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Form - S T C V-O4
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SEC.-1 T- / N-R W
ADDRESS - % ST, CROIX COUNTY, WISCONSIN
SUBDIVISION LOT - LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H 63 /
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDICATE NORTH ARROW
BENCHMARK: Describe the verzical reference point used tij } ~L 1
Elevation c,f vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer: liquid Capacity:(
Number of rings used: - Tank manhole cover elevation: rr
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side,Q Rear, O feet
from nearest property line Front, 0Side, 0Rear, 0 feet
Number of feet from: well building- i'
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE KEVRIZSI? S I DF
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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: / Trench:
Width: Length: r Number of Lines: Area Built:/
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side,O Rear,r' Ft:
f
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 0 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, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
/ ter,' _q {
Dated Plumber on Job:
7 if, i r,c .~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 5707
nCONVENTIONAL ❑ALTERNATIVE st ate Plan l).D. Number
I
El Holding Tank El In-Ground Pressure ❑ Mound If assigned
NAME OF PERMIT HOLDER'. ADDRESS OF PERMIT HOLDER'. INSPECTION DATE.
Denniz Hu ins R. R. 2, New Richmond, W1 I --a 4y
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.
SW SW, Section 24, T31 N-R 18W, Town o j Sta t PnaiAie
Na-, of Plumber. JMPIMPRSW No. County. Sanitary Permit Number.
Cat PoweAz 1563 St. CAoix 49482
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIOUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING CrOV
/ P OVIDED PROVID
X5.5 YES LINO ❑ 4N0
BEDDING'. VENT DIA.: VENT MATE. HIGH WATE NUMBER OF ROAD'. PROPERTY WELL BUILDING VENT O FRESH
ALARM LINE. AIR INLET.
r FEET FROM
DYES LINO G DYES LINO NEAREST
DOSING CHAMBER:
MANUFACTURER. BEDDING. LIQUID CAPACITY PUMP MODEL PUMP; SIPHON MANUFACTURER JWLOCKING COVER
PROVIDE: PROVIDED'.
DYES LINO DYES LINO DYES LINO
J WELL BUILDING; I VENT TO FRESH
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY
(DIFFERENCE BETWEEN FEET FROM uNr[~~ AIR INLET.
PUMP ON AND OFF) DYES LINO NEAREST JJ
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING,
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH: LENGTH NO. OF DISTR. PIPE SPACING COVER INSIDE DIA UPITS LIQUID
BED/TRENCH TRENCHES M/~iiir AL. PIT DEPTH.
S Z L
DIMENSIONS 1112
GRAVEL DEPTH FILL DEPTH K PIPF DISTRPIPE DISTR. PIPE MATERIALNODIST NUMBER OF PROPERTY WELLBUILDINGVENT TO FRESH
BELOP PEI AE CpvER INLE END t. PIP FEET FROM LINE AIR INLET.
l// NEAREST
Y
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 ma certain ~thit ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for med m sand TIONS MEASURED.
DYES NO
~ / A ERMANENT M RKERS OBSERVATION WELLS
SOIL COVER TEXTURE
❑Y S LINO EYES LINO
DEPTH OVER TRENCH:eED DEPTH OVER TRENCH BED DEPTH OF TOPSAIL OD ED SEEDED MULCHED
CENTER EDGES D D LI
❑Y NO YES LINO YES NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH. NO.OF Lf ERAL PACIN RA L DEPTH BE W PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DIST .PIPE ANIFOLD MATERI IN O. DISTR. DISTR. PIPE DISrHIBUTION PIPE MATERIAL & MARKING
ELEV.. ELEV. DIA. ELE PIPES DIA.:
ELEVATION AND
DISTRIBUI ION
INFORMATION HOLE SIZE HOLE SPACING DRILLED COR C LV COV MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
❑Y LINO DYES NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WEL [NIMBER OF PROPT OM LINE:
❑ YES ❑ NO ❑ YES D NO 3,31 REST
2 I z
6-32.-
1
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Sketch System on ty file for audit.
Reverse Side. 49
SIG E TITLE.
