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Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP 1vGSSe✓1e f SEC. T N-R~_W
ADDRESS S~f S7/-. ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE g~
PLAN VIEW
Distances and dimensions to meet requirements of ILIIR, 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
~ ~I II
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~ ~r•~ f.ly
E-
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AvIf 711
17
6'4, 74-
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: /po Proposed slope at site:
SEPTIC TANK: Manufacturer: ~l/oes Liquid Capacity: /~Dp
Number of rings used:
Q Tank manhole cover elevation: /®p,B
17'S-e, OWlejL r
Tank Inlet Elevation: JnB~ Tank Outlet Elevation:
Number of feet from nearest Road:
Front, Side, Rear, O /pD feet
.From nearest property line Front, 0Side, ORear, 0 feet
Number of feet from: well //T' building: s~
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
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: .Ar Trench:
Width: Length: S- Number of Lines: J Area Built: y0
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear, e Pt
Number of feet from well:
Number of feet from building: /,7f
(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:
Dated: /6 -Plumber on job:
'
License Number:
3/84:mj
I
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & B IL NGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7$,R9 BUREAU OF PLUMBING
MADISON, WI 53707
N?~~ONVENTIONAL DALTERNATIVE state PlanLD.N-ber
(lf assigned)
D Holding Tank ❑ In-Ground Pressure ❑ Mound
i
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: IN ECT N DATE
Tom Le Mire 190th St., Somerset, WI 54025 ~a
MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: 11-61 111, F. PL ELEV.
NW NE, Section 36, T31N-R19W, Town of Somerset
Name of Plumber. MP/MPRSW No.. Coumy. Sanitary Permit Number.
David B. Fogerty 3289 St. Croix 69660
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY TANK INLET ELEV.: TANK OUTLET ELE V.. WARNING LABEL LOCKING COVER
P OVI D PROVIDED
ES ENO EYES ENO
BEDDING. VENT DIA. VENT MATL HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING. VENT TO FRESH
ALARM FEET FROM LINE ~7 ^ AIR INLET
EYES ENO / DYES ENO NEAREST
DOSING CHAMBER:
MANUFACTURER BEDDING LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED.
DYES ENO DYES ENO EYES ENO
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) DYES ENO NEAREST 11111 1
SOIL ABSORPTION SYSTEM. Check thesoil moisture at the depth of plowing ILFNt;'H JDIAMETER 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:
WIDTH- LENGTH NO. OF DISTR PIPE SPACING; COVER INSIDE DIA -PITS LIQUID
BED/TRENCH .q TRENCHES 7PE HIA DEPTHDIMENSIONS •yJj
GRAVEL DEPTH FILL DEPTH DISTRPIPF DISTRPIPE DISTR. PIPE MATERIALTR NUMBER OF PROPERTY WELLBUILDINVENT TO FRESH
BELOW PIPES ABOVE COVER ELEVINLi ELEVENDZ FEET FROM LINE. AIR INLET.
/ NEAREST--s
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
E meets the criteria for medium sand. TIONS MEASURED.
YES ENO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
EYES ENO DYES ENO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH; BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES.
EYES ENO EYES ENO EYES ENO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH. NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPF. 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
DYES ENO DYES ENO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE.
EYES ENO DYES ENO NE',AREST
Sketch System on county file for audit.
Reverse Side.
SIGNATURE. TITLE.
DILHR SBD 6710 (R.01/82) /
I
wlsconsln APPLICATION FOR SANITARY PERMIT
1;7,DILHR COUNTY
(PLB 67) UNIFORM SANITARY PERMIT #
~ OEGRRTTT1EnT OF
InOUSTRV, LRBOR 6 HUMRn RELRTIOns
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWN R MAILING ADDRESS
Q * J
P O ERTY LOCATION CITY:
VILLAGE:
114111,C1 /4, S , T N, R E (or oWN o
LOT NUMB BLOCK NUMBER SUBDIVISION NAME RE R AD LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED 03~-jG 6 ~d
u'y1 or 2 Family Number of Bedrooms. 3 Public (Specify):
THIS PERMIT IS FOR A:
i1Q 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.
