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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
' INSPECTION REPORT Sanitary Permit No:
395104 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID N
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j.
Permit Holder's Name: City Village X Township Parcel Tax No:
Plourde, Doug Somerset Township 032 - 1098 -80 -000
CST BM Elev: f Insp. BM Ele` : BM Description: n
crb e7L7 CST >V �r.. S
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
l Benchmark
Alt. BM 3 �, L r
76 ao • 3`1
Bldg. Sewer
i S
t Inlet c
SUHt_ t
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic , 5' > 15b' Dt Bottom
Dosing Header /Man.
Aeration Dist. Pipe
Holding Bot. System V (-3 `G>( f
PUMP /SIPHON INFORMATION Final Grade
Manufa urer De St Cover
GPM
Model Num r Q
R, 1" L.-IC
TDH Lift tion Loss System Head TDH F 1
:7, /
Force In Length Dia.
OIL ABSORPTION SYSTEM
4ONKTREN P Width Length f No. Of Tren es PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIM NS �$ P 2 h
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Ma ufpc eF.. _ n_
INFORMATION Type Of System: ( r CHAMBER OR _
UNIT Mod Number:
a. u
DISTRIBUTION SYSTEM
Header /Mani �t Distribution x Hole Size x Hole Spacing T > 56 ent to Air Intake
Pipe(
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of dded xx Mulched
T7 Seeded /So
Bed/Trench Center Bed/Trench Edges Topsoil Yes * No (] Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: d? /Ro/ C) t Inspection
Location: 566 Hwy 35/64 Somerset, WI 5402 (SW 1/4 SW 1/4 35 T31 R19W) 353119459E Unknown Lot 2
1.) Alt BM Description = C
2.) Bldg sewer length= 30 r V
- amount of cover —in n
c4 LIZ"
." ►, � e�� .�,. a-� e try 1. —I
W n revtslo Required X� Yes No l'
Use other side for additional information. H,�74�
Date Insepctors Signature Cart. No.
SBD -6710 (R.3/97)
3
Sanitary Permit Application Safety & Buildings Division
In accord with Comm 83.2 1, Wis. Adm. Code 201 W. Washington Ave.
See reverse side for instructions for completing this application PO Box 7302
1 4sconsin Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302
Department of Commerce [Privacy Law, s. 15.04(1) m)] (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.
County ate Sani Pe it Number ❑ Check if revision to previous application State Plan I. D. Number
1,v St
3
I. Application Infof mation - Please Print all Information Location:
Property Owner Name Property Location
A.
Fjv /� 1/4 1/4, S N, (o
Pro erty Owner's Mailing Address of Number Block Number
s
City, State Zip Code one Numb fr C{:1 I Subdivision Name or CSM Number
couli
,el IJT
o
II. Type of Building: (check one) ❑ City
1 or 2 Family Dwelling - No. of Bedrooms :_ r r° ~t \ C5 ❑ Village
❑ Public /Commercial (describe use):_ , per' ! Town of
❑ State -Owned
Nearest o
Parcel Tax I mber(s)
_ IT c{Stl
III. Type of Permit: (Check only one box on line A. Check box on line B if applicab C l 9 _ 60 6)
A) 1. ❑ New 2. DkReplacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to
System System Tank Only Existing System
B) Permit Number Date Iss ed
A Sanitary Permit was previously issued D L - -� / 9�
IV. Type of POWT System: (Check all that apply)
'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. Dispe Area Information: 7,2- r s s
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed Rate (Gals. /day /sq. ft.) (Min. /inch Elevation
-✓ ,
Vrl. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
Tanks Tanks
1 9 ❑ ❑ ❑ ❑
0
❑ ❑ ❑ ❑ ❑
VIII. Responsibility Statement
I, the and rsigned, assume responsibility for installation -9f the POWTS shown on the attached plans.
Plumbe 's N
)erint) PI umber's 'gnature o s
I MP /MPRS No. Business Phone Number
y - - 3J S
lu ber's Address Street, City, State Zip Code)
W. County/Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued ssuing Agent Signature (No stamps)
[approved ❑ Owner Given Initial Adverse Surcharge Fee)
Determination rr 2 - 2S
X. Co nditions of Approval /R for Disapproval:
*��il / izec�;ot...- o'Y 21G T�1� 40 ✓4,.- L.1((l �F �(rov< Cl.� < °lJw lT ex;sfr 7'GI,,,J� �S
'�'q�,faact>I e-F- �i l ( ��wf `XJ FJr ��5�2/�A�A/'�/i'c�4 �Ofr 1A^�1.�'14Gfk ✓C ✓S __// OPGUu..- H,- e..�L�q���s.
