HomeMy WebLinkAbout006-1022-80-000 I
Wisconsin Department of tommerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM County:
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information ou rovice may be used for seconds purposes [Privacy Law, s.15.04 353223
Y P Y secondary ( cY i m.
Permit Holder's Name: ❑ City []Village ❑}{Town of: State Plan ID No.:
Dollerv. Kathleen I Town of Cylon et }I 2( iwf. /d
CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.:
tro . ` ( XI . 0 1_ t " P UG_ t B t 1 006 - 1022 -80 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic S -�- 60 /5-41D en Alt. 60,0
Dosing (-loo . BM
Aeration Bldg. Sewer 77 , 0 j
Holding St /Ht Inlet(Q
TANK SETBACK INFORMATION St/ Ht Outlet ---�
TANK TO P/ L WELL BLDG. Verittake ROAD Dt 12
Septic > 10D r 5 3, 6 NA Dt Bottom /5 IZ T2. Og
Dosing < < y' + ! is $ ' NA Header / Man.
Aeration NA Dist. Pipe j, 9' 9, Z
Holding Bot. System
a PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand St cover
lb Model Number 0 ✓�(' M
LiftJo Lrictionea .\ System. TD 1 ,40 t ! o� 3 . d0 , D
Forcemai n Length oZ 'ls Dia. ;L 14 Dist. To Well > S3
u
SOIL ABSORPTION SYSTEM
%W TRIENQ Width !
I Len th I No f T nches PIT No. Of Pi Inside Dia. Liquid Depth
D M JC IMEN I
SETBACK
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING nu facture INFORMATION TypeO n 1,ob � >Z0 OR CHAMBER o e Number:
' System: �Ulo�rvdCa
DISTRIBUTIOIX SYSTEM
Header / Ma f
az w Distribution Pipe(s) q x Hole Size x Hole Spacing Vent To Air Intake
!! -
Length Dia. '� Length +b•S Dia. 01.17 Spacing t
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed/ Trench Center Bed/ Trench Edges Topsoil ❑ Y s No []Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: 24 / q in #2:o&P is /soe
Location: 2351 222nd Av ue,D Par I (SW1 /4, SE1 /4, Sec ion 1 T31N -- 148 7' I
_•
1.) Alt BM Description =
2.) Bldg sewer length = 53.0
- amount of cover = > 6 • o oy
3.) Contour = at" 4 - 4 • (o �,s�� �' t o off' Ott I Lo L tot
rtt , `l�►'IS'N c.t
a 7 l y
W!�
Zoo
Ian revision required? ❑ Yes j o " I II I
No 2
s r s -6710 (R.3/97) 'd f ditional infoon. D ( 14 7m0 g f. s ` Date Inspector's Si nature Cert. No
BD .�l
� ���L.. w'k' 1 e0 .0�
q 0 >f- at IS swx ocwr rwA-" ,� , �, pe,,, eft, 1 :-, - M.s4. PLJa,-
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
—4- ----_ . .
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Safety and Buildings Division
Vi scons i n SANITARY PERMIT APPLICATION 201 W. Washington Avenue
P O Box 7302
Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size.
• See reverse side for instructions for completing this application Sta a sanitary Permit Number
*35
Personal information you provide may be used for secondary purposes ❑ Check it revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Property Owner Name Property Location
- K� C_eF� t l .lDe u__e tZ_Y L,) 1/4 56 1/4, S 1 C T a t r N, R ((e ?(ter) W
Property Owner's Mailing Address Lot Number Block Nu mber
Z.� J 1 ZZz_ ��
City, State Zip Code Phone Number Subdivision Name or CSM Number
asE2 �� LAr 1 (- 115 c
II. TYPE B 1 DIN : (check one) ❑ State Owned ❑ it Nearest Road
Public 1 or 2 Fam ily Dwelling - No. of bedrooms �_ Ci Town OF -`� �Z- "CL AV
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 10,
1 ❑ Apartment / Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel / Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV TYPE OF PERMIT (Check only one box on line A. Check box on line B, if applicable)
A) 1. ❑ New 2 ® Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
______System ________System _____________ Tank Only______________ Existing System ________ Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental them.
I�n+P
11 []Seepage Bed 21 ❑ Mound 30 ❑ Specify Type Holdin Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSOR PTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade
3�� Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) — E
Feet Feet
VII. TANK Capacity,
in gallons Total # of Site
INFORMATION Manufacturer's Name Prefab. Can- Steel Fiber- plastic App.
New Existing Gallons Tanks concrete structed glass App.
Tanks Tanks
Septic Tank or Holding Tank iZZ Z w 7Z � KA1 � ® ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ I ❑ 1 ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) PI m rs Si ture: ( ps) PRSW No.: Business Phone Number:
icI CL r✓� 2zc�5�4- 115)(07x -
Plumber's Address (Street, City, State, Zip Code):
[44'-1 I3 - AJ
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate slue Issuing Agent Signature (No Stamps)
> dApproved E] Owner Given Initial Surcharge Fee)
Adverse Determination ^
X.�JVDITIONS OF A OV L / EASONS FOR DI P ROV
t) _- c uy 3 0� 2� f
SBD -6398 (R. 4/99) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2.:YQUr, arlitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin AdministFallk ve;Cocle will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained- the septic tank(s) must be pumped b a licensed pumper er Whenever
9 Y p p Y P p p Y p P
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608- 266 -3151. — -
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
Vlll Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County / Department Use Only.
Complete plans and specifications not smaller than 8 1/2 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; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
-----------------------------------------------------------------------------------------------------
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) fora number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
ai '.. +. o • .. .
Safety and Buildings
10541 N RANCH ROAD
HAYWARD WI 54843
TDD #: (608) 264 -8777
Visconsin www.commerce.state.wi.us
Department of Commerce Tommy G. Thompson, Governor
Brenda J. Blanchard, Secretary
December 17, 1999
CUST ID No.226564 ATTN: POWTS INSPECTOR
ZONING OFFICE
RON E FRIEDELL ST CROIX COUNTY SPIA
1419 13TH AVE 1101 CARMICHAEL RD
BARRON WI 54812 HUDSON WI 54016
RE: CONDITIONAL APPROVAL
Identification Numbers APPROVAL EXPIRES: 12/17/2001
Transaction ID No. 285272
Site ID No. 184168
SITE: Please refer to both identification numbers,
Site ID: 184168 above, in all correspondence with the agency.
ST CROIX County, Town of CYLON; 2351 222ND AVE, DEER PARK 54007
SW1 /4, SE1 /4, S10, T3 IN, R16W
Facility: KATHLEEN DOLLERY 2351 222ND AVE, DEER PARK 54007
FOR: `
Description: Temporary Holding Tank, 300 GPD
Object Type: POWT System Regulated Object ID No.: 637111 PL O W,T,
■ This approval is for the temporary use of a septic tank/pump tank as a holding tank. The use of the holdincoadi
shall be discontinued when the mound is installed or no later than June 30, 2000. �Ic
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes A�pEPARTME�T� of
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in " gtpNpF SAF
chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. 44....
The following conditions shall be met during construction or installation and prior to occupancy or use: S1E celloRR�
1. This plan action is subject to designer comments on the plan.
2. A high water warning device shall be installed so that it activates 1 foot below the inlet pipe per COMM
83.18(7)(b).
3. Vent to be installed per COMM 83.18(7)(e).
A copy of the approved plans, specifications and this letter shall be on -site during construction and open to
inspection by authorized representatives of the Department, which may include local inspectors. All permits
required by the state or the local municipality shall be obtained prior to commencement of
construction /installation/operation.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
Sincerel , DATE RECEIVED 12/14/1999
FEE REQUIRED $ 60.00
FEE RECEIVED $ 60.00
PATRICIA L SHANDORF , POW LAN REVIEWER BALANCE DUE $ 0.00
Integrated Services
(715) 634 -7810, FAX: (715) 634-5150, M -F 7:45 AM - 4:30 PM
PSHANDORF @COMMERCE.STATE.WI.US WiSMART code: 7633
s
CONCRETE HOLDING TANK DESIGN
Single Tank Option
INDEX AND TITLE SHEET
Project Kathleen Dollery
Owner Kathleen Dollery
Address 2351 222nd AV
Deer Park WI 54007
(715) 269 -5559
Legal Description SW SE S10 T31 N R16W
Township Cylon County StCroix
Subdivision Name Lot No.
