HomeMy WebLinkAbout030-2006-95-004 • C b'i p 1 9 0 2 I 3 A .U . O
m V
I I U
3 0 0 �' o p p I o � o K o ° CO j c' °w •
? C w O? R" 5 C W O 4 W P F+1
a Z Z t co m I o0 o n R m tO
m m m O C N i N CO O
a 7 O 00 y -� I N N a 7 Q
tD n 7 7 O O O A y (D O v �+
otO 3 m 3 1 B rn � fD c a a 3 I o b iv tOr
t c
m co D a I c cn ZD F .. 5
m w a m m co D a m
C N Ia N I z C O. W O N
I 3 O a',m� l N 3 O o m
a - I O L
@
y v OOVO = I 01 y O W= y C
C l C. i 3
'o
Z 000- Z 000-
* I T � <Wz
m -1 c cntn l CO , 3 NNN D
3 �vv 3 �o�eo
M CD
rr I a 5" I S m I Q 5" 3 d rr
w
Z I Z ` �I
Z W Z Z -� Z
O : I @ O
CD I m •
v (D c
m
yy ��Npp �f
I W � m
a 3 I o 3 m 3
z CD o `� o ' t6 I A
I N I y C
a I a i' 7-
I � I
z-+
I W V W
I CL `Z Z
p -� Z
p I g x z
m
9 z I y m
g.
m a a m
3
is R C I N C
Z a I z a
m m I m
C I
I v I
m y
f - I
' ' v
I I
N o
I I I o
I I I a
o f o w
CD I m v
N
o I c
I o i I 0 '10
I �
I
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER " TOWNSHIP SEC. T ,? N —R W
ADDRES ST. CROIX COUNTY, WISCONSIN
17UP�soy
SUBDIVISION S (OU / LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of ILHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
a
C
�o►
J /000 GAL
(5 ,7
t�
I t j ?x'70
� � I sccp�tc� =13
� i r
L1
/O4�D INDICATE NORTH ARROW
S W GOT s ToWe sou ,L
BENCHMARK: Describe the vertical reference point used (V L07 Sr.� /R4A/
Elevation of vertical reference point: Proposed slope at site: 3 9°
SEPTIC TANK: Manufacturer: Liquid Capacity: /Q O 6
Number of rings used: Q Al Tank manhole cover elevation: /0 3 Z Z
�.
Tank Inlet Elevation: Tank Outlet Elevation: AM 6 Q
Number of feet from nearest Road: Frontk Side,0 Rear, O X00 feet
From nearest property line Front 1 0 Side,w Rear, O 2510 feet
/VO eu&zc eq `
S ,
Number of feet from: well building: f
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump del: Pump /Siphon Manufacturer: Pump Size
Elevation of et: Bottom of elevation:
Pump off switch elevat Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nea t property lin Front, O Side, O Rear, 0 Ft .
umber of feet from well:
Number of feet from building:
Include distances on plot plan).
SOIL ABSORPTION SYSTEM
i
Bed: )' Trench:
Width: 19 Length: Q . Number of Lines: Area Built:
I I Fill depth to top of pipe: 36 Al
Number of feet from nearest property line: Front, O Side, O Rear , fit. �
Number of feet from well:
Number of feet from building: 1210
�
(Include distances on plot plan).
SEEPAGE PIT
e: Number of pits: Diameter:
Liquid the Bottom of seepage pit elevation:
Area Built:
Has either a drop box O distribution box O been used on an of the above soil
absorbtion sytems? (Check one
HOLDING TANK
Manufacturer: Ca ity:
Number of rings used: Eleva on o ottom of tank:
Elevation of inlet:
Number of feet from neare property line: Front, 6 O Rear, O Ft.
N er of feet from well:
umber of feet from building:
Number of feet from nearest road:
arm Manufacturer:
Inspector:
Tl- ,•,..,t If Q� 'Rl , } - „ter n„ ;ni,•
-
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
M/AD460,11,4 9J1 53707
NW4, NE4, S34 ! T30N —R19W ffT ❑ALTERNATIVE State Plan I.D. Number:
Ilf assigned)
Town of St. Joseph
El Holding Tank ❑ In- Ground Pressure ❑ Mound
of 3 Stout Addition
NAME OF PERMIT HOLDER: J ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Tom Johnson Route 2, Hudson, WI 54016 7'ri)) _ 87
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF.. PT. ELEV.: CST REF. PT. ELEV:
Name o Plumber: MP /MPRSW No.: County: Sanitary Permit Number:
Donavin Schmitt 3205 St. Croix 96018
SEPTIC TANK /HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
-. / ..YES ONO DYES AaNO
BEDDING: VENT DI .: VENT MATL.: HIGH WATER( R OF ROAD: ROPERTY ELL: BUILDING: VENT TO FRESH
ALARM. FEET Rom, ^ LINE: U0 ,' `AIR INLET:
❑ YES *4NO ` C- 1 " ❑ YES NO NEAR T dOO P � W
DOSING CHAMBER:
MANUFACTURER. BEDDING LIQUID CAPACITY. PUMP MODEL. PU P /SIPHON MANUFACTURER. WARNING LABEL i LOCKING COVER
PROVIDED: PROVIDED:
❑YES ❑NO DYES ONO OYES ONO
GALLONS PER CYCLE: PLIMP AND CONTROLS OPERATIONAL NUMIBER�OF PROPERTY WELL. BUILDING. I VENT TO FRESH
AIR INLET:
(DIFFERENCE BETWEEN FEET FRAM
LINE.
