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' Wisconlin Department of commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y St. Croix
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)], 3
Permit Holder's Name: ❑ City ❑ Village ❑ wn of: State Plan ID No.:
Buck, Richard 0/11wo & n,fler I Richmond Township
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
w . o' t C* . p' z I gnn #:- 1 - k�l� 026- 1018 -10 -100
TANK INFORMATION E EVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 12-00 Benchmark �. / Igo. 0
Dosing Alt. BM --_�
Aeration Bldg. Sewer Q, t2 93 0 2'
Holdin St! Ht Inlet 3 42 Z/
TANK SETBACK INFORMATION St/ Ht Outlet lo. 3Z 9/• B2'
TANKTO P/L WELL BLDG. Ae nttake ROAD Dt Inlet
Septic ZS 30 ` NA Dt Bottom
Dosing NA Header / Man. Ip, io , /. I N ,
Aeration A Dist. Pipe
Holding Bot. System Slsk�
PUMP/ SIPHON INFORMATION Final Grade
Manu turer emand St cover o '76 ZS
Model Number GPM
TDH Lift L Ion TDH Ft ead
Forc In Length Dia. Dist.Towell
SOIL ABSORPTION SYSTEM • , � � 42•S - D' �» 1
BED/TRENCH Width , No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION 3 3' DIMENSION
SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING M ny f
ur r:
CHAMBER - Std
INFORMATION Type Of
�6 r _ M el Num er:
System: >Z0 - OR UNIT
DISTRIBUTION SYSTEM
Header / Mani d(d Distribution Pipe(s) 1 le Size 1 x Hole Spacing Vent To Air Intake
Length Dia. ength Dia. cing - *Clo t
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed / Trench Edges Topsoil ❑ n va Yes [] No ❑ Yes [] No
ns ec io
COMMENTS: (Includecodediscre ancies person p a e t��
Location: 1730 105th Street, Hu son, VII 5401b llv 1�4 SW 1/4 5 T30N R18W) - 05.30.18.63B -Lot 1 I-L.'s
1. Alt BM Description = 5'] C°""' C �wse w�' Ste""
+It l n
2.) Bldg sewer length= 3D ' ( O T ( • 4
- amount of cover �1►�Z�
3� 6v.,+ - Q 6e- db ✓ w� Jr� � a pc� 3) t t
{�Iw�e. SYy�t tJres A^6a �� �4L�_ bs Soil 4/ I I
C- T L,-, �h�ev-�'`�r � /,o &4 t r
> Z to
Ptar( revision required? ❑ Yes No
Use other side for additional information. lZ Z.`C S
X ,
SBD -6710 (R.3197) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
N*iS ANITARY SCO►1S %I1 PERMIT APPLICATION 2 1 Box Washington Avenue
Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 81/2 x 11 inches in size. 1 G �m
• See reverse side for instructions for completing this application State Sanitary Numbe
Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N
Property Owner Name r Property Location
���� 1 1/4, S T , N, R E (on UW
Property Owner's Mailing Address - Lo Num er Block Number
AiS 4'te � Zip Cod `honeN � umber Subdivision Ipme or CSM Number OF BUILDING: (check one) ❑ State Owned it Vil l a ge e
- / Nearest Road
Public or 2 Family Dwelling - No. of bedrooms 0 Town
III BUILDING USE (If building type is public, check all that apply) P cel Tax Number(s)
1 ❑ Apartment/ Condo Cn�g 2 171 A ssembly Hall 6 ❑ Medical Facility me 10 ❑ Outdoor Recreational Facility
3 E] -
Campground 7 ❑ Merchandise: / Re s ��� 11 C] Restaurant/ Bar/ Dining
4 E] Church/School 8 E] Mobile Home ,aril � � 1.2 E] Service Station /Car Wash
5 E] Hotel /Motel 9 ❑Office/ Facto y s; ,%� Q 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line'A. Ch nje B, if applicable)
A) 1. New 2. ❑ Replacement 3_ ❑ t of �� 4 Reconnection of 5. E:] Repair of an
System 9
-- - - - - -- System ------- - - - - -- Tpnk Only'F ^ - - - -- Existing System - - - - - -- Existing System
t - - - - - -- -------------
B) ❑ A Sanitary Permit was previously issued. Permit Number , ` Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 []Holding Tank
12 [Seepage Trench 22 E] In-Ground Pressure 32 r 42 E] Pit Privy
13 ` Seepage Pit t 43 E] Vault Privy
14 E] C
System -In -Fill r r�
VI. ABSORPTION SY STEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) ,k Elevation
t� &-a-e W___ �a Feet C) ,,2 Feet
Cap acit y
VII. TANK in Ca allo
