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Form- STC _1
AS BUILT SANITARY SYSTEM REPORT
d
OWNER _TOWNSHIP Sy^ S~~ SEC. X02 T N-R~W
ADDRESS - + ST. CROIX COUNTY, WISCONSIN
w l s C-0,-IS/ n
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I.LHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
r'
OXCA,
~ a
a
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used 11)C~ ►n ~Y-~
i
Elevation of vertical reference point: f0~. Proposed slope at site: S !o
SEPTIC TANK: Manufacturer: i Liquid Capacity: boo
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front 10 Side 0 Rear, O feet
From nearest property line Front,0 Side,0 Rear, O feet
Number of feet from: well building:
(Include this information of the above plot plan)( 2 reference dimenRiE SIDE septic tank)
SEE REVE
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: V Trench:
Width: / Length: Number of Lines:-~- Area Built: /ySf~
Fill depth to top of pipe:
Number of feet from nearest property line: Front; O Side, ® Rear, O Ft.
Number of feet from well: / 00
'
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
r 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, 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
FMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
.OR HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
® CONVENTIONAL ❑ ALTERNATIVE State Plan I D Number
` ❑ Holding Tank El In-Ground Pressure El Mound of assigned)
i
re ~ - cv/S, e f;
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE
Wade Field R~=. -PS S.0J
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.. CST REF. PT ELEV
NW-1, NW-,, Section 12, T31N-R19W, Town of Somerset
Na,- of Plumber. MP/MPHSW N,>. Co~~~1y Sanitary Permit Number_
Calvin Powers
i Jr. 1563 St. Croix _ 169616
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LCAPACITY TANK INLET ELEV TANK OUTLET ELEV. WARNING LABEL LOCKING COVER
PROVIDED PROVIDED.
DYES ENO DYES ENO
BEDDING: VENT DIA.. VENT MATI HIGH A UM OF ROAD. PR DPERTV WELL BUILDING JVENT TO FRESH
A AH A _ FROM LINE AIR INLET
DYES ENO L S ❑N EAREST
DOSING CHAMBER:
MANUFACTURER BEDDING. LIOII ) C ACI T 1P WIDE I Pl1MP SIPHrIN M1^ANDI A,- 1UHE47 WARNING LABEL LOCKING COVER
PROVIDED PROVIDED.
DYES ENO DYES ENO DYES ENO
GALLONS PER CYCLE: 111-P AND CONTROLS OPERATIONAL NUMBER OF PI(nPEHTY [NFU BUILDING IVENTTO FRESH
(DIFFERENCE BETWEEN FEET FROM LVF AIR INLET
PUMP ON AND OFF) DYES C_ !.NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing F'+";-I • nInME 11 1; IMATIRiAL 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:
WIDTH LENGTH NO III DIS7H PIPE SPnI:W1, C(bEH 1 INSIDE DIA =PITS LIQUID
BED/TRENCH TRF -~I PIT DEPTH
DIMENSIONS Z
GRAVELD PTH FILLDEPTH DISTH PIPE It ISTH PIPE DISTR. PIPE MATERIAL N. DIS v NUMBER OF PHOPERTV WELL 6U1 DI G' VENT TO FRESH
aELdw PI Es ABOVE COVER E NL{/r~ E y NO PIPE M
S FEET FRO LIN AIR INLET
~ ~ ~ ~ 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-
D meets the criteria for medium sand. TIONS MEASURED.
YES NO
SOIL COVER TEXTURE - II-IMANINT MAHKEHS OBSEHVATIONwELLS
DYES ONO DYES ENO
DEPTH OVER TRENCH HED DEPTH OVER THENCH HFD DEPTH ()F T(IPSfIIL St)DDE I1 JFE UEO MULCHED
CENTER EDGES
L1 YES. ENO DYES ENO EYES ENO
PRESSURIZED DISTRIBUTION SYSTEM:
LATEHAL SPACING (;HA VEVEL DEPTH HE LOW PIP(- FILL DEPTH ABOVE COVER
BED/TRENCH WIDTH LENGTH NO TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO DISTH DISTR PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV. ELEV. DIA ELEV. PIPES DIA.