PUMP ON AND OFF) - ]YES ONO AR
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 RCE
the soil is dry enough to continue.) tAA 1 N1 l
CONVENTIONAL SYSTEM:
�y �f WIDTH LENGTH NO. OF DISTR. PIPE SPACING. VER INSIDE DIA.. #PITS: LIQUID
TRENCHES: �( TERIALt O JT DEPTH:
I DI�t1E.hiS1r.C9i' s � _
GRAVEL DEPTH FILL DEPTH DISTR. PIPF DISTR. PIPE DISTR. PIPE MATERIAL: TR NU ER OF PROPERTY WELL BUILDING: VENT TO FRESH
BELOW PIPES. ABOVE COVEH. ELEV. INLET ELEV. END: P PES. :LINE AIR INLET:
to" + 3Cv I to as NE
MOUND
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of t�e fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to m e certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for modium sand. TIONS MEASURED.
1:1 YES ONO
SOIL COVER I TEXTURE PERMANENT MARKERS OBSERVATION WELLS
DYES 1:1 NO ❑YES NO
DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTH OFTOPSOIL. SO DED. SEEDED. MULCHED.
CENTER. EDGES.
❑YES ❑NO ❑YES ❑NO DYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH: NO. OF LATERAL SPACING: GRAVE DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER.
�y{ TRENCHES:
„yr�".�
..,' MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD RIATERIAL, NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
°A . ELEV.: ELEV.: CIA .: ELEV.: PIPES: DIA.:
HOLE SIZE HOLE SPACING. DRILLED CORRECTLY: OVER MATERIAL - . VERTICAL LIFT CORRESPONDS TO APPROVED
., PLANS.
DYES ❑NO
OYES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION LLS: ^R"' ° LIRNE:ERTY WELL'. BUILDING:
n YES ONO S ❑NO ht #
G �l
00
Sketch c� .5
Sketch System on Retain in county file for audit.
Reverse Side.
o ATURE: TITLE:
DILHR SBD 6710 (R. 01/82) Zoning Administrator
SANITARY PERMIT APPLICATION COUNTY
� DILHR In accord with ILHR 83.05, Wis. Adm. Code r
STATE SANITARY PERMIT #
6 6) Ar
—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 �j
1. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION FOR VARIANCE ❑ YES L/11 NO
PROPERTY OWNER PROPERTY LOCATION
7 '/a '/4, S T , N, R E (or
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
oel r
CITY, STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD, LAKE OR LANDMARK
❑ VILLAGE
II. TYPE OF BUILDING OR USE SERVED: Q — aOJ S
Number of Bedrooms if 1 or 2 Family 63 OR ❑ Public (Specify):
III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable)
1. a. L/N 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. ry Conventional b. El Alternative c. El 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. X Seepage Bed b. ❑ Seepage Trench c. ❑ See a e Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
Feet Private ❑ Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
[ Tanks I Tanks structed
r ,
Septic Tank or Holding Tank > ❑ ❑
Lift Pump Tank/Siphon Chamber El El ❑
VII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Name (Print): Plumb 's Signature: (No Stamps) M PRSW No Business Phone Number:
D�)&&&A 5�--*v � , , Plumber's Address ( m
treet, City, State, Zip Code : Nae of Designer:
d
VIII. SOIL TEST INFORMATION
Certified Soil Tester (CST) Name CST ##
z1, -,, s y
CST's ADDRESS (Street, Ci , State, Zip Code) Phone Number:
c u"
IX. COUNTY /DEPARTMENT USE ONLY
❑ Disapproved S nitary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial rcharg� Fee
Adverse Determination ��
X. COMMENTS /REASONS FOR DISAPPROVAL:
kai, Apprc)cel bic�
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
F� •
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 revisions 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 bye pumped by a licensed- 4
pumper whenever necessary, usualiy 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. Prcperty 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' /s 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 ater
included the creation of surcharges (fees) for a number of regulated practices which Wisco IKi'S
0
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- f
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
SBD -6398 (R.03/86)
r
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
Location of Property IZ 3 %, Section , T -R W
Township
T
Mailing Address
Address of Site A&
Subdivision Name
Lot Number
Previous Owner of Property S"' �X ,t_.1�12
Total Size of Parcel
Date Parcel was Created Z 3 _g y
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number VO I as recorded with the Register of Deeds.
