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Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SEC. ,C T .-Cr N-R / 7 W
f3~/~c~~`' ST. CROIX COUNTY, WISCONSIN
ADDRESS
SUBDIVISION X1 LOT 1111,5~ LOT SIZE
PLAN VIEW c ~C
>cPS
Distances and dimensions to meet requirements of 11HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
~i 70
63 93
1310 Z/-v' - -
r 7-1
>
16o, yP 5-3
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used /Q12 12;'&2C? 67-1
Elevation of vertical reference point: X(90,0 Proposed slope at site: 12 70
SEPTIC TANK: Manufacturer: -eXX Liquid Capacity: leoo ~2gls,
Number of rings used: /r,4,~2 Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,0 Side,k:::2~) Rear, O feet
.From nearest property line Front, 0Side, ORear, 0 %U feet
Number of feet from: well 55 f building: f(~
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
a
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: 4 /Botom of 4onper elevation:
Pump off switch elevation: Ga 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: /V& 5 Trench:
i
Width: Length: Number of Lines: - Area Built:
Fill depth to top of pipe: ,2. U "I
Number of feet from nearest property line: Front, O Side, O Rear, D Vt.2
Number of feet from well: f
Number of feet from building:,
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: ,Diameter:
Liquid depth: Bottom /4epag4 it e levation:
Area Built:
Has either a drop box O or distr but n bo en used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: ! pacity:
9 6
Number of rings used: jvat on of bo om of tank:
Elevation of inlet:
Number of feet from nearest ropy lin Front, O Side, 0 Rear, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: Plumber on job: 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, WI 52•707
• ,UigONVENTIONAL ❑ALTERNATIVE State PlanLD.N„mbe,
(If assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
Brent Wernlund Baldwin, WI I-/-
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.
SE NW, Section 26, T28N-R17W, Town of Rush River
NamP of PI-her JMI/MPRSW No.. County Sanitary Permit Number_
Everett Boldt 4489 St. Croix 64868
SEPTIC TANK/HOLDING TANK: °
MANUFACTURER. 1 LIQUID CAPACITY TANK INLET ELEV.. TANK OU LET,EI.,EV.. WARNING LABEL LOCKING COVER
PROVIDED'. PROVIDED-
'/I) C ;%i~ YES ❑NO ❑YES ~<NO
BEDDING. VENT DI VENT MATL. JHWATER NUMBER OF ROAD. PROPERTY WELL. JBIJILDING. VENT TO FRESH
LINE AIR INLET.
AARM. FEET FRO~f 1
❑YES NO ❑YES O N
DOSING C AMBER:
MANUFACTURER BEDDING. ILIOU111 CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED.
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY JWELL BUILDING I 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 LJDIAMETER MATERIAL AND MARKING
or excavation. Of soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH. LE NGTH NO. OF DISTR. PIPE SPACING COVER PCIA Jt PITS JLIQUID
BED/TRENCH _ c TRENCHES MA AL DEPTH
DIMENSIONS
GRAVEL DEPTH FILL DEPTH L~EV~ PIPF DISTR. PIPE DISTR. PIPE MATERIAL. NO. DI NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH
BELOW PIPE p~ ABOVE COVER NLE1 EL EV END PIPE FEET FROM ,LINE. AIR LET"f
F
U4' a, 4 5 < NEAREST-►
d /
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-
❑YES ❑ meets the criteria for medium sand. TIONS MEASURED.
NO
SOIL COVER TEXTURE PERMANENT MARKERS JOBSERVATION WELLS
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL SODDED SEEDED JMULCHED.
CENTER EDGES.
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH NO. OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD 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
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
❑YES ❑NO ❑YES ❑NO NEAREST
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Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE"' , TITLE.
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DILHRSBD6710(R.01/82) ~ ~ I
w;sconSIn, APPLICATION FOR SANITARY PERMIT
DILHR COUNTY
(PLB 67) UNIFORM SANITARY PERMIT #
1ET InOUSTRV,LRBOR&HUMRn RELRTIOnS J
!/J~~~
-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 MAILIN DRESS
PROPERTY LOCATION °CFT--Y- /
S E 114,/(x` 1 /4, S T,*, N, R J-/ 11 (or) W TOwN oF: s J~' r-
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
a~~f
A
111,4
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms. 3 ❑ Public (Specify):
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.
X 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: o,,,qc ee4i?
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mond In-Ground Pressure
Total #of Pre S to Steel Fiberglass Plastic
Gallons Tanks Co cr t Cons ructed
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):
~a
0 W Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for ins tion of the private sewage system shown on the attached plans.
Name of Plumber (Print): gnature. c MP/MPRSW No.: Phone Number:
Plumber's Ae}dress: Name of Designer:
A' CcJ s - rn •e
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
❑ Owner Given Initial
n 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
r
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 of master plumber restricted who will install the system, ci
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.
