HomeMy WebLinkAbout030-2087-50-000 ENT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS
DIVISION
.IAN NDLATIONS PERCOLATION TESTS (115 P.O. BOX 7969 SON, WI 53707
MADI
(H63.0911) &Chapter 145.045) .. jqqS
LOCATION: SECTION: TOWNSHIP/ TY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
NE � /4NE�/4 22 /T 30 11/11 191d.') W St. Joseph 5 n/a n/a
COUNTY: OWNER'S BCKMM NAME: MAILING ADDRESS:
St. Croix Richard Stout 1353 Awatukee trl, Hudson, Wi. 54016
USE DATES OBSERVATIONS MADE
NO, BEDRMS.: 1COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence 3 n/a N ew ❑Replace 13 -23 -92 1 3-31-92
RATING: S= Site suitable for system U= Site unsuitable for system 0 - 20 9 7 _ 51 0 � + 'j
CONVENTIONAL: MOUND: IN- GROUND - PRESSURE: SYSTEM -IN -FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
HS DU CAS ❑U , ®S ❑U ❑ S gU ❑ S gU conventional trench mound for alt.
If Percolation Tests are NOT required DESIGN RATE: I If an portion of the tested area is in the
under s.H63.09(5) (b), indicate: n/a Floodplain, indicate Floodplain elevation: n/a
decimal' PROFILE DESCRIPTIONS page 34 BxB
BORING TOTAL DEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTHW ELEVATION OBSERVED EST- HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B_ 1 6.50 99.55 none 5.00 .00, 10yr3 /2,1., .92, 10yr4/4, sil., .50,10yr3 4
.s. 2.58 1 5 /4,co.s.,1 /50,10yr4 /3mot. s.l.
B _ 2 7.00 99.55 none 5.50 . 92, 10yr3/2,1.,1.25,5yr3/3,gr.l.s., 3.33,7.5yr4/4
4 mot. s.l.
B _ 3 7.16 100.15 none 5.66 .83 10yr3 /2,1. .50 7.54r3/4, gr.sil 75,7.5 4/41. .
(3.5II, .5yr4 /4co.s.,i.50�0yr+ /4- mot.s.l.�l0yr5 /4 5yr5/6
B- 4 4.33 99.30 none 3.33 .92,10yr3/3,1., .58,10yr4/4sil.,.83,7.5yr3/4 l.s.
1.00 4 4 s.l. w bands 1 3 3 mot.s.l. 1 r5 /4mot. il.
B_ 5 5.92 99.30 none 4.17 .92,10yr3/3,1., .5810yr4/4sil., 1.255yr3/2 gr.l. .
1.42 7.5 4 4 l.s. 1.75 1 4 3 s.l. w abundant mot.
B 5yr /4. alt. layers of sil. & s.l.
decimal' PERCOLATION TESTS
TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES
NUMBER XM3M6 AFTERSWELLING INTERVAL -MIN. PERIOD 1 PERIOD PER1003 PER INCH
P_ 1 2.00 none 30 5 % 5 5 1
P_ 2 2.00 none 30 3- 3 4 3 9
P- 3 2.60 none 5 2 4 }
P_ _ 4 2.00 none 30 1 2 2
P- 5 2.00 none 30 3 2- 24
P-
PLOT PLAN: 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 slope,
97.55 for original area, 101.00 for alt. mound,,
SYSTEM ELEVATION a,•
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ST. CROIX COUNTY ZONING DEPARTMENT'
AS BUILT SANITARY REPORT
Owner D /eW & f R T `
Address _ � -, ;, •�;T U�c�lx , .