5K P ( �r V�► rev% ow e_r '''Prn f o-ilec - f Ct
SBD -6398 (R. 07/00)
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
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. Revi wed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). !rte
�— 3 0
Property Owner Property Location
Govt. Lot S 114 114 S T N R E (0 6
Xac A-4eple Property Owner's Mailing Addres Lot # Block Subd. Name or CSM#
City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road
❑ New Construction Use: Residential / Number of bedrooms Code derived design flow rate GPD
4 Replacement ❑ Public or commercial - Describe:
Parent material eg st/ Flood Plain elevation if applicable Zk ft.
General comments
and recommendations:
1 1 Boring # ❑ Boring
Pit Ground surface elev. _ ft. Depth to limiting factor //f in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
99 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
/ ✓
E1 ✓
s / ✓
- - ✓
Boring # ❑ Boring
Pit Ground surface elev. 9G. 9s ft. Depth to limiting factor / in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD 1ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2
JJ � S
✓ .�
fraK
* 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 Nam (PI se Pri S' natu CST Number
i
Address Date Evaluation Conducted Telephone Number
e'
SBD -8330 (R07750)
I
i
Property Owner U wojx Parcel ID # Page ---2— of
Boring #
❑ Boring
3 a 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 /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2
/ r
6 -
o, as' u!
❑ 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 /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
F-1 Boring # ❑ El Pit Boring
Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2
I
* 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.07 /00)
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Private Onsite Wastewater Treatment System Management Plan
Septic Tank And Gravity In- Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment
System (POWTS) shall include information and procedures for maintaining the system within
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or governmental unit. The approved plans and permits for system are on file at the county
zoning or health department.
This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
10567-P (R.6199).
Table 1: System Design Specifications
Sanitary Permit Number
Number of Bedrooms 3
Design Flow - Peak (gpd) Sb
Estimated Flow - Average (gpd)
Septic Tank Capacity (gal)
Soil Absorption Component Size (W)
Type of Wastewater Domestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Design Flow - Peak (gpd) �D
Maximum Influent Particle Size (in) 1/8
Maximum BOD (mg /L) 220
Maximum TSS (mg /L) 150
Table 3: Maintenance Schedule
Septic Tank Inspect and / or service once every 3 years
Outlet Filter Inspect once a year and clean at least once every 3 years
Soil Absorption Component Inspect once every 3 years
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks
under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with
NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
Restrooms).
The operating condition of the septic tank and outlet filter shall be assessed at least
once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure
proper operation. The filter cartridge should not be removed unless provisions are made to
retain solids in the tank that may slough off the filter when removed from its enclosure. If the
i
Management Plan for a Septic Tank and Soil Absorption Component
filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously.
Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of scum and sludge in the tank
exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the
time of an assessment, maintenance personnel shall advise the owner of when the next service
needs to be performed to maintain less than maximum scum and sludge accumulation in the
tank.
Manhole risers, access risers and covers should be inspected for water tightness and
soundness. Access openings used for service and assessment shall be sealed watertight upon
the completion of service. Any opening deemed unsound, defective, or subject to failure must
be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by
an effective locking device to prevent accidental or unauthorized entry into the tank.
No one should enter a septic or other treatment or holding tank for
any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within the septic or other
treatment of holding tank may contain lethal gases, and rescue of a
person from the interior of the tank may be difficult or impossible.
Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the
tank is no longer used as a POWTS component.
Soil Absorption Component
The soil absorption component serving this structure is designed to accept domestic
wastewater from a residential facility. The limits of operation of this component are shown in
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good water
conservation practices by all occupants and the installation of water conserving plumbing
fixtures are key factors in extending the useful life of this component.
The soil absorption component's operation must be assessed by inspection at least
once every three years. The inspection shall include recording the levels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. On steeply sloping sites, areas of erosion should be identified and
reported to the owner for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
Traffic around or over the soil absorption component should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
impossible to repair until weather conditions improve. In general, soil compaction over this
component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to
more intense, and earlier, organic clogging of the soil.