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING, OHILLED COHHFC I I V COVER MATE RIAL VERTICAL L IFT CORRESPONDS TO APPROVED
PLANS
DYES NO EYES ENO
COMMENTS: PERMANENT MARKERS JOBSERVATION WELLS NUMBER OF PROPERTY WELL BUILDING.
FEET FROM NE
D YES ❑ NO ❑ YES L~ NO NEAREST-
I1
7
t V J
Sketch System on R my file for audit.
Reverse Side.
ISIINATuREY,,.. ITITLI~-~
DILHR SBD 6710 IR. 01/82)
Wisconsin APPLICATION FOR SANITARY PERMIT ~I
13 LH'R COUNTY
(PLB 67) UNIFORM SANITARY PERMIT #
E OEPfiRTTT1 1T OF
A In DUSTRY, LRBOR 6 HUMRn RELRTIOns
-Attaci-i complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less th 8'hx 11 inch~eys, in size,
-See reverse side for instructions for completing this application. PLEASE PRINT (~.a ~r j 0 L'Lj
PROPERTY OWNER MAILING ADDRESS
PROPERTY LOCATION Bi+*:
!1/ W1/4 Al' /4, S T i', N, R 1 - ! (or) W o N oF: j Cr~rrc!~r S ~ t
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE! STATF P AN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED `;~v a~ ~CJ3Y -~D~C>d
1 or 2 Family Number of Bedrooms. '
❑ uhlic (Specify):
THIS PERMIT IS FOR A:
❑ 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.
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 ~6 - I t'l loc" Q
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):
JW Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of rivate sewage system shown on the attached plans.
Name of Plumber (Print)' 1 ISignat OP/MPRSW No.: Phone Number: 1. e Plu er's Address) J Name of Designer:
Jf ~
~.Lhf r „J lid / I C, / '
COUNTY/ DEPARTMENT USE ONLY
Signature o Issuing Agent: Fee: Date:
El Disapproved
9,v 49 .07 ❑ Owner Given Initial
(wI r/}11) 11_e - 00, / 5- 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.
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.
1
APPLICATION FOR SANITARY PERMIT
I
S T C - 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
Location of Property ((-h A/ (A-) 14, Section I , T 31 N - R. W
Township (1y'r-tt ) ~r S
Mailing Address ~ k &
Subdivision Name A.1 14
Lot Number / Z,,
Previous Owner of Property
Total Size of Parcel
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:
1. Warranty Deed 1
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.
PROPERTV OWNER CERTIFICATION
I (We) eeAt i-6 y that at-Z d.ta.temen.te on -th i s 6o4m ane tAu.e to the best o6 my (ouh. )
know.Zedge; that 1 (we) am ( cute) the owneA (s) o6 the pnopexty da c&ibed in .th i.6
.in6o4mation 6o4m, by viAtue o6 a wa4&anty deed teco&ded in the 066-ice o6 the
County Reg.iAteA of Deeds as Document No. ; and that I (we)
pnesentey own the pnopobed z to bon the sewage di6pozat ayb-tem (on 1 (we) have
obtained an easement, to hun with the above de cubed pnopehty, bon the
con,6 t, u c ti-on o j said system, and the same has been duty necon.ded in the O j 6 ice
o6 the County Regiz teA o6 Deeds , as Document No. ) .
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
H
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9
S T C'- 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT Ho
St. Croix County z
r.)
OWNER/HER L,0 r .4
a o-,6 /!7> ROUTE/BOX NUMBER /FIA~e Number
CITY/STATE ~`,1 ZIP
PROPERTY LOCATION: Section L, T N, R W,
Town of ( rsc~'r'. ; ~Un,~,vcs C 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.