o�r� &Ay _ /�� COUNT
City /State QPZ R SC r V, .3 y s- .%; �ONiNGOFF
sS /
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Legal Description:
Lot _ L Block dfA- Subdivision/CSM # P3AS p,r - if�oR r/�
'/. '/, [� Sec. Z2, TAN -Rf�W, Town of ST, �A.; �y PIN # 03d -2088 -
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer �,UE� S Size ST/PC / oD Setback from: House Well ?6' P/L �; t
Pump manufacturer �fyF�. k- Model _ /y 7
Alarm location 416"
OLDING TANKS ONLY)
Setbacks: Serince roa air intake Water Line
Meter location
Alarm locat'
SOIL ABSORPTION SYSTEM:
Type of system: 71 Width -3 Length S Number of Trenches 2-
Setback from: House A 16 Well j, PAL Jam! Vent to fresh air intake fpp
ELEVATIONS
Description of benchmark 7- / If i 1cc, A jlo 50 L 0 �. ,E Elevation 14o, 0
Description of alternate benchmark Elevation
Building Sewer ST/HT Inlet OU ST Outlet-
PC Inlet _Rf, 77
PC Bottom _ G, y Header/Manifold Top of ST/PC Manhole Cover
Distribution Lines (!) 7 2 (14
Bottom of System (j) �/' 7 5 (2)
Final Grade 0) _ 2 5- U-)
Date of installation /O_ /y/ ff Permit number 315f 4 11 State plan number /1/4
Plumber's ' nature License number . 22f2 411 Date /0 / /1126
Inspector � slt �3�.1 G
complete plot plan
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count y
Safety and Buildings Division
INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 315941
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
DIETHERT, TODD ST. JOSEPH
CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.:
l �c� I'b ,g�e4j l 030-208f-50-000
IF V
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
e eZ DDC7 Ben h g �.�2 I0y/r (DO
W Z60 1414 0 A- 3.33 I0/
Aeration Bldg. Sewer
Holdi St/ Inlet
TANK SETBACK INFORMATION t W Outlet ��/. 98 .
TANKTO P/L WELL BLDG. Air to
I ntake ROAD Dt Inlet �S6 .
ir
Septic g�'" NA Dt Bottom 7-� 1*5_ V
si 7 g' NA Header / Man.
Aeration Dist. Pipe !o•DY 1a,0� `�
H ing Bot. System
PUMP/ SIPHON INFORMATION 5_5 rn- WAX. Final Grade
Manufacturer Demand 5y. d ✓ s
Model Number ?' 0
TDH Lift 1 30c l Lrictior Syetem� TDH /b.�Ft
oss Forcemain Length Dia. F arr I Dist.Towell
SOIL AB ORPTION SYSTEM
BED r r RENCO Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIM 5 Z I DIMENSION
SETBACK
SYSTEM TO P/L BLDG WELL LAKE /STREAM LEA ING Manufacturer:
INFORMATION Type �� L/ r CH MBE Model N e
R r:
Sys t l ° f Z Z( ° 1 -Zl�, OR U
DISTRIBUTION SYSTEM
Header/Manifold u Distribution Pipe(s) Hole Size x Hole Spacing Vent To Air Intake
Length Dia Length � Dia. 7J Y Sparing q Cku'an 5 ✓ "
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS (Include code discrepancies, persons present, etc.) /03.