1
INCLUDE WITH THIS APPLICATION THE FOLLOWING
A Warranty 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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPFRTy OWNER CERTIFICATIO
1 (We) ceht 6y that att Stdtement6 on this 6onm ane tr ue to the best a6 my (oun)
knowledge; that I (we) am (one) the owner (.$) o6 the pro putty dens cA ib ed in th,ia
.inbonmation 4onm, by vi ttue ob a waAAanty deed neconded in the 066ice o6 the
County Register o 6 De as Document No . os ed s to � q �� to on the sewage ; and that I (W p nes en tey
awn the p p �s di s o-s ss z on I we have obtained an
2 c►� y
easement to nun w.tth the above debcA bed na e�tt on the construction a said
p p N, � �
,aybtem, and the dame has been duty %eco&ded in the 066ice o6 the County Register o6
Deeds, ab Document No. -3 ) .
SIGNAT 0V.OWNER SIGNATURE OF CO -OWNER (IF APPLICABLE)
-,ZL t
DATE SIGNED DATE SIGNED
F-'.
s
z
N
" H
a
STC - 105 r
a
H
SEPTIC TANK MAINTENANCE AGREEMENT 0
0
St. Croix County z
' d
_ a
OWNER /BUYER A0 /"/ s)HA/ Ce A/ M
ROUTE /BOX NUMBER T
z Z Fire Number
,CITY/STATE 61A s6�v �� !`. ZIP_.
PROPERTY LOCATION: , _IVt ' , Section , T ,3.0 N. R_Z_�
Town of /! L Z , St. Croix County,
Subdivision 5j�� �` Lot number .3
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 N
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart - b
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Offkge within 30 days
of the three year expiration date.
SIGNED
DATE 4
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.
leo
`I - i
���
��
i
��,
!� ��
DEP A RTMEIIT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDiJ5TRY, DIVISION
LABOR AND PERCOLATION TESTS (115 ) M
H', %IAN RELATIONS ADISON WI 5370
!,
LOCATION: SECTION: OWNSHIP �Y: L . T �NO.:BLK. NO.: SUBDIVISIO
I VW'10014 i T:3oN /R '91(,, !'" �C7�G2 � �3 e.J/�1�. V• S P 11473
COUNTY: WNE MAILING, DRESS:
}. Cresf� ��c u� gt�+ ,.`f' C?rt 13� d �Jsd•� 1.c�1. 640
USE DATES OBSERVATIONS MADE
P ,�// NO.SEDRMS.: COMM R ALD S R PTION: I NS: TESTS: Residence l / L"iNew ❑ Replace L // /a
RATING: S= Site suitable for system U= S ite unsuitable for system
CO ®ENTIO : M �. �� IN GZ ❑� RE: S S�TEM-I ILL HOLDING TANK: RECOnME�NDI � 'E ( op ti o n al)
I to ,
�
If Percolation Tests are NOT required DESIGN RATE: S S TEM ELEV. If any portion of the lot is in the
under s.H63.09(5)(b), indicate: 0 Floodplain, indicate Floodplain elevation: All
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER - INCHES CHARACTER OF SOIL WITH THICKNCSS, COLOR, TEXTURE, AND DEPTI -1
NUMBER } DEPTH IM. ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
1oz, 3 A/ o kic�, �. 1.5 +� 1,Zsic —7 16' sl ►��
B -,;Z - 1, 1 ,oL. a aV1 7 7t ! ' i, Z GAJ sal �. �,l Z' s z,�,'
B -3 &A Iaz, � 3 � sl
r ,
3 /0 11 � (a . H t .�, ' 1.31J S 1 , v. S i , .
B_ L( - je t - ( 501. 4J0 y 7 7•�l 1•L�3� 3�Z�S 3 t S�
B - , 3 O p ' 7. 2 13 iU },� z t S 1 1 S 1 L
B_
PERCOLATION TESTS C �, C" S
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL -MIN. PERIOD 1 PERIOD 2 R PER INCH
P . 30 -718
P- Z 3, G /V a o f f t cA 5 % 16 1 4 8
P.3.\ '7
P-
P-
PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zantol and vertical elevation reference points and show their !ocatio . on the r,lo: Plat Show the surfaca cI Joi c•, di Al Loringa dnd the disectiun a116 parcent
of land stop.
