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Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP S t} SEC. T N-R~W
ADDRESS w ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of 11HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used dt~c
Elevation of vertical reference point: x%04 Proposed slope at site: f
SEPTIC TANK: Manufacturer: Liquid Capacity:
Number of rings used: _ Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front tok Side ,Q Rear, O feet
From -siearest ProP 1erty line Front 1 Side Rear, <
O ,O , O 6 feet
Number of feet from: well f-d , building: i,
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDF.
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: x Trench:
Width: Lendfh t Number of Lines: Area Built: t i
Fill depth to top of pipe:
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).
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:
of r" _
Dated: / Plumber, on job:
License Number:
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR A HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS
I;.O. 80X 7968 DIVISION
BUREAU OF PLUMBING
MADISON, WI 53707
CONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number:
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (If assigned)
NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER INSPECTION DATE:
Ed Delander 1407 Wellesley Ave., St. Paul, MN 55015 7x19-g4 !~O
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV..
NE4 NE4 of Section 25, T28N-R20W, Town of Troy
Name of Plumber. IMP/MPRSW NOT.. County Sanitary Permit Number:
William Schumaker 6382 St. Croix 79144
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY. TANK IN ET ELEV. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
a••' PROV DED. PROVIDED:
'I" , YES ❑NO ❑YES &XK O
BEDDING: VENTPI VENT MATI JHIGH WATER NUMBER OF ROAD: PROPERTY WELL. JBUILDING. JAIR VENTTOFRESH
ALARM FEET FROM LIN INLET:
❑YES O l~ C_ ❑YES ❑NO N
EST DOSING CHA BER:
MANUFACTURER [71 NG LIQUID CAPACI 1Y UMP MODEL PUMP;SIPHON MANUE ACTURER WARNING LABEL LOCKING COVER
PROVIDEDPROVIDEDES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NU ER OF PROPERTY WELL BUILDING (DIFFERENCE BETWEEN - F LINE JVENTTOFRESH
AIR INLET
PUMP ON AND OFF) ❑YES ❑No i NE ST T_ -
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing IIIIA101 TEH MATE HIAL AND MARKING
or excavation. (If soil can be rolled into a wire, aconst ction II c ease until FORC
the soil is dry enough to coninue.) 66 MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENGTH NO. OF =.ATE' COVER INSIDE DIAaPl iS LIQUID
THENCIiFS~, PIT DEPTHDIMENSIONS 7 h'
FILL DEPTH UIS1VI PIPE DISTH PE DISTR PIPE NUMBER OF PROPERYENT TO FRESH
BE LOW PIP
II f
FEET FROM ABOVE COV R tINLfI LIN67 IR. ET
l _NEARE T__--_►_~ f VQ t j1011,11
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
SOIL COVER TEXTURE JPIIIIIANI NI MAHKFFIS OBSERVATION WELLS
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH BF.U DEPTH )F TOPSOIL )Of 1) SEEDED MULCHED
CENTER EDGES
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH NO.OF LATERAL SPACING (TRAVEL DEPTH BE LOW PIPF FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIATPIPES DISTR DISTRPIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEVELEVDIAELEVDIA.'.
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECT LY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE
❑YES ❑NO ❑YES ❑NO NEAREST-
. _j
1
Sketch System o_ n county fl for al
Reverse Side.
~ jt SIGNATURE TITLE
DILHR SBD 6710 (R.O1/82)
wlsconsln APPLICATION FOR SANITARY PERMIT
COUNTY
DILHR
'
(PLB 67)
- nOUSTRY.L TOFRBOR 6 MUTRn gELiiTlOns
I UNIFORM SANITARY PERMIT #
nOUSTRV,
-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
CD e)Ct 7 e 1`16 7 / e &0_5 A -e M f a4 4 M, .I/
PROPERTY LOCATION CITY:
WN G :
Ahg/ 1/4x1/01/4, Sa , Til" N, R90 E (or) 11 1
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, L KE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED a -115` Ow
X 1 or 2 Family Number of Bedrooms: 3 ❑ Public (Specify):
THIS PERMIT IS FOR A:
M1 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.
9 Seepage Bed ❑ Seepage Trench C1 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 -
El An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total #of Prefab. Site
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity ddd
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):
r U ~3 ex Private E] Joint [11 Public
1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): Signatur MP MI No.: Phone Number:
1%/r,l SC_ huma°Y - (p27.-?)
11107 Plumber's Address: Name of Des' er:
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
/ t~ ~~6 ❑ Owner Given Initial
J / Approved Adverse Determination
Reason for isa ro .
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.
