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AS BUILT SANITARY SYSTEM REPORT
OWNE TOWNSHIP . L 'S�� SEC- T-_j3N -R#W
ADDRES Z !7 ST. CROIX COUNTY, WISCONSIN.
/F►e Ut wov, W�,S'
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
OW EVER THING WITHIN 100 FEET OF SYSTEM
a
NO
Idiae othArrow ' I
] SC Lt: I U _
, 3�V It p *s4 BENCHMARK: (Permanent reference Point) Describe: .41fo�
Elevation of vertical reference point: Slope at site:
SEPTIC TANK: Manufacturer: LJ :E t ' s 5 Liquid Capacity: 1 000 CQAI IONS
Number of.rings on cover : S Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gala pump set for a cyc a 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
REPORT OF INSPECTION - INDIVIDUAL StWAGL SVST - LM
San.i to i1 I'eiIrni (,�Q
Stotry Sep.ti.(`1461 e--�-
NAMt eJI ne hti
p St. CAa4 x Countil
Sectio Lot # Subdiv.Le -i.on
St_ PTIC TANK
Si rc' gat.tonb Numbers o6 compantme.n-ts
0 A t v ( om: wett Building 1 12% s Yo
HighwateA
PUMPLNG CHAMBER
S i ze gatton,6 Pump Manu6ac.tun Model' Number
Ilol "DING TANK
gallons Numbe.A o6 Compan.-tme.Yits .
Pu m r'en Ata)tm Sya.tem
04 5 "`" wr+" ' ` `.,,,.. ,. A , AII"'6°Wttdi ng 1
Highwa.teA
AI,SORPTION SITE
1.;c (l '� _ Tn -e_nch
h; tok i cv ,(o m: w e,tz k . _ BuiZA r20 s o e
Highwa.teA
A6'ti011.l'T ION SI D I MEN SIONS
W (d th ' 0 6 -tAeneh f 6t RequiAe.d aaea `p
I ngth o6 each lone. {�.t Depth oA cock below tiX.e z in
Num o6` I e,,6 Depth o6 n.oeh ove tife - �zl - - <n
Total I'eng.th o6 t.i.ne.6 /Q.S 6-t Depth ob tite below gn.a.de�1_� ^._�n
1 Distance between ti.ne.e_�e 6t Stope o "VAe.nch __ 'CH. poll 100 At
d
Totax ab area (� 6 Type. o6 Coven.: Paper. o etnaw
— - --
P71 DIMENSI
_ 6A�
Numbers o-A p.i.tb GAave (' (TI p4 t,s yee nn
Ou taide. diame-te_n.,_ 6x D e p t h befow .i.nXe-t {�(
Tot.af abeoAption ane.a 6,t
Area nequi.lted - ht
PL State and County State Permit #
6 7
Permit Application County P r it #
m g m
for Private Domestic Sewage Systems County 9 re
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
G ��/�E'G— ,PT z �o�' /7y �UD �viS. sy /G
B. LOCATION: _ % 5 - 1 - %, Section 3�, T N, R E (or) W Lot# City
Subdivision Name, nearesoa , lake or landmark Blk# Village
f4(,,<1A)JZY .1) — If AZW G�i►lt> Townships D
'
C. TYPE OF OCCUPANCY: *Commercial *Industrial * Other (specify) Variance
Single family _ (� Duplex No. of Bedrooms .7— No. of Persons Z'
D. SEPTIC TANK CAPACITY /OV Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete X ' Pouredlin -Place Steel Fiberglass Other (specify)
New Installation Replacement X
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured -in -Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft.
New Replacement X Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top No. of Trenches
Seepage Bed: — X _Length — _Width /_ Depth 3T 4, Tile depth (top �� No. of Lines
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land % Distance from critical slope
WATER SUPPLY: SUPPLY: Private g Joint ❑ Community ❑ Municipal ❑
Owners name as listed on EH 115 if other than p resent 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,
NAME ,(7QfRT Z��fJ�t' /G6iT C.S.T. # ✓ �OZy��— and other information
obtained from C$T (owner /builder).
Plumber's Signature MP /MPRSW# f I
Phone # 7�j 3 -Z - -IR- 5 0
Plumber's Address 2 AI OE V CIA/ GUNS
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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•- EH 'x.15 R.. 9/78
< REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
sHl , sE , //qq I —/.
LOCATION: /4, / 4, Section 3,T N,R (or) W, Township or Municipality /
Lot No. , Block No. County 57
u iwsion Name
Owner's /Buyers Name: G &r9ti1_
Mailing Address: Ar. Z ROX 17 UDfOA0 6 0/f J O/& t o
TYPE OF OCCUPANCY: Residence x No. of Bedrooms Z COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT EM `F 01 - 6A ,41 ER
DATES OBSERVATIONS MAD SOIL BORINGS Z8 ZM. PERCOLATION TE
SOIL MAP SHEET Sys /� NAME OF SOIL MAP UNIT 5 /A
w J d�i SL SvA
PERCOLATION TESTS.