g Total # of r Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass plast App
New Existing structed
Tanks Tanks
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ I ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plum is Name: (Prin Plumb s ;gnature: (No ps) MP /MPRSW NO.: Business Phone Number:
w
Plu er's Address (Street, City, State, Zip Code):
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Aanitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signat a (No Stamps)
p Approved El Owner Fee) Owner Given Initial d� �2
Adverse Determination
X. CONDITIOhIS OF APP OVAL / �QNIR DISAPPROVAL ,
A,/( 5e7 5 act l , —_ r
SBD -6398 (R. 4199) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber = R
i
INSTRUCTIONS f '
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained: "The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608- 266 -3151. - -
i
To be complete and accurate this sanitary permit application must include:
I. Property owml-.4r's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and-specifications not smaller than 8 112 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location - holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
----------------------------------------------------------------------------------------------------
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
Plot Plan
PROJECT 1J //// �c �// L✓I ADDRESS A�
1/4 1/4S /T ? N/R W TOWNex�"Aly11velkOUNTY
Byron Bird Jr. 220527 – – DATE ' ee BEDROOM
CONVENTIONAL IN -GR D PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZ LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE ABSORPTION AREA / of chambers a
BENCHMARK V.R.P. o m W/tf � SSU ELEV T - 100'
❑ BOREHOLE • WELL *H.R.P. /��
SYSTEM ELEVATION
j6'Long ent
Sidewinder High
Capacity Leaching
Chamber with 31.8 ft A2
per chamber
34" Grade at System Elevation
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Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Divisi5ir.,afety and Buildings Page of
Bureau lfn Services in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and f
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION - Please print all information Re 'wed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
Govt. Lot plok 1/4 �2 1 /4,S T e ,N,R � E (o&l
Property Owner's Mailing Address C/ Lo Block# Subd. Name or CSM#
City 4 State Zip Code Phone Number City ❑Village T wn Nearest Road
7 101 It o — f
(� New Construction Use: Residential / Number of bedrooms Addition to existing building
(] Replacement ❑ Public or commercial - Describe: -
Code derived daily flow __Z�q6 I7 gpd Recommended design loading rate . �^ bed, gpd/fi gpd/fi?
Absorption area required bed, ft trench, ft Maximum design loading rate _gy bed, gpd/ft gpd/ft
Recommended infiltration surface elevation(s) - ft (as referred to site plan benchmark)
Additional design /site considerations g
Parent material a Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U Unsuitable for system S❑ U � s El s❑ u �S ❑ U El cyl I E] S E �
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD/ft
g Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Li I
Ground
el v
Depth to
limiting Xr (win
fact 9r
min. 7 gO' K
rf - Remarks:
Boring #
o ,'/ /' 4 ez
I JV
Ground ' 8
elev.
97— Ift .
Depth to n
limiting
factor Y 0n CR p/X
rA!dre in. Remarks: Name (Please Print) Signatu �` ` FCC Telepho a No.
ate –;' T Number _
�� �.. G �` �r A oc3 J —✓ `7� _ /�� '�%� 4 3 °
I'I ,
� ` � SOIL DESCRIPTION REPORT
PROPERTY OWNER Page
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
o� 1 ,� S- �� iH G o - J-
Ground
elev.
Depth to
limiting 36 ;
factor
-7
j' Remarks:
Boring #
El d /tti-�2
Ground
elev.
ft.
Depth to
limiting
factpr,
'in.
_ Remarks:
,4 -5 —
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GIRD in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,
Trench
Boring #
Ground
e
1e` =e ft.
