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.wsaonsirt Department of Commerce PRIVATE SEWAGE SYSTEM County-
Safi* and Buildings Division INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) SanitarxeermitNo.:
Personal Information you provice may be used for secondary purposes [Privacy Law, s.15.04 0)(m)). 383806
Permit Holder's Name: ❑City C] Village J:I Vbwrk*e State Plan ID No.:
Lange, Lyle Richmond Township
CST BM Elev.:• Insp. BM Elev.: BM Description: Parcel Tax NA
v � v 6 � S �• �� 026 - 1021 -10 -000
r TANK INFORMATION EL E ATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic d a O Benchmark /00. /S AO
D05tn9 Z we P oo Alt. BM
Bldg. Sewer
olding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet Z..5' 3 f.2. 4 2.
TANKTO P/L WELL BLDG. Airi to ntake ROAD
Air I
Septic 7� l yV` 1 - Z 7, NA
pak6e►g Z e � �' S -� ys-r NA Header /Man. A0 f2. /,5-
r -rs ? .If r .
Aerati NA Dist. Pipe y T o o q2 ,
Holding Bot. System Z y 1 .2$'
PUMP/ SIPHON INFORMATION Final Grade
S
b
,
fadurer - Demand St gZci
Model Numbe M
TDH Li Friction m TDH F �,
oss ea
Fo main I Length Dia. Dist. To we
SOIL ABSORPTION SYSTEM
2, —
BED / REN Width Length S` 2s- No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIME DIMENSION
" L Manuf ct rer:
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM
INFORMATION Type O HAMBE Moe Numb
I i
_ System: COhv y / - � -� �• � � �� OR UNIT
DISTRIBUTION SYSTEM Abu
Header /Mani of Distribution Pipe(s)�, x Hole Size x Hole Spacing vent To Air Intake
Length Z 0 Dia. y Length 33�G s ' Dia. Spacing 3" S /v4
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 ❑ Yes [] No ❑ Yes ❑ �No
COMMENTS: (Include code discrepancies, persons present, etc.)
Inspection #1: !L 1 y / 0D Inspection #2:
Locatim 1768 95ir; Street, New Richmond, WI 54017 (SW 1/4 NE 1/4 6 T30N R18W) - 06301873B
1.) Alt Al Deseriptwn =i,, ow Laden s6 r�... i hG5 s (��� ir• 214
2.) Bldgsewer lenga'' _ to Lk
- amount of ce- :-r =
4 , k %,�e�. Sf: q ��Y wc�r' Gda s 46a,• �o h 7
Plan revision required? ❑ Yes 0 No 6
Use other side for additional inforniation. Z vv
SBD -6710 (R.3197) Da Inspector's nature
a Cert. No.
X
-I I I p
FD ° o
2-o
COUNTY ZONING OFFICE
Certification Statement
For Utilization of an Existing Septic Tank
This is to certify that I have inspected the septic tank presently serving the
L-4 LE- LAOL residence (previous owner: S A M. E ) located in:
S 1/4, NE 1/4, Sec , T LI N, R W, town of �►C rl w�c�►vn ,
County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in
good condition, and it ap ars to be functioning properly.
Last time servi
Did flow back occur from absorption Vstem? Yes No � (If no, skip next line.)
Approximate volume or length of'=ftd: gallons minutes
Construction: �. Prefab Concrete Steel Other
Manufacturer (if known): UO rionu1 rJ
Age of tank (if known): 2 ytA ►2s
(Signatu (Name) Please Print,
RECMO '
mFas z23Z 4 2- i Z / q E 0 7 2000
(Title) (License Number) (D
w sjc
%o10 W4G 0V
Form to be completed by licensed plumber (s. 145.06, Wisconsin Statut
disposer (NR 113 Wisconsin Administrative Code)
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank condition, I certify that the
tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm.
Code (except for inspection opening over outlet baffle).