2
I T
Management Plan for a Septic Tank and Soil Absorption Component
Plantings of deep- rooted trees and shrubs directly over or within ten feet of the
component should be avoided since root intrusion into the component may obstruct wastewater
flow.
3
I
xGlw
( DOCUMENT NO. STATE BAR OF WISCONSIN — FORMA 2
' p WARRANTY DEED
VOL 674 PAGE 196 T416 SPAa MEU"FD RM NaCD1101N0 DAM
se
SIARS oFFKE
GERALD WA RREN an ST. Clgf� 00., h+f6,
BETTY JUNE PLOURDE, as 3oin� t tenants Reed CR ix 0 t},;s 29th
conveys and warrants to DOUGLAS RICHARD PLOURDE day of Se pt a D. 199 8'3
and CONSTANCE MARIE PL.O 1 DR., as j at 4:30 P
tenants ,
�awt:.� Dews a�ruau To
I
I
GHERTY AND DUNLAP
I the following described real estate in St. Croix County, 328 Vine Street, P.O. Box 32
State of Wiscor in:
Hudson, Wisconsin 54016
l i A parcel of land in the subdivision located
1 in the Southwest Quarter of the Southwest
a Quarter, Section 35, Township 31 North, Tax Key No.
Range 19 West, Town of Somerset, St. Croix
County, Lot 2, as recorded in Volume "4 ", i
on Page 1110 of the Certified Survey Maps,
in the St. - roix County Register of Deeds
Office, Document No. 373572, recorded on
September 2'8, 1981. Subject to an easement
starting in the Southeast corner of Lot 2, BE
hence West on the South line of said lot, Y
for 478 feet, at a width of 66 feet, which
strip is to be used for the development of EXE MPn
a road for that section. The granteE- is
also granted fuli use of the roadway ease -
ment presently in existence in the Southwest
Quarter of the Southwest Quarter of Section
j 35.
u
This i homestead property.
(is; (is not)
Exception to warranties:
r
i
y
Dated this _ 16 th da of September tg 8 3
!
1
s (SEAL)
r l� a �� f CV' � i-c c2 �- LSEAL)
a GERALD WARREN PLOURDE
i
(SEAL) �t �_ e-r - . - (SEAL)
•
BETTY J N�RDE
!
1 POTHENTICATION ACKNOWLEDGEMENT
Signatures aulhenticat : this day of STATE OF WISCONSIN
St. Croix County.
Personally came before me, this (10 day of
• S t g 83
TITLE: MEMBER STATE BAR OF WISCONSIN _ the above named
a not' —
authorized by § 706 ]6, Wis. Stabs.) Gerald Warren Plourde and Be Ju ne
Pl ourd e '
This instrument was drafted by
Susan Schleif Gherty
GHERTY AND DUNLAP -� - --
Hud Wisconsin 540 16 totrle -rd U4 , 4 erson S who executed the ;Oregoingin-
t' d the same.
(Signatures may be authenticated or acknowledged. Both are not
necessary.)
O
NpJr _ _ .•_ C 1X County, Wis.
'Names of parsons signing in any capacity must be typed or printed below then signatures.
My (,yo�tsgion is. pe'•n (If not, state expiration date:
WARRANT/ Mr - STATE BAR OF WISCONSIN, FROM NO 2 - 1977 Stock No 13002
2 3
ti 11.E �
F
i ,. •• , SEP 2g
OJO d 1)"& CD
ftow
Ciou
CERTIFIED SURVEY MAP s
LOCATED IN THE SW I/4 OF THE SW 1/4 OF SEC-35,
T31 N,R19W, TOWN OF SOMERSET, ST. CROIX COUNTY
I, Arthur L. Wegerer, registered land surveyor, hereby certify: That in
full compliance with the provisions of Chapter 236.34 of the Wisconsin Statutes
and the provisions of the St.Croix County Subdivision Ordinance and under the
direction of Gerald Plourde, owner of said land, I have surveyed, divided and
mapped said parcel of land, that such plat correctly represents all exterior
boundaries and the subdivision of the land surveyed; and that thr.Is land is
located in the SW4 - 6f the SW4 of Section 35, T31N, R19W, Town of Somerset,
St.Croix County, Wisconsin, to -wit:
Commencing at the S4 Corner of Section 35; thence West along the section
line 1322.68 to the SE corner of the SW4 of the SW4; thence N1 11 W along
the east line of said forty 242.31 to the point of beginning; thence S$$'3$
W 544.001 thence N "W 546.78t thence N$$ °3$ 544. to a point on
the east line of the 34 of the SW4; thence 31'21 "E along said line 546.7$?
to the point of beginning.