DILHR SBD 6710 (R. 01/82)
~ n wisconsin APPLICATION FOR SANITARY PERMIT
~COUNTY
(PLB 67)
Ct,SPRRTTEn?i OF UNIFORM SANITARY PERMIT #
In OUSTRY, LRBOR 6 Humpn RELRTIOnS
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size.
-See reverse side for inst ctions for completing this application. PLEASE PRINT
PRO RTY OWNER MAI NGADDRESS
PROPERTY LOCATION -r-LT-Y:
j VI~.LRGE:
~f 1/k;/0 1 /4, N, R / (or(VO
~'owN OF:
LOT NUMBER BLOCK UMBER SUBDIVISI N NAME NEAREST ROAD, LAKE R LANDMARK STATE PLAN I.D. NUMBER
( ?(2
TYPE OF BUILDING OR USE SERVED 0 ` - -
1 or 2 Family Number of Bedrooms. ❑ Public (Specify): f
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.
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: r
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):
~1ti 'z """2 Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of he private sewage system shown on the attached plans.
Na of Plumber (Prit): Sign urei' MWMPRSW No.: Phone Number
Plum be s Address: 1 / Na me o#~Designer: f/
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
❑ Owner Given Initial
i~,~lit c/ 47 (p'lF~ ~!t } 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 F
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/contractQZ,("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 X241 2~ 1
Location of Property , Sy1 4, Section , T N - R y _ W
Township
Mailing Address
2J
Subdivision Name
Lot Number
Previous Owner of Property
Total Size of Parcel
Date Parcel was Created
Id all corners and lot lines identifiable? Yes No
I Is this property being developed for resale (spec house) ? Yes No
1
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
1 (we) een.titby that a" Statements on ,thin 6onm ane t ue to the best o6 my (oun)
knowledge; that I (we) am (ahe) the owneA(s) ob the pnopenty dani.bed in th,u6
inbowation bon.m, by vi tue ob a wa"-anty deed neconded in the Obbice ob the
County RegiAtei. ob Deeds as Document No. ~-V, ~2 and that I (we)
pneseWy Own the pn.oposed site borp, the. sewage .bpoha~system (OIL I (we) have
obtained an easement, to n.un R i th the above d"oL bed pnopeh ty, bon. the
co"t&uctior ob said system, and the same has been duty n.eeonded in the Obbice
ob e Couw y Regi -tvL ob Deeds, as Document No.
SIGH E CF O'WNEE SIGNATURE OF CO-OWNER (IF APPLICABLE)
ADATE/SIGN,E/D DATE SIGNED
r
S 'f C - 105 r
y
H
SI?P'1'IC TANK MAINTENANCE ACREEMENT o
St. Croix County
c7
H
OWNER/BUYER r rn
z 4441 rS - - - -
ROU`1F/BOX NUMBER Fire Number
C I' T Y / ";TA T E - -LIP ~
PROPERTY LOCA'TIUN: %4, `-4, Section i'N, R__Ls1 __W
'L~ , St. Croix County,
Town of
Subdivisions Lot number-_~
Improper use and maintenance of your sirptic system could result in
its premature' failure to handle wastes. Proper maintenallCC coll-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed sel)tic tank Dumper. 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 maw be eligible to receive it grant Cur
a maximum of. 60% of the cost Of replacement of a failing; system,
which Was in operation prior to July 1, L978. St. Croix County
accepted this program in Atrg,,ust 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
H
three year expiration. o
I/WE, the undersigned, have read the above requirements and agree u,
to maintain the private sewage disposal system in accordance with ~
the standards set forth, herein, as set by the Wisconsin Depart- b
meet of Natural Resources. Certification form must be completed
and.returned to the St. Croix County Zoning Office within 30 days
of the thi yc,ir
S I C N 1', 1)
1) A' C F. 5
f~
St. Croix County 'Louing O1 Lice
1? . 0 . Box 93
Hammond, W : 54015
715-796-22:19 or 715-425-8363
Sign, date and return to above address.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDING
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS \ / MADISON, WI 53707
(H63.090) & Chapter 145.045)
LOCATION: SECTI N: TOWNSHIP/MUNI IPALITY: LOT NO.: BILK. NO.: SUBDIVI ION NAME:
/I3 N/R (or) VII r
C NTY-,: OWN R'S/BUYER'S NAME: MAIL
NG ADDRESS:
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL,DESCRIPTION: ~~yy PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence
❑ New XJ Replace }
3
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND:
IN-GROUND-PRESSURE: SYST M-IN-FILL OLDING TANK: REC MMENDED SYSTEM: (optional)
E
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: LFloodplain, indicate Floodplain elevation: / /
T3
PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTHf$1, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
_W 4664 - lUe rye //`,).E/t
B-
7 17
' iat t
B
B-
Fr PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER I-14CHeS AFTERSWELLING INTERVAL-MIN. PERI 1 PER10 2 PERT 3 PERT H
P- 3 ~
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 o the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope. n k
6 / s~~O
SYSTEM ELEVATION
1 sC~C .?.Q o S7T~ -1
4
TG-ST'S
-
'
70
t
-
,
I
83 AD _sOul 7! oT..~i,Jc
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.