N Li z Signature r - FF F x '
MP/(MPR ZZ3Z 2 Z cAwp51Wormslcatification 1/97
Sanitary Permit Application Safety & Buildings Division
In accord with Comm 8311, Wis. Adm. Code 201 W. Washington Ave.
sCans�n See reverse side for instructions for completing this application PO Box 7302
Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302
Depdrtment of Cerrtinieree (Privacy Law, s. 15.04(lxm)] (Submit completed form to county if not
state owned
Attach complete plans to the county copy only) for the system. on paper not less than 8 -1/2 x 11 inches in size.
Coun State Sanitary Permit Number ❑ Check if revision to previous application State Plan 1. D. Number
ro'
I. Applic Information - Please Prin all Information Location:
Property Owrw Name Property Location
L -ICE L M1 L, E 5 V✓1 /a A 1/4 S L T A(
Property ownces Mailing Address Lot Number Block Number
r
City, State Zip Code Phone Number Subdivision Name or CSM Number
RL\a R ieNlv` � li� '1/�'( 5'tbl
II. Type of Building: (check one) �,, , ❑ Village
IA I or 2 Family Dwelling - No. of Bedrooms -- * � Town of �) C 4 m o � JD
• Public/Commercial (describe use) :_ ' f ` �E,V tJ
• State -Owned
Nearest Road 1 S j
L i v
ST C ROIX ! Parcel Tax Number(s)�� _ 1BZ /,0 60 6
III. T ype of Permit: Chec ?&,o I
e n 1' f applicable)
3 a
A) 1. ❑ New 2. lacement i Replacement o 5. 6. ❑ Addition to
System 012systern ` a Ilk C Existing System
B) t Date Issued
❑ A Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply)
PKNon- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
• Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
• At-grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other.
V. Dis ersaMeatment Area Information: VSll 2A H/1-11 AP. Nl E /NoE(L 1 C /LTRAZORS
1. Design Flow (gpd) 2. Dispersal Area 1 3. D' 4. Soil A Gcation 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed Rate ( lday /sq. R) (Mintnch) Elevation
�Sv ✓ l� l ZS 6 YZ �� . 3 . `�� , ,7 9J ✓ ��, 5
VII, Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con - Con- glass
New I Existing crete structed
Tanks Tanks
SEPTI 10DO J 00
SEPTV_Y 800 � 1 yJ� C_� ❑ ° ❑ ❑
VIII. Responsibility Statement
I the undersigned, assume respo nsibili for installation of the POWTS shown on plans.
(pri MMSPO
Plumbees Name nt) s ( s): RS . Business Phone Number
.Q mil= F 1 �c 223 Z'fiL 715 — Z7 4 — 3) 41
Plumbees Address (Street, City, State, Zip Code)
20 X - z9S [RE.SS W1 5 9
IX. County/Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps)
R Approved ❑ Owner Given Initial Adverse Surcharge Fee)
Determination Z �DO II Z� Z o �-
X. C Conditions of A /Reasons for Disap /ad%
wit exrsi.1 Sa�/C is kseA� a Ccrt;cQ;H at e� =s:.� 4•' acCa�s �D 6P �isvia(��2>
�E ex %s�."Y sysfe"� needs a6gkl4klea 1/Cr Eawrwi ex, 33.
r S� v V i � ci � r ✓ c o 2v� �.`os� 5.
11 - 22 -99 10:05 CROSS COUNTY ID= 7152943138 P.01
CROSS COUNTRY EXCAVATING
PO BOX 295 /104 CLARK RD,
DRESSER. WI. 54009
(715- 294 -3141
11•
DATE:
TO NAME.
8
` `�-�$Le
FAX NUMBER � '
FROM N AME-
FAX
NUMBER. 7152943138
a
-
NUIVIBER OF PAGES INCLUDING COVER SHEET
IF CONYXZTE AND LEGIBLE INFORMATION IS NOT RECEIVED, PLEASE
CONTACT US. TRANK'YOU.
11 - 22 -99 10:05 CROSS COUNTY ID= 7152943138 P.02
LYLE ..1AKL. SW VI WE t4 sec L - 7.3v i. j2 1B y✓'
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of _S
Division of Safety and Buildings
in accordance with Comm 85, Wt's. Adm. Code 5
County
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must
include, but not limited to; vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. _
Please print all information. wed ' —� Date
i Personal information you provide may be used for seconds Q. (Privacy Law, s. 15.04 (1) (m)).