Contains 6.82 Acres subject to roadway easement over the easterly 66?
thereof. ��((
Dated this j) - M day of SL=P`rVL1zyg ,1981.
Arthur L. Wegerer S-
Kozel, Wegerer , a C;l; g%�. Inc.
F FORTY COR. .0
lip 40.6
ARTHUR L
N t WEGERER S -
:.{ ' S-963
EAST L I N E SW SIN ELLSWORTH •
WIS.
U N P L A T T E D LANDS ••..,,,,,,,,�,...�•
C
N88 "E 544.00 `moo, TEMPORARY CUL-DE-SAC
'
: Z 190. 478.00 166.
:C: APPROVED
. D N Z
•--+ W LOT t w 28 1981
3.41 ACRES 40 LINE p .1
rn N �_ { 148724.2 SQ. FT.) N D
3.00 A C. TO R.O. W .
.0 4 Iss.00 N "� ST. CROIX COUNTY
COMPREHENSIVE PARKS PLANNING,
ROAD WAY EASEMENT
m AND ZONING CO "TTF&
ROAD : 0 Q
(— M
j :z � W LOT 2 i W� :D W E
•Q tp 3.41 ACRES 40 LINE :Z
(n _ 0 (148724.2 SQ.FT.) q,
000 3.00 AC. TO- R.O.W. I S CALE 1 = 200
9
478.00' I 6
S88 0 38 18 W 544.00 0 100' 200' 400'
;\ 2, BEARINGS REFERENCED TOTHE
EXISTING EASEMENT . SOUTH LINE OF SEC. 35JASSUMED
FOR INGRESS AND EGRESS N \ BEARING WEST)
\ ----- --EXISTING ST I NG ROADWAY FROM
UN PLATTED LANDS _ _ ,
s� S. T. H. 735 "AND "64
EAST 1322.68 WEST 1322.68'
ORTY COR.
SW COR. SEC.35, SOUTH LINE SEC.35 S 114 COR. SEC.
T31 N, RI9W. 35 T31N,R19W.
O =SET 11(24" IRON PIPE WEIGHING (C.S.M.)
1.13 LBS. PER LINEAL FOOT.
Volume 4 Page 1110
81 -141 THIS INSTRUMENT DRAFTED BY
ST CROIX COUNTY
SEPTIC "TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
'Owner/Buyer DO maeA $ �P. AoLtRQE
Mailing Address 5 Ijk)Y 3� —boy
Property Address sSomEjesE T `wx SS�oZS
r (Verification required from Planning Department for new construction)
City /State SoYYILw'SEj Lt��_ Parcel Identification Number
LE GAL DESCRIPTION
Property Location SLIT ' /,, SLR! ' /,, Sec. 36 , 'TZ) N -R W, Town of % .
Subdivision , Lot #
Certified Survey Map # Volume , Page #
Warranty Deed # , Volume , Page #
Spec house O yes JJ no Lot lines identifiable yes O 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 disposaI 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
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the three year expiration date.
/0
SIONAILIU OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are tnrc 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. Y�&)
Q
SIGNA OF 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
.
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 ,/!r ,o /�� residence located at: 5u)_ %, %,
sec. R Town of �",,K 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
Did flow back occur from absorption system? Yes No- (if no, skip next
line.
Approximate volume or length of time: gallons minutes
Capacity: ,�f�
/
Construction: Prefab Concrete Steel Other
Manufacturer (if known) :
Age of Tank ( i f known) : 44 2 _
4 I
(Signature) (Name Please Print
(Title) (L�se Number)
7�
(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 nspection opening over
outlet baf le} .
Name ,, Signature
MP /MPRS
' e AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SEC . -W±W
ADDRESS ST. CROIX COUNTY, WISCONSIN.
