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Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ~ lei {J y TOWNSHIP IZJ:~, SEC. T _3 ~l N-R W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION 7 LOT LOT SIZE J~
PLAN VIEW
Distances and dimensions to meet requirements of ILH.R 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
zz
a
r
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used 4 /z'_ j4
Elevation of vertical reference point: A6 Proposed slope at site: ~Tp
SEPTIC TANK: Manufacturer: 'We61c'15 Liquid Capacity:
Number of rings used: Tank manhole cover elevation: IDO
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,`) Side,Q Rear, Ofeet
From nearest property line Front,nSide,ORear,O ( feet
Number of feet from: well 4)lkl building:
(Include this information of the bove plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
J
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:
r" (Include distances on plot plan).
4-.
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width:6~z-' Lenith: S(~ Number of Lines: Z Area Built
Fill depth to top of pipe:
Number of feet from nearest property line: Front, ( Side, o Rear,O 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
al""rbtion 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, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated. 2-(~~Plumber on job*./.. - i
License Number: 6e
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LA,13OR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 79,69 BUREAU OF PLUMBING
MADISON, WI 53707
=kONVENTIONAL ❑ALTERNATIVE :State Plan ID Number
J Holding Tank ❑ In-Ground Pressure ❑ Mound ;
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPECTIO ATE.
Arnold M. Beihoffer I R. R. 1, Somerset, WI 54025 v
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV
SW4 NE4, Section 31, T31N-R18W, Town of Star Prairie
Warne of Plumber. MP/MPRSW No County Sanitary PeriniI Nu robe r_
IGary L. Steel 3254 St. Croix 64917
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV. WARNING LABEL ILOCKING COVER
1 PRI~OVtIDED PROVIDED
~f ? h I~IYES LINO OYES LIVNO
BEDDING. VENT CIA VENT MATL. HIGH WATER NUMBER OF ROAD: PROPERTY WELL. BUILDING. JVENTTOFRESH
ALARM FEET FROM uNE ' AIR INLET
OYES NO DYES NO NEAREST ` Z-,;-
DOSING CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LA L LOCKING COVER
P VIDED. PROVIDED.
OYES LINO AY YES LINO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPER LL 1BUILD11G,. FAIR ENT FRESH
E
(DIFFERENCE BETWEEN FEET FROM LINE INLET
PUMP ON AND OFF) OYES NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing JLINt,Tl jDIA-/T11 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 LENGT NO OF IDISTR PIPE SPACING COVER =INSIDE DIA 'PITS LIQUID
l rREyFHES MAI"E~tIAL DEPTH
DIMENSIONS J L- ~1~
GHAVEI_ DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. STR NUMBER OF PROPER TV WEL LBUILDIN6 A VERNT TFRESH
BELaw PIES ABOVE c VER ELEV INLET ELEVEND PIP sn FEET FROM
NEAREST uN NLC
~ ~ ~ rte` r
MOUND SYSTEM:
Mound 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-
OYES LI NO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE PERMANENT MARKERS JOBSERVATION WELLS
(
OYES LINO OYES LINO
DEPTH OVER TRENCH: BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES
EYES LINO EYES LINO OYES LINO
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. JD~STRPIPE DISTRIBUTION PIPE MATERIAL & MARKING;
ELEVELEVDIAELEVPIPES DA..
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
OYES LINO OYES NO
COMMENTS: PERMANENT MARKERS OBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING
FEET FROM LINE.
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
Sketch System on Retain in.county file for audit.
Reverse Side.
SIGNATURE ITITLE,'
DILHR SBD 6710 (R. 01/82)
Wisconsin APPLICATION FOR SANITARY PERMIT
'DILHR
(PLB 67) _^5/.! r X COUNTY OEPRRTTT1EnT OF
1111111 In CIUSTRV, LRHCIR 6 HUTRn gELRTlOnS UNIFORM SANITARY PERMIT #
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8/,x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROP RTY OWNER MAILING ADDRESS
PROPERTY LOCATION 64-T-':
VIL4AGE- ' f _ n
0 1/4 G 1/4, S._3 , V!, N, R 46Y (or) W TOWN OF: ~~4-✓ {'ter Fr
LOT NUMBER JBLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
VV V~7 .0 ac,
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms. 1~-
Public (
73 F Plbllc( Specify):
THIS PERMIT IS FOR A:
"Q New System ❑ Tank Replacement ❑ Repair
El 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 -
E] 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 C)
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):
= S CCU ( Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
NaM"f Plumber (Print): Signature: J ~MPRSW No.: Phone Number:
4C~
Plumber's Ad ess: Name of Designer:
Fs', /0- cc(a - t.,( , , t
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: El Disapproved
❑ Owner Given Initial
!v ySJ 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.