Property Ow er \ x a \, ! �`\ Property Location
y' `;' `• Govt. Lot 114 114 S T N R(or 1N
Prope wner's Mailing ress , , of # Block Subd. Name or X114#
City Stat Zip Nufnber City ❑ Village Town Nearest Road
z (i
❑New Construction Use: JZ Reside rlxtaN u dooms /` Code derived design flow rate GPD 3
�r
Replacement Public or o al - DescR:
Parent material
oo
Fld Plain elevation if applicable ft,
General comments
and rec , s frs�z.�• E-C ���5� —
F/-1 ❑ Boring
y
Boring #
® Pit Ground surface elev.-�6-- 7
ft. Depth to limiting factor =� ��� in. �
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2 u.
S.
_ s
O
❑
8a Boring -Boring # "1` v
Pit Ground surface elev. �'�, ft. Depth to limiting factor /S in.
Soil Application Rate v
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. C nt. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
-L ✓ '
3
4( ° q f , �k 3
' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name ease 'nt Signatur CST Number
- AJA
Address a Evaluation Concluded Telephone Number
I �
Property Owne ' Parcel ID # - - Page of
�' -?Z / / /
F-31 Boring # Boring
® pit Ground surface elev. _ Wr9 � ft. Depth to limiting factor > / �'S in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
6 /
T
X32.11
Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth . Dominant Color > Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2
❑ Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 - 264 -8777.
SBD -8330 (R.6/00)
/�OUSC Wit"/AZ
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R5
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer LEI LE L AW_-7k
Mailing Address 1 L b '7 5 T N ST ALW Q id - ri ak3 ti Mt/ 51M
Property Address S AmE
(Verification required from Planning Department for new construction)
)
City /State Parcel Identification Number D2 4* - /OZ 1 - /D
LEGAL DESCRIPTION
Property Location -SW ' /a, W& '/<, Sec. /— , T 3 o N -R )B W, Town of V-►dAX\,
Subdivision , Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # 3 1 7 D 3 Volume Page #
Spec house ❑ yes ❑ no Lot lines identifiable ❑ 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 wastewater disposal 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.
I/we the undersigned have read the above requirements standards
gn q is and agree to maintain the private sewage disposal system with the Stan
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
days f the three year expiration date.
/6 / 31 / 0 0
SIGIJKTURE OF APPMANT DATE
OWNER CERTIFICATION
I (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
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
) ItZ �92�CC �v / / xx:!�
S15RA OF APPLICA017 DATE
* * * * ** 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 Re gister of Deeds office
PP Pe h' g
a copy of the certified survey map if reference is made in the warranty deed
I
DOCUMENT NO. STATE BAR OF WISCONSIN —FORM 3
QUIT CLAIM DEED
317030
THIS SPACE RESERVED FOR RECORDING DATA
BY THIS DEED VirginiA M_ rlymtmr ____ — eEGISTERS OFFICE
ST. CROIX CO., WIS.
Grantor __ , Recd for Rocofd this � d-
guit- claims to Lyle H Lange and Hong Thi Lange _ _____
husband and wife, as joint tenants Yof__ July _ M. 19_?3
Grantee_, for a valuable consideration 0
"w wl
the following described real estate in St. Croix County, State of Wisconsin:
RETURN TO
All of that part of the Southwest Quarter of the j
Northeast Quarter (SW4 NEh) of Section Six (6) - _ -- - -- -
i
Township Thirty (30) North, Range Eighteen (18) Tax Ke #
West lying North and West of the town road as now This is nOt_ homestead property.
laid out and traveled through said 40, excepting
and reserving to Grantor an easement for ingress
and egress to the pond located in said 40 extending EM
66 feet wide from the most Southeasterly point of #
said town road.
EXEMPT '
This deed is given to correct the title and descriptions contained in
the following deeds recorded in the St. Croix County Register of Deeds
Office:
I
1. Warranty Deed dated January 31, 1973 and recorded in Volume 494
of Records on page 579 as Document No. 314763.