LOCATION: ST. JOSEPH 22.30.19,NE,NE 695 N. BAY ROAD
1ojlS/ p
Plan revision required? ❑Yes ] No
Use other side for additional information. 6,0 TF i
e
SBD -6710 (R.3/97) Date Inspector's Signature rt. NO
V i sconsin SANITARY PERMIT APPLICATION 01 E Washn
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Department of Commerce Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County , `/
than 81/2 x 11 inches in size. J<
• See reverse side for instructions for completing this application State Sanitary Pe rmiitNumber
The information you provide may be used by other government agency programs ,�/ E] Check if revisiUnn to'pre "vio -s application
[Privacy Law, s. 15.04 (1) (m)]. OC15 Av. g /c (,f , Edy". [State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION
Property Owner Name Property Location
" F 1/a ` c 1 /a, S Z T �� , N, R E (or
Propertf Owner's Mailing Address Lot Number Block Number
/q 1 7""" s :
Cit , State Zip Code Phone Number Subdivision Name or CSM Number
II. TYPE OF BUILDING: (check one) E] State Owned !t� Nearest Road
❑ Villa
Public in 1 or 2 Family Dwelling - No. of bedrooms -3 Town OF sy r 7os A1,01.9 7-,41 a,+ W 0 ,+ 0
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) RR- 3 0, /q 3
. 7_37
1 ❑ Apartment / Condo 0 0 — 90 8 — 0
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. V' New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an f
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 Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ® Seepage Trench 22 ❑ 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
SD I j 202 , 8 7 -15 Feet 4f, 75' Feet
Ca pa
city
TANK in allo c)t s Total # of r Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks
Septic Tank or Holding Tank M I EE/t'3 IM ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber 7 840 ® 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 er's Signature: (No cz Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
Gce SO E z
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing A gent Signature (No Stamps)
Approved []Owner Given Initial qty T1 Surcharge fee) e
Adverse Determination /� V 0
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -6398 (R Imo) DISTRIBUTION: Original to County. One copy To: Safety All Buildings Division. Owner, Plumber
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' PAGE OF
PUMP CHAMBER CROSS SECTION ARID SPECIFICATIONS
VENT CAP
4 "C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING
JULICTION BOX MANHOLE COVER
25' FROM DOOR. IZ'M11l.
wINDOW OR FRESH i
AIR INTAKE I
AL GRADE
'1' MIW.
I B' Ir111J.
CONDUIT
PROVIDE I INLET AIRTIGHT SEAL ( �/
APPROVED JOINT A I I AP PROVED JOIN
W /C.Z. PIPE I I I W /C.I. PIPE
EXTEWDIW AR
6. 3' t I ALMA EXTENDING 3'
ONTO SOLID SOIL d ( 11 ONTO 306I0 SOIL
I
I ON
I
CLCV. �al FT. PUMP —� �'
� OFF
0
CONCRETE DLOCK
RISER EXIT PERMITTED OWLd IF TANK MAQUFACTURCit HAS SUCH APPROVAL 3'APPRaVSD
. �r001 Nii
SEPTIC E SPECIFICATIOUS
DOSE ujE�it"' S
TAIJK MANUFACTURER: NUMBER OF DOSES: PER DAy
TA NK SIZE: pk) O GALLONS DOSE VOLUME /
ALARM MANUFACTUREGR: TA �L��T INCLUDING OACKFLOW: lks, 9 GALLONS
MODEL NUM6CR: 1114 CAPACITIES: A= INCHES Olt 3 7 Y S GALLONS
SWITCH TYPE: /2�/?4- uR L 4 5 = INCHES OR y3.7 G+LLOLIS
PUMP MANUFACTURER: ZaELLC2 C- INCHES OR 1 - 3 41 GA L60LI S
MODEL NUMOCR: 1 9 1 0 0 - INCHES OR .- GALLONS
SWITCH TYPE: /�EiPLL/R u MOTE: PUMP AND ALARM ARE TO BE
MINIMUM DISCHARGE- RATE 37, '/y GPM INSTALLED OW SEPARATE CIRCUITS