SYSTEM ELEVATION 9• C ,, i _
P-
'K
i I
A f'ffplout 4
k
P - 3-- _ 0 2. 3_ -__�. _ ��_4 _ _._._ ._ -� 1___ �_ _ __ _ _. _. {��
- _ I e,
f �-
'f�
_
r �a t
6 �_
) E I �
r� {
l rAe ( I
( z I
s'
.w I
7
I !
e .lt�C�.c10 Svu•fh
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin
Admimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLE ED ON:
A
d Z�
CTi
� ADDRESS:
CERTIFICATION UMBER: PHONE NUMBER optional):
2386, zoo 7
10 ir3
o" v 'S CST SIGN ATU
r a
!� DISTRIBUTION: Original -Local Authority, 2nd page-Bureau of Plumbing, 3rd page - Property Owner, 4th page-Soil Tester.
DILHR -SBD -6395 (N. 03/81)
f
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM county: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
430392
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1 xm)).
Permit Holders Name: city Village X Township Parcel Tax No:
Johnson, Tom I St. Joseph Township 030- 2006 -95 -004
CST BM Elev: , Insp. BM Elef : BM Description: Section/Town/Range/Map No:
lap . 4 01e, - CsT" Bwt 1 34.30.19.373J
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
s� o ,os:3•' �,�,
ST -s► tlPr z� r IF Alt. BM
Aeration Bldg. Sewer
Holding
St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO PIL WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic ► r Dt Bottom
50 > lot
Dosing ' f ? r �+ , , � Header /Man. .W
5 +
Aeration ipe
S
/' s4ei—wimi
Holding Bot. System
Final Grade SIA IL
PUMPISIPHON INFORMATION L X.L.". Oli
Manufacturer Demand St Cover I,� 6�l 2 /
GPM
Model Number
TDH Lift on Loss System Head TDH Ft ,
Force m ' Length I Dist. to Well
r'Z S +� �.
SOILAJJ SYSTEM (41 Ck&
dtW RENCIP Width Length I No. Of Trenches r DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIM S 3� 2 i )
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer.
INFORMATION CHAMBER OR ( O D if- E:Q
Type Of V (� > I (yo, , Icb, UNIT Model Number.11. It
DISTRIBUTIONS STEM . F/0
Header /Manifold Distribution ix Hole Size Ix Hole Spacing Vent to Air Intake
Pipe s) ri
r
Length Dia Leng Span
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
ed/Tren Center Bed/Trench Edges Topsoil Fa Yes M No I El Yes ® No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: rs /� 3 Inspection #2:
Location: 661 Pine Valley Trail Hudson, WI t 554�4016 (NW 114 NE 1/4 34 T30N R19W) Unkno
1.) Alt BM Description = 5• -'Z w' G_ Cdr • "r
2.) Bldg sewer length = T +
- amount of cover = ? + +
IJ3 �� � A -•.0 G tv
S -40 ? `r6
• of 4-S 2 46K 61 5 Plan revision Required? Fo + - j
Use other side for additional information.
SBD -6710 (R.3197) Date Insepctors Signature Cert. No.
Safe ty Buildings and Buildin Division County
201 W. Washington Ave. P.O. Box 7082
8t ^ . C ,�
irsconsin Madison, WI 53707-7082 Sanitary Permit Number (to be filled in by Co.)
Department of Commerce (608) 261 -6546 430 3 9 2_
Sanitary Permit Application State Plan I.D. Number
In accord with Comm 83.21 Wis. Adm. Cod e, personal information you provide
may be used for secondary purposes Privacy Law, s 15.04(1 xm) jec Address (if different than mailing address)
I. Application Information - Please Print All Infor
Property Owner's Name Parcel # Lot # 3 Block #
2 200 030 - —ao 46 MT
Property Owner's Mailing Address Property Location
City, State with �(�/ , /., Vim /., Section
p raver to
O nail . nd void circle
11. Type of Building (check all that apply) T 3� N; RE o
it 1 or 2 Family Dwelling — Number of Bedrooms
Subdivision Name CSM Number
Public/Commercial — Describe Use
�z ,
❑ State Owned - Describe Use J ❑Ciry ❑village &Town t ,
III. Type of Permit: (Check out y o on line A. Complete line 8 if applicable)
A. ❑ New System Replacement Syst ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
$• ❑ Permit Renewal ❑ Permit Revision Change of Cl Permit Transfer to New 'st Previous Permit Number and Date Iss
Before Expiration Plumber Owner
IV. Type of POWTS System: Check all that apply)
�!