2. Warranty Deed dated August 31, 1970 and recorded in Volume 464 of
Records on page 474 as Document No. 301958.
I
3. Quit Claim Deed dated May 28, 1970 and recorded in Volume 461 of
Records on page 541 as Document No. 300703.
(CONTINUED ON REVERSE SIDE)
�i
Executed at NPw Ri chmond, W i cnnns i n this _. 29th _ day of --,T
SIGNED AND SEALED IN PRESENCE OF (SEAL)
I
__V M. _ C r ___
N/A
(SEAL)
N/A (SEAL)
(SEAL)
Signatures of Virginia M_ Clymer
authenticated this 29th da of June 19 .
G. E. Norman
Title: Member State Bar of Wisconsin *XXbWVXiVy1t
• } QbalOi670i [dt1�X9idCxmdCM�C�?i}.C
STATR OF WISCONSIN 1
13/ County.
Personally came before me, this 11 N/A day of 19�,
the a bove named N/A
N/A
to me knowA } be.the person— who executed the foregoing instrument and acknowledged the same.
z N/A
1 th" 'instlument was drafted by
w,. DO;sr, .Drill, Norman & Bakke
,,, Wisconsin 540 17 Notary Public County, Wis.
w- OrA6 nas of witnesses is optional. My Commission (Expires) (Is)
Itsates of persons siWalaR'in any capacity should be typed or printed below iig.
racE535
"W 'CLAIM DRiD —aTATR BAR OF WISCONSIN, FORM NO. 3 — loll
499 PacE538
•tip -� -t �` y r'.,' �` �:�
4. Warranty Deed dated September 22, 1967 and recorded -in
Volume 436 of Records on page 367 as Document No. 2898k9:
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Form - S T C - 1
L
AS BUILT SANITARY SYSTEM REPORT
r
OWNER � �Y�t�?� �t e (j �C TOWNSHIP SEC . T N-R _W
ADDRESS ST. CROIX COUNTY, WISCONSIN
�1
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
�p
fea
dV/�
,8
s
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PAN
4
INDICATE NORTH ARROW
i
BENCHjrIW: Describe the vertical reference point used
Elevation of vertical reference point: 44 Proposed slope at site:
SEPTIC TANK: Manufacturer: iquid Capacity: d
Number of r`�ngs used: w Tank manhole cover elevation:
Tao Inlet !3levation: —, _ Tank Outlet Elevation: Q �
Number of f:.et from nearest Road: Front,O Side, Rear, 0 feet
From aearest property line Front,OSide,t'ARear,O Iz feet
Number of feet .from: well ^ , building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
i
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 ABSORBTION SYSTEM
Bed: Trench
i
f
Width: Length:( Number of Lines: Area Built
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear, 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
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation Lf ho *rum 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• di
i
Dated: Plumber on job: Z --
License Number:
I
3/84:mj
DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS
I
LABOR &HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISON
P.O,BOX'7969 BUREAU OF PLUMBING
'MADISON, WI 53707
SEA, NW 4, Section 6,T30N-Rl8UXONVENTIONAL ❑ALTERNATIVE (Il a:,Pgned)D. Number
Town of Richmond El Holding Tank ❑ In Ground Pressure ED Mound
HWY 64
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DA E:
Sherman Boucher Route 4 New Richmond WI 54017 �1 y� /
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN'. REF. PT. ELEV.: 1 1' 5T REF. PT. ELEV.
Name of Plumber MP /MPRSW No, '. Counly. Sanitary Permit Number:
Calvin Powers Jr. 1563 St. Croi 102861
SEPTIC TANK /HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.'. TANK OUTLET ELEV: WARNING LABEL LOCKING COVER
(� P OVIDED'. PROVIDED ��yy{{
Y (�GJQIY� 1dOC7 YES ONO DYES La1NO
BEDDING. VENT DIA.: VENT MAIL .: HIGH WATER NUMBER OF ROAD' PROPERTY WELL' BUILDING. 1 1ENTTOF ESH
I� J ALAR- LINE S� AIR INLET
DYES NO 1 ES NO NEARES �-
DOSING CHAMBER:
MANUFACTURER BEDDING: LIQUID CAPACITY PUMP MODEL. PUMP /SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED'.
