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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM count 9i. Croix
Safety and Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sani'l9s Lfllit No.:
may be used for seconds purposes [Privacy La , s.15.04 (1)(m) . D
'on you rovice secondary P �e 1
Personal ulfom�IaU Y P Y �
�t of � me: ❑ City ❑�t nShip State Plan ID No.:
CST BM Elev. Insp. BM Elev.: BM Description: ParctWt!68 -80 -000
TANK INFORMATION ELEVATION DATA -e 3D' l9• 2.Z8'
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 2 SQ �gr>pghin
Dosing
Aeration Bldg. Sewer
Holdi St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outle& ate 1
TANKTO P/L WELL BLDG. Vent to ROAD Dt Inlet ( A`
Air Intake
Septic aaW - NA Dt Bottom 3 20 QS• �S'
Dosing f3bt > ( CaD > 0� NA Header / Man. p 0 • 3fl
.00 • 40
Aeration NA Dist. Pipe , 9t r
.20 ,• SO'
Holdi S$ab4trtem , i „ To
PUMP / SIPHON INFORMATION Final Grade 3 -So 10
t
Manufacturer
jjfbIM Demand
ti� r , f
Model Number GPM u
TDH I Lift S o Friction,, ya System TDH q�Ft Loss
\5 Forcemain Length -%2pl Dia. 2 Dist. To Well
SOIL ABSORPTION SYSTEM () Q e - 4r�w.►a.�•
BED/TRENCH Width / Le r N O Trenches PIT No. Of Pits Inside Dia. Liquid Depth
D IMENSIONS 3 l 1 2 D IMENSION S
LEACHING nu ure
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM �,,� Ib,r- Sr?>�luh
INFORMATION Type O CHAMBER Mo a Number:
System: CO. y33 > f m 7_0D 7_0D � I
OR UNIT
DISTRIBUTION SYSTEM s�" 171L.
Header/ am old Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. t 9 > �
%ytft 140th Avenue s y Pt g 017 6V*Mnj116014t2&i[8 @B�R )004 3019228 B
.¢eP�kW% ewer length = Depth Over xx Depth Of xx Seeded / Sodded xx Mulched
Bed T_rSFAbf rtgsf cover = Bed /Trench Edges Topsoil ❑ Yes ❑ No C] Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) X� \ LX r - Vv , C Z d a• t, ►_ AOL eel It
► c3v�. �...r
dx-"
CS -es -01
Plan revision required? ❑ Yes K No # It
Use other side for additional information. 1 0T o l ol l
� 1 % Inspector's Signature Cert No.
SBD -6710 (R.3197) L.3;, t�Qc.s
I
LIB Cewelri 3"
Sanitary Permit Application Safety & Buildings Division
In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave.
See reverse side for instructions for completing this application PO Box 7302
N vi sconsin Personal information you provide may be used for secondary purposes Madison, WI 53707 - 7302
Department of Commerce
[Privacy Law, s. 15.04( i)(m)j (Submit completed form to county if not
state owned.)
Attach complete plans (to the county copy only) for the t less than 8 -1R x 11 inches in size.
County r State Sanitary Perm 'Number ❑ C of , to pre i¢u�a lication State Plan 1. D. Number
I
lu
. Application Information - Please Print all Information Location:
Property Owner Name ` r Property Location
e _ ¢ "_? ! n �wl/454�/4, SZ /T , R
Property ai g Address _— Lot Number Block umber
ST CROIX I
couttlY
City, State Zip Code P : N Subdivision Name or CSM Number
II. Type of Building: (ch'6ck one) ❑ City
or 2 Family Dwelling - No. of Bedrooms: ❑ Village
❑ Public/Commercial (describe use) :_ > of �`�
[3 State-Owned LJ
Nearest Road / )O
2 x fig- Paul T ax Number(s)
III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) 77 r 7 7 - — 00 d
A) 1. ❑New 2. acement 3. Replacement of 4. S. 6. Addition to
System System Tank Only A �4 2 Existing System
$) 13 Permit Number Iss
A Sanitary Permit was previously issue
IV. Type of POWT System: (Check all that apply) t Z�.% _ Je Tk - ;zz
❑ Non - 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 rsaVPreatment Area Information:
1. Design Flow (gpd ) 2, Dispersal Area 3. Dispersal Area 4, Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade
Re ed Proposed Rate (Gals. /day /sq. R.) (Mtn. /inc Elevation
-�' 3 / , 7 +6
VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete strutted
Tanks Tanks
6 d
Phu
7 ❑ ❑ ❑ ❑
,- t o 06
VIII. Responsibility Statement
1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
P lum is Name (print) Plumber l MP/[ IPRS No. usiness Phone Number , �--9 � .