Depth to
limiting
facto
7 in Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
' Remarks:
SBD -8330 (R. 07/96)
Soil Test Plot Plan
Project Name Richard Buck Byron Y ird Jr.
Address 964 70th Ave r
Rob Wi 54023 CSTM #220527
Lot � ,�
- Subdivision Date 8/14/
NE 1 /4SW 1/43 T 3 0 N /R W Township Richmond
M Boring Q Well PL Property Line C
BM or VRP Assume Elevation 100 . op of Steel Fence Post
System Elevation 89.6 * H R P Sa as B
Alternate Benchmark Top of Property Line Pipe @ 93.3
105th St.
66'
620'
Alt.
174' Prop Line B.M.
w
v
Pro 4 180' �o
Bedroom
1 House
CD 20' B.M.
r
CD
B -4 20' 20' _ I
1
Rep A Pri A
35'
8 '
68' -3 I
B-
40' -2I
0% Slope
240' Property Line
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer 5l C Q c
Mailing Address 9 - 7 D
.30 2n- �'-- bt`.
Property Address 0
(Verification required from Planning Department for new construction) {�
City /State teU 2 4a 1 0 el Identification Number b -- !D / 8 - /D - /oz)
Pl
LEGAL DESCRIPTION
Property Location A t ' V4, (� V/,, Sec. , T -2 a N
-RJEW, Town of ,d
Subdivision , Lot # _.
Certified Survey Map # E� 9 , Volume 3 , Page # 37,2
Warranty Deed # (/ C�' Volume I _ 16 _ _ _ , Page # 3 ?�
Spec house ❑ yes ($ Lot lines identifiable 0 yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
f the expiration da e.
Cg S LEE/ 0
SIGNATURE OF APPLICANT DATE
OWNER CERTIFICATION
1 (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
TGNA erty described above, by virtue of a warranty deed recorded in Register of Deeds Office. 4 �
o�
OF APPLICANT DA
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * **
** Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
. A► 3 f6
A, 1 l) �` 3 l 0 0&22519
STATE BAR OF WISCONSIN FORM 3 -1998 KATHLEEN H. WALSH
REGISTER Documeat N r
C LAIM EED ST. CROIXOCO., WW1
RECEIVED FOR RECORD
Olivia Bathen, glut- claims to Olivia Bathen and Richard G. Back, as 05 -05 -2000 9:30 AM
Tenants in Common, the following described real estate in St. Croix County,
State of Wisconsin: QUIT CLAIM DEED
EXEMPT ti
CERT COPT FEE:
A parcel located in part of the NE 1/4 of the SW 114 of Section 5, T30N, RI 8W. COPT FEE:
Town of Richmond, St. Croix County, Wisconsin; further described as Lot 1, TRANSFER FEE: 5.40
in Certified Survey Map Sled September 16, 1999 in Vol. 13, page 3723, as PAGES: FEE: 10.04
PAGES: 1
Document Number 610469.
Recording Area
Name and Return Address
Ronald L. Stu
VAN DYK, &BOYLE & SILER, S.C.
Post Office Boa 127
New Richmond, WI 54017
026,1018- 10-100
Parcel Identification Number (PIN)
This is not homestead property.
Dated this day of 2000.
*Olivia Bathen '
i
AUTHENTICATION ACKNOWLEDGMENT
Signatures) ) 7q T� STATE OF WISCONSIN )
)ss.
County )
4- n,�11� Personall came before me this _ day of
authenticated this y day of !`may 2000. y
.2000 the above named
Q to me known to be the persons) who executed the
I
• _c�d - $ I �. foregoing instrument and acknowledge the same.
TITLE: MEMBER STATE BAR OF WISCONSIN
(if not,
authorized by § 706.06, Wis. Stets.)
Notary Public . State of Wisconsin
THIS INSTRUMENT WAS DRAFTED BY My Commission is permanent. (If not, state expiration date:
Ronald L. Siler ' 20 — .)
VAN DYK, O'BOYLE & SILER, S.C.
Post Office Box 127
New Richmond, WI 54017
(Signanttes may be authenticated or acknowledge. Both are not
I
not n �.
610469
`
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V01.13 Page 3723