OYES ONO ❑YES ONO D YES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) OYES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH'. LENGTH NO. OF DISTR. PIPE SPACING COVER INSIDE CIA &PITS LIQUID
BED /TRENCH ' THENC�ES MAT IAL j PIT DEPTH
DIMENSIONS `
GRAVEL DEPTH FILL DEPTH UISTH PIPF DISTR. PIPE DISTR. PIPE MATERIAL. NO. DIST ER OF PROPERTY WELL BUILDING VENT TO FRESH
BELOW PIPES ABU E COVER ELEV. INLET ELEV. END. PIPES LINE n �` ( AIR INLET
"7 EST
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-
meets the criteria for medium sand. TIONS MEASURED.
DYES ONO
SOIL COVER I TEXTURE PERMANENTMARKERS OBSERVATION WELLS
OYES ❑ NO DYES ONO
DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED =PSOIL SODDED SEEDED MULCHED
CENTER E
DGES.
❑YES ❑NO
DYES 11 NO [—]YES ONO
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 MAT ERIAL NO DISTR DISTR PIPE DISTRIBUTION PIPE MATERIAL & A9AHKIN6
ELEV. ELEV.'. CIA.. ELEV. PIPES DIA..
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS
LIFT CORRESPONDS TO APPROVED
DYES ONO — ]YES NO
COMMENTS: PERMANENTMARKERS: OBSERVATION WELLS'. NUMBER OF PROPERTY WELL: BUILDING.
o FEET FROM LINE
h� p n DYES 1:1 NO [:]YES ❑NO q �NEAREST
A. % d�
•�' AGE
Sketch System on i Retain in county file for audit.
Reverse Side.
SIGNATURE TITLE
Zoning Administrator
DILHR SBD 6710 (R. 01/82)
DILHR SANITARY PERMIT APPLICATION oo �/
In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT#
/0 (9
Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER
8% x 11 inches in size.
—See reverse side for instructions for completing this application. PETITION
1. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES IR N O
PROP TY OWNER PROPERTY LOCATION
-5 � ef, M CX f3c) W C cin 145 E' /4 AJ UJ /4, S T Q N, R I R (or) W
PR PERTY OWNER'S MAIL AD RESS LOT NU BER I BLOCK N MBER SUBDIVISION NAME
CITY, STAT ZIP CODE PHONE NUMBE CITY N NEARES / T I RR TI OAD, LAKE OR LANDMARK
VILLAGE: tr y
Y
II. TYPE OF BUILDING OR USE SERVED: C.'!, • 1W • M& —
Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify): N
111. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable)
1. a. X New b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an
System System Septic Tank Only an Existing System Existing System
2. ❑ A Sanitary Permit was previously issued. Permit ## Date Issued
3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements.
4. ❑ The System is shared by more than one owner /building. Attach Common Ownership Agreement to County Copy.
IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2)
1. a. Xconventional b. ❑ Alternative c. ❑ Experimental
2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In -Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. ❑ seepage Bed b. See a e Trench c. ❑ See a e Pit
2. PERCOLATION RATE 3. ABS(5RI AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
3 7 q ? 5 ' 5 – . Feet Private ❑ Joint ❑ Public
VI. TANK CAPACITY I Site
in g allons Total #of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank Do
Lift Pump Tank/Siphon Chamber ❑
VII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of private sewage system shown on'the attached plans.