Plumber's Address treet, City, State, Zip
0 2 �� s 7U
IX. County/Department Use Only
13 Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued I mg Agent S'gnature (No stamps)
Approved ❑ Owner Given Initial Adverse ination Sur harge� S r
Determ
X. Conditions of Approval /Reasons for Dis
► �I l �e�R -P t- s 1Q-e_ ,�a,�� ou` �e� a.
Cgrl_�70tt !A mrm�
P k19 N
PROJECT Peaav Thomas S 818 140th Ave New Richmond Wi 54017
SW 1/4 SW 1 /4s 24 /T 3 W TOWN St. Joseph COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 4/27/01 BEDROOM 3
CONVENTIONAL IN-GROUN D E SURE CONVENTIONAL LIFT XXX HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE 1.2 ABSORPTION AREA 377 # of chambers 22
BENCHMARK V.R.P. Top of Steel Fence Post ASSUME ELEVATION 100 Filter SIM-TEC Wine
❑ BOREHOLE O WELL •H.R.P. Same as Benchmark
SYSTEM ELEVATION 98.7
Alt. BM Top of Steel Fence Post with Orange Ribbon @ 98.2
Well
12' X 52' .
Drainfield 1000 Existing 3
Failing on Bedroom 0
c 0 , T 0 , House
0 15 ' �c. �►. 8�„
M
B -4 100'
Plans Designed Using
Conventional Powts
Manual Version 2.0
125'
T
100'
B -1 Alt.
Vents 50' M.
10'
40' B 2 -3' X 69' Cells with >3'
Spacing
9%
Slope
B -3
Vents
nt
50'
> 12" Sidewinder High
?6ntg Capacity Leaching
Chamber
Grade at System Elevation
34"
140th Ave
PLO PLAN
PROJECT I eaav Thomas DRESS 818 140th Ave New Richmond Wi 54017
SW 1/4 SW 1 /4S 24 /T 30 N/ 9 W TOWN St. Joseph COUNTY ST. CROIX
i
i
MPRS Shaun Bird 226900 DATE 4/27/01 BEDROOM 3
CONVENTIONAL IN -GROU D E SURE CONVENTIONAL LIFT XXX HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE 1.2 ABSORPTION AREA 377 # of chambers 22
BENCHMARK V.R.P. Top of Steel Fence Post ASSUME ELEVATION 100° Filter SIM -TEC Inline
❑ BOREHOLE O WELL *H.R.P Same as Benchmark
SYSTEM ELEVATION 98.7
Alt. BM Top of Steel Fence Post with Orange Ribbon @ 98.2
Well
12' X 52' A .
►� Drainfield 1000 Existing 3
Failing Gallon Bedroom 0 ,
a 0 , Tank
T j 40'
0 15 ,
M
B -4 100'
Plans Designed Using
Conventional Powts
Manual Version 2.0
125'
T
100'
B -1 Alt.
Vents 50 M.