VERTICAL DIFFERENCE CETWEEM PUMP OFF AIJO..DISTRIBUTION PIPE.. AS FEET /•�•; GL /�N
+ MINIMUM NETWORK SUPPLY P ... . . .. .. . 2.5 FEET
+ _/DO FEET OF FORCE MAIN X �J¢W_ F Y otEFRICTION FACTOR ' 6 2 FEET
TOTAL DYNAMIC. HEAD = 30 -IJ FEET
INTERNAL DIMEIJSIOW OF TANK: LENGTH ;WIDTH ;LIQUID DEPTH
SIGNED: LICEWSE NUMBER: !t ��7y� DATE: Zy -W
'T�b � /�1�7;y�aT
DUSTRY,NT OF REPORT ON SOIL B ORINGS AND SAFETY &BUILDINGS
N
RR ff �� DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON N W BOX 53
HUMAN = ,RELATIONS
(H63.090) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/ Ty: LOT NO.: BLK. NO.: SUBDIVISION NAME:
NE � /4NEN 22 /T 30 N/R 19Idor) W St. Joseph 5 n/a ASS LAKE l�
COUNTY: OWNER'S 6X@L4 NAME: MAILING ADDRESS: X
St. Croix Richard Stout 1353 Awatukee trl, Hudson, Wi. 54016
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: DESCRIPTION: COMMER IAL PROFI E DE RIPTIONS: LATION TESTS:
esidence 3 n/a 91N ew ❑Replace 1 - 23 - 3 -31 -92
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN- GROUND - PRESSURE: SYSTEM- IN- FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
S 0 U �S ❑ � ®S ❑ U ❑ S 9U] ❑ S iEj I conventional trench . )mound for
If Percolation Tests are NOT required DESIGN RATE: I If an portion of the tested area is in the
under s.H63.09(5) (b), indicate: n/a Floodplain, indicate Floodplain elevation: n/a
decimal' PROFILE DESCRIPTIONS page 34 BxB
BORING TOTAL ELEVATION PTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH OBSERVED EST. IGHES TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B_ 1 6.50 99.55 none 5.00 .00, 10yr3 /2,1., .92, 10yr4 /4, sil., .50,10yr3 4
.s. 2.58 10 r5 /4,co.s.,1 /50,1 r4 /3mot. s.l.
B _ 2 7.00 99.55 none 5.50 . 92, 10yr3 /2,1.,1.25,5yr3/3,gr.l.s., 3.33,7.5yr4/4
m . s.l.
B 3 7.16 100.15 none 5.66 .83,10yr3/2,1. 50 7.5yr3/4, r.sil 75,7.5yr4/41. .
(3.58, . 5yr4/ 4co. s., i. 50i0yr� + /4- mo.s.l.�l0yr5 /4- 5yr5/6
B _ 4 4.33 99.30 none 3.33 .92,10yr3/3,1., .58,10yr4/4sil ... 83,7.5yr3/4 l.s.
1.00 4 4 s.l. w bands 1 3 3 mot.s.l. 10 5 /4mot. it
B_ 5 5.92 99.30 none 4.17 .92,10yr3/3,1., .5810yr4 /4sil., 1.255yr3/2 gr.l. .
1 42 5 4 4 l.s. 1.75 10 4 3 s.l. w abundant mot.
B _ 5yr /4, alt. layers of sil. & s.l.
decimal' PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES
NUMBER XM3EOG AFTERSWELLING INTERVAL -MIN, PERIO 1 PE RIOD2 PERIOD3 PER INCH
P- 1 2.00 none 30 5- 5 5 1
P- 2 2.00 none 30 3 -2 34 3,,
P- 3 2.60 none 5 4 'z 4 s
P- 4 2.00 none 30 2'z
P- 5 2.00 1 none 30 3 2% 2- 4 13
P-
PLOT PLAN: 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 slope.
SYSTEM ELEVATION 97.55 for lDriginal area, 101.00 for alt. mound," OK
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer ;C D /Q 0
Mallliia ALWi'ubd / y35 y7 1 T S 0"t-n w W Sy 92
Property Address _e�Z6 NOR TH flA Y AyAD
(Verification required from Planning Department for new construction)
City /State 5o/`9E/t s er IVY Parcel Identification Number 0 " 2088 —S
LEGAL DESCRIPTION
Property Location '/4, ^ /1( E ' / 4, Sec. T N -R__& W, Town of Sj_r S H
Subdivision L3A55 L,497 /160 A 7 , Lot # 5�
Certified Survey Map # , Volume , Page #
Warranty Deed # , Volume , Page #
Spec house ❑ yes 0 no Lot lines identifiable Q yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements 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.
C/ �/ & 7 / 2Yl j �'
SIGNATL4?t'OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
7 /�yl9lf
SfGNATM 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