Plumber's Name (Print): PI ber' Signatu : (No tamps) MP /MPRSW No.: Business Phone Number:
Z F t
P bF er's Address ( reet, City, St Zi ode): Name of D signer:
I
VIII. SOIL TEST INFORMATION
Certified Soil Tester (CST) Name CST #
r L 2 "1
CST's ADDRESS4Street, City, State, Zip Code) Phone Number:
o 0r e w 1 m Z L I 1 1 7 .� I V Z O
IX. COUNTY /DEPARTMENT USE ONLY
❑ Disapproved S nitary Permit Fee Groundwater ate l issui g Agent Signature (No Stamps)
Approved ❑Owner Given Initial �1 �} charge Fe -e9
Adverse Determination
X. COMMENTS /REASONS FOR DISAPPROVAL:
SBD -6398 (formerly Plb -67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION ,
TO THE APPLICANT: '
1. This sanitary permit is valid for two (2) years;
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable;
3. All revisigns to this permit must be approved by the permit issuing authority. A new permit may be needed
if there is a change in your building plans, system location, estimated wastewater flow (number of bed-
rooms, etc.), depth of system, or type of system;
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. Private sewage systems must be properly maintained: The septic tank(s) should be pumped by a licensed
pumper whenever necessary; usually every 2 to 3 years,,
6. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 608 - 266 -3815.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description where the system is to be
installed;
II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat
restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling;
III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or
repair;
IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project
is in conjunction with University of Wisconsin;
V. Absorption system information: Provide all information requested in ##1 -6;
VI. Tank information: Fill in the capacity of every new and /or existing tank, list the total gallons to be installed,
number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete
for all septic, lift /siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. 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. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County /Department Use Only; .
X. Comment area for use by county or resaon given when application is disapproved.
Complete plans and specifications not smaller than 8' /z 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 of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service;
streams and lakes; dosing or pumping chambers; 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.
---------------------- ------ ----------------------- --- — ---------- — ------------ — ---------- — ------------------------------------------- —
GROUNDWATER SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more
commonly known as the groundwater protection law. This change in statutes was the
result of over 2 years of steady negotiation and public. debate. The groundwater bill Ground
included the creation of surcharges (fees) for a number of regulated practices which disco Iws e
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasure
is used in your building is returned to the groundwater through your soil absorption o
system or the disposal site used by your holding tank pumper.
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground- t
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
SBD -6398 (R.03/86)
APPLICATION FOR SANITARY PERMIT
STC - 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 _ � �� m cc 60 tkc—
Location of Pit operty k N W hr, Section , T N -R� W
Township
, ,7—
Mailing Address
�. �Y U '
Address of Site
Subdivision Base
Lot Number IV
Previous Owner of Property C q Le -
0-_ YI C N f
Total Size of Parcel
Date Parcel was Created 2, /3 8 - 2
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes X No
Volume and Page Number 2, 3 V as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A Wartantq Deed which includes a Document number volume and page number and the
Seal of the Register of Deeds In addition, a certified survey, if available, would be
helpful so as to avoid delays of the reviewing process. If the deed description refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATIO
I (We) ceAti.6y that att Atatementh on thin anm ahe th.ue to the best o6 my (oun)
hnautedge; that I (we) am (ahel the owneAf s� 06 the phopeAty deAchi.bed in this
.in6ohmati.on 6onm, by viAtue o6 a waAAanty deed neconded in the 066ice o6 the
Cc�utt y .. RegiA teh o6 Deeds ass Vocument No. O 2 `f1 ; and that I (We) ) pnez en,tt
aun the p�topoeed a i to bon the -sewage dvspo�s AAA em (on I (we) have obtained an
eae emen.t, to nun with the above dens ch i.bed pnopen ty, bon the corutnuctti.on o6 chid
aydtem, and the name hae been duty kecoAded in the 066.tce o6 the County Reg taten o6
Veede , OA .Ooeumen t No. ) .
SIGNATURE Op OWNER SIGNATURE OF CO -OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
e
THIS SPACE RESERVED FOR RECORDING DATA
0OCUMENT N O. WARRANTY DEED
• STATE BAR OF WISCONSIN FORM 2-1982
4 3024' ._ +.
Boo
_ K —7-9.1,._
qq
PA.E _ •x
`� ttEGSTERS OFFICE
ST. CROIX CO., Wis.
Charles A. Donnelly, Jr. and Judith Ann Recd. for Record this 17t -'d.