10'
40' 2 -3' X 69' Cells with >3'
Spacing
9%
Slope
B -3
Vents
50'
2L, Sidewinder High
Capacity Leaching
Chamber
34 Grade at System Elevation
IV
140th Ave
j , C " �Q00
Wisconsin "SQ'LUA sconsin De rtment of Commerce �` . REPORT
Division of Safety and Buildings t ' ' UN .
in acc�d�rrbe with Page ,f
g � ode ( '5 ; 1 n
County - C' r O 1
Attach complete site plan on paper not less than ti'i��y1 ; e8 in_�IZe`Y(a�i i ust
include, but not limited to: vertical and horizontal rate d pi t A . and Pamei I.D.
percent slope, scale or dimensions, north arrow, and to d d t o nearest road. r 00 C
Please print aM information. C' 1 /7 R viewed by Date
Personal Information you provide may be used for secondary purposes (Privacy Law, a. 15.04 (1) (m)),
Property Owner Property Location ILL
Property Owner's Mailing Govt Lot s 1/4 ,s /4 S 2 T 3 v N R
I E( W
Lot # I 1311odt # Subd. Name or CSIM
AC., / IV-Z-
Y State Zip Code Phone Number ❑ City C) Village Town Nearest Road
r CA 61 ( J' D
VV-
[3 New Construction User Residential / Number of bedrooms Code derived design flow rate _ GPD
Reptacement (] Public ar mercial - Desaibe:
Parent material Flood Plain elevation if applicable l/ R,
General owynents
and recommendati)ns:
L_J Borg # �] Boring y
Pit Ground surface eley ft. Depth to limiting facto In. Soil Appli=bon Rde
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPOW
in. Munsell tau. Sz. Cont. Color Gr. Sz. Sh. I •Eff #1 I •Eff#2
r2 r
Or-
O
2 Bo " # ❑ Boring �f
C] pit Ground surface elev�% ft. Depth to limiting factor in.
Soil Applicallim Rats
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots G
In. Munsel tau. Sz. Cont. Color Gr. Sz. Sh, •Eff#1 - Eff#2
s - , 5
3 1 & 41 S s
Z. O
• Effluent #1 a BOD > 30 < 220 mg(L and TSS >30 1 150 mgA ' Effluent #2 a BOD 130 mgiL and TSS < 30 n)WL
CST { Print) lure
`1
d Addrew Date Eval Conducted T w NNu rn
l L
Property owner _ Parcel ID # �____ pop d
IN Bonn # �] Boring
' Pit Ground surface elev. JQi 2 k. Depth to limiting factor �� - in. —ia—ApokoWn
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munself Qu. SL Cont. Color Car. Sz, Sh, NEW 'E1S►2
r r V J
2
# t ❑ w
7► �
,.IaA Pit Ground surfM elev. ft. Depth to limiting factor �y lrt, Rob
Horizon Depth Don k*M Color Redox Description Texture Structure Consistence Bountfary Roots Opw
in. Munson Qu. Sz. Cont. Color Or, 3z. Sh. 'LflIM1 •$1fpZ
# ❑ � around surface elev. k. Depth to MTOWg factor M.
❑ Pit -M R111k
Horizon Depth DomirmontCollm Redox Description Texture Structure Consistence Soundeq Root
in. Munsel Qu. Sz. Cont. Color Or. St. Sh. f ool
1
i
Effluent 01 = BOD r 30 1220 n4L arxi TSS 3 -30:1 1 50 mg L • EfBuent #2 . wo, S 30 rr9% and Mg 30 mpfL
The Department of Commerce is an equal opportunity service provider and employer. If you teed aseistanee to acosas serviced or
need material in an alternate format, please contact the department at 608-266-31S 1 or TTY 608 -264 -8777.
seo•nss cs.amol
Soil Test Plot Plan ;
Project Name Peggy Thomas Shaun Bird
Address 818 140th Ave
New Richmond Wi 54017 CST 226900
Lot ----- Subdivision -- --- -- Date 10/28/00
S W 1/4 S W 1/4S 24 T 30 N/R 1 9 W Township St. Joseph
❑ Boring ( ) Well PL Property Line County S T. CROIX
BM or VRP Assume Elevation 1 oo ft. Top of Steel Fence Post with Orange Ribbon
System Elevation 98. *HRP Same as Benchmark
Alt. BM Top of Steel Fence Post with Orange Ribbon @ 98.2
Well
12' X 52' r
Drainfield 1000 Existing Failing anon Bedroom
c 0' T� 0 House
T 0
° 15'
M
125'
105'
104'
g- 103' * t.
