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• Form-STC- 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SEC. T O N-R ,L-W
ADDRESS 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
I '
a ARM y47 4 sic, f-jr
VeN - L _i
Me INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: rp'oposed slope at s He:
- -
SEPTIC TANK: Manufacturer: Glf.(y~.~~r Liquid Capacity: /O"
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front , Side, Rear, O a feet
From nearest property line Front 10 Side, Rear, O O feet
Number of feet from: well , building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
P CHAMBER
Manu cturer: Liquid Capacity:
Pump Mode • Pump/Siphon Manufacturer: Pump Size
Elevation of in t: Bottom of taffr elevation:
Pump off switch eleva on: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet f nearest prope line: Front, O Side, O Rear Ft.
Number of feet from wel .
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: X Trench:
Width: 17 Len$th: Number of Lines: Area Built
Fill depth to top of pipe:
Number of feet from nearest property line: Front, ® Side, O Rear,O Pt .2
Number of feet from well: `
Number of feet from building:
°s
(Include distances on plot plan).
SEEP E PIT
Size Number of pits: Diameter:
Liquid the Bottom of seepage pit elevation:
Area Built:
Has either a drop box or distribution box O been u d on any of the above soil
absorbtion sytems? (Chec one).
HOLDING TANK
Manufacturer. Capacity:
Number of rings used: vation of bottom of tank:
Elevation of inlet:
Number /of property line: Front, O Side, O Rear, OFt.
feet from well:
from building:
nearest road:
Alarm Inspector
Plumber on job: ~~~G-✓~
Dated:
License Number :
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, Will 53707
XMONVENTIONAL ❑ALTERNATIVE State Plan LD.Number:
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (if assigned)
NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTIO DATE:
Richard Rosen Glenwood City, WI Q 7` •s~Q
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. IT. ELEV.:
NE SE, Section 34, T30N-R15W, Town of Glenwood
Name of Plumber: MP/MPRSW No. County: Sanitary Permit Number:
Gale W. Smith 5690 St. Croix 64883
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV. . WARNING LABEL LOCKING COVER
/ 6 w , 2 PROVIDED: PROVIDE
ES ❑ NO ❑ NO
BEDDING: VENT DI-A.. VENT __~M HIGH WATER NUMBER OF ROAD: IPROPERTY WELL BUILDING: V TO FRESH t
ALARM I J FEET FROM LINE: LAIR I LE
OYES O OYES NO NEAREST -
DOSING C AMBER:
MANUFACTURER. BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP IP ON MANU FACTO F: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
OYES ONO OYES ONO OYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLSOP ATI AL: NUMBER OF PROPERTY WELL: BUILDING: IVENTTOFRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET:
PUMP ON AND OFF) OYES ONO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing 1 FN/;ur JDIAMFTER 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.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENGTH IND OF ]DISTR. PIPE SPACING: COVER JINSIDE DIA #PITS LIQUID
TRENCHES. MAT L: PIT DEPTH:
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE ERIAL N D STR. NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE CO R ELEV. INLET. ELE END PIPES. LINE A AIR INLET:
y Q FEET FROM /l}-
G- Q 2~ U 2- 2 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.
OYES ONO 1--) z
SOIL COVER TEXTURE PER AN T MARKE RVATION WELLS. _7~
❑Y S ONO OYES ONO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. DED: SEEDED: MULCHED.
CENTER. EDGES.
ES ❑ OYES ONO OYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH TRENCHES: LATERAL SPACI GRAVEL DEPTH BE PIPE: FILL DEPTH ABOVE COVER
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE IM ANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEV.. ELEV.: _ DIA.. ELEV.: PIPES: DIA.:
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
OYES ONO OYES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
DYES ONO DYES NO NEAREST
Sketch System on Retain county file for audit.
Reverse Side.
SIGNATURE: ITITLE~7
DILHR SBD 6710 (R.01/82)
wlsconsln APPLICATION FOR SANITARY PERMIT
I CA- COUNTY
ILHR (PLB 67) UNIFORM SANITARY PERMIT #
r OEPRRTRIEnTOF
InOUSTRV,LRBOF16HUrnjj RELRTIOnS
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/zx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER 4MA ADDRESS
PROPERTY LOCATION :
14S91/4,s34, 2 N, RCS M (or) LT NUMBER BLOCK NUMBERSUBDIVISION NAME ST ROAD, LAKE OR LANDMARK ATE W. Nt BER
TYPE OF BUILDING OR USE SERVED Q ~ll `~77 r
X 1 or 2 Family Number of Bedrooms: r ublic (Specify):
THIS PERMIT IS FOR A:
New System El Tank Replacement El Repair
❑ Privy
El Replacement Soil Absorption System ❑ Revision
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
X Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
System-In-Fill
❑ 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 0
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):
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
MP/M}MR3YMeNo.: Phone Number:
Name of Plumber (Print): Signature- r (7.) 2X4_- 47
e M
/
Plumber's Address: Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signatur of Issuing Agent: F e: Date: ❑ Disapproved
El Owner Given Initial
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`-1n ic~ate gpecifical(y-v at 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;
.ti
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 froiv 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/contractQi~,("spec
house"), then a second form should be retained and completed when the property is
sold and submitted to this office with the appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property
Location of Property- ~4, Section , T N - R W
Township i~
Mailing Address
Subdivision Name
Lot Number
Previous Owner of Property
Total Size of Parcel IJZ•ti
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 as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
10 Warranty Deed
2. Land Contract
3. Other recordings filed with the Register of Deeds Office
In addition, a certified survey, if available, would be helpful so as to avoid delays
of the reviewing process. If the deed description references to a Certified Survey
Map, the the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
I (We) centi% y that aU 6tatemenX,6 on this 6oAm ane tAue to the best o4 my (oun)
know.bedge; that I (we) am (ahe) the owner (s) of the pnopeA,ty descAibed in this
inAonmation Rohm, by viAtue o4 a wannanty deed heconded in the O~4ice of the
County Regiz ten o~ Deed6 _a4 Document No. and that 1 (we)
phesent2y own the puposed site ion the b age posatsystem (on I (we) have
obtained an eadement, to tun with the above de.6cAi.bed ptopenty, {Yok the
consfituction o~ bai.d system, and the same had been duty tecotded in the O~6ice
o6 the County Regizten o~ Deeds, as Document No. ) .