LOT
SUBDIVISION LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
�lFy.I'HING WITHIN 1 FEET OF SYSTEM
f�l
20 e
I d i a e o th A ro
SC LE:
BENCHMARK: (Permanent reference Point) Describe : IA.� "j T'r' y
Elevation of vertical reference point: Slope at site:
SEPTIC TANK: Manufacturer L Z6 � Liquid Capacity: "X%1,4z
Number of rings on cover Tank manhole cover elevate
Tank Inlet Elevation: Tank Outlet Elevation: "
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set. or a cycle gallons; total capacity o
distribution lines gallon: size o pump head;
gallon per minute horsepower brand name of pump
�> and model number
Type of warning devIce
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover
Type of warning device`
SEEPAGE PIT SIZE: Number o pits -- feet diameter
feet liquid depth seepage pit in eft pipe- elevation
bottom of seepage pit 4; evation feet.
SEEPAGE BED SIZE: number (if lines wi th leagth dept
SEEPAGE TRENCH: width length -
PERCOLATION RATE AREA RE U D A llft�
INSPECTO'""`
DATED -/�' - `�Q PLUM ON JOB ?
T' LI NSE NUMBER
i
I DEPARTKENT OF INnUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR& HUA ! }l RAATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 799 BUREAU OF PLUMBING
MADISON, WI 53707
CONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number:
(If assigned)
❑ Holding Tank ❑ In- Ground Pressure ❑ Mound
NAME F PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION ATE:
8 �0 82 ►0:3a
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
cd S e a s
Name of Plumber MP /MPRSW No.: County: Sanitary Permit Number:
SEPTIC TANK /HOLDING TANK: 1 1 A . S-
MANUFACTURER, LIQUID CAPACITY: TANK I LET E EV.. TANK OUTLET ELEV. WARNING LABEL LOCKING COVER
1 2 PRO DED: PR OO VI �eL���
YES ONO DYES NO
BEDDING: VENT DIA.: VENT MATL.. HIGH WATER PROPERT WELL: BUILDING: VEN TO FRESH
ALAf}4}. LINE: lAl INLET
YES ONO /
1 NO ' � ,�!` �'�„� � Ott' JO a
OSING CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY J IUMI MODEL. J IUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
OYES ONO DYES ❑NO DYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL F PRUPERTV WELL. BUILDING: I VENT TO FRESH
(DIFFERENCE BETWEEN�r g `' LINE AIR INLET:
PUMP ON AND OFF) OYES ❑NO
SOI L ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing Le vGTH I DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until"
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM: �
' °�� w WIDTH. LENGTH NO. OF DISTR. PIPE SPACING. COVER p INSIUE DIA.. PIT LIQUID
TRECZHE M IAL: y DEPTH.
R V L DE TH FILL DEPTH DISTR_ PIPF DISTR. PIPE DISTR. PIPE M TERIAL: NO- R w PROPER V WELL: BUILDING: VENT TO FRESH
BELOW PIP S ABOVE COV R ELEV. INLET ELEV. END. PIPE `�. LINE: AIR INLE
o --
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: \mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
OYES 1:1 NO
SOIL COVER. TEXTURE. JPERMANENT MARKERS. JOBSERVATION WELLS
❑YES 1:1 NO 1:1 YES LINO
DEPTH OVER TRENCH;BED DEPTH OVER TRENCHiBED DEPTH OF TOPSOIL. SODDED SEEDED: MULCHED.
CENTER EDGES.
DYES 1:1 NO OYES ONO [!]YES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH. NO. OF 'LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
TRENCHES:
gd 4:
x
MANIFOLD PUMP MANIFOLD 'DISTR PIPE MANIFOLD MATERIAL. INO.DISTH. DISTR, PIPE DISTRIBUTION PIPE MATERIAL & MARKING.
ELEV. DIA, ELEV. PIPES: DIA.:
" \HOLE SIZE HOLE SPACING. DRILLED CORRECTLY. COVER MATERIAL- VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
DYES ONO I DYES 1:1 NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: PROPERTY WELL: BUILDING:
LINE:
E. 7 DYES ❑NO, DYES ONO
Sketch System on Retain ounty file for audi,
Reverse Side.