M.
5'
' 10'
0'
40' B 40 0'
' 9%
B - 3 Slope
50'
140th Ave
uHAMP�ER CRO: 5CG''Giv C1a}J 4 QF t�i"A'PI f�5
JJJwestaJnee
V C ►j C.& p
• c. _. E P I P c -- T....T
I WLAT.�(RPRRgF �� APPROVED LOCKIAIC+
I I
. 0CR .'JJVC"! ►� �MAQNOLC Cdv
-- aq : RO,h COCA. _ l 0 80X j ER
'1IA4pw OK VRcS
AIR IAJ -Av.0
i � GRADE ---� i
f
IV„�1�{. I \ w rnwww rwn ww4
AIRTliiJi7 SEA
I
A f�l
i ALARM
S �
i {
*APPROVED + I Oki
JOINTS WITH
FT APPROVED PIPE
3' ONTO LMQ
o
SOLID $OI L
COJJCKETC Dt,OC.K
RISER EXIT PrFA!7rCV 0A1LJ IF TAWK /v%AJdUFACTURCR HAS SUCH APPIlOVAJ-
_3PECiF1GAT{ONS
�05t f
TA#4KS MAWUFACrUJiL V, P /� ..r �...„.._ tituM6ER OF DOSES: PER DA:!
TAWK SIZE: 2(o '- 1.3S DOSE NOLWME i
AL-Agm n"wrAc rulkCa: IAI CLd t31N6 DACKFLOW: ' GI�ti�DASs
MODCA L ljUj0k &tR : L` CAPACITIES! A e�r �5 MILS OR GALLONS
swJTCk Ta1PCt 'ti l -,
8 ca. fIJtMES OR Q GALLQIdS
p�M? N1AIJi.1FaCT1,11lf �� G e S JauL+�[S 010. ��� 4AL{.QIJ!
M oa El. ULLMR►tlt: Se 0• Imc ES OR L..S.L GALLOWS
N TWPII:: ✓ r� l Q� l / �'C
— nl P UMP TF:
� AND ALAF(M ARE TO OC
MINIMUM DISCHARQC KATC -.•
r +A GPM +NSTALJ.CD ON / SEPARATt airtewITs
VERTICAL 0IFF9KtQf OCTWCCAI PUJ*u Gfp ARID DJSrWlbUT:ON PIPE.. L�.n.Z. 4 . FEC•'r
+ MJJ;JIMUM NETWORK SUPPLU PRESSUKE5.iMTL. C F,.� ., ZE&� FEET
+ .. r£ET Of i'pRCt I1A1N X ° 6 f 6pFXPR1GTl01J FACTO# L ,._�," ffE7
TOTAL C SWAMIC. HE s � F L IC r
iuF CIt A1AL. D{ME t T. A? K: L.EIvGTh ;WI DTH ! .r.�;LIQUID DEPYH
---- ---- -_ :- I C E 0 5 E A.lU!'1 8 E R
Engineerin D• 40
. k,�` 7
Performance Data
40
PUMP Characteristics
Motor usdt �,�� 20
Moeaol Models $0040011 SH040M2
AetoMA M SWIF40A1 SHEF40A2 V 1
wer 4/10
Fell food Amps 12 1 6.5
Motor Typo Slffdod Pete (4 Pole) 0
a.PJL 1550 10 20 30 40 50 60 10
1 1 � GPM
Voltele 290 Total Head (feet) 10 1 17 31 25 28 30 35
Herb 60
re 120° r MoL Fbdd Teta . f m) 3.0 4.3 5.2 6.1 7.6 $.5 8.8 10.7
NEMA Dodp A GPM (US GPM) 70 60 50 40 30 20 10 0
lexhHoe Om A ( W/—sec) 4.4 3.8 3.2 2.5 1.9 1.3 .63
— F —
EWdWx SIM 11 2 "M" Dimensional Data
So1W 3/4"
W6W 28 3-7i8' 6-WO' (1 e8,211) 1. All dimensions in inches. (Metric for
Power Cord 18/3, Sn, 20' std (98'4 5'(127) in ternatio nal use).