*Non - Pressurized In -Ground ❑ Mound ? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑
Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑
Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain)
V. Dis ersal/Treatme t Area Information:
Design Flow (go) ign Soil Application Rate(gpdsf) ispersai Area Required (sf) Dispersal Area Proposed (si) System Elevation
— 60JQ f , 4 / r j"5 6
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank - / l
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plu Signature MPIWRSbtumber Business Phone Number
G s�
Plumber's Address (Street, City, State, Zip e)
_-
VIII. Coun /De artment se Onl
Approved ❑Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Is in gent Signature o Stamps)
Surcharge Fee) r� r-b1 ,�., --� �
❑ Owner G iven Reason for Denial L7V
1X. Conditions of Approval/Reasons for Disapproval
SYSTEM OWNER:
1 Septic tank, effluent filter and
dispersal cell must all be serviced 1 maintained
as per management plan provided by plumber.
2. All setback requirements must be maintained
as per applicable code /ordinances.
Attack complete plans (to the County only) for the system on paper not less than gl/2 x 11 inches in site
1
SBD -6398 (R. 08/02)
t�I�pUL dG/�?' e� 1itlSPEtT /on pj/11sS _ _ -
,
i
_
/A 0,-"2-3
i
- -- -- --
D�
2 ,
V' LUC
1 14
�/o TREkc� ! B � � ;lam G� �s•/
Q � XEw ,2G/ GL �iiTE2 74wK _ -
- ,.
j
d E L/
Nt
CUB �
CG - ,7w VA�cE _�.c. --
cDW y._. - -
r
IWAr 3'
s s r — rcll - _ t 96
_ _ Off/ 0
j To � scEL__
J�
P L 1317 Tv�o OF_ ' /l it/E66E cQVC/1 _ S�
J as 0, - A ----,
M
tlorr-
K - pl?lWWAY _
VALVt
EX /srinrG
7A.
1 � I
-
GlDsl.�nt c5'D &6
r _ _ _ _ _ _ - _ _- _ ___ __ __ _ _ - _ __
--
_. _ _ __
_ _ _ __
__ __
_.
___
__
__ __
__ _ _ ___
_. _ _ _ _ __
__ _ __
__
_.
--
__ __
__
__ __
___
__
__ __
_.
__
__ _ _ __
- _ _ _.
1170
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Tom Schmitt
Attach complete site plan on paper not less than 8' /: x 11 inches in size. Plan Pfan must St. Croix
include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. O
Plea Reviewed By •YT - Date
Personal information you pmW may be us or nary purposes (Priv Law, s. 15.04 (1) (m)).
Property owner P 2 4 - Property Location
Johnson, Thomas Govt. Lot NW 1/4 NE 1/4 T 30 N R 19 W
Property Owner's Mailing Addre Lot # Block # Subd. Name CSM# ✓ , L j . ZONING OPEICP 3 � I 661 Pine Valley Trail S7. CROIx COUNTY
Z j Y
City J City _j Village ✓V1 Town Nearest Roa
Hudson WI 54016 1 715 - 549 - 6196 St.Joseph I Pine Valley Trail
a Con ion
Use: ✓_j Residential /Number of bedrooms 4 Code derived design flow rate 600 GPD
acemen J Public or commercial - Describe:
rial Glacial Till Flood plain elevation, if applicable na
General comments
and recommendations: Area is suitable for a conventional system with a 0.4 gpd /sgft rating. Possible system elevation is 96.0'.
F-1 Boring # I Boring
N Pit Ground Surface elev. 100.08 ft. Depth to limiting factor 94+ in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz
"Eff#1 - Eff#2
1 0-6 10yr3/4 none Is 1msbk mvfr gw 1f .7 1.2
2 6 -36 7.5yr4/6 none sl 1fsbk mfr gw .4 .6
3 36 -94 7.5yr5/4 none sl 1 msbk mfr --- .4 .6
❑ Boring # I Boring
e Pit Ground Surface elev. 100.70 ft. Depth to limiting factor 97 + in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
"Eff#1 I `Eff#2
1 0 -7 10yr3 /3 none I 2fsbk mfr gw 1f .5 .8
2 7 -28 10yr414 none sil 2msbk mfr gw ----- .5 .8
3 28-42 10yr5/4 none sl 1fsbk mfr gw - -- .4 .6
4 42 -97 7.5yr4/6 none Is 1 msbk mvfr — -- .7 1.2
' Effluent #1 = SOD 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD <30 mg/L and TSS <_0 mg/L
CST Name (Please Print) Signature: t CST Number
Thomas J. Schmitt @ �2c , 227429
Address Tom Schmitt Date Evaluation Conducted Telephone Number
1595 72nd St., New Richmond, WI 540117 8/29/03 715 -247 -2941
i
Property wner Johnson, Thomas Page 2 of 3
3 ] rtY Parcel ID # a9
F Boring # J Boring
N' Pit Ground Surface elev. 100.84 ft. Depth to limiting factor 96+ in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots 2
*Eff#1 *Eff#2
1 0 -11 10yr3/4 none I 2fsbk mfr cw 1f .5 .8
2 11 -25 10yr4/4 none scl 2msbk mfr gw 1f .4 .6
3 25 -52 7.5yr4/6 none sl 1 msbk mfg gw ---- -- .4 .6
4 52 -96 10yr5/4 none sl 1 msbk mfr — .4 .6
F—I Boring # Boring
J Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
*Eff#1 *Eff#2
F-I 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
*Eff#1 *Eff#2
* Effluent #1 = BOD 5> 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.