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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 `~B te" C
Location of Property b-N 14, Section. T .1 N R W
Township
Mailing Address
Subdivision Name
Lot Number ~co
Previous Owner of Property
Total Size of Parcel AIAL4 1- ctic U
Date Parcel was Created
Are all corners and lot lines identifiable? X 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:
1. 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) eeAti..6y that ate statement6 on this 6onm oAe ttu.e to the best o6 my (our.)
knowledge; that I (we) am (an.e) the owner(s) o6 the pnopenty debcnibed in thiA
.in6o4mat.ion 6o4m, by vi tue o6 a warranty deed neeonded in the 066.iee o6 the
County Reg-i.dten o6 Deeds a,e Document No. l Cx:" -C, 5- ; and that I (we)
p4esentZy own the proposed 6 to bon the sewage di4po-,6-a-E-.6ystem (on 1 (we) have
obtained an easement, to hun with the above desCni,bed pnopenty, bon the
con.6txucti.on o6 said system, and the same had been duty tecoxded in the 066ice
o6 the County Reg" eA o6 Dee as Document No. y~ ~ ) •
SIGNATU OF 0 ER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
H
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ST C'-105 r
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SEPTIC TANK MAINTENANCE AGREEMENT Ho
St. Croix County z
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OWNER/BUYER
ROUTE/BOX NUMBER Fire Number
~.~~~v~i;~; ZIP j1jC7~L
CITY/STATE
PROPERTY LOCATION:-'-"Z- 4, 4, Section TtiY_N, R"7 _W,
Town of ~G3'S~`' 75;~✓h l ' 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
I
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. yo
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with H
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 witiin ays
of the three year expiration date. /
SIGNED '6
i
D ATE St. Croix County Zoning Office
P. 0. Box 98,
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
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DEP°aRTNTOF. REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS
INC~USTRY, c DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 53707
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATION:4y7 SECTION: TOWNS HIP/~: LOT NO.:BLK. NO.: SUBDIVISION NAME:
'/a r/a /T2~'N/Ri71(or Wry ✓~i iii
COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
L19 Residence L~ NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
New ❑Re lace
1-3 -
RATING: S= Site suitable for system U= Site unsuitable for system
rCON E NTff D: IN-GROUND-PRESSURE: SYSTEM-I~Fl HOLDIN~TA : RECOMMENDED SYSTEM:(optional)
S S DU ❑S NU ❑s❑s
[.n:d Tests are NOT required DESIGN RATE: any portion of the tested area is in the
H63.09(5)(b), indicate: [Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH W ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B -
W, 3q
B- ~-~v21 "R
' 1C
B- , Z, 2~~
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER +Ne-I+E-& AFTERSWELLING INTERVAL-MIN. PERIOD t PERIOD 2 PERIOD 3 PER INCH
P-
p- _2
P- 3~'' 3 .
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 q5~ /
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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:
~Ve_ 2
ADDRESS: CERTIF CATION NUMBER: PHONE NUMBER (optional):
aSS~ 7if qq-3379
S -TUREE:` ,
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
N TRIkh" ION FOR lPL. 0_ G F0,RP ap s - SBD - 6395 '
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Parcel 028-1035-60-000 01/25/2007 11:23 AM
PAGE 1 OF 1
Alt. Parcel 26.28.17.216F 028 - TOWN OF RUSH RIVER
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 -KRUEGER, MARY
MARY KRUEGER
181 CTY RD Y
BALDWIN WI 54002
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 181 CTY RD Y
SC 0231 BALDWIN-WOODVILLE AREA
SP 1700 WITC
Legal Description: Acres: 4.660 Plat: N/A-NOT AVAILABLE
SEC 26 T28N R1 7W 4.66 AC IN E 1/2 NW 1/4 Block/Condo Bldg:
COM 402.45 FT S & 862.5 FT E OF NW COR
SE NW, TH E 453.6 FT TO 1/4 LN, N 421 FT Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
TO CL HWY, N 79 DEG W 451.6 FT, TH S 501 26-28N-17W
FT TO POB
Notes: Parcel History:
Date Doc # Vol/Page Type
11/02/2006 837972 WD
11/02/2006 837971 QC
02/27/2006 819307 EZ-U
04/21 /2003 717815 2210/378 WD
more...
2006 SUMMARY Bill Fair Market Value: Assessed with:
166169 207,100
Valuations: Last Changed: 08/30/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.000 20 000 151,300 171,300 NO
PRODUCTIVE FORST LANDS G6 3.660 21, 800 0 21,800 NO
Totals for 2006:
General Property 4.660 41,800 151,300 193,100
Woodland 0.000 0 0
Totals for 2005:
General Property 4.660 41,800 151,300 193,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 117
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00