Parcel ID Number 006 - 1022 -80 -000 S.
Plan Transaction Number Zalry
rV
COM E t
Index and title sheet Page 1 NIi>s
Holding tank specifications Page 2
Site plan Page 3
Holding tank agreement Page 4 3PONDENCE
_ -- Z �-Z
Designer Ron Friedell _
Signature i U4 Phone No. (715) 637 -3020
License Number 226564 Date I-
Notice: Tampering with this file by unauthorized persons is prohibited.
Deliberate modification will result in disciplIvarp action under s. 145.10, Wis. Stats.
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1 )(m)).
SM- 10463 -E (R.05J98) 1 Design Message(s) to Consider! Page 1 of 4
HOLDING TANK SPECIFICATIONS
Single Concrete Tank option
Complete Red Boxes Only In ounds Metric
If one- or two- family, number of bedrooms [_ 2 _]
And/Or .... Non-residential flow per day gpd or 0 JLpd
Minimum holding tank volume required 2000.0 Igal or 7570 IL
Proposed tank size is too small[ Increase tank size.
Holding tank capacity proposed 1272 gal or 4814.52 L
Manufacturer ISkaw Pre -cast
Alarm manufacturer 19 J Electro
Alarm model number
Depth from inlet invert to service alarm F t �.0 in or 30.5 cm
Liquid depth of tank below inlet invert T 3'sIin or 96.5 cm
HOLDING TANK CROSS SECTION manhole cover with
locking device and
vent junction
finished ,t -•'�_ warning label
cap g rade box ---�
12" (30.5 cm) min. 4` (10 cml min.
vent pipe conduit ---�
18'(4e cm)
Electrical as per NEC 300.
12.0 in. t� -------
building sewer
blind plug 30.5 ctr service inlet
to seal alarm on
outlet Note: All tank
26.0 in. of joints, and
66.0 crr, joints between
Manhole and vent locations tank openings
may be reversed. and piping are
sealed water
tight.
3 in. (75 mm) bedding under tank.
Tank is anchored as necessary to negate buoyant forces.
Project: Kathleen Dollery
Transaction Number: Page 2 of 4
.5
HOLDING TANK SITE PLAN
Project: Kathleen Oollery
N Legal Description: SW SE S10 T31 N R16W
Subdivision Name:
Scale: 1: 40 Transaction I.D.: Lot No.:
222nd AY
r— --1
[
n , t
w�kA_ I
c� flrr, �� mlrutx, fit.. ►on
Top of 5A5e -*-_MT CokxjUera WA%A,
Weu_ L.oc.Axtorj
141. 14 0t , 0 1 t4, TAN It
1250 g p, t_ 5Kaw _11 IC.
Male T A0K 15 rt 5e USE AS �Gw.flIrJG�rtAaK,
UIJTIU (P, 2.poo Al D2 Bef - CR*, A M0VfJD
51JS'TaM wtu. 56 ComPUXta10 AAD TOO
' AIJ VK W"," 136 C4AA►)c MD West,,.
y� Page 3 of 4
Arok-A $ �IAP.�C.f�1. �At7 f tLl" 'l 1�RoP. �.1IrJ�
HOLDING TANK SERVICING CONTRACT
i «m�o�s�iR..`i /1G.t3t�m�►�T UNttt., tp�3O�2tjoo
Contract Date f
This contract is made between the
-- - - - - -- -- — --------------------------
Holding Tank Owner(s) Name(s) and I Pumpers Name
6- I � elA L , �6 �fe
We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal descriptions:)
SW %/ SE, S/o %
----------------------------------------------------- - - - - -- -- - - - - --
1. The owner agrees to file a copy of this contract with the local governmental unit that has signed the pumping agreement
required in Ch. ILHR 83.18(4) (b), Wis. Adm. Code and with the County of S I C t^ n / Y
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and
to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the access road or
drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the
pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper.
3. The pumper agrees to submit to the local governmental unit which has signed the pumping agreement required by s. ILHR
83.18 (4) (b), Wis. Adm. Code, and to the County, a report for the servicing of the holding tank(s) on a semiannual basis. The
pumper further agrees to include the following in the semiannual report:
a. The name and address of the person responsible for servicing the holding tank;
b. The name of the owner of the holding tank;
c. The location of the property on which the holding tank is installed;
d. The sanitary permit number issued for the holding tank;
e. The dates on which the holding tank was serviced;
f. The volumes in gallons of the contents pumped from the holding tank for each servicing;
g. The disposal sites to which the contents from the holding tank were delivered.
4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract,
the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the local
govemmental unit and the County named above within ten (10) business days from the date of change to this service contract.
Owner(s) Name(s) (Print) t Owners Signature(s) Subscribed and swom to me on this date:
t
i
Today's Date
t
Pumpers Name (Print) t Pumpers Signature !+Aary Public Signature
1
t
Bf�c�
� ilea/
Pumpers Registration Number Commission Expiration
7, 5 - 3
Drafted by KDo 'FeilMDE4.A-
Safety and Buildings Division
Vi sconsin S ANITARY PERMIT APPLICATION 201 B Washington Avenue
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code
Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. 5T C,2_0I Y,
• See reverse side for instructions for completing this application State sanitary Permit Number
Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
KAtT SLJ Se va, S p T J, N, R j ( XQr) W
Property Owner's Mailing Address Lot Number Block Number
2 22z r-j AV ---
Cit State Zip Code Phone Number Subdivision Name or CSM Number
E 0 F_ TACK 1 t5l
II. TYPE OF BUILDING: (check one) ❑ State Owned [] C it y Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms � b Town OF C. - (Loo 22Zv AV
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 10
1 ❑ Apartment/ Condo
gip tozz 80— 000
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash
5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV TYPE OF PERMIT (Check only one box on line A. Check box -on line B, if applicable)
A) 1. ❑ New 2 gg Replacement 3, ❑ Replacement of 4, ❑ Reconnection of 5. ❑- Repair of an
_____System ________ System _____________ Tank Only______________ Existing System ________ Existin�System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM (Check only one)
Non- Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 KL Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 C] In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 1 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
Z56 25p q Feet Feet
Capacity
VII TANK in Ca gallo s Total # of Prefab. Site Fiber- Plastic Fxper.
INFORMATION New Existin Gallons Tanks Manufacturer s Name Concrete strutted Steel glass App.
T nk Tanks
Septic Tank or Holding Tank 750 --- 150 3 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ,5m 1 - � 1600 1 ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plu ber Signat re: (No S ps MPRSW No.: LBusiness Phone Number:
olJ FRI L.L. Z.Zlo S(p4- '115 X31- Z cD
Plumber's Address (Street, City, State, Zip Code)
IX. COUNTY/ DEPARTM USE O
❑ Disapproved Sanitary Permit Fee OncludesGroundwater ate ssu aE:i = L
Surcharge Fee)
Approved ❑ Owner Given Initial
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS rOIR DISAPPROVAL:
SBD- 6398 (RA 1/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in.the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or pl umber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608 -26 &3151.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and'mailing address. Provide the legal description and parcel tax numbers) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check - only one on line A. Complete linj B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 81/2 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; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; Q complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
---------------------------------------------------------------------------------------------- - - - - --
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
Safety and Buildings
10541 N RANCH ROAD
HAYWARD WI 54843
- TDD #: (608) 264 -8777
Vhsconsi►n www.commerce.state.wi.us
Department of Commerce Tommy G. Thompson, Governor
Brenda J. Blanchard, Secretary
November 15, 1999
CUST ID No.226564 AT77V.• POWTS INSPECTOR
ZONING OFFICE
RON E FRIEDELL �,.- �r r - / „�8�T CROIX COUNTY SPIA
1419 13TH AVE 101 CARMICHAEL RD
BARRON WI 54812 1DSON WI 54016
RE: CONDITIONAL APPROVAL
APPROVAL EXPIRES: 11/15/2001. Identification Numbers
Transaction ID No. 277121
Site ID No. 184168
SITE: '
' Please refer to both identification numbers,
Site ID: 184168 �` above, in all correspondence with the agency.
ST CROIX County, Town of CYLON;`2 I' 222ND AVE, DEER PARK 54007
SW1 /4, SETA, S10, T31N, R16W
Facility: KATHLEEN DOLLERY 2351 222ND AVE, DEER PARK 54007
FOR: MOUND, 300 GPD, REPLACEMENT SYSTEM
Object Type: POWT System Regulated Object ID No.: 637111
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in
chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements.