•, Pc 3zP3
• a
/1/ofe B OPP17 3 c.ias Clos
eknlu f- eX,3� -�y n n sys
710 / Ile r'/ 57 C/ ' /$
Wit(.!,,e 7 L-e 'n f 7' a /Aoi
NN
X
� uSt
I
r�
—s
M rz a / S e Piny
k4 4L
� � Csv�•e.� �j� e'� ���z- f�
1 71 r 73
1
A'
a,00u I S-- A.,,►; f1�
" �� � �`n e C T
� �/ Ira 1
C ?�r) .2 Y7 W
raw- r x 0.00
1170
Wisconsin Department of Commerce SOIL EVALUATION REPORT P age 1 of 3
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Tom Schmitt
Attach complete site plan on paper riot less than 8'% x 11 inches in size. Plan must County St. Croix
include, but riot limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or danemsions, north am w, and location and distance to nearest road. Parcel I.D.
Please print all information. R By Data
Personal inkimalim You provide may be used for secondary purposes (Pmacy Law, s. 15.04 (1) (m)). do 2 z 7
Property Owner Property Location J
Johnson, Thomas Govt. Lot NW 19 NE 19 S 34 T 30 N R 19 W - ] Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
661 Pine Valley Trail
City State Zip Code Phone Number _J City ]village ✓] Town Nearest Road
Hudson I WI 1 54016 1 715 - 549 - 6196 St.Joseph I Pine Valley Trail
New Construction Use: ✓j Residential / Number of bedrooms 4 Code derived design flow rate 600 GPO
I Replacement I Public or commercial - Describe:
Parent material Glacial Till Flood plain elevation, if applicable na
General comments
and recommendations: Area is suitable for a conventional system with a 0.4 gpd/sgft rating. Possible system elevation is 96.0'.
F-1 Boring # _j Boring
Pit Ground Surface elev. 100.08 ft. Depth to limiting factor 94+ in. Sal Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots PD /fP
*Eff#1 *EW2
1 0 10yr3/4 none is lmsbk mvfr gw if .7 1.2
2 6 -36 7.5yr4/6 none sl lfsbk mfr gw .4 .6
3 36-94 7.5yr5/4 none sl 1 msbk mfr -- -- .4 .6
r
4�
F-1 Boring # I Boring
✓l Pit Ground Surface elev. 100.70 ft. Depth to limiting factor 97 + in. Sal Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
*Eff#1 *E02
1 0-7 1Oyr3/3 none I 2fsbk mfr gw 1f .5 .8
2 7 -28 10yr4/4 none sil 2msbk mfr gw ---- -- .5 .8
3 2842 10yr5/4 none sl 1fsbk mfr gw — .4 .6
4 42 -97 7.5yr4/6 none Is 1 msbk mvfr ---- .7 1.2
.y Z.
' Effluent #1 = BOD 30 < 220 mg/L and TSS >30 < 150 mg /L ' Effluent #2 = BOD S mg/L and TSS <,.�10 mg/L
CST Name (Please Print) Signature: CST Number
Thomas J. Schmitt �io r 227429
Address Tom Schmitt Date Evaluation Conducted Telephone Number
1595 72nd St., New Richmond, W1 54017 8/29/03 715- 247 -2941
i
property Owner Johnson, Thomas Parcel ID # Page 2 of 3
3 ] F Boring # -� Boring
✓I Pit Ground Surface elev. 100.84 ft. Depth to limiting factor 96+ in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
"Eff#1 "Eff#2
1 0-11 10yr3/4 none t 2fsbk mfr cw 1f .5 .8
2 11 -25 10yr4/4 none scl 2msbk mfr gw 1f .4 .6
3 25 - 52 7.5yr4/6 none sl 1 msbk mfi gw — .4 .6
4 52 - 10yr5 /4 none al 1 msbk mfr — — .4 .6
F-1 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
"Eff#1 `Eff#2
F-1 Boring # ` Boring
?Pit Ground Surface env, ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP
'Eff#1 'Eff#2
* Effluent #1= BOD ? 30 < 220 mg/L and TSS >30 < 150 mglL ' Effluent #2 = BOD5< 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
'11 C1 -- T'T'Xr 4^0 -%,CA 0"17-7
a
-e�
o;
S I
d �V ia Y
f.J�I
3 �
t*t
ve
t
--51
� � ��,�' Qh' = �oP o� 'y �r►�tar+. hale J
t E Ca,rG. ��► o � S ep {z. T'a- -�
l4' 3, BZ Bh� 3 z 'bar d 8e4 Gb+rnei aJ�
! h t1+a f asSa+ -� 1J Kti..,s LY ' I, t�
Pj .ae G/0 �/ Ira,'/ CS ?' a
? /S'} 1 Y7 -oz9 t1I
*J t
awn s �•F o'� s''�= �b f � f.