(30' optioad)
( - al 2. (omponent dimensions may
Mater ials of Construction Y°ry } 1/8 inch'
Naadle Swoloss Steel DISCHARGE 3. Not for construction purpose
LubrWW 01 (98.42) 1-11V NPT unless certified.
Moto Ho Cost Iron FLOAT
SWITCH 4. Dimensions and weights are
C Coo � approxitnnte.
Mlaft Stool
Meckoo1 l SW Faces carbon /Car" 5. We reserve the right to make
Shah Seal Sod Body: An" revisions to our product and their
Sprbp Starless Stool specifications without notice.
Bellows: lowN
WW OWN ti -3i8"
Brows• Sloava Bear (26e.92) (258,76)
Lower SM& Row Ild 111aar
Bottom 1Mate Polvestor Ceoted Steel
Fosteun Staloloss Stool a•sra
LOP Inle"W Thomotidook
I r r�1 n 199 yd#nct4 Pumps, Ashiood, Q',,o. W1 Rights Reserved.
" 1 HYDROMATIC" m uthorizeci Loc Distrd itor-
oy Road Ashknd, Ohio 44805 TO. 419. 289.3042 fox: 419- 281.4081
�y 0
Web Site: wwxpentairpump.com unsrri,�
'S Off CIS IN ALL MAJOR CRIES AND COUNTRIES
the allow Poeas of Yow Ahons di—ory for Your !oral Wslr&ujor
r^■" W 02 668Q 1 198 5M N/
- - /rote. 1
.,
ST. CROTX COUN'T'Y ZONING OFFICE
CERTIFICATION STATEMENT
FOR WIMIZATION OF AN EXISTING SEPTIC TANK
This in to certify that I have inspected the septic tank presently serving
the residence lacaGed at : s
see. Z ` t O r Y, R W, Town o- t�� , St . Croix
County, Wisconsin. 'Upon inspection, I certify that I have found the tank and
baffles to be in good condition, and it appears to be functioning properly.
Last time serviced , 2-o6 J
Did flow back occur f ron absorption system? Yes No /)�"- (if no, skip next
1 i.ne .
Approximate volume or length of time: gallons minutes
Capacity:
Construction. Pre?aB 7` Steel Other
Manufacturer ( wn) , b we rS
Age of T (if ) T 0 \
ture ;Named Please Print
zfzzz -5 1 �� 6 aO
(Title ) (License Number
-2
( Date)
Form to be completed by licensed plumber (a. 145.o6, Wi.aconsin statutes) or
licensed disposer (NR 113 Wisconsin Administrative Code)
Plumber (applying for sanitary pexmit) Certification:
In accepting the above statement regarding existing septic tank condition, I
certify that the tank, to the best of my know a e, wi conform to the
requirements of ILHR 63, his. Aden. Code (except f spect' n opening over
outlet c baffle) .
Nance `� � ��''"` � � Signature
MP /MPRS Z2Ga)(Ib_
ST CROUC COUNTY
SEPTIC'TANK MAIN'I"ENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
I
Owner/Buyer ° L f
Mailing ddress g� N
g �
v
Property Address
(Verification required from Planning Department for now construction)
City /State Parcel Identification Number
LEGAL DESCRIPTION
Property Locations' / � %,, Sec: / T �O N -R W, Town of ✓ � v 1�
Subdivision Lot #
Y p . Volume . Page #
Ce i Survey Ma #
Warranty Deed -3 Volume /�� Page #
Spec house O y no Lot lines identifiabl�es 0 no
SYSTEM MAINTENANCE
Improper use and maintenanosof 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 afI"ect 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, restrictedplumber or a licensed pumper verifying that (1) the ou -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 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
stag your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
{lays of th throe year iration date.