The following conditions shall be met during construction or installation and prior to occupancy or use:
1. This plan action is subject to designer comments on the plan.
2. The orientation of the mound system must be such that the mound's longest dimension is perpendicular
to the direction of maximum slope.
3. The area 25' below the downslope edge of the mound must remain undisturbed.
4. Abandon failing system per COMM 83.03(2).
A copy of the approved plans, specifications and this letter shall be on -site during construction and open to
inspection by authorized representatives of the Department, which may include local inspectors. All permits
required by the state or the local municipality shall be obtained prior to commencement of
construction /installation/operation.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
Sincerely DATE RECEIVED 11/08/1999
FEE REQUIRED $ 180.00
i FEE RECEIVED $ 180.00
PATRICIA L SHANDORF , POWTS PLAN REVIEWER BALANCE DUE $ 0.00
Integrated Services
(715) 634 -7810, FAX: (715) 634-5150, M -F 7:45 AM - 4:30 PM
PSHANDORF@COMMERCE.STATE.WI.US WiSMART code: 7633
Safety and Buildings
10541 N RANCH ROAD
HAYWARD WI 54843
TDD #: (608) 2648777
isconsin www.commeroe.state.wi.us
Department of Commerce Tommy G. Thompson, Governor
Brenda J. Blanchard, Secretary
November 15, 1999
CUST ID No.226564 AM: POWTS INSPECTOR
ZONING OFFICE
RON E FRIEDELL ST CROIX COUNTY SPIA
1419 13TH AVE 1101 CARMICHAEL RD
BARRON WI 54812 HUDSON WI 54016
RE: CONDITIONAL APPROVAL
Identification Numbers.
APPROVAL EXPIRES: 11/15/2001
Transaction ID No. 277121
Site ID No. 184168
SITE: Please refer to both identification numbers,
Site ID: 184168 L above, in all correspondence with the agency.
ST CROIX County, Town of CYLON; 2351 222ND AVE, DEER PARK 54007
SW1 /4, SETA, S10, T31N, R16W
Facility: KATHLEEN DOLLERY 2351 222ND AVE, DEER PARK 54007
FOR: MOUND, 300 GPD, REPLACEMENT SYSTEM
Object Type: POWT System Regulated Object ID No.: 637111
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in
chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements.
The following conditions shall be met during construction or installation and prior to occupancy or use:
1. This plan action is subject to designer comments on the plan.
2. The orientation of the mound system must be such that the mound's longest dimension is COhti�E
perpendicular �I
to the direction of maximum slope.
��E
3. The area 25' below the downslope edge of the mound must remain undisturbed.
4. Abandon failing system per COMM 83.03(2).
A copy of the approved plans, specifications and this letter shall be on -site during construction and open to
inspection by authorized representatives of the Department, which may include local inspectors. All permits
required by the state or the local municipality shall be obtained prior to commencement of
construction /installation/operation.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
Sincerely, DATE RECEIVED 11/08/1999
tRE VIEWER FEE REQUIRED $ 180.00
FEE RECEIVED $ 180.00
PATRICIA L SHANDORF , POWTS BALANCE DUE $ 0.00
Integrated Services
(715) 634 -7810, FAX: (715) 634-5150, M -F 7:45 AM - 4:30 PM
PSHANDORF @COMMERCE.STATE.WI.US WSMART code: 7633
r
MOUND SYSTEM DESIGN
Residential Application
INDEX AND TITLE SHEET
Project Kathleen Dollery
Owner Kathleen Dollery
Address 2351 222nd AV
Deer Park WI 54007
715 269 -5559
Legal Description SW SE S10 T31 N R16W
Township melon County St Croix
Subdivision Name Lot No. w Ny
-, r
Parcel ID Number 006- 1022 -80 -000
GS
Plan Transaction Number
�p DdDEN
Index and title sheet Page 1
Mound calculations Page 2
Mound drawings Page 3
Pres. dist. calcs. and laterals Page 4
TDH and pump tank drawing Page 5
Site Plan Page 6
Pump Curve Page 7
Designer Ron, riedell License Number 226564
r
Signature Phone No. (715) 637 -3020
Date
Notice: Tampering with this rite by unauthorized persons is prohibited.
Deliberate modification will result In disciplinary action under s. 145.10, Wis. Stats.
Personal information you provide may be used for secondary purposes [Privacy Law, x.15.04 (1)(m)].
SBD- 10462 -E (R.05/98) Page 1 of 7
1gJ -1 (-z�
i
MOUND SYSTEM DESIGN
Complete red boxes as necessary. 1000 gpd maximum design flow.
Inch- ounds Metric
Residential or commercial? r (r or c) (y or n) Replacement system?
Creviced bedrock site? n (y or r
Slope 9 % .
Wastewater flow rate 300 gpd �� 1136 Lpd
Depth to limiting factor 30 in 1 76.2 cm
In situ soil infiltration rate 0.6 gpd /ft 24.4 Lpd /m
Contour line elevation 97.2 I ft ' 29.63 m
Use standard fill depths? x OR Design depth? in cm
Place X in box to use standard depths (24 and A +4 inclusive) OR specify design fill depth.
Center or end manifold a (c or e Hole diameter Q.25 in 0.125. 0.156.0.188.0.219,
n ')A n ')a4 nr n t 1A Inch nnly
Lateral spacing 0.00 ft Use 0 lateral spacing for trenches.
Estimated hole space 2.50 ft Not a final calculation.
Number of laterals 1 Pump tank elevation 76.5 It Outside bottom of tank.
Forcemain length 260.0 ft Forcemain diameter 2.0 in 1.5, 2 3 or 4 inch only.
2.067 in Actual I.D.
HOLE DIAMETER CONVERSIONS
1/8 = 0.125 114 - 0.250
SYSTEM SOLUTIONS Inch-pounds Metric 5132 = 0,156 9/32 = 0.281
Estimated daily flow 300 gpd 1136 JLpd 3/16-0,188 51116=0.313
7/32 = 0.219
Absorption cell
Design load rate & area 1.2 gpd/ft' 250.0 ft �.,OY 23.23 m
Linear loading rate (LLR) 6.00 gjiyft 74.4 Lpd /m
Design width (A) 5.00 ft 1.52 m
Cell length (B) 50.0 ft 15.24 m
Depth of cell (F) 1 10.0 in 1 25.4 cm
Sand filter
Upslope fill depth (D) 12.0 in 30.5 cm
Downslope fill depth (E) 17.4 in 44.2 cm
Basal area required (gpd /infiltration rate) 500.0 ft 46.45 rn
Supporting components
Topsoil depth 6.0 in 15.2 cm
Subsoil depth at center 12.0 in 30.5 cm
Subsoil depth at cell wall 6.0 in 15.2 cm
End slope toe length (K) 10.68 ft 3.26 m
Up slope toe length (J) 6.70 ft 2.04 m
Down slope toe length (1) 13.50 ft 4.11 m
Total mound length (L) 71.36 ft 21.75 m
Total mound width (W) 25.20 ft 7.68 m
Project: Kathleen Dollery
Transaction Number: Page 2 of 7
i
MOUND PLAN VIEW
observation pipes (typical)
J
25.2
I ft A A= 5.00 ft 1.52 m
7.68 m ' B = 50.0 ft 15.24 m
W 1� B J= 6.70 ft 2.04 m
I K 1= 13.50 ft 4.11m
K = 10.68 ft 3.26 m
L !L-1 71.36ft
21.75 m typ: obs. pipe
(anchored securely)
I = down slope dimension ] = absorption cell (AxB)
J = up slope dimension = plowed area (LxW)
K = end slope dimension B" (152 mm)
T
MOUND CROSS SECTION
subsoil cap D = 12.0 in 30.5 cm
lateral topsoil G H E = 17.4 in 44.2 cm
invert 98.70 ft F = 10.0 in 25.4 cm
elev. 30.08 m ?;; ::::::::;:` F G = 12.0 in 30.5 cm
ASTM C33 H = 18.0 in 45.7 cm
D Sand Fill E
sys. 1 98.20 ft y
elev. 29.93 m 97.20 ft contour ..,
29.63 m elev. 9 % - ---}
slope
D = upsiope fill depth plowed layer
E = downslope fill depth Note: Absorption eel media will consist
F = absorption cell depth of aggregate and pipe with laterals
G = subsoil + topsoil depth at cell wall centered across AxB media. The cell
H = subsoil + topsoil depth at cell center media is covered with geotextile fabric.