.. - - -- Donnelly fiusbarid wife ............. ........................ • - - - - -- t I
Way of Sept. A.D. 19
.... •-•--••••-•....--••• ................................•---•-----..........--•----- ........................... 8:30 A
convgs and warrants to .................... .
................. ...............................
S herman R. Boucher and Jean M. Boucher
..... .• .... . - - -. ._. .............. . .•• ..•..._ .......... .r.. .........
...... husband. and as survivorship,.marital
..........
. ... i4 .f.�r •'
Property ..... ..............••• --
•--------------•-•-••-----•--••----..........--•---...............-•----•....--•---- •••..........................
.............................•..................... I.............................. ............................... RETURN TO -
....__. ........................................................................... ...............................
the following described real estate in .............. St . Croix
State of Wisconsin:
Tax Parcel No: ..............................
The Southeast Quarter of the Northwest Quarter of
Section Six (6), Township Thirty (30), Range Eighteen (18).
G
O
This deed is given in partial satisfaction of a land contract ,
dated December 13, 1985, recorded in Volume 728, page 357 -358
as Document Number 407840 in the Register of Deeds Office
in and for St. Croix County.
This .......iS_- 110 't..___. homestead property.
(is) (is not)
Exception to warranties: municipal and zoning ordinances, easements,
restrictions of record and any lien or encumbrance created
by the act or omission of Grantee.
fc. 4
Dated this ............. .- ....._..... day of �- {- ..qt ••-- . ............ ••.........._., 19 7
------------------- ...... ..... (SEAL) . ..... !... ........................... SEAL)
i e................................................................... .... Charles.....
......................-•-- •----- ..._....._•- ••...... - -- (SEAL) ... ... � ..... (SEAL)
Judith Ann Donnell
-• ......................•••-------•-- ••- ••......- ••- •••••......... Judith Y..
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) O Judith A. Donnelly STATE OF WISCONSIN
ss.
.......... .... •--- ....--- -•• -•• j - ............................................. ST. CROIX
--- - ------- - - - - - -- - -- County.
authenticated this /� ---- day of.September 19.8 Personall -- came before me this .4th ------- day of
$eptenl �r. ............. 19..8.7. the above named
.: ' Yn. C --- Ch?rles. nellx...............................
8.40tiPl�!!!!9 ssl� =aia �lQ�
"
4� L tary Public
--- ---- •-------------------------•----•------------.....------•----...------•----------
f not , - ----- ----- - - - -- --- -•..........
,.. authorized by § ?06.06, Wis. State.) to me known to be the person ............ i the
foregoing instrument and acknowled�p�_ jsj�qv %,.
,WSTRUMENT WAS DRAFTED BY n. aNpMa' Q/1j
a -- Law -. Offices ........................... �yt .• -... TA� 0 RY
�esQ??
• mond WI 54017
... • .... .. . -• -S t . -• Q. -- ••• - •
• , ar -- Notary Public ...... �enty,
i 3rt Oraay be authenticated or acknowledged. Both My Commission is permanent. f t, �q t '
1 .are nbt'�z}e�e��sary.) P��� a n „
a � �
date: )
'Names of persona signing in any capacity should be typed or printed below their signatures. ��NOgNN
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc.
FORM No. 2— 1942 ?li:�cackc•t, %V;S.
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ST C- 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT Ho
St. Croix County z
t7
OWNER/ftUANM ,e f r 10, 13 U,J 04 a�� H
t�
ROUTE /BOX NUMBER Fire Number
CITY/ STATE `. �J ZIP
PROPERTY LOCATION :° 1, "k, Section ro T 30 N, R _ W,
Town of L ive7 - kn . / St. Croix County,
Subdivision Lot number 11114. `
� 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
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 ZoU'Ff e within 30 days
of the three year expiration date.