SIN F APPLICANT DATE
OWNER CER TW C TION
I (we) certify 11 statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the prop de a ove, by virtue of a warranty deed recorded in Register of Deeds Office.
GNA OF AffiPLIcANT DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * + « *«
** Include with,thls 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 %
Maintenance and Contingency Plan for a Septic System
Maintenance Plan
1. Septic Tank is to be pumped once every 3 years.
2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in
order to extend the maintenance interval of the filter.
3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of
the cells.
4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system.
5. The owner agrees to save this plan.
6. Do not plant trees nor park nor drive over system.
Contingency Plan
1. If system fails, determine cause of failure, use alternate area and install new system or
install system at a lower elevation.
2. Replace any other failing components as needed.
Plumber: Shaun Bird 715- 246 -4516
PC, "" 7 V 1 9, (1 3 y z 6
We
Shaun Bird #226900
L
DOCILIM,EriT NO.
OTATE BAR OF WISCONSIN FORM 3-1982 TN's 8"Act " 12KRY110 PC" ""uno
QUIT CLAIM DEED
St. Croix
State of Wisconsin: RIETURN TO arren W.
New Richmond, WI 54017
East Half of the Northeast Quarter of the Southwest Quarter of the
southwest Quarter (E� of NEk of SW]% of SWh) of Section Twenty-four
(24), Township Thirty (30) North, Range Nineteen (19) West.
This conveyance is made pursuant to a Judgment of Divorce rendered
in the Circuit Court for St. Croix County, Wisconsin, on October 24,
1994, Case No. 93-FA-291.
Thomas
Signaturew ..... STATE OF
authenticated this ;P, thi nd ..... d o f
in
TITLE. MEMBER STATE BAR OF WISCONSIN
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED Xe
... Richmond. W1 54017 t
(Signatures may be authenticated or acknowledged. Both MWd t1f not, state expiration
are not necessary.) i
W.
QUrr CLAM DEED STATE RAR OF WISCONSIN wiin Lft.1 Bla,,k CO. 1�.
_ ___
• AS BUILT SANITARY SYSTEM REPORT
.'IE11 1• .3, , T0 - SEC. TJON, R W
,0. ADDRE S .._STj,Z ° 4 , J��2�.4 , ST. CROIX COUNTY, WISCONSIN. 9%
'BDIVISION , LOT LOT SIZE .
PLAN VIEW
-Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHI 100 FEET OF SYSTEM
Ll
?TIC TANK(S) MFGR. - _CONCRETE STEEL
NO. of rings on cover Depth DRY WELL
'. "7NCHES NO. of width length area
no. of line widt lengt are
depth to top of pipe
3REGATE 1��2y --:! ct'P_.b- -OTC i
RATE f _,, AREA REQUIRED 4 � AREA AS BUILT -1
:claimer: The inspection of this system by St. Croix County does not imply complete /
:pliance with State Administrative Codes. There are other areas that it is not possible/
inspect at this point of construction. St. Croix County assumes no liability for
tem operation. However, if failure is noted the County will make every effort to
,..ermine cause of failure.
'ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
INSPECTOR
DATED /� — PLUMBER JOB
I
L CENSE NUMBER
r •
REPORT OF INSPECTION-- 174DIVIDUAL SE?JAGE DISPOSAL SYSTEM
s Sanitary Permit //`�
State Septic
'�', E C ' r . TO�.'NSHIP
Crq 'x County
S'?T'TIC T, 4 , TR
„�
S S� k 30 c
S ize gal Ions. "umber r) 7 Compartments
Distance From: Tlell ft. 12% or greater slope fY.