Designer notes:
Project: Kathleen Dollery
Transaction Number: Page 3 of 7
PRESSURE DISTRIBUTION CALCULATIONS
Absorption cell Inch-pounds Metric
Width (A) 5 ft 1.52 Im
Length (B) 50.0 I ft 1 15.24 Im
Lateral specifications
Number laterals 1
Holes /lateral 19 holes
Lateral length (P) 46.50 ft 14.17 m
Hole diameter 0.250 in 6.35 mm
Lat. dis. rate 22.14 gpm 1.40 Us
Sys. dis. rate 22,14 gpm 1.40 Us
Hole spacing (X) 31 in 78.7 cm
Lateral diameter Pipe diameter Design options Design choice
Designer must 1 in (25 mm) Place X in red
"X" one choice 1 114 in (32 mm) box of chosen
from the options 1 112 in (40 mm) x diameter.
provided. 2 In (50 mm) x x i
3 in (75 mm) x
Manifold diameter Pipe diameter Design o ptions Design choice
Designer must 1 in (25 mm)
'X one choice 11/4 In (32 mm) None required.
from the options 1 1/2 in (4o mm) No choice necessary.
provided. 2 in (50 mm)
3 in (75 mm)
41n(loor
Distribution system contains: 1 Lateral(s)
LATERAL DIAGRAM - END CONNECTION
Place correct lateral diagram b dicki in one of the drawin s at right and dragging the dla ram into this area.
Y n9 9 9 99i 9 9
Laterals centered over the A & B dimension end cap
P
•
Last We rlrillod nowt to end cap IF X Laterals & Force main of PVC Soh 40
Holes drilled on the bottom of the lateral (per COMM Table 84.30 -5)
equally spaced : permanent end marker
Inch-pounds Metric
Lateral length (P) 46.50 It 14.17 m
Lateral spacing (S) 0.00 ft 0.00 m
Hole spacing (X) 31 in 78.7 cm
Manifold length 0 ft 0.00 m
Hole diameter 0.250 in 6.4 mm
Lateral diameter 1 2.00 lin 50 mm
Forcemain diameter 2.00 in 50 Imm
Project: Kathleen Dollery
Transaction Number: Page 4 of 7
TDH and Pump Tank Drawing
Total Dynamic Head
Operational head 2.50 ft Mdm m
Vertical lift 21.50 ft m Are laterals the highest point In the
Friction loss 2.30 ft m system? Yes "X" here.
Total dynamic head 26.30 If no, what le the highest elevation
Dose Volume downstream of pump?
Dose is > 10 times lateral volume Foroemsirt drain
Lateral void volume 6.1 gal 30.7 L back to tank? (Y one)
Minimum dose 81.0 gal 306.6 L x Yes
Drain back 45.3 gal 171.5 L E No
Dose volume 126.3 al 478.1 L
Typical Pump Chamber Layout
In combination with state approved treatment tank. Tank construction as per Comm 83.20(3) WAC.
approved manhole cover with
T weather proof warning label and locking device
Wade levels juneflon box
disconnect grade levels
�► alternate
4" vent pipe electric as per NEC 300 and E---- outlet
" Comm 18.28 WAC location 18" (46 cm) min.
waN of pump & approved
chamber or outlet joint
combination tank
A Provide 114" weep hole or err&
alarm on siphon device as necessary
pump on B
Orade levels
pump 77.2 ft C - pump tank manhole a 4" (10 cm)
off elev. 23.5 m minimum above finished grade
D - vent =12" (30.5 cm) minimum
above flnMed grade
76.5 Ift Pump tank elevation
3 " (75 mm) of bedding under tank 23.3 I m bottom of tank
Tank manufacturer SKAW 1272 Combo. Tank
Pump tank capacity 14.231galfin
Pump tank volume 500 gal
Pump manufacturer Goulds Inches Gallons
Pump model number 3 85 WEO H J� A 19.3 274.0
B 2 28.5
Alarm manufacturer S J lectro C 8.9 126.3 v
Alarm model number 1101 p D S 1 71.2
Project: Kathleen Dollery
Transaction Number. Page 5 of 7
5rr6 'PLa�
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N
i
DR ve
fry'
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LL-
S �a�ope
`oe� otp�
1 Q �•
O F3m Bt3� -N MiA'itK i�'1. Io0.0
T op aF 1 PVG Pipe
..
s �-��� �p u� r Pimp c��►�. ,�h o� A 40 N�r� o
�kA%o n 9At. ComB�aAT�o�T Jk
ttnour.�0 S T�NUI C�
Goulds
Submersible
Effluent Pump
3885
CANADIAN STANDARD ASSOCIATION sP
APPLICATIONS • Three phase:'' /2 HP FE ATURES Motors Fully submerged in
Specifically designed for the 1'/2 HP 200/2301460 V, impelled Cast Iron, se m i : , high -grade turbine oil for
60 Hz, 3500 RPM. Class S = lubrication and efficient heat
following uses: insulation, overload boon+ non -clog With p transfer .
• Homes out Was for Mechanical Seal
protection must be Designed for Continuous
• Farms protection. Ssilanced fbr
• provided m starter unit. Op eration! Pump r
Trailer courts • Shaft: threaded, 400 series smooth operation, Silidon p p stings are
• Motels bronze ImpdOer evaifabld es within the motor manufacturer's
stainless steel ( recommended workin limits,
• Schools ' an optlon 9
•Hospitals Bearings: ball bearings ,f ,y" Can be Operated Continuously
upper and lower. Cegtng. Cast iron volute
• Industry without damage.
• Power cord: 20 foot type fbr maxlrCum effidiency. r 8 U p per • Effluent systems standard length (optional 2" NPt discharge adaptable x :f Bearings:
pp r and .
lengths available). for slide rail systems, ' „lower heavy. duty bearing
SPECIFICATIONS Single phase: and % HP Maehsnl i "Seal: SiliCOti r� construction >�
Pump: -16/3 SJTO with three carbldd W Old an Carbide tower Cable. Severe duty
• Solids handling capabilities: prong plug 3 /4 .1 V2 HP sealing faces. Stainless steei rated, oil and water resistant.
3 /4 " maximum. — 14/3 STO with bare leads. metal parts, BU NA N Epoxy seal on motor end
,,,� • Discharge size: 2" NPT. Three phase:' /z -1'/2 HP elastomers s:t provides seedndary moisture
�- Capacities: up to 128 GPM. -14/4 STO with bare �` -_ ase'of outer jacket
barrier In c
$het G�drtosion�resstarif , w ;.
• Total heads: up to 123 feet leads. On GSA listed stalniass steefaa hreaded ° L damage and to prevent oil
TDH. models — 20 foot length wicklhg,
design; Gocknut inn three _ ,
• Mechanical seal: silicon SJTW and STW are phasd Mildele t guard d -ring: Assures' Obsitive
carbide -rotary seattsilicon standard. again "6oitr� nt damage
tbv ' Y s ea li ng agai dbntprbihants
carbide - stationary seat, 300 on acCiddrital erse rotation. _= and oil leakage,:
series stainless steel metal ".
parts, BUNA -N Olastomers.
• Temperature:
METERS FEET
104 °F (40 °C) continuous 90
140 °F (60 °C) intermittent. slrh11:8� aa196'
• Fasteners: 300 series 25 80 „ , izE sot los -
stainless steel. E, sorLp ar3
• Capable of running dry 20 70 e1 !'iFf
without damage to
z
components. ' so
Motor: 50
• Single phase: Y3 HP, I IS 15 �
or 230 V 60 Hz, 1760 RPM; 8 40 u
/2
' HP,115 V, 60 Hz, a .�,' k ;
3500 RPM; '/2 HP - 1'/2 HP, i0 30
230 V, 60 Hz, 3500 RPM, E
Built -in overload with 20
5 d
automatic reset. 10
Class B insulation:
0 0 0 10 20 30 4b �� . ',�f1 `'YO ` 80 90 100 110 120 130GiPM
0 0 , . 20 30 m
CAPACITY
W Goulds Pumps, Inc. Effective May, 1994
1 11 B3885
Wisconsin Department of Industry, Pa e 1 of 3
LaborandjlumanRelations SOIL AND SITE EVALUAT10�11- DEPORT 9
Division of Safety & Buildings to accord with ILHR 83.05 Wig; Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, bi.47 "' St. Croix
not limited to vertical and horizontal reference point (BM), direction and % Of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. ( 006- 1022 -80 -000
APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION w REV WED BY DATE
�: 0 -
PROPERTY OWNER: PROPE k
Kathleen Dollery GCV4. I OT_„ SW 1/4 fit" "' 010 T 31_, N,R 16 xE (or) W
PROPERTY OWNER' MAILING ADDRESS LOT f AME OR CSM #
2351 E 222nd. Ave. ZZ na
CITY,
Dee Park, WI . 540071P CODE PTO Z69B�59 ❑CITY ❑VILLAGE nOWN NEAREST ROAD
( )L y Cylon I 222nd. Ave.