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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property CQ ✓ / 4 d:- r
Location of Property ,61,15 Section , T N-R Q a W
Township fo
Mailing Address/ 3 (Q ~'n ~,Y Gr/ /
Address of Site
Subdivision Name
Lot Number j
Previous Owner of Property /t elle r
Total Size of Parcel 0j• 3
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 and Page Number /;2- 7 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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPFRTV OWNER CERTIFICATION
I (We) cehtjy that a2C.6tatement6 on this boAm ace tAue to the best o6 my (ouA)
knowledge; that 1 (we) am (ace) the owneA (.6) o j the p to petit y da cnib ed in thii s
in6oAmati.on boAm, by viAtue o6 a waAAanty deed teco&ded in the 06gice o6 the
County RegisteA o4 Deeds ass Document No. 2 ; and that I (We) ptesentty
own the pupoaed site 6oA the sewage dispoS system (oA I (we) have obtained an
easement, to tun with, the above de6cAibed ptopenty, bon the con.6tnucti.on of.6aid
.6ystem, and the same has been duty AecoAded in the 04jice o6 the County RegisteA o6
Deeds, a.6 Document No.a3
ea - - - -D
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
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SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County z
t7
OWNER/BUYER J6 ~ C Irv{ X -e 4ne`r,o,-
ROUTE/BOX NUMBERt 3 Dr~G•~~sr~ Fire Number
CITY/STATE Sr zip UoZ Z
PROPERTY LOCATION: (j, Section 126'- , TRE N, RjjW,
Town of llo~ , St. Croix County,
Subdivision Lot number
I
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. H
0
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- ro
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 z2z~
• DATE
St. Croix County Zoning Office
P.O. Box 9a
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
(H63.090) & Chapter 145.045)
LOCATION: SEC NON: TOWNSHI UNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
NE--ME0~ Z s TZSN/RAE co -~-~oY _
COUNTY: OWNER' UYER'SNAME: MAILING ADDRESS: ~yO7 ~e'
S~'. ~Z,olx p I.AN b ~1~, S r~ ` 1~11V , ssI o.s
USE DATES OBSERVATIONS MADE _
NO. BEDRMS•: COMMERCIAL DESCRIPTION: PROFILE DES RIPTIONS: PER OLATI0N TESTS:
[!Residence A~ .New ❑Replace
y-ZV_8(O lv,~ -
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-G Site unsuitable or MOLDING DED SYSTEM: (optional)
®s ❑u ff ®u ®s au as ®u ~'eo,uu `nooatr~
[under Percolation Tests are NOT required DESIGN RATE: F
n
y portion of the tested area is in the w
s.H63.09(5)(b), indicate: Li S S odp
lain, indicate Floodplain elevation: 'v
PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER- FA19~FE9 CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH in OBSERVED EST- HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 1 ~o.b~ ~03.0~ ivo~E > 1D.b~ N•o' qtr G-1 BnsiITs; Z.aI @n -T I; 1•o'3nsl•
B- Z 8.0~ 98•"7 I~otti1E > $,p' o.~' fl1LGY tan St'1 Ts ~ Z. 3' Leh si I ; o• b'
%
h
S 1 w /Gv Ll- L4 t3 n- rn 'Q S
~ ~ 0,7' Dh-GY Bn si I TSB z. 3' )3rI si I ; o, ~ ~ S! •
B- 3 1l• 5 1o~•t• 3 1>,1ei > 11 • S 3xs TB Z m 42 S Z, " 13 s ' Z•7 ' rnedi S
' o• r,' D~ 6'i Dh Si 1 Ts ; S' L3h si l ; o•-)r Zm S
B- 4 8•y ~oo•o ~D~E. > $ ,y o 3n l3 • IS •o' 3 ty,QCQ ~
B- S ~O.S~ \01.'~ - > l0• S' DtzGr SM Si 1 Ts ; 3.S' 3nsi I ; o,~' 8h S1
6-
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 PERI D 3 PER INCH
P-
P
P- ►as L(- pl~E 1 s ft-r Rx3 L9 ..00,1 ELI i J4 &-Aj U G
P-- HTLV C- uR -iz, c h 3L/S7 r=k1 1° J y- K LILl
P- Z" Gp OV~1a a!S U 0/V 1_
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. 1tJ~1'IR~. - qs.7 r ~Pt6~ ~Q ~'1N1~1Z~ LONNY Sr%vtD
SYSTEM ELEVATION
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SC-t`~LE i - 40 ~tC T IRS SNOW IJ
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.
NAME( print : S WERE COMPLETED ON:
~`Cl-4V\-: L, wEG~z~-z 86
ADDRESS:
~Z L 4 zr~l X. 2Z(~ 35 C! W ATION NUMBER: PHONE NUMBER(optional)-
S 0 1 57~ 7JS_q ZS-®!6V
S ATU E:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and
IL
DILHR-SBD-6395 (R. 02/82) - OVER -
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Parcel 040-1159-20-000 02/07/2007 10:51 AM
PAGE 1 OF 1
Alt. Parcel 25.28.20.621 B 040 - TOWN OF TROY
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 - WHALL, JOSEPH M & GEORGIA F
JOSEPH M & GEORGIA F WHALL
283 PLAINVIEW DR
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 283 PLAINVIEW DR
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 7.050 Plat: N/A-NOT AVAILABLE
SEC 25 T28N R20W 7.05AC IN NE NE LOT 1 Block/Condo Bldg:
CSM 6/1777
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
25-28N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1193/187 WD
07/23/1997 738/22
07/23/1997 514/127
2007 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 07/21/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.040 90,000 198,100 288,100 NO
AGRICULTURAL G4 4.000 400 0 400 NO
Totals for 2007:
General Property 7.040 90,400 198,100 288,500
Woodland 0.000 0 0
Totals for 2006:
General Property 7.040 90,400 198,100 288,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 215
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00