Pa of
POWTS OWNER'S MANUAL & MANAGEMENT PLAN
A
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Septic Tank Capacity v� a l [3 NA
Permit # Septic Tank Manufacturer — ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer 2
❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model _ ❑ NA
Number of Public Facility Units R NA Pump Tank Capacity gal ® NA
Estimated flow (average) Y gallday Pump Tank Manufacturer ® NA
Design flow (peak), (Estimated x 1.5) g allday Pump Manufacturer 0 NA
Soil Application Rate , gal/day/ft' Pump Model ® NA
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit ® NA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cells) ❑ NA
Biochemical Oxygen Demand (BOD 530 mg /L M In- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound
Fecal. Coliform (geometric mean) 510` cfu /100ml ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y in dia. ❑ NA Other: 47 13 NA
Other: ❑ NA Other: ❑ NA
"Values typical for domestic wastewater and septic tank effluent. Other: 0 NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA 11 ear(s)
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA
❑ month(s) (Maximum 3 years) ❑ NA
Inspect dispersal cell(s) At least once `every: ! yearls)
❑ month(s) ❑ NA
Clean effluent filter At least once every: ■ ear(s)
❑ month(s) ■ NA
Inspect pump, pump controls & alarm At least once every: Q year(s)
' ❑ month(s) IN NA
Flush laterals and pressure test At least once every: ❑ year(s)
Other: ❑ month(s) 0 NA
At least once every: ❑ year(s)
Other. ❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
I
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
�
units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
1
.'" Page of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tankls) for the presence of painting products or other chemicals
that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at. the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cellls) in one large dose, overloading the cellls) and may result in the backup or surface discharge of
effluent. To avoid this situation h a ve the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
I
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
within 15 feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or.must be taken, to provide a code compliant
replacement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
® The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is ava ilable a holding
tank
may be installed as a last resort to replace the failed POWTS.
❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time.
< <WARNING> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
1
PERSON FROM THE INTERIOR OF A TANK MAY BED DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
E e Name — —
ne Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name — Z
Phone Phone
I ive Code.
2 & 3
Wisconsin Admini document was drafted in compliance with chapter Comm 83.22(2)(b)(1)Id1 &If► and 83.54(11, l l (1,
This doc P
I�,
ST. CROIX 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 residence located at: �[UL /, N e 1/, ,
Sec. _3 Ll , T . Q N, R_J_�_W, Town of ST, Zb���p�y 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 5PRIA16- 1003
Did flow back occur from absorption system? Yes No (if no, skip next
line.
Approximate volume or length of time: gallons minutes
Capacity: 11,00
Construction: Prefab Concrete )c Steel Other
Manufacturer (if known) :
Age of Tank (if known) :
�ONi4Ui.v cJGlf� lTT
(Signature) (Name) Please Print
(Title) (License Number)
(Date)
Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or
licensed 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). (�
Name 7:7 Signature
M MP �12/
ST CROIK COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND .
OWNERSHIP CERTIFICATION FORM
owner/Buyer _ /_DlylrZa&&W I
Mailing Address 6AU &AfL_ f' AL h
Sr
Property Address G / RlArm 1-JA Lt v OZ G1/� S'6 .//� /. .5 i®.zs
(Verification required from Planning Department for new construction)
City/State 1',p VAIV Jl . Parcel Identification Number 6 30 - Zro 6 - `ts -
LEGAL DESCRIPTION
Property Location ,CCU %,, , _ V4, Sec. 3'1 , TWN -R12�_W, Town of _S%> r7osa—a/L .
Subdivision -
. Lot # 3
Certified Survey Map # Volume = . Page # _.�•
Warranty Deed # y�1 9.t _, Volume 7 Page #
Spec house ❑ yes 11 no Lot lines identifiable ® yes ❑ no
STEM 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
mastorplumber, 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 113 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
days the three ar expiration date.
GNATURE APPLICANT 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 pro rty desc ' d above, by virtue of a warranty deed recorded in Register of Deeds Office.