[ ] New Construction Use [x] Residential / Number of bedrooms 2 [ ] Addition to existing building
j Replacement [ ] Public or commercial describe
Code derived daily flow 300 g pd Recommended design loading rate • 5 bed, 9pd /ft •6 trench, gpd /ft
Absorption area required 250 bed, ft 250 trench, ft Maximum design loading rate .5 bed, 9pd /ft .6 trench, gpd /ft
Recommended infiltration surface elevation(s) 98.20 ft (as referred to site plan benchmark)
Additional design / site considerations system el . based on contour line of el ( 97.20'
Parent material alacial drift Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN GROUND PRESSURE AT GRADE 7 SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem ❑ S 1 U ®S El ❑ S Kl U El S K) U [IS K7 U El S M
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trerlctl
1 -6 10yr3 /3 none 1 2msbk mfr Cs 2f .5 .6
1
2 -20 10yr4/4 none sil 2msbk mfr gw if ] .45 .6 Ground 3 0 -36 7.5yr4/4 none sl 2msbk mfr gw if .6
98 4 6 - 72 7.5yr4/4 c2d 7.5yr5/8 scl M na na na np '.2
Depth to
limiting
factor
36
Remarks:
Boring #
1 -10 10yr4 /3 none sl 2msbk mfr gw 2f .5 �.6
2 2 0 - 10yr4 /4 none sl 2csbk mfr 9W if .5 .6
3 2 -30 7.5yr4/4 none scl 2msbk mfr gw if .4 .5
Ground
elev. 4 0 - 60 7.5jc474 c2p 7.5yr5/8 sacl M mfr na na np .2
98 ft.
Depth to
limiting
factor
30"
Remarks:
CST Name: -- Please Print Gary L. Steel Phone: 715 - 246 -6200
Address: 1554 200th- Ave., New Richmoa, WI 54017
Signature: Date: 10 -24 -99 CST Number: m02298
ell
PROPERTY OWNER Kathleen Dollery SOIL DESCRIPTION REPORT Page 2 Of 3
PARCEL I.D. # 006- 1022 -80 -000
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BounclWy Roots GPD /ft
..................
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends
1 0 -9 10yr3 /3 none 1 2msbk mfr gw 2f .5 .6
La ":' 2 9 -19 10yr4 /4 none s i 1 2msbk mfr gw 1f .5 .6
Ground 3 19 -34 7.5yr4/4 none scl 2msbk mfr gw if .4 .5-
elev. 4 34 -60 7.5yr4/4 c2d 7.5yr5/8 scl M na na na np ! .2
9 4.8 ft.
Depth to
limiting
factor
34'
Remarks:
Boring #
13
Ground
elev.
ft. —
Depth to -
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
13
Ground
elev. j
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
r
STEEL'S SOIL SERVICE
Gary L. Steel Kathleen Dollery 1554 200th Ave.
CSTM2298 Sw4SE4 S10- T31N -R16w New Richmond, WI 54017
MPRSW -3254 town of Cylon {715) 246 -6200
N
1 110
BM.= top of 1 pv pipe C el. 100.00
Alt. BM.= top of 1 pvc pipe C el. 98.70
IL
0
qA
u
(� o0
Gary L. Steel
10 -24499
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
/� / OWNERSHIP CERTIFICATION FORM
�5
Owner/Buyer a / e e I � + � ��e �^
y
Mailing Address
Property Address Sa a S Q b o u e
(Verification required from Planning Department for new construction)
City/State beer PC( r K �g pamel Identification Number (�_�� /b c%? --O c)
LEGAL DESCRIPTION
Property Location S LJ %,, %,, Sec. > 6 . T - , 3 / N -R Town of
Subdivision Lot #
Cu ed Survey Map # Volume , Page #
Ww"U,0 # �- / q1 Volume 10 0 S
. rage #
Spec house 0 yes Cy no Lot lines identifiable 0 0 no
SYSTEM MAINTENANCE
Improper use and maimtenanceof 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
plumberjourneyman plumber. restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, Stage 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.
171 9y'
SIGNATURE OF APPLICANT DATE
. OWNER. CERTIFICATION
I (are) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
IGNATURE OF APPLICANT DATE
* * * * ** Any information that is mis- represented may result in the sanitary peanit 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
DOCUMENT NO. STATE BAR OF WISCONSI ORM it - 1982 ... SPACk RESERVED ROR RECORDING OATH �'!
LAND CONTRACT
Individual and ('ar,arnte �
434918 '$25,000 BE USED FOR ALL TRANSACTIONS WHERE OVER; R EGISTE R'S OFFICE
`$25,000 IS FINANC`D TRANSACTIONS) NON - CONSUMER i
_ , Sr CROIX I
ST, C ,
ftc'd for Record
Glenn Anderson a /k /a Glenn Z
Contract by and between I +
�( L. Anderson and Jean M. Anderson husband and wife MAR 1988
i -• ------ - --------------------------- - - - - -- - ------------- •---- - - - - -- - - --
�I ---- • - as -- -Dint tenants= •• -•- ( ", at 11:00 AM
whether one or more) and ... Kathleen L. Dollery�_ a single woman
4 ..___ ( "Purchaser ", whether one or more). ! tspltter of Deeds
Vendor sells and agrees to convey to Purchaser, upon the prompt and full per-
formance of this contract by Purchaser, the following property, together with the
rents, profits, fixtures and other appurtenant interests (all called the "Property "), i f -
in
St. .. CroiX_-- •_ - - -•- ----------- County, State of Wisconsin: RETURN To
;Century 21, Indianhead Realty
+' ;New Richmond, Wisconsin 54017 f
Tax Parcel No . ... .......... ............... . "..."
(� The SW-4 of the SEZ of Section 10- 31 -16.
l
I ' Subject to recorded easements, reservations, and rights of way.
I
i
I i
This .. " - is nOt homestead property.
(is) (is not)
Purchaser agrees to purchase the Property and to pay to Vendor at . -any place designated by them
36 000 00 3,600.00
the sum of $----- --------- -----I.----- --- ------ ---- •---- - ----- In the following manner: (a) $ - -- ..................... . --- - -• - --
at the execution of this Contract; and (b) the balance of $ ....... 32_s 400. 00_ _______ _ _ _ _ __ together with interest from date
g *
1 � hereof on the balance outstanding from time to time at the rate o f ... per cent per annum
until paid in full, as follows -
There shall be monthly payments of principal and interest in the amount of
$328.65 per month, commencing on April 1, 1988, and continuing on the 1st
day of each month thereafter until March 1, 2003, at which time and date '.
all remaining principal and any accrued interest shall be paid in one balloon
payment. There shall be a penalty of $3.50 for any monthly payment paid after
the 10th day of the month.
Pr o vided ho wever the entire out the n matur t date hall be paid in full on or before the.__..__• day of I',
I (
------------------------ ' ( Y )
Following any default in payment, interest shall accrue at the rate of ... 9 ...... .% per annum on the entire amount Ii
in default (which shall include, without limitation, delinquent interest and, upon acceleration or maturity, the entire
principal balance).
i
Purchaser, unless excused by Vendor, agrees to pay monthly to Vendor amounts sufficient to pay reasonably antici-
pated annual taxes, special assessments, fire and required insurance premiums when due. To the extent received by Vendor, I'
Vendor agrees to apply payments to these obligations when due. Such amounts received by the Vendor for payment of
taxes, assessments and insurance will be deposited into an escrow fund or trustee account, but shall not bear interest
unless otherwise required by law.