SIGNATURE: TITLE:
DILHR SBD 6710 (R. 01/82)
i
DEPARTMENT OF APPLICATION SAFETY &BUILDINGS
INDUJI'RY FOR SANITARY DIVISION
LABOR AIND., PERMIT P.O. BOX 7969
Hl`1'MAN RELATIONS (PLB 67) MADISON, WI 53707
Attach plans for the system on paper not less than 8 x 11 inches in size. Include a plot plan that is dimensioned or H o sc a 11 oFr�Z
and vertical elevation reference points must be shown. All appropriate separating distances and physical character' as 4e" i1h
H - 63, Wis. Adm. Code, must be shown. An index pa ]e or each page must be signed, sealed and dated by the desi n . If deif a Ma
Plumber, the date, signature and license number mu ;t be shown. A legible reproduction of the soil test report a ow s y
included. O� yj /9� :—
Property Owner: Mailing Address•.
Property Location: C age or Township: County
'/a ' /aS" T NCR (or) W
Lot Number: Blk No:: Subdivision Name: µ Nearest oad, Lake or andmark: State Plan I.D. Number:
�. (If assigned)
TYPE OF BUILDING
Number of
❑ Public* ❑ Variance ❑ Other (specify)* Bedrooms:
54 1 or 2 Family * State Approval Required.
TOTAL NUMBER PREFAB POURED -IN NEW 'REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE STEEL FIBERGLASS INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY
HOLDING TANK CAPACITY
LIFT PUMP TANK /SIPHON CHAMBER
MANUFACTURER: +�
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental ;K Seepage Bed ❑ Seepage Pit
❑ Alternative (specify) ❑ Seepage Trench
Water Supply: Owner's Name as Listed on So I est Report (If other than present owner):
❑ Private Joint ❑ Public
1, the undersigned, hereby assume responsibility for i stallation of t vate sewage system shown on the attached plans.
r a of Plumber: Si re: MP /MPRSW No.: Phgne Number:
.� (1 ��
r s Address: of Designer '
I 44akw A L
COUNTY /DEPARTMENT USE ONLY
Si ature f Issuing Agent: OO I Fe ; Date: APPROVED Sanitary Permit Number:
O dd
DISAPPROVED Q
Reason for Disapproval:
i
Alternate counsels) of Action Available:
j
Change of ownership, building use or plumber req ires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior to in-
stallation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White- County, Canary - Bureau of PI mbing, Pink - Owner, Goldenrod - Plumber
DI LHR -SBD- 6398 (8.07/81)
DEPA NT OF „ REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS
11�1DUS DIVISION
LABOR AND PERCOLATION TESTS (115 P.O. MADISON WI 79
HUMAf4 AECATIONS
LOCATION: SECTION: H IP /MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
H/R �(or) W I TOWNS
COUNTY: OWNER'S BU ER'S NA E: MAILING ADDRESS:
4
USE DATES OBSERVATIONS MADE
7BI 1COMMERCIAL DESCRIPTION: � EST
F2
S:
Residence O ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system H H , 6 6r-k rA earn SQ nC�
CONVENTIONAL: MOUND: IN- GROUND-PRESSURE-. SYSTEM- N -FILL OLDING TANK: RECOMMENDED SYSTEM:(option I
S ❑U EIS ❑U ❑ S ❑U EIS ❑U EIS ❑U s
If Percolation Tests are NOT required DESIGN RATE: SYS T M
If any portion of the lot is in the P v,>
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elev id7Y
ill
PROFILE DESCRIPTIONS S ri 1 -7 1
BORING TOTAL DEPTH TO GROUNDWATER - INCHES CHARACTER OF SOIL WITH THICKNE SOLO URE, AN. EPTH
NUMBER DEPTH IN, ELEVATION OBSERVED E T. H ST TO BEDROCK IF OBSERVED (SEE ABBR .A BA /P '
B
B- 7
S
B- >
B
B- > > >
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL -MIN. PER OD 1 PERT D 2 PE RIOD P E R I NCH
P- / C' 1
7
P
P- S'
P
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-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slop.
SYSTEM ELEVATION / ®P
r - , ---- „__
q 3
I e Y s
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7
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....... - «..... ae ... F. .... e ems, .........,E........,
1, 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 COMPLETED ON:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optional):
y // ✓
CS GN T R
DISTRIBUTION: Original -Local Authority, 2nd page - Bureau of Plumbing, 3rd page- Property Owner, 4th page-Soil Tester.
DILHR -SBD -6395 (N. 03181)
P077. i i
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