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
- /,7 2DATE GNED DATE SIGNED
H
U1
9
S T C - 105 r
r
9
H
SEPTIC TANK MAINTENANCE AGREEMENT H
0
St. Croix County z
d
OWNER/NOW ~sc. ✓
ROUTE/BOX NUMBER Fire Number
`CITY/STATE ~ ~'tP' L L✓ .cam Z I P ..Sly/ Old
PROPERTY LOCATION: l~l s Section, TAO N, R, ,-W,
Town ofL-"O0 C/ 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. Crolx.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 stems agree to keep their systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. H
0
E
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with 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 J
DATE 2 C~"
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
N
LABOR BOX HUMAN REDLATIONS PERCOLATION TESTS (11J) MADISON WI 53707
(H63.090) & Chapter 145.045)
LOCATION: SECTION: p ~s TOWNSHIP LOT NO.: BLK. NO.: SUBDIVISION NAME:
N,aS/ 3 /T 13o N/R/J 1 (or C
COUNTY: OWNER'S/BUYER'S NAM MAILING ADDRESS:
ly- 3P
USE DATES OBScRVATIONa MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFIL DES RIPTIONS: [ER/CO~,ATI O N TESTS:
Residence V /1 ~O New ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system T J
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optiona 1
®s Du ®s ❑u s ❑u I DS Mu Xs ❑u«, a
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: 9 / Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 6.38 0 None . 3~ l '
O' 7SI, sc.
B- 3 7 33/ o~. ' rirJ0 k 7, 33' s'` 7S' s c.
B- 0 S ' d -A P , D
17 /
7.5 ' p5:ob /Uoae S' /-3 ~ / "Be,
PERCOLATION TEST
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 3 PER INCH
P- 2.17 /Ud i/
P- zsr' Q " X40- AV 9'
P- /Vo k I/ ♦i s'
P-Ai 00 J"
P- 01 11
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 99. #9
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I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord Stith the procedures and methods specipfie~d /in the Wisc9nsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. / Ca + ,_T-:2
f NAME (print): TESTS WERE COMPLETED ON:
ADDRESS: CERTIF A ION NUMBER: PHONE NUMBER (optional):
17
• / J Trig f j" r
CST SIGNATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
D I LH R-SB D-6395 (R. 02/82) -OVER -
L
UC 'IONS FOR COMPLETING FORM 115 - SBD - 6395
Tr e nr nnI and accurate soil test, you) iii
is -o n project;
. . 'AXL..
4. Is this a
EnD ,9err TANlk' nn r °y rr ALL
`UT NI'T
Is ,')own he
7. r curately loc ti
ta: t
a V in the appropriate box;
I -"fais~r;
T-"TS MUST BE FILED WITH THEW
r,
-IATI ^a... -,FkTIr- TESTERS
3")
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This wail test report is the first step in securing a sani_ary nit. The cc y or the Department may re<xtlest
verification of this soil test in the field pricer ace, A -le` ! set of plans for the private
sewage system an-1 permit application mu be sr : the late local authority in order to
obtain a permit, T mit rnus be in ' ar ?osted prior to the start of any construction.
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Smith Plumbing & Heating PHONE (715) 265-4838
l'lGh p r daSG~ GLENWOOD CITY, WISCONSIN 54013
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Smith Plumbing & Heating PHONE (715) 265-4838
" ~l O S 1~1 GLENWOOD CITY, WISCONSIN 54013
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Parcel 016-1074-80-000 01/25/2007 09:39 AM
PAGE 1 OF 1
Alt. Parcel 34.30.15.518B 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
O - ROSEN, RICHARD O & HELEN L
RICHARD O & HELEN L ROSEN
1242 HWY 128
GLENWOOD CITY WI 54013
Districts, SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 1242 HWY 128
SC 2198 GLENWOOD CITY
SP 1700 WITC
Legal Description: Acres: 1.000 Plat: N/A-NOT AVAILABLE
SEC 34 T30N R15W PT NE SE COM 520 1/2 FT Block/Condo Bldg:
S 35 DEG W OF E 1/4 COR SEC 34, TH N 39
DEG W 198 FT, TH S 38 DEG. W 220 FT, TH Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
S 39 DEG E 198 FT TO CEN HWY 128, N 38 34-30N-15W
DEG E 220' TO POB
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 711/617
2006 SUMMARY Bill Fair Market Value: Assessed with:
165737 239,100
Valuations: Last Changed: 10/06/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.000 7,500 181,900 189,400 NO
Totals for 2006:
General Property 1.000 7,500 181,900 189,400
Woodland 0.000 0 0
Totals for 2005:
General Property 1.000 7,500 181,900 189,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 118
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
E
k
ROSEN, RICHARD NE SE, Section 34,
Glenwood City, WI T30N-R15W
Town of Glenwood
San.Permit#64883 5-10-85 G. Smith
Conventional, New 1? V'2)
INSTALLED 5-6-85