NATURE F APPLICANT 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 Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
, � �tA�l4�R WaC N/OIMA>i-1Mt TMMNAORIIMIPP#WPOR11110011b"MOATA
z _ WAAROJM 0GlD
; 1 S or" *`
�a sP ATCRIATI Q QTCi1T r±d 1�1+ � T1A
srntiT a# +ch a t'
i w„rdwMnrwia HnM13 NTCHA, T, TnN11sax
w • �,,+ and:�('. • 1WIRR JxR Snll n b and B ----
W118 an inint
# MTura TO
iMiotlowNipdaioribadntatiaataNt 4 t. �:rni= Cow". =
Stabaf Wboon*r.
TM tioM NIK
P►Zrt of northwest Quarter of Northeast Quarter of
Section 34p Township 30 North, Range 19 West described as follows:
t Certified Survey Map filed October 3. 1984p in Vol. "5 " .
ETHER WITH AND SUBJECT TD a 66 foot private road easement as
shown or, said Certified Survey Map and Certified Survey Map filed
in Vol. "4 0 9 page 1063.
Lot 3 CSM Vol. 5. page 1473 is served by a private roadway. Purchaser
agrees to pay a prorata share of the cost of maintenance of the
private roadway.
S
E
This is not non+.w..a property.
a/ a �►
Exowion to warrant -Im
o ad the 28 day of Fl _hrua, y 87
f (SEAL) u . (SEAL)
f
Janet P. Stout
(SEAL) PEAL)
f -
a
AUTHENTICATION ACKNOWLEDGMENT
SlpnatunlN) STATE OF WISCONSIN
A. DO St. Croix county.
au"Ontioated thti da of ••' A'T Y - �y pe=Wly oame befom me this 8 tray of
4� Feb uary , i9 87 the above iwnad
•
Richard 0. Stout and
too Janet P. Stout
TITLE: MEMBER STATE BAR OF • �.
of not, M `� to m. know" to be the person $ who executed the
aulhoraed by f M6.011, vela. s4a.) t eru t and Ives. t w ���)
TM Ii IMW ENT i OMMO By
• Patricia A_ nntseth
N Public At- rrnix County, Wis.
(Sipnahm may be authentlooW or soknowk dped. BoM My ComnlWWon N parnanent. pf not, hate expiation
an ta! tteoeeeary.) data: D e- _ 1 n
•wM.. of r«sma NOMni M anp aa.aaNp M�aule tM tp.ae «ptMw tide.lMk NiiwMwM. NTf 2W
tiVAaIiAMTr opts KATE aM Of w140010M Nako Forms. P.O. Cox 10700.Oroon sap. wo 56107 -010i
farm No. t — teai
�U, LuA
LL iL
s� o
10 N .
00._.
z 53
d , � �;, Vd 3A
H ^ � 1 co ^
H c 0 1�0 -
H H 7+ ti , t7Sp� W 44 � rl
w
N O+ ao 3
m o N 2
X (t
l0W i m (0 M UI1
W $41 HO 1iO oo Mo He
x a .J►
aA
tl1 0 9 O \ 0 I
s s' 1 i8L'89V 2 „9T,OTo90N �i
w c� 00'08 00'S9T 3i
W \ p' 0 0
v
O •� O,
h o o O i 3 ti '0
c9 \ •' 1
00 co
r11
Lo
O N rn N H^ W^ O I
Z w o 4-3 W 01
H bi U' _ a
N m 01
i o a N U N U O
M d CO
C �O N z
`°� �I • N I — r �
a M 1� s w rs ) H M 61
M � F 1 M
Cl- H cn >C 3 � 3 r N
A O W
4A 11>1
b a 9 �
01 ZI n v o
ENO �I y c�
2 W U Q
� O 3 HE-4 ov
C/ E ° a � x �i - w Z
W c01 `+� O
cm W t11 1 N �, N �' N H
NI N N N�
0 U
u- WO M U W L n
I— Oo b ,N wo �1 0 .
W \ rn NG J°i=iaW OS W
'r Ln . r. MMMOO 40 tow c' F,
o
W o
W °M � 5d o °°
�. M
H U ° ° � G
W \H 2: V
v z w - : S q • 5 Lb Z0S
3„SZ
,59' �/1 xsnoS- HS2iog N
� flNI
� W - peuMO -S
5 N F' o
H ��. W o
w o � SO�IH3 ' ' w r
0 0�
E' `n Z Sfl'I 89'1 H o
O Ln
P4 ISMflgala 3NO2iI/ „bZ
� OI•lIH '�
2 �IOHI „T • U o
H . QNnO 3 ' HdI d U:
o ZS gt13fl a[13
w •3„5 ° - Hsgor�
o', a�wnss�r fl�II' b/1 n s �„�.
Q301� ausa3H SO[tII2i�i �3
O 3HZ 0S �j�'.+.Y
a ��