SIGNED 1 inr%
DATE
-- —�
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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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR RE LATIONS PERCOLATION TESTS ( P.O. BOX 7969
HUMAN RE \ 1 MADISON, WI 53707
(H63.090) & Chapter 145.045)
LOCATION: SECTIO • TOWNS HIP /M M: LOT NO.: BLK. NO.: SUBDIVISION NAME:
SE 1 /4W 1 /4 6 /to N/R 1 8f (or) W a n a n a
COUNTY: OWNER'S NAME: MAILING ADDRESS:
R R. 4 New Richmond Wi. 54017
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: C DES RIPTION: PR DESCRIPTIONS: A TESTS:
11 esidence 3 n/a New ❑Replace I 11 - 10 - 87 11 -10 - 8 7
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTI NAL: MOUND: IN- GROUND STEM -IN -FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
D
E] $ U EIS �c ]U ®S OU ❑ S Ex U ❑ S []U conventional trench
DESIGN RATE:
If Percolation Tests are NOT re uired
Q If any portion of the tested area is in the
under s.1-163.09(5)(b), indicate: n/ a Floodplain, indicate Floodpiain elevation: n/a
decimal" PROFILE DESCRIPTIONS Page 27 MD2
BORING TOT DEPTH T GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ELEVATION OBSERVED EST.Hl HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 1 6.58 99.22 none >6.58 .75bl.1. .50bn.s.1. 5.33 bn.c.s. &g.
B- 2 6.83 99.15 none >6.83 .50bl.1. 1.00bn.sil. 1.00bn.s.1. 4.33bn.c.s. &g./
B- 3 1 6-83 100.95 none >6.83 .75bl.1. .75bn.sil. .83bn.s.1. 4.50bn.c.s.
B- 103.50
B 102.31
B-
decimal PERCOLATION TESTS
TEST H WATER IN HOLE TEST TIME DROP IN WATER LEVEL- INCHES RATE MINUTES
NUMBER AFTERSWELLING INTERVAL -MIN. PER t PER1002 PERI0133 PER PER INCH
P-1 3 none 3 6 6 6 <3
P -2 3.57 none 3 4% 4 4 1
P 6 6 <3
r P.
S�,e math bu�.Ilrl $
New
Sy vi�
® V e o, 4 02 4RK 5 1'.-4 f 1�o
p 130t, "5
TReA - X !a 0
S.er -- h T14n1, IOC-� l(j007a�
U S LC, le-
C4vtn ower'S V r
O 63
0' ° � 3 2.' i 3v t
lop
1
a9.K
\� 100, 9S
1 i
.
ELT9, L 2
! V
I f S �• y� Al L !� 5 �� � T 3 o iv l � c✓
hid' Yy V1 �Ca �� �-h cf�
PAGE OF
C r C) 10 a A 13�n Sys e41 -,
Fresh Air Inlsls And Observation Pipe
( Approved Vent Ca
Minlrnum 12" Above
Final Grade
20. 42" Above Pipe _ 4" Cost Iron
To Final Grade Vent Pipe
Marsh Nay Or Synthetic Covering
trio 2" Aggregate
Over Pipe
Oletriballon —Tee
Pips — 0 0 0 0 0
Aggregate
Be neath Pipe o Perforated Pipe Below
Be
o _ Coupling Terminating At
Bolcom Of System
p rupolif
�If:J•.T t or, ��/ / � I
SOIL FILL
DISTRIBU PIPE
APPROVED S4MTHETIC COVER
r o e �-�_ OR 9.� OF ST RAW
MATEIZI
2" OF A6GREGATE —�� r OR N MAy
M ARS
ELEV. OF E� L e !o OF 1 2 - 2 1 �z AGGREGATE '09
F T� ,
DISTRIgtJT10W PIPE TU BE AT LEAST 3 IIJCHES BELOW ORIGIMAL GRADE
AAIU AT LEASTLO IUCHES BUT AIO MORE THAI) 42 IMCNES BELOW FINAL GRADE
MAXIMUM DEPTH OF EXCAVATI FR OM OR116INAL 6KADIZ WILL BE c IAI CNES
MINIMUM 9r �P cy
Prli OF EXCAVATION! O/A. t'14114qL GRAY€ WILL BE Iric"ES
SIGHED:
LICEUSE DUMBER:
i
DATE: 3 l
110 J