L!!!~Seepaye 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:
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 ,W
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
? / ,S7 P--Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
am of Plumber (Print): gna MP/MPRSW No.: Phone Number:
p 1
ElLi tier's A dress: Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved 12 y ❑ 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
i
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
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 /yli(/ '4 XIA Section, T N - R_ W
Township LQI~R~LS
Mailing Address -Zoe-
Subdivision Name
Lot Number
4-Previous Owner of Property e-
Total Size of Parcel `fir S
-Date Parcel was Created Jay P si /~J~j
Are all corners and lot lines identifiable? r~ Yes No
Is this property being developed for resale (spec house) ? Yes (,~No
Volume 914-1 and Page Number S-(, ! as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed ~f~~E' ~e'/r7~
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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPFRTV OWNER CERTIFICATION
I (We) eettti{y that aU Statement6 on -thii6 6otm ahe ttcue to the best o4 my (outs)
knowledge; that I (we) am (cute) the owneA(s) o6 the pAopenty de,6cAi.bed in this
in4onmation 4o&m, by viktue o6 a watucanty deed teco&ded in the 0j6ice ob the
County Registeh o{ Deeds as Document No, and that I (we)
pnmente.y own the pnopo6ed A to ion the bewage disposi~ystem (on I (we) have
obtained an eab emen t, to tun with the above des nibed pn.opeAty, Ooh the
con,6 tAuctLon o6 z aid b ys tem, and the same had been duty neconded in the O j 6ice
o6 the County Reg.czten o~ Deedb, az Document No.v
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
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STC - 105 r'
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SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
ROUTE/BOX NUMBER ZqD S7`,
JZ~
«Fire Number I
CITY/STATE ZIP PROPERTY LOCATION: (,f~_, ~{f_4, Section 'r--7/ N R _l _W,
I
Town of Z St. Croix County,
Subdivision Lot number
' I
I
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
I/WE, the undersigned, have read the above requirements and agree vii
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-
ATE
St. Croix County Zoning Office
P.O. Box 9£
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
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NDUS INDUSTRY,
NDUS 1'ivITRY, , REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
LABOR ANLD' P O BOX 7969
PERCOLATION TESTS (115 DIVISION
HUMAN RELATIONS (H63.09(1) & Chapter 145.045) ~r MADISON, WI 53707
LOCATION: / SECTION:
~ 36 /T.?/ (o OWNSHIP MUNICIPALITY: LOT NO.: BLK. NO.: rUBDIVIbION NAME:
C UNTY• OWNER'S/BUYS 'S NA E:
MAILING ADDRESS:
USE S 74. l .
r~r~ NO. BED- S.: COMMERCIAL DESCRIPTION: DATES UBSE NATIONS MADE
~1Residence PROFILE DESCRIPTIONS: PERCOLATION TESTS:
11~Kw ❑Replace
rs"" Y / d s
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: Mp:❑~ IN-GROU ~~XJN(J+ pPaSSURE:SYSTEIVI_IaILLHOGTANK: RECOMMENDED SYSTEM: (optional)
SS UU U (u'~S U ~_V
If Percolatio~Tests re NOT requ ired DESIGN RATE:
under s.H63)r indicate: red If any portion of the tested area is in the
Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
NUMBER DEPTH IN, ELEVATION CHARACTER
BORING TOTAL DEPTH TO GROUNDWATER-INCHES OF SO WI H TH KNES , COL R, TEXTUR AND DEPTH
OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B
22
B n f/ ~r S S/ .z,
>
B- 2 /
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B-
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B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. DROP IN WATER R LEVEL-INCHES RATE MINUTES
PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P-
/p
P-
P 3 z,
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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hrc
mS: /Q.fc /may .v .•~`n.t~r~ ~ rrO ~ S~ ,
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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.
E (print):
' TESTS WERE COMPLETED ON:
ADD_R~ESS:
CER FICA ION NUMBER: PHONE NUMBER (optional):
4
2
20 f e~ I Z SIG U
O 'S p2 3
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82)
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T
d ST. CROIX COUNTY
WISCONSIN
g.. ZONING OFFICE
rav~rF r
795-2239 (HAMMOND)
425-8363 (RIVER FALLS)
HAMMOND, WI 54015
January 13, 1986
David B. Fogerty
Fogerty Heights Rd.
Roberts, WI 54023
Dear Dave:
We have been holding the Sanitary Inspection Sheet for the following
system (s) :
Tom Le Mire - Town of Somerset
Please turn the As-Built into this office as soon as possible, so that
we may complete our file.
Until such time as all As-Builts are received by the Zoning Office, no
further permits will be issued, or inspections made.
If you have any questions, please feel free to contact this office.
Sincerely,
Thomas C. Nelson
Assistant Zoning Administrator
mj :1/86
01/25/2007 03:09 PM
Parcel 032-1099-30-200 PAGE 1 OF 1
Alt. Parcel 36.31.19.4618-10 032 - TOWN OF SOMERSET
ST. CROIX COUNTY, WISCONSIN
Current X
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 - LEMIRE, THOMAS
THOMAS LEMIRE
745 190TH AVE
SOMERSET WI 54025
SC = School SP = Special Property Address(es): Primary
Districts:
Type Dist # Description " 745 190TH AVE
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 26.400 Plat: 1531-CSM 06/1531
SEC 36 T31 N RI 9W NW NE LOT 1 OF CSM Block/Condo Bldg: LOT 1
6/1531 ALSO BEG N1/4 SEC 36;TH S 89 DEG Tract(s): Sec-Twn-Rng 40 1/4 160 1/4)
E540.71';TH S 00 DEG E 660';TH S 89 DEG
E 330';TH S 00 DEG E 664.50';TH N 89 DEG 36-31N-19W NW NE
W 843.14';TH N 00 DEG E 1323.21' POB
Notes: Parcel History:
Date Doc # Vol/Page Type
01/12/2001 636746 1575/175 WD
07/23/1997 714/567
2006 SUMMARY Bill Fair Market Value: Assessed with:
145810 425,200
Last Changed: 07/14/2004
Valuations:
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.000 58,000 221,700 279,700 NO
0 42,800 NO
UNDEVELOPED G5 21.400 42,800
Totals for 2006: General Property 26.400 100,800 221,700 322,500 Woodland 0.000 0 0
Totals for 2005: General Property 26.400 100,800 221,700 322,500 Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 09/07/2005 Batch 05-7
Specials:
Category Amount
User Special Code
Special Assessments Special Charges Delinquent Cha 0 00
0.00 0.00
Total