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Form - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ,y1,,,/,ti TOWNSHIP ~TAti7.>H SEC. ;w_3 T 3 i N-R t? W
ADDRESS ~P3 t?ny
/67 i? ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT ~y/G¢ LOT SIZE PLAN' VIEW
Distances and dimensions to meet requirements of I•IIHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
/Du.G .%1 ECp.
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LG✓L
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INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used &,,I to E1.m0-ote p/.,`'
41yP / 1•I hW N~
Elevation of vertical reference point: -Jjffi Zoo" Proposed slope at site: 7E-
SEPTIC TANK: Manufacturer: GJ~.ic~~s Liquid Capacity: j000 i
Number of rings used: / Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side, Rear, O /L 6 feet
.From nearest property line Front 10Side ,0Rear, 0 feet
Number of feet from: well >leo` building: i.S'
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
nnn nrc.r•r nrl e.r....
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, Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed:_ Trench:
Width: /Length: Number of Lines:_ Area Built: X36
Fill depth to top of pipe: Y-~t~
Number of feet from nearest property line: Front, Q Side, O Rear, 0 Ft
Number of feet from well: > 600
Number of feet from building: 6 °a
(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, OFt.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: 'It-( S6 Plumber on job:
License Number: E329
3/84:mj
DEPART MENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, 011 53707
❑CONVENTIONAL ❑ALTERNATIVE State Plan I.D. Numner
❑ Holding Tank ❑ In-Ground Pressure El Mound of a:. xf
AV-PA11,00 AU
NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER. INSPECTION A E
Merlin Frank Rt. 3 Bx 167B New Richmond, Wi. 54017 8/12/86 2:30
BENCH MARK (Permanent reference pomt) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEv.. CST NEF PT. ELEV
NW-NW'-4 Sec. 23 T31N R17W Town of Stanton
Namr nI Plumper. 1MP'MPRSW No.-. County Sanitary Permll Numlter.
Mike Wilson 6388 St. Croix
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAPACITY TANK INLET ELEV. TANK OUTLET ELEV. WARNING LABEL LOCKING COVER
2,n PROVIDED PROVIDED 1W , 1J~1 YES ONO OYES NO
BEDDING. - IVENTDIA. VENT MATL. HIGH WATER INVMB9R OF ROAD. PROPERTY WELL BUILDING (VENT TO FRFSH
C I JALAR "t FEET FROM LIN / 5 AIFT wLEr
DYES NO OYES NO NEAREST
DOSING CHAMBER:
MANUFACTURER 7INGS LTOUIDCAPACITV PUMP MUUEL PUMPSIPHON MANUF ACTUHEIT WARNING LABEL LOCK ING COVER
PROVIDED POVIDED
EONO OYES ONO OYES ONO
GALLONS PER CYCLE: JPUMP AND CONTROLS OPERATIONAL. NUMBER OF PF7()PE It IV 11111 LL 1111111 DING VENT TO FIIISII
(DIFFERENCE BETWEEN FEET FROM LINE I AIRINLET
PUMP ON AND OFF) OYES ONO INEAREST->
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH IDI ANIF IF I+ IMATI IIIAt ANO MARKIN,,,
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDT LENGTH INI OF UISTR PIPE 6SPACING C VEH JINSIDE DIA ~PIIS :AOL
TRENCHFS TE H IAL: PIT OFPiFt
DIMENSIONS
OHAVEL DEPTH FILL DEPTH UISTH PIP! UISTH PIPE DISTR. PIPE ERIAL NO J 5TH NUMBER OF PROPERTY WELL HUILOING VENT TO f H! SII
1RE LOW PIPES ABOVE COVER FCIf V IIN~I PI' l ELEV END PIP LINE A I I IINLE T
G Zip - 7 Z INEARESTFROM FEET
7/ ~ovD f lra~t t~J
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-
OYES ONO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TF-xTURE TUITNI-ANE NI MAHKF RS I I I4Sf Ii VA II(I N WI l l S
DYES ONO _ _DYES _ LINO
DE PTH OVER THE N(:F1 HED ]DIPTIIIIVIII THENCH BEII DEPTH OF TOPSOIL ISOLILIF 1) SEE OFD Ml1L(:I+fD
CENTER EDGES
OYES ONO OYES ONO DYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH NO. OF LATERAL SPACIN GHAVEL DEPTH HF LOW VIP! FILL OFPTIf AHOVf COV! H
BED/TRENCH TRENCHES
DIMENSIONS
MANIF UIU PUMP MA N1 Ff1111 UISTR PIPE MANIFOLDMATEHIAL NO DISIII I:ISIH I'IPF I W; IIIl11111 PINPIPI MATTHIAI 7(I ~1AllK INIELEVATION AND ELEV ELEV. DIA
ELEV. PIPES DIA.
DISTRIBUTION
INFORMATION HOLE SLIF HOLE SPACING DRILLLOCOFIHf CTI.Y _ COVFH MATERIAL VEI+TICAI I IF T CDHRESPnNDS IO APPHUVI 11
PL AnIS
DYES ONO OYES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROEPS HiY WELL BUILDING
FEET FROM LIN
OYES ONO DYES ONO NEAREST_-
V
N
0) 0
Sketch System on _71 in county file f r audit.
Reverse Side.