0
E
I/WE, the undersigned, have read the above requirements and agree U)
to maintain the private sewage disposal system in accordance with x
H
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 - y
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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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS
N
INDU6TRY, DIVISION
P.O. BOX 76
LABOR AND PERCOLATION TESTS (115) MADIS
ON WI 53707
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION: OWNSHIP/ LOT NO.: BLK. NO.: SUBDI I ION NAME:
/ a ' 0 ' 0`2 / T 3 N/R I I I (or, WT SU
rne-C s>r 04 COUNTY: OWNER'S/641 _ MAIL] NG~IADDRjZ S: _ / I [J fl k~ 1 O d
L
51 C_ t'c Ix "-dc-
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
IResidence ` ;1 ❑New XReplace S--
J -
r
RATING: S= Site suitable for system U= Site unsuitable for system 4
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: NJIF I LL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
ES ❑U IRS ❑U 9S ❑U ❑ S CTU ❑ S ~ ~✓1 -
If Percolation Tests are NOT required DESIGNPATE: If any portion of the tested area is in the
under s.H63.09(5) (b), indicate: Floodplain, indicate Floodplain elevation: A
P OFI-L DESCRIPTIONS
F- 4~
BORING TOTAL DEPTH TO GROUNDWATER F8 CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER gve. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
- ,
B-Z L-1, b -GI 51, L ,1 r23,' Z: :04 5 ~ o- OR, Is Y4)-.Y In _5
L) ,8-2,713n s,/
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 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
AA
A6en~o,Or>~.` At L,., i Ti'ems..
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I, the undersigned, hereby certify that the soil tests reported on this form were made by mein 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): 1 TESTS WERE COMPLETED ON:
UCL-KO-0;/~ ~j -ZE-9S
A RESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
S-VQ
CST SI ATURE:
y
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
'ILHR-SBD-6395 (R. 02/82) - OVER -
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~JVor1~~ Scn,~~,~-T
Fresh Air Inlets And Obcervallon Pipe
C~~ Approved Vent Cap
Mlnlmum 12° Above
Final Grade
l)- 42° Above Pipe -4° Coat Iron
To Final Grade Vent Pipe
Maras Hoy Or Synthetic Covering
Min 2° Aggrapole
Over Pipe
01111trlbullon - Tee
pipe 0 0 0 0 0
6° ApQregol• rr- Pertoraled Pipe Below
I- Cowpling Terminating At
Bottom Of Syblem
SOIL FILL
DI STKIIBU7101' PIPE gPPR_7VE0 pIJNTM
F_TIC COVER
° 'MATER14 ;DP. OF STRAW
rOFJ\GGRE6ATE-~' OR J~A~LSN HAS
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nF REGATF-
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ELEV. OF'~Q FEFT- `
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D15~ RIA'_JTIr")1) PIPE TO PE AT LEAST - iU( HIE 5 BELOW C`PIC IIJAL GRADE
Ak)L Ar LEAS-1 ZO IUCHF_`., f3LIT I,IC) MC1F-F_ TI-IAK.H IKJCHES L9ELOW FINAL GP_ADE
MAXIMUM ®P-PrM OF EXCAVAT100 FKOM 0Kl!G1NAL 6KADF- WILL BIL ' I"CHE5
MIINIMuM ®EP1"H OF EACH AD(DP1 FKOM 11*61WAL GRAIDE WILL BE -INCHES
S161.1ED :
LICENSE 00MBER: ~ l
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DATE.
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Parcel 032-1034-10-000 01/25/2007 12:53 PM
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Alt. Parcel 12. 1.19.165B 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 - FIELD, WADE C
WADE C FIELD
709 CTY RD H
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 709 CTY RD H
SC 4165 OSCEOLA
SP 1700 WITC
Legal Description: Acres: 2.000 Plat: N/A-NOT AVAILABLE
SEC 12 T31N R1 9W CQM-S-LN-RfW--GT-Y-!'W- Block/Condo Bldg:
RUNNING ALG THE LN NW1/4 NW1/4 SEC 12, \
AT A POINT 360'E OF Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
S PARALLEL WITH W LN 291'; TH E PARALLEL 12-31N-19W
WITH N LN 300'; TH N TO S LN OF R/W; TH
W TO POB
r
Notes: Parcel History:
Date Doc # Vol/Pag Type
07/23/1997 891/554 /
07/23/1997 687/230
07/23/1997 541/584
2006 SUMMARY Bill Fair Market Value: Assessed with:
145218 162,600
Valuations: Last Changed: 07/23/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 32,000 91,300 123,300 NO
Totals for 2006:
General Property 2.000 32,000 91,300 123,300
Woodland 0.000 0 0
Totals for 2005:
General Property 2.000 32,000 91,300 123,300
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 130
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00