Payments shall be applied first to interest on the unpaid balance at the rate specified and then to principal. Any
amount may be prepaid without premium or fee upon principal at any time after.... c . o . s - n . . g ............... 19 ........ (OR)
there• -Irra� - be�ee- grepeytnettb-( rf- prinerpa�-• w• itkocrb�permisei»�x Vetrder
In the event of any prepayment, this contract shall not be treated as in default with respect to payment so long
as the unpaid balance of principal, and interest (and in such case accruing interest from month to month shall be treated
as unpaid principal) is less than the amount that said indebtedness would have been had the monthly payments been
made as first specified above; provided that monthly payments shall be continued in the event of credit of any proceeds
of insurance or condemnation, the condemned premises being thereafter excluded herefrom.
{j Purchaser states that Purchaser is satisfied with the title as shown by the title evidence submitted to Purchaser I
jl for examination except: no exceptions. l
Purchaser shall not create or permit to accrue liens or adverse claims against
�I the Property which constitute a lien or claim against Seller's interest in the
Property. Purchaser shall pay to Seller all amounts, costs and expenses, including ;.
reasonable attorneys' fees, incurred by Seller to remove any such liens or adverse
claims. I'
Purchaser agrees to pay the cost of future title evidence. If title evidence is in the form of an abstract, it shall
be retained by Vendor until the full purchase price is paid.
I f closin
Purchaser shall be entitle to take possession of the Property on ........ date .. ........ o ................. .$ - ... ................ 19.......
Out One.
i
STATF- BAR OF WISCONSIN Stock NO. SO1
FORM No. 11 — 1982
. Not 804ME254
Purchaser promises to pay when due all taxes and assessments levied on the Property or upon Vendor's interest
in it and to deliver to Vendor on demand receipts showing such payment.
Purchaser shall keep the improvements on the Property insured against loss or damage occasioned by fire, ex-
tended coverage perils and such other hazards as Vendor may require, without co- insurance, through insurers approved
by Vendor, in the sum of
$ full insurable value but Vendor shall not require coverage in an amount more
than the balance owed under this Contract. Purchaser shall pay the insurance premiums when due. The policies shall
contain the standard clause in favor of the Vendor's interest and, unless Vendor otherwise agrees in writing, the original
of all policies covering the Property shall be deposited with Vendor. Purchaser shall promptly give notice of loss to
insurance companies and Vendor. Unless Purchaser and Vendor otherwise agree in writing, insurance proceeds shall
be applied to restoration or repair of the Property damaged, provided the Vendor deems the restoration or repair to be
economically feasible.
Purchaser covenants not to commit waste nor allow waste to be committed on the Property, to keep the Property
in good tenantable condition and repair, to keep the Property free from liens superior to the lien of this Contract, and
to comply with all laws, ordinances and regulations affecting the Property.
Vendor agrees that in case the purchase price with interest and other moneys shall be fully paid and all conditions
shall be fully performed at the times and in the manner above specified, Vendor will on demand, execute and deliver to
the Purchaser, a Warranty Deed, in fee simple, of the Property, free and clear of all liens and encumbrances, except
any liens or encumbrances created by the act or default of Purchaser, and except: ons
...-.- ... -- ...... on ...... .............
. ..................................•-•----•-•------•-•---•---•-- •-- •- ....._........._... -• - -•• ......................----_...._.._•--•--•-••-•-•-•-----•--.........---•-
. ..................••----...._.........---................---......... ......_.........- •--- .......... I ............................ _........ .........._....................
-------------------------------------------------------••---------•---..................•--•...... ...._..._......-- •- ••...... - -•• .......................................
.... - -- •---------------•-.......----•------....-------------- ..._•.........................................................
....--- •- •- - - -• -• .............................................
Purchaser agrees that time is of thMssence and (a) in the event of a default in the payment of any principal or
interest which continues for a period of .......... days following the specified due date or (b) in the event of a default in
performance of any other obligation of Purchaser which continues for a period of ...30... days following written notice
thereof by Vendor (delivered personally or mailed by certified mail), then the entire outstanding balance under this contract
shall become immediately due and payable in full, at Vendor's option and without notice (which Purchaser hereby
waives), and Vendor shall also have the following rights and remedies (subject to any limitations provided by law) in
addition to those provided by law or in equity: (i) Vendor may, at his option, terminate this Contract and Purchaser's
rights, title and interest in the Property and recover the Property back through strict foreclosure with any equity of
redemption to be conditioned upon Purchaser's full payment of the entire outstanding balance, with interest thereon from
the date of default at the rate in effect on such date and other amounts due hereunder (in which event all amounts previously
paid by Purchaser shall be :forfeited as liquidated damages for failure to fulfill this Contract and as rental for the
Property if purchaser fails to redeem) ; or (ii) Vendor may sue for specific performance of this Contract to compel
immediate and full payment of the entire outstanding balance, with interest thereon at the rate in effect on the date of
default and other amounts due hereunder, in which event the Property shall be auctioned at judicial sale and Purchaser
shall be liable for any deficiency; or (iii) Vendor may sue at law for the entire unpaid purchase price or any portion
thereof; or (iv) Vendor may declare this Contract at an end and remove this Contract as a cloud on title in a quiet -title
action if the equitable interest of Purchaser is insignificant; and (v) Vendor may have Purchaser ejected from possession
of the Property and have a receiver appointed to collect any rents, issues or profits during the pendency of any action
under (i), (ii) or (iv) above. Notwithstanding any oral or written statements or actions of Vendor, an election of any
of the foregoing remedies shall only be binding upon Vendor if and when pursued in litigation and all costs and expenses
including reasonable attorneys fees of Vendor incurred to enforce any remedy hereunder (whether abated or not) to tale
extent not prohibited by law and expenses of title evidence shall be added to principal and paid by Purchaser, as in-
curred, and shall be included in any judgment.
Upon the commencement or during the pendency of any action of foreclosure of this Contract, Purchaser consents
to the appointment of a receiver of the Property, including homestead interest, to collect the rents, issues, and profits of
the Property during the pendency of such action, and such rents, issues, and profits when so collected shall be held and
applied as the court shall direct.
Purchaser shall not transfer, sell or convey any legal or equitable interest in the Property (by assignment of any
of Purchaser's rights under this Contract or by option, long -term lease or in any other way) without the prior written
consent of Vendor unless either the outstanding balance payable under this Contract is first paid in full or the interest
conveyed is a pledge or assignment of Purchaser'a interest under this Cont.rnet soley as security for an indebtedness of
Purchaser. In the event of any such transfer, sale or conveyance without Vendor's written consent, the entire outstanding
balance payable under this Contract shall become immediatelydue and payable in full, at Vendor's option without notice.
Vendor shall make all payments when due under any mortgage outstanding against the Property on the date of
this Contract (except for any mortgage granted by Purchaser) or under any note secured thereby, provided Purchaser
makes timely payment of the amounts then due under this Contract. Purchaser may make any such payments directly to
the Mortgagee if Vendor fails to do so and all payments so made by Purchaser shall be considered payments made on
this Contract.
Vendor may waive any default without waiving any other subsequent or prior default of Purchaser.
All terms of this Contract shall be binding upon and inure to the benefits of the heirs, legal representatives,
successors and assigns of Vendor and Purchaser. (If not an owner of the Property the spouse of Vendor for a valuable
consideration joins herein to release homestead rights in the subject Property and agrees to join in the execution of the
deed to be made in fulfillment hereof.)
Dated this ....
29th February ..... .......... 19.88....
---• •- day of
...... j.,.. = "�: f _- ._...._(SEAL) L.a.:��. /.�_a� 7`--:_'(SEAL)
Kathleen L. Dollery * Glenn Anderson
* ----------------- ---------- •- ••.... .... ---- - - - - -- ....................... .............. ................
........ .......... ..................... SEAL i" i . . .... �:aa.'.;j..:.'..- .(SEAL)
Jean M. Anderson ............ .
AUTHENTICATION ACKNOWLEDGMENT
f
Signature(s) STATE OF WISCONSIN'
St Croix ss.
uary
......................... County. 29t named S
authenticated this ........ day of ........................... 19...... Personally c before me t . day of
Febr �
Fe - •---• ........................ 19....--- he a bove C
.........-•.....-• .............................. ............................... Kathleen L. Doller , Glenn Anderson t
. and Jean M. Anderson , . .... ; ? (`' ; "
-••----- •- • -•-• ----------- --- - - - - - -- ---- --- - - -••. .--- •--- •..--------- .................................. •••.....--••- ••--- ............._....-- .. -
- --
TITLE: MEMBER STATE BAR OF WISCONSIN
-•--•--••--•--•---•-----•--•--.....-• ............ ...... :........................