NAMErint): / TESTS WERE COMPLETED ON:
AD R S: CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST 4Sr AT U R E:
l
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. °
DIL-HR-SRD-6395 (R. 02/82) - OVER -
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Fresh Alf Inlets And Obcervotlon Pipe
~ Approval Vent Cap
Mlnlmum l2" AbuVs
Fl-al Grad.
~U- 42" Above Pipe _ 4 Caof Iran
To Flnal Grads Vent Pipe
Marsh Hay Or Synthetic Covering
min 2" Aggregate -
o•er Pip.
DlefrlDullan
Pipe-' 0 0 0 0 -Too
G Aggregole
Beneath pipe 0 Perlorn led Pipe Belaw
o Caypling Terminating At
Bottom Of Syalam
1J l 1 (1 c. I t~ I"'G. C'1 { ._~-.,F_. 1.`a.•~-.
/ I
SOIL FILL
DISTRIBUTIOF.1 PIPE, ~NTM
APMOVEO S ETIC COVER
aMATMJW OR 9" OF STRAW
2"oFAGGfRFGAlE --J~~ OR MARSta HAS
/ OF 1z 21/Z AGGREGATE
E V OF
F EF.T__,~
DISTRIBUTIc71J FIFE TU BE AT LEAST szL_L_- IIJCHES BELOW ORIGIIJAL GRADE
ARIL AT LEASTZO IIJCHES BUT 1.10 MORE THAI H2 INCHES bLLOW FINAL GRADE
MAXIMUM DkPrH OF F-XCAVAT100 FROM U►{IGMJAL 60K WILL BF_ IKJCHES
MMMUM OCPrH OF FACaVATID0 iKOM C4~ i(,IWAL 6RAPE WILL BE INCHES
~ ^ t
LIC E IJ SE IJUMBE 13:
DATE : Ila
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' Parcel 038-1099-60-000 01/31/2007 09:41
PAGE 1 OF I
F
Alt. Parcel 24.31.18.415C 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
O - NIELSEN, KAREN C
KAREN C NIELSEN
2009 CTY RD CC
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 2009 CTY RD CC
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 1.640 Plat: N/A-NOT AVAILABLE
SEC 24 T31 N R1 8W 1.64A IN SW SW COM SW Block/Condo Bldg:
COR SEC 24, TH N 236 FT TO POB: N 260
FT, E 275 FT, S 260 FT TH W TO POB Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
24-31 N-1 8W
Notes: Parcel History:
Date Doc # Vol/Page Type
09/19/2005 806706 2890/459 WD
04/26/2001 643821 1626/307 QC
07/23/1997 512/404
2006 SUMMARY Bill M Fair Market Value: Assessed with:
175515 155,500
Valuations: Last Changed: 10/14/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.640 41,000 96,400 137,400 NO
Totals for 2006:
General Property 1.640 41,000 96,400 137,400
Woodland 0.000 0 0
Totals for 2005:
General Property 1.640 41,000 96,400 137,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 305
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00