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 r yl,& d,
w
Location of Property It Section / T N - R W
Township Y-1 yq--pl
Mailing Address_ )L,
Subdivision Name
Lot Number `
Previous Owner of Property n~ ? d,
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 1?_3 ~ 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) eeAti6y that aU statements on this 6o)un aAe -tAue to the befit o6 my (ouA)
knowledge; that I (we) am ( ahe) the owneh (s ) o6 the pnopeAty des eye i.bed in this
injonma.ti.on bonm, by vi4tue of a wa4Aanty deed %eco4ded in the 06jice o6 the
County Reg.i.a.teA o4 Deeds as Document No. 2 / ; and that I (we)
phesentf-y own the proposed site 6o& the .sewage diZpo.6 system (on 1 (we) have
obtained an easement, to nun with the above descAibed pnopexty, jon the
con.atxucti.on o6 said system, and the same has been duty neeonded in the 0jjice
o6 the County Regis.ten o6 Deeds, as Document No. ) .
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
z
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ST C- 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT H
St. Croix County z
J, y
OWNER/BUYER i C7 r
ROUTE/BOX NUMBER Fire Number
CITY/STATE ] ZIP
PROPERTY LOCATION: 5 1~4, 4..,// Section,3/ T 11-13 / N, R1,g W,
Town of St. Croix County,
Subdivision y~f ~l Lot number I
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con- i
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. y
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- u
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Office within 30 day
of the three year expiration date.
SIGNED
DATE ' `6 '25 5
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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DUS DEPARTMENT T OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS \ / MADISON, WI 53707
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/ Y: LOT NO.:BLK. NO.: SUBDIVISION NAME:
0 '/a eIa ,'i /T.3/ N/R% (or) W _5
COUN Y: /BUYER'S NAM AILING ADDRESS:
USE ~
NO. BEDRMS.: COMMERCIAL DESCRIPTION: DATES OBSERVATIONS MADE
~~j PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence 1LXNew ❑Replace
✓L o~ Z Z-cS- ~-Z Z-6
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUNDPRESSURE:SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
~S❑U ~S❑UC S❑U ❑S~U ~SZU
plfPercolation Tests re NOT required DESIGN RATE:
If any portion of the tested area is in the
r s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
4~~s' fIl f PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER D€xFh-M, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
17
(~9 l0l~€_ `"%S•~, nSl.~ ~ .C,S. 3~ l~1 rno
l
IYJ
_V7. 6.5 51
~ 3
B -
^j i PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER ffiC-HES AFTERSWELLING
INTERVAL-MIN. PERIOD t PERIOD 2 PERIOD 3 PER INCH
P_ b
P- Z / /v 0 3
P- /11 C) -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.
J ~y
SYSTEM ELEVATION
I _
4 '77
"
f.I 00~ ~/n Ate` I°~.y f y 3 ,
6P
E .
A
:
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.A § ) _
5
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:
ADDRESS:
CERTIFICATION NUMBER: PHONE NUMBER (optional):
~lo -6 ZOC~
CST SIC3JVATUR a
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) -OVER -
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Parcel 038-1127-50-100 05/18/2006 12:25 PM
PAGE 1 OF 1
Alt. Parcel 31.31.18.517D 038 - TOWN OF STAR PRAIRIE
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
PATRICK C & SANDRA A LAIS O - LAIS, PATRICK C & SANDRA A
1867 CTY RD C
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 1867 CTY RD C
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 1.130 Plat: N/A-NOT AVAILABLE
SEC 31 T31 N R1 8W PT SW NE LOT 1 CSM VOL Block/Condo Bldg:
6/1535 1.138AC
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
31-31 N-1 8W
Notes: Parcel History:
Date Doc # Vol/Page Type
06/08/1999 604567 1432/464 PR
07/23/1997 1 491 QC
07/23/1997 54/21 (CtM
07/23/1997 714/234
2006 SUMMARY Bill Fair Market Value: Assessed with: a i` y
0
Valuations: Last Changed: 10/15/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.138 79,200 120,300 199,500 NO
Totals for 2006:
General Property 1.138 79,200 120,300 199,500
Woodland 0.000 0 0
Totals for 2005:
General Property 1.138 79,200 120,300 199,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 222
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00