Building £t. Wetlands f~
Fighwater ft.
DISPOSAL SYSiL,b2 Tile Field or Seepage Pit(s)
Distance From: T1C.1?. ft. 12% or greater slope ft
Buil(.inx:, ft. Wetlands f
FIELD bighwater ft.
Total.length of lines ft. -Dumber of lines Length of
each line ft. Distance between lines ft. Width of the
trench ft. Total absorption area sq. ft. Depth
of rock below the in. Depth of rock over tile in. Cover
over rock Depth of tile below grede in. Slope of
trench in ner 100 ft. Depth to Bedrock ft. Depth to
around water ft.
PITS
?Dumber of nits . Outside diameter ft. Depth below inlet
ft. Gravel around *pit: __yes no. Total absorption area
sq. ft.
Square feet of seepage trench bottom area required
I.quare feet of seepage nit area required
.Lnspected by: Title:
Approved Date 197_
Rejected Date 197_
EH 115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION: ``al ��' /a, Section Y, TIC-IN, R 1-5 E (orkg Township or Municipality
Lot No. Block No. r'CI
County c- 111
Subdivision Name
Owner's Name: "''� T) Ince 5j Q
Mailing Address:
TYPE OF OCCUPANCY: Residence \ No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS 7 PERCOLATION TESTS
SOIL MAP SHEET _ 3 SOIL TYP -6' r1� -5 L 7'
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN /IN
YZ,
'' `i �/ �0 5�_ `�` `l
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
0 ✓! > �l - ' Z- o - 71C S
Yl00C -yo5t- J f- /6 '!G 5
2 v f- O - `)LS
S` C O ? cq z /3 Z - yosL
Z 0775 3L - Y-954 _ ; a - iG
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of sui able are s. dicate number of square feet of absorption area
needed for building type and occupancy. j�� b e- J e Indicate scale /
or distances. Give horizontal and vertical referen5F points. Indicate slope. II
o .c,
b y n
P
Of 4 1.�, ► ( Y�
.1
t N
Ci
O 9A 10
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 location of test holes are correct
to i' o best of my knowled77 d belief.
print) C i^ Certification No. s-s —5 3
taller if known
,c_�__ d�
CST Signature
'iORITY
a
State and County State Permit # /
P LB67 Permit Application County Perini —
for Private Domestic Sewage Systems County
•
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
m T am PS 5 v L
B. LOCATION: _ % %, Section T N, R E (or) Q Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township :5r e.
C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance
Single family �c Duplex No. of Bedrooms 3 No. of Person
D. TYPE OF APPLIANCES: Dishwasher _-i� YES NO Food Waste Grinder _YES,� NO # of Bathrooms
Automatic Washer YES NO Other (specify)
E. SEPTIC TANK CAPACITY /OCO Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation _ Addition_ Replacement — Prefab Concrete
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) L 2)�L3) _'T otal Absorb Area /� sq. ft.
NewX Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length '� Z / Width I Z,i Depth Vi�"' Tile Depth L No. of Lines .
Seepage Pit: Inside diameter Liquid Depth Tile Size
y
Percent slope of land �? to $ Distance from critical slope
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared
by the �fiee Soil Vo l '—p
NAME o, UI � c n C.S.T. # S ` �'�� and other information
obtained from CC A --e (owner /builder).
Plumber's Signature MP /MPRSW# /5 � Phone # �y� — s �-��
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in cord with
H62.20, including well). CC i _ / _ j/ 0
,
o
�
°1
Do Not Write in Spac Below FOR DEPARTMENT UU -7 Y
Date of Application O Fees Paid: State Count � Date
Permit Issued /-BAieeted Issuing Agent Name
'nspection Yes No Valid# Date Recd
county (w tM a copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 {{
Mate (pink copy) 4. plumber (canary copy) 1
Revised Date 6/11/76
J