(If not, -••-• ....................... ............................... --- .............-- ••-•- --- .._....p ..... `-----------------------------------
authorized by § 706.06, Wis. Stats.) s
to me known to be the erson ..... who muted the
foregoing �iinstrufnent a nd acknowledg W -. mee
THIS INSTRUMENT WAS DRAFTED BY �, ••.••• `V���j�
-V—� VVV ""V"�II •
Eric J. Lundell Box 157 --- •• -••. -- ....... - -- ..�.....• ...
'... - John D. Walsh (`.
New Richmond, Wisconsin 54017 St. Croix:
................. ...................... ..... . . .. . ............................ Notary Public ......................... *_
i My Commission is permanent: (fnat „ ,gtatcr` xpir'atrtr
(Signatures may be authenticated or acknowledged. Both /-'
not necessary.) December 10 .)
- of persons signing in any capacity should be typed or printed date: ” .. ................ ........ - -... " "• "•••' - "•'
signatures. ' �i� f_ •'••....•••• e� \� ���
of
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FR2 : W I CV SRLES
KVLLUNUIVIC
A Product of Wick Building Systems, Inc.
P.O. Box 530 - Marshfield, Wl 54449 - (715).387-2551 Last Page
Attach Print on this Page: 10/11!1999
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RE-431 28x44 2BR 2B 1203 SQ. FT.
10/11/99 MON 10:26 [TX /RX NO 63771
Wisconsin Department of Industry SOIL AND SITE E V A L U AT I O —JWP O R T Page 1 of 3
Labor arkUquman Relations
Div Safety & Buildings in accord with ILHR 83.05, W Adm. Code
y COUNTY
.A,
/
Attach complete site plan on paper not less than S 1/2 x 11 inches in size. Rfan must include; lint 7-r1 St. Croix
not limited to vertical and horizontal reference point (BM), direction and % f slope, scale or PARCEL I.D. # / e , 3i
dimensioned, north arrow, and location and distance to nearest road. 00 6- 1022 - -000 /
«,
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION'.' ' ST REV D -Z
" - W r.19 "
WEBBY DATE
C�v: X
-
PROPERTY OWNER: ROPE O0A*JCE ;
Kathleen Dollery G OT.. SW 1/4 .5k' ,S10 T 31- N,R 16 i (or) W
PROPERTY OWNER':S MAILING ADDRESS LOT ll C # U AME OR CSM #
2351 E 222nd. Ave. Z na
CITY, S er T Park, WI. 540071P CODE PTPY �IUMBEEL []CITY [ MEOWN NEAREST ROAD
L6y 55 59 Cylon I 222nd. Ave.
[ j New Construction Use [x Residential ! Number of bedrooms 2 [ ] Addition to existing building
J Replacement [ ] Public or commercial describe
Code derived daily flow 300 gpd Recommended design loading rate • 5 bed, gpd /ft •6 trench, gpd/ft
Absorption area required 250 bed, ft2 250 trench, 11 Maximum design loading rate • 5 bed, gpd /ft .6 trench, gpd/ft
Recommended infiltration surface elevation(s) 98.20 ft (as referred to site pla benc hmark)
Additional design/ site considerations system el. based on contour line of elk 97.20'
Parent material glacial drift Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem I ❑ S U U IN S ❑ U EIS U U - EIS KI U ❑ S Q U ❑ S CCU
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench
1 -6 10yr3 /3 none 1 2msbk mfr cs 2f .5 .6
1
2 -20 10yr4/4 none sil 2msbk mfr gw if .5 .6
Ground 3 0 -36 7.5yrg /4 none sl 2msbk mfr gw if .5 .6
elev.
9 _ ft. 4 6 -72 7.5yr4/4 c2d 7.5yr5/8 scl M na na na np .2
Depth to
limiting
factor
36
Remarks:
Boring #
1 -10 10yr4 /3 none sl 2msbk mfr gw 2f .5 .6
2 0 -22 10yr4 /4 none sl 2csbk mfr yw if .5 .6
3 2 -30 7.5yr4/4 none scl 2msbk mfr gw if .4 .5
Ground
elev. 4 0 -60 7.5yc474 c2p 7.5yr5/8 S&ti M mfr na na np .2
98 ft.
Depth to
limiting
factor
30"
Remarks:
CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200
Address: 1554 200th. - Ave. , New RichmoO, WI 54017
Im
Signature: �� 0 OD Date: 10 -24 -99 CST Number: m02298
PROPERTY OWNER Kathleen Dollery SOIL DESCRIPTION REPORT Page_
PARCEL (D. # 006- 1022 -80 -000
Depth Dominant Color Mottles Texture Structure Roots GPD /ft°
Boring # Horizon Consistence Bax�dary
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends
0 -9 10yr3 /3 none 1 2msbk mfr 9w 2f .5 .6
2 9 -19 10yr4 /4 none sil 2msbk mfr 9w if .5 .6
Ground
3 19 -34 7.5yr4/4 none scl 2msbk mfr 9w if .4 .5.
elev. 4 34 -60 7.5yr4/4 c2d 7.5yr5/8 scl M na na na np .2
9 4.8 ft.
Depth to
limiting
factor
34"
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Y
STEEL'S SOIL SERVICE
Gary L. Steel Kathleen Dollery 1554 200th Ave.
CSTM2298 SW4SE4 S10- T31N -R16w New Richmond, WI 54017
MPRSW -3254 town of Cylon {715) 246 -6200
N
1
BM.= top of 1 pvc pipe C el. 100.00
Alt. BM-= top of 1 pvc pipe C el. 98.70
222 n d. Fr • �' f 7- 60 I+
Q
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Gary L. Steel
10 -24499
• AS BUILT SANITARY SYSTEM REPORT
P1NER • /61"y , TO SEC. /O N, R�W
I.O. ADDRESS , ST. CROIXItOUNTY, WISCONSIN. .
'= BDIVISION LOT LOT SIZE
PLAN VIEW
-Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
a h
u1 r
... ��
S \
z
"1PTIC TANKS) /L ► MFGR. U,1 �: CONCRETE y STEEL
NO. of rings on cover Cj Depth G," DRY WELL N &a -jP--
.ENCHES NO. of ---. width length area
-:D no. of lines ? _ width Z length 33 area 3�iL
depth to top of pipe
]GREGATE `3
-RK RATE AREA REQUIRED 3 7 541" - AREA AS ,BUILT
:�sclaimer: The inspection of this system by St. Croix County does not imply complete %
mpliance 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
'stem operation. However, if failure is noted the County will make every effort to
'. cause of failure.
uEASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
'INSPECTOR + �S
DATED //� ?��� PLUMBER ON JOB C S �-
6 H fl �.
LICENSE NUMBER y Z / Z--
w i
I i
REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM
SanitaAy PeAmit as�o
State Septic
SAME Township St. C&oix County
(rcation S(4) S I E Secxian _Lat # S lb divi-6ion
E PTIC TANK
Size Z gaExon,6 NumbeA ob eompan.-tmen.t.6
)(',stance ,6Aom: Wett Buitding 1.2% stope
Highwa.teA
'_ LIMPING CHAMBER
�r2
S i z e _gatto n4 _ Pump Manu 6aetuneA l i ^ Ma de.E Numb e , -,JfV - 11C
IO LDING TANK
Size gattons Num eA 6 CompaAtment,s
PumpeA f A a ye-tem
f
4.6 tanee 64om: Wett ' Buy 2ding 12% �stape__
Highwa.te.A
,B S'ORPTION SITE
Bed TAeneh
('.,s-tance 6nom: Wett Building r2% �s tope
Highwa.teA
[SO RPTION SITE DIMENSIONS
Width o A tAeneh At Req u� Aed aAea 3
Length o.6 each Une _1_7 _6.t Depth o6 tock bekow tike -�n_ An
Numbers o6 eine.6 Depth .o6 Aoek oveh. -tile 2-- .i.n
Totak .Length o tinee _ -6-t Depth o6 -tile below gnade _ — 7 4
Dd.e-tanee between tZne At Stope ab -tAeAch tin. pe.n, r00 A
I o1_a( albs U)4Jt an aAea
r �� (, _ 6t type. a6 CoveA: PapeA aA trcaw
'IT DIMENSIONS
Numb en OA pit's avet aAound
Ou-tstde dli.ame-teA __ be�ow in. et {�t
To-tat ab , mption ` Aea 6 t
AAea AequtiAed At
NS P- ECT -D _ %'�-� -z fir- TITLE
PPROVED DATE f 198
'EJECTED DATE 1 9 8
I[ASON FOR REJECTION
s ko �.-
I
REPORT ON INSPECTION OF SANITARY PERMIT #
1 Name and Address of Permit Holder Person /Persons at Site (2 )Date of Inspection
'�& 44 14.4.1'_ 1 )�e ��j I ,, r s, se o. o ns a ing p umber
Time of Inspection
13
INSTALLATI CONSISTS OF: ❑ Septic Tank ❑ Seepage Trench ❑ Dosing Chamber
[]Seepage Pit ❑ Seepa a Bed ❑ Holding Tank []Fill System
ermanen reference in Describe:
Elevation of vertical reference point: Slope at site:
(5)MATERIAL AND DEPTH OF SEWER:
(6)SEPTIC TANK: Manufacturer: Liquid Capacity:
Tank Inlet Elevation: Tank Outlet Elev:
# ft to lot or property line: # ft to well
(7)DOSING TANK: Manufacturer: # of gallons:
# of gallon pump set for a cycle gallons; total capactiy of distribution
lines gallon; size of pump head; gallon per minute ;
horsepower ; brand name of pump and model number
Is the warning device installed? ❑ YES ❑ NO Wired? ❑YES ❑ NO
8 HOLDING TANK: Manufacturer of gallons ;
construction ; depth to the cover ft; If septic tank is
being used are baffles removed? YES ❑ NO; ft from residence;
ft from well; ft from property line. Type of warning device
Is the warning device installed? ❑ YES ❑ NO; Wired? ❑ YES ❑ NO;
Locking device on cover? []YES ❑ NO; Diameter of vent and material ;
Distance from building to vent
(9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth;
ft to residence; ft to well; ft to property line;
ft to ordinary high water mark of lake or stream; ft to edge of slopes
greater than seepage pit inlet pipe - elevation ft; bottom of
seepage pit elevation ft.
(10) SEEPAGE BED SIZE: ft width; ft length; tile depth;
lineal feet tile; ft to residence; ft to well; ft to lot or
property line; ft to ordinary high water mark of lake or stream; ft to edge
of slopes greater than 20% falling away toward lakes, water courses or drainage ditches
Elevation of tank discharge line entering bed ft.
11 SEEPAGE TRENCH: Total length of seepage trench ft; width ft;
tile depth ft; ft to well; ft to ordinary high water mark of
lake or stream; ft to edge of slopes greater than 20% falling away toward lakes,
water courses or drainage ditches; elevation of tank discharge line entering seepage
trench ft.
(12) Has system been installed in area indicated on EH 115? []YES ❑ NO
(13) Has system been installed in fioodway? ❑ YES ❑ NO Floodplain? ❑ YES []NO
DILHR -SBD -6095 N.0 /80
Signature of Inspector
T -
° REPORT ON INSPECTION OF SANITARY PERMIT # J
1 Name and Address Permit Holder Person /Persons at Site (2 )Date of Inspection
ame, ress, I se o.�o ns a in Plumber
Time of Inspection
3 INSTALLATIO CONSISTS OF: [I Septic Tank ❑ Seepage Trench ❑ Dosing Chamber
❑ Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System
(Permanent re erence oin Describe:
Elevation of vertical reference point: Slope at site:
(5)MATERIAL AND DEPTH OF SEWER:
(6)SEPTIC TANK: Manufacturer: Liquid Capacity:
Tank Inlet Elevation: Tank Outlet Elev:
# ft to lot or property line: # ft to well:
(7)DOSING TANK: Manufacturer: # of gallons:
# of gallon pump set for a cycle gallons; total capactiy of distribution
lines gallon; size of pump head; gallon per minute ;
horsepower ; brand name of pump and model number
Is the warning device installed? []YES ❑ NO Wired? ❑ YES []NO
8 HOLDING TANK: Manufacturer of gallons ;
construction ; depth to the cover ft; If septic tank is
being used are baffles removed? YES []NO; ft from residence;
ft from well; ft from property line. Type of warning device
Is the warning device installed? ❑ YES ❑ NO; Wired? []YES ❑ NO;
Locking device on cover? []YES ❑ NO; Diameter of vent and material
Distance from building to vent
(9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth;
ft to residence; ft to well; ft to property line;
ft to ordinary high water mark of lake or stream; ft to edge of slopes
greater than seepage pit inlet pipe - elevation ft; bottom of
seepage pit elevation ft.
(10) SEEPAGE BED SIZE: ft width; ft length; tile depth.;
li.neal feet tile; ft to residence; ft to well; ft to lot or
property line; ft to ordinary high water mark of lake or stream; ft to edge
of slopes greater than 20% falling away toward lakes, water courses or drainage ditches
Elevation of tank discharge line entering bed ft.
1 SEEPAGE . Total length of seepage trench ft; width ft;
tile depth ft; ft to well; ft to ordinary high water mark of
lake or stream; ft to edge of slopes greater than 20% falling away toward lakes,
water courses or drainage ditches; elevation of tank discharge line entering seepage
trench ft.
(12) Has system been installed in area indicated on EH 115? [:]YES ❑ NO
(13) Has system been installed in floodway? []YES ❑ NO Floodplain? [ ❑ NO
DILHR -SBO -6095 N. /8
Signature of Inspector
1
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i
PLB'67 State and County State Permit # 9 1e)
Permit Application County Permit
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:
h /-
C yep . A
B. LOCATION: � ' / 4 ' /4, Section _La, T_�k N, R_16& ..(o) Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
e ' I Township 177" ja&
v�! i (eS q�?� � peg' - � R 4" , Cj
C. TYPE OF OCCUPANCY; Commercial *Industrial *Other (specify) Variance
Single family _J4 — Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY jhho Total gallons No. of tanks
HOLDING TANK CAP CITY Total gallons No. of tanks
Prefab concrete Poured -in -Place Seel Fiberglass Other (specify)
New Installation Replacement
Lift Pump Tank or Siphon Chambe gallons Prefab concrete --i/— Poured-i n-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: percolation Rate Total Absorb Area sq. ft.
New Replacement ✓ Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth top) No. of Trenches
Seepage Bed: � th -3� Width �2 Depth` Tile depth (top) l ri No. of Line
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land Q Distance from critical slope
WATER SUPPLY: Private Joint ❑ Community ❑ Municipal ❑
Owners name as listed on EH 115 if ot than present owner:
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 Certified Soil Tester, t/
NAME � S C.S.T. # 'S�j . and other information
obtained from owne T uilder).
Plumber 's Signature P /MPRSW# � ' Phone # X5 — ' : Z 6 � r n
Plumber's Address `
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
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Do Not Write in Space elow FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application (� Fee Paid: State A/." Co my oZ /. d'C) D � ZRO
Permit Issued /Rejgcted—( ate) Issuing Agent Nam �tJ
Inspection Yes �( No State Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy)
- Revised Date 7/1
all
EH y i 1 5 Rev. 9/78 .�,.
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
' WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
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LOCATIO /4, %, Section E (or�V Township or Municipality 2
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Lot No. , Block No. County
S ubdivision ame �
Owner's /Buyers Name:
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Mailing Add ss: ? /N+'� / c>
TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS � G� PERCOLATION TESTS
IV
SOIL MAP SHEET jC NAME OF SOIL MAP UNIT
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHE
NUM- SINCE HOLE HOLE AFTE INTERVAL RATE
BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN /IN
P- o / 1 1
P -� 2 A90 S4 / '/ �, - /
P- Z " J /S
P—
a
P— 2
P—
SOIL BORING TESTS
I
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK
` OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B-
B_
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B
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PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) indicate on the plan the location��??nd��square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy - 3�� d F�/�` ,Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope. �E'
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I, the undersigend reby certify that the soil tests reported on this form were made by me in accord with the procedures and met s
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knowledge and belief.
Name (print) Certification No. L��s —
Address
Jf
Name of installer if known
Copy A — Local Authority CST Signature