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE BOLE AFTER INTERVAL MIN /IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P / / 40 //o /3Oke �a 1 ?Zane 20 777- /
P—
P w—
P -3 2
P—
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
NUMBER TEXTURE, MOTTLING AND DEPTH TO BEDROCK
INCHES
/E OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B— yw Q. > � n � y- s;�- . y " ,� N -may. S /;, 26 "47'
B—
B- 2 196 > 9 p 'y . s %� , f"c>/ 80.5 L , ?.2 "1_ ,&- 5' /1 , 5 „ i� Qa. sL-
B—
B- 3 �� �9� r , y�. S�[, S "L�13� -(, . SiL 2/ „ � Qa.S.'L, GS A ' G/ 4•✓ L
B—
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy& 3 ,Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope. 10 44 /NF1ELV Fp/2 2
h6oe2. 3 ve er. All `,P fpr►ce s r
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000r S��c ?i�l�t� Po�TS.
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4 eiet/ANA) Of- NA 1uQAL �, 4PS A 5 Te O 1 9.e O M SFD
SA rEM /'S 12 2..� �v � Q /30&AA /S •%e kge- d—& f-)
ST. CROIX COUNTY ZONING DEPARTMEN
AS BUILT SANI'T'ARY REPORT
Owner & *Ok
Address _Jb / U o�aol
/` c „ �X �. ` unlrY
City /State
-- dun ts1�st L-��l ��i i �GaFFICr
Legal Description:
Lot Imo} Block -&(- Subdivision/CSM #
'/� 5W ' /,, Sec. ;, T, jo N -RAW, Town of�7 PIN #
U 2V -- /0 .9 2-
SEPTIC TANK -- DOSE CHAMBER HOLDING TANK INFORMATION:
Tank manufacturer Umnow" Size ST/PC jocg Setback from: House 3S Well P/L 147 " ,0 "
Pump manufacturer A-1 Model / VA
Alarm location &4
( y
Service road it intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM:
Type of system: 7 Width _ Length _,V Number of Trenches
Setback from: House �//' Well P2 /00 Vent to fresh air intake _ &
ELEVATIONS
Description of benchmark Elevation 00 a
Description of alternate benchmark 1?6 ?"Tor? 0/- Sil�iivG _ Elevation o
Building Sewer ST/HT Inlet ST Outlet-- PC Inlet
PC Bottom --ALA— Header/Manifold Top of ST/PC Manhole Cover ,
Distribution Lines (1) // (�) .5,9r `/ ( )
Bottom of System
Final Grade (/) d, ® (Z) PO 0 ( )
Date of installation IN ?/ S Permit number State plan number
Plumber's signature icense number .1 21 Y Date J'//2/
Inspector
Complete plot
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
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)j. 315983
Permit Holder's Name: ❑ City ❑ Village CyTown of: State Plan ID No.:
LINK, RIENER ST. JOSEPH
CST BM Elev.% Insp. BM Elev.: BM Description: Parce Tax No.:
IC) I cep >� ` 030 - 1092 -60 -000
TANK INFORMATION ELEVATION DATA g
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic + I C67 Bench If e) G�• �S �(} (?y
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet 9-97
TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet
Air I
Septic NA Dt Bottom
Dosing TVA Header/ Man.
Aeration NA Dist. Pipe , Z,7�o 00 • J S
Holding Bot. System �i
PUMP/ SIPHON INFORMATION Final Grade T r �.r o.q
Manufacturer and
Model Num D GPM
TDH ft Friction System TDH Ft
Forcemain Ff Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width — Of Length No. Of Trenches PIT No. Of Pits Liquid Depth
DIMENSIONS 3 SL'ZS DIMENSION
SYSTEM TO P / L I BLDG I WELL LAKE/STREAM LEACHI Manufacturer:
SETBACK CHAMBER
INFORMATION Typ / — odel Num
Sys eV j I S �---� OR UNIT
DISTRIBUTION SYSTEM
Header / an old jo Distribution P a(s) # p 1 x Hole Size x Hole Spacing Vent To Air Intake
Length 1 Dia- � Length ��.�ertr `7 Spacing e t /00—
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.)
LOCATION: ST. JOSEPH 31.30.19.338D,SW,S 1201 MCKINLEY DRIVE 4 q � jtl.t
0
Plan revision required? ❑ Yes [ldNo p �
Use other side for additional information. O Z
SBD 6710 (R.3/97) Date Inspector's Si nature e, No.
V isii�onsin SANITARY PERMIT APPLICATION 20 Safety and 1 E. Washingtonn A evision
In acco d with r 1 L HR o P.O. Box 7969
Department of Commerce t 83 05, Wi s . A d m. Code Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County V'
than 8 1/2 x 11 inches in size. 4
• See reverse side for instructions for completing this application State Sanitary Permit
The information you provide may be used by other government agency programs ❑ Check if revision to previous appf -ation
9
v
[Privacy Law, s. 15.04 (1) (m)]. W ' UC/ State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N
Property O ner Name Property Location
L & /a - va, S T , N, R E (or�N
Property wner's Mailin Address Lot Number Block Number
O — t_ A
Cit , fate Zip Code Phone Number Subdivision Name or CSM Number
. ' 1 _5_ ( 11014 ( > s c
II. TYPE OF BUILDING: (check one) ❑ State Owned 0 C Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms _.� Town OF Ts
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 E] Apartment/ Condo 31• 30- / 7 . 838A O "Go
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 Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 ❑ In- Ground Pressure ��� 1 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. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) /' Q q Elevation
Q 63 8(0 . v / Feet Feet
Capacit
VII. TANK in Ca allons Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existin structed
T nks Tanks
Se crank a QQ QQ(, OLU ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewa e s stem shown on the attached plans.
