4~ 34 Section T_2L_N-RLE_ W
Township SQ X11 e f Se T-
Mailing Address r / 0,0 It s e.7- 16dd ~ ® Z-5-
Address of Site g ~nJ L
Subdivision Name
Lot Number
Previous Owner of Property -r*^,$ 6re Al
Total Size of Parcel /a,j et fd1G' ~Q eS
Date Parcel was Created ~lG/7e• ~~a'lo
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume 17'I 7 and Page Number fl? 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 (We) cexti.6y that att ~Statement6 on th z harm ane true to the best ob my (oun)
know.-edge; that I (we) am (ake) the owner(,6) ob the pnoperrty desckibed in this
inbonmati.on bonm, by viA tue o6 a waAAanty deed neconded in the O bb.i,ce o6 the
County Register ob Veed6" Document No. y1y%23 ; and that I (We) pnesentty
own the proposed date bon the sewage di6pod sys em (on I (we) have obtained an
easement, to nun with the above debchibed pnopehty, bon the constnucti.on ob said
.syetem, and the same has been duty recorded in the Obbice ob the County Regi6ten ob
Veeda, ab Document No. 1.
b
A 61v OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
ZL&
/
DATE SI D DATE SI ED
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SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
cy
14 O S 6 H
OWNER/BUYER d o 51/1071-c- -je M
J
ROUTE/BOX NUMBER /ff f 29V Fire Number
.CITY/STATE gyoo"e4y& :;E~ ZIP -5-90 2 ~
PROPERTY LOCATION: " 4, NE Section ( T "3) N, R 1cl W,
Town of St. Croix County,
Subdivision 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 pdt 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
three year expiration. H
0
E
I/WE, the undersigned, have read the above requirements and agree z„
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- v
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
DATE Ax- $ 6
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.
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS MADISON, WI 53707
^ (ILHR 83.0911) & Chapter 145)
IVISION NAME:
D
LOCATION: SECTION: OWNSHIP/ UNICIPALITY: LOT NO.:BLK. NO.rS
'/a 1e~/a .21 /TI/ N/R/ E (o .e
COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS:
CrDsfC Joe 0:5 /a C o f SO e t 4.4'
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
XResidence ANew ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system o
ICEISDU ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
as❑u as❑u as❑u os❑u 1 '_3
~_0 112,
ell
I
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicat C4L% Floodplain, indicate Floodplain elevation: D
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- / ,7 ®`/o rL---RCF~ i5;20--7
B-a 7 n
B-3 76ate
Z ~5 /ell ,-P
B- pnc
B 5~ c C 9o -2 3~
d~-
B-
f PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER ! AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD3 PER INCH
P-
P r
P- ~ h Ja
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.
,57 f_
SYSTEM ELEVATION 7 /C 9~, .mac
d 4.. C
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w ~,drl ~ar~ ~ rl-
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4qp-r <J
TN
Ja -r-
- _ ► A Fri ~n t?rr „7 10
3
A!)
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 (prin r TESTS WERE COMPLETED ON:
- _-7 -
ADDRES : CERTIFICATION NUMBER: PHONE NUMBER (optional):
zgs
CST SIGNATUR .
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) -OVER -
a 11 5 it te,
ALL
UUn ~ropriate box;
12, M< f l S . ' ~ BE FILED WITH THE
LC.1,A J
TX mIED SOIL TE'
s' B
Y ovv
F
Pt 11'
r'
I I WL
{:e P(")in
T THE OWNER:
Th, sail test report is the first step in securing a sanitary permit. The county car the Department may request
rn of this sail test in the field prior to permit issuance. A complete set of plans for the private
system and a permit application must he submitted to the appropriate local authority in order to
a permit. The sanitary permit must he obtained and posted prior to the start of any construction.
PLOT PLAN
PROJECT cJ oe c jcc J~~ C ADDRESS
TOWNIV._71c,-se;COUNTY
MPRS Byron Bird Jr. 3318 DATE ~7 -
BEDROOMS CLASS PERC ENTIONALA IN-GROUND PRESSURE
CONVENTIONAL LIFT_ MOUND_ HOLDING TANK
SEPTIC TANK SIZE LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA PERC RATES BED SIZE 1~X 3 '
Benchmark V.R.P. Assume Elevation 100'
Location of Benchmark T /3s•~~c.~ Corn e 51`~.~5
* H. R. P.~-~ • C - ~,2 ,
M Borehole Q Well Scale_ _ zC Feet
O Perc Hole System Elevation ~3 u
TYPAR COVERING
2"
12" 3' 6' 3' 3' 4' 4' 3'
1 Sewer Rods
12' 18' 24'
r-2 4c > `j
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Parcel 032-1054-20-100 02/06/2007 04:39 PM
PAGE 1 OF 1
Alt. Parcel 21.31.19.269C 032 - TOWN OF SOMERSET
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - OSVATIC, SANDRA & JOSEPH J JR
SANDRA & JOSEPH J JR OSVATIC
2086 CTY RD I
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 2086 CTY RD I
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 12.211 Plat: N/A-NOT AVAILABLE
SEC 21 T31N R1 9W NE NE 12.211 ACRES LOT Block/Condo Bldg:
2 CSM VOL 6 PAGE 1666
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
21-31 N-1 9W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 747/537
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/23/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 12.210 94,000 74,000 168,000 NO
Totals for 2007:
General Property 12.210 94,000 74,000 168,000
Woodland 0.000 0 0
Totals for 2006:
General Property 12.210 94,000 74,000 168,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 125
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00