G
SIGN TITL
DI LHR SBD 6710 (R. 01/82)
I
® wisconsin APPLICATION FOR SANITARY PERMIT -
(PLB 67) & COUNTY
DILHR
- OEPRRTTEnT OF
#
InOU5TRY, LRBOR 6 HUmgn RELgTlons UNIFORM SANITARY PERMIT
ff3
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
/ye r -r r+ k 6 ry
PROPERTY LOCATION CITY:
,,v&.)1 14ww 1/4, S N, R / E (or VILLAGE: S
Tl~
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME rNEAREST42ZM? LAKE OR LANDMARK STATE PLAN I.D. NUMBER
. s
7: 14 1 ILt '
TYPE OF BUILDING OR USE SERVED ~ 03 ~QS
1 or 2 Family Number of Bedrooms: Public (Specify): /V
THIS PERMIT IS FOR A:
X New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
5~. 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 GOO
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 .10
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
/p 63P g~ ? ❑ Private X Joint ❑ Public
1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): Signature: /MPRSW No.: Phone Number:
/"I i~i 6 61. L.~, 4 xe r~
6-7 V?
Plumber's Address: Name of Desig
ner:
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
W,ij,ae 61, (~a_Q,S(,~.e,[./ `2 lr~~ Q~~/ O/ ❑ Owner Given Initial
Al o-t/ Q 0 (O ~ Approved Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or 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.
70 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
roust 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.
Form - S T C 100
Owner of Property -e Y' ! r\ rUY~~
Location of Property ~ N U,, Z, Section
Township ~l A- 1n~ p
Mailing Address
5 X0)7 T3 ox rb~l ~ ~ _
Subdivision Name
Lot Number
Previous Owner of Property
Total Size of Parcel
Date Parcel Was Created
Are all corners identifiable? Yes No
Include with this application one of the followin :
.Certified Survey Map
.Deed
.Land Contract, or
KOther I+egal Document which describes the property
PROPERTY OWNER CERTIFICATION I
I (We) certify that all statements on this form are true to the best of my
knowledge; that I (we) am (are) the owner(s) of the property described in this
information form, by virtue of a warranty des r cordgd in the Office of the
County Register of Deeds as Document No. r~o ;and that I (we)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an casement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of the County Register of Deeds, as Document No. )
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED
DATE SIGNED
it
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STC - 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County x
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OWNER/BUYER ~Y t~11'1 F QAA "i
ROUTE/BOX NUMBER 0Y , I Lj 13 Fire Number .CITY/STATE Jy ~U-~ L (i)VY1 C V1 CI ZIP b ~
PROPERTY LOCATION:_W 1%, 1%, section oJ3, T N, RW,
Town of S-'a 0 , 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 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
three year expiration.
0
• E
I/WE, the undersigned, have read the above requirements and agree EA
to maintain the private sewage disposal system in accordance with x
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.'~-~2/T~. r
DATE (p
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
P.O. BOX 76
HUM-AN REILATIONS PERCOLATION TESTS (115) MADISON, WI 53707
(H63.090) & Chapter 145.045)
LOCATION: SECTION: /MUNICIPALITY: LOTNO.:BILK. NO.:SUBDIVISIONNAME:
'/4 /T N/RoEA I
COUNTY: BUYER'S NAME: MAILING ADDRESS:
.S 'Y r L ~'ti -r , / It?-? Rok 147n Al w
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: ~ ~PROFILE DESCRIPTIONS: 1PERCOLATION TESTS:
.Residence Ql NeW ❑Replace g l ~6
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
[.0-1 S ❑U ® S ❑U IS ❑U ❑ S ZU ❑ S ZU
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: 1D L Floodplain, indicate Floodplain elevation: /yIyl
_~¢T PROFILE DESCRIPTIONS
BORING TOTAL D PTH TO GROUNDWATER-I€S CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH I.W. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B Si 7$" fll0 h Et [ T r 0, L
.2 L
r
B- 3 b~ r
B- L c?S. S i I v S C T S L 3,47 0"
S w- r
B-
B- 5 die a 7- "/_7 L? c-- 7!
PERCOLATION TESTS
TEST DEPTH. WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING 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
_
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Sit
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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:
. ^GliG, t LSO SS -'B'-74(1
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
h *V .C o 1 is ? I- s r t--" S'/00/ 7 7/s--.2 6 k- a s ? 7
CST SIGNATURE:
IMSTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
--77U--`--3 R OM L ETI C ~ a 11 - D - 6395 r
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Parcel 036-1054-60-000 02/06/2007 04:55 PM
PAGE 1 OF 1
Alt. Parcel 23.31.17.346 036 - TOWN OF STANTON
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 - FRANK, MERLIN A & JOAN H TRUST
MERLIN A & JOAN H TRUST FRANK
181121 OTH AVE
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 181121 OTH AVE
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 23 T31 N R1 7W 40A NW NW Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
23-31 N-1 7W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/10/2003 729662 2309/500 QC
2007 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 05/06/2003
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 37.000 2,800 0 2,800 NO
OTHER G7 3.000 20,000 180,400 200,400 NO
Totals for 2007:
General Property 40.000 22,800 180,400 203,200
Woodland 0.000 0 0
Totals for 2006:
General Property 40.000 22,800 180,400 203,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 143
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
I