Plumber's Name: (Print) PI er's Signature: (No m P /MPRSW N Business Phone Number:
DmV.44'(0y 7 O n -L
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater at ssue Issuing A nt ' n ture (No Stamps)
A
,� �l Approved ❑ S rcharge Fee) 1 (Jp Owner Given Initial U (
Adverse Deter mination j
X. CONDITIONS OF APPROVAL / REASONS FOR SAPPROVAL: 1j Ll
SBD630 (1.111/86) DISTRIBUTION: Original to County, One copy To: Safety a Buildings Division, Owner, plumber
,
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ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
A
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently
serving the /EA/E / V residence located at:
cSGU 1/4, x _ 1/9, Sec. 31 T _30 N, R_ Iq W, Town of
S'%. S��N 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 UlVlNOClJ_/If
Did flow back occur from absorption system? Yes No (if no, skip
next line)
Approximate volume or length of time: gallons minutes
Capacity:
Construction: Prefab Concrete x Steel Other
Manufacurer (if known):
Age ank (if know ):
LAI—�Af cs��/
(Signature) (Name) Please Print
.2 21.7 Yl
(Title) (License Number)
(Date)
Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes)
or Licensed Disposer (NR 113 Wisconsin Administrative Code)
— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
condition, I certify that the tank to the best of my knowledge will
conform to the requirements of ILHR -83, Wis. Adm. Code (except for
inspection opening over outlet baffle).
Name - AWA &l �5 �; j Signature MP MPRS �� /7y�
5/88
wiscon Department of Industry SOIL AND SITE EVALUATION
Lbor anal-Tpman Relations Page l of 3
Division of Safety and Buildings in ce with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less t x 11 *11c hes i .;R n must County
include, but not limited to: vertical and hod efer ce nt M), rpeti n and
percent slope, scale or dimensions, north o and to � t�d�istanc�iearest road. Parcel LD. # -- /�¢2 —
_ .� ego 4Y
APPLICANT INFORMATION - P ea4e p in# all'I 010 n fz v P R? Ow by. Da
Personal information you provide may be used f r seepndary purpt sus cy Law, s� (t) (m)). .5 l� �1 /) ��,
Property Owner +PIING OFFICE \ w Property Location
Govt. Lot `J C� 1/4�' - 1 /4,S Tad ,N,R f Y E (or)46
Property Owner's Mailing Address `�., + i ` Lot # Block# Subd. Name or CSM#
CLC it e
City State Zi Code Phone Number
� ❑City ❑Village 0 Town Nearest Road
❑ New Construction Use: ❑ Residential / Number of bedrooms Addition to existing building
j] Replacement ❑ Public or commercial - Describe:
Code derived daily flow gpd Recommended design loading rate a bed, gpd/fl 47 trench, gpd/ft
Absorption area required bed, ft S 3 trench, ft2 Maximum design loading rate 7 bed, d/ft N
g g gp F trench, gpd/ft
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material 45:4a, a ,'a' l Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = unsuitable for system ®S ❑ U , ❑ u ® S El S El ❑ S ®U ❑ S R u
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
f / 0 -�8 7, s s
Ground
elev
s'9 ft. y 4 S &I : Sr
Depth to
limiting ;
factor
in.
Remarks:
Boring #
AZ s
. 7,0741 7" 7' d P7 S° 1 a 5;�2 / 1 -7 -F
Ground
8 glee
y SQ ft.
Depth to
limiting
factor
-,3A'—in. Remarks:
CST Name (Please Print) Signature Telephone No.
l ; 'a l k nz !� r> rC c��-? �< 71 s - 3 P'&- -
Address Date CST Number
10-flot way x,sTvVg SIC
49 A'/
ct
ST
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
n OWNERSHIP CERTIFICATION FORM
Owner/Buyer / C / ENC k /A'
Mullliig Addlimin
Property Address /,to j 1"9 Qp ZZ(& QA1
(Verification required from Planning Department for new construction)
030 — /49. 2 — 30
City /State Parcel Identification Number n zo - /0 9a - 6,6
LEGAL DESCRIPTION
Property Location .Ul %,, SE ' /a, Sec. _3j T .30 N-R Iq W, Town of STi e®
Subdivision &A , Lot # W—
Certified Survey Map # , Volume , Page #
J: � Warranty Deed # , Volume , Page #_
Spec house ❑ yes C4 no Lot lines identifiable JU 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 plumberjestrictedplumber 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, 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.
� L - D &j '?/ 3 / 9
S GNATURE 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.
4 ,- 1 Y' / 3 /
IGNATU�RE F APPLICANT DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department.******
** Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed