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AS BUILT SANITARY SYSTEM REPORT
, TOWNSHIP r SEC T, RR� W --
J. ADDRESS , ST. CROIX COUNTY, WISCONSIN.
3DIVISION , �„ � , LOT LOT SIZE
PLAN VIEW
Distances b dimensions to meet requirements of H62.20
_ SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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:'TIC TANK(S) , MFGR. CONCUI TE Indicate Nohth Anna
,��,. _� ,TEFL S ca.t e �
N0. of rings on cover _— Depth — DRY WELL
- '. -NCHES NO. of - width length area
no. of line width Z.L length area
depth to top of pipe R '
; EGATE 11 — c�
•a.: RATE AREA REQUIRED ( AREA AS BUILT
01 ;claimer: The inspection of this system by St. Croix County does not imply complete
:x-pliance 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
;tem operation. However, if failure is noted the County will make every effort to
:':ermine cause .of failure.
'.-ASES AND OILS SHOULD NOT BE:DISPOSED THROUGH THIS SYSTEM.
• `INSPE
DATED 9 �� -' y' . PLU;iBER JOB ,4GU"TQ
LIC NUMBER
z
REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
•
Sanitary Penm.i,t � <
.. State Septic_,_�
NAME Town
� 'ci S Croix Caurt y
-_ Location / ecZi an
SEPTIC TANK
Size gattonb. Number o6 Compantmentz
Diztance Ftcom: Wett o 12% an greaten d.Cape it
Bu.itd.i.ng _ 6 Wettands --"`" � •
H.ighwatetc
DISPOSAL SYSTEM
D.iztance Fnom: WeZz o 12% an gneaaten stope
Bu.iZd.ing 2 ( 4 6t, wetZ andd F t.
H.ighwaten �.
FIELD DIMENSIONS:
Width o6 trench /, "2— St. Depth o6 rock below t.ite /L in.
L Length o6 each .b.ine it. Depth o6 rock oven t.iZe L " .i n.
Number o6 Z ines Z- Depth o 6 Cite b eZow grade Z5 .in.
Totat length o Z i nes 2- 6t. Sto pe o trench in pen 100 6t.
D.i.6Lance between Zinez 6t. Depth to bedro 6t•
Tota.0 abz onbt.ion area �`�:`� 6t2 Dept to groundwater __..__ 6t,
Required area i 2 Type a6 Coven: ✓ Pape an Stxaw
PIT DIMENSIONS:
Numb en o6 pits Grave. around pits ye.6 no
Outside diameter 6 Depth b eZow .inZet 6 •
2
TotaZ abs otcbt" a ea 6t z
A -
Anea req "red 6t
INSPECTED BY
TITLE i
APPROVED ,DATE ./ 197
REJECTED ,DATE 197.
EH 1.15
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
_ DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION: ' / <,�'/4, SectioQ 14N, R 17 Ij (or) W Township or Municipality �Z'AA)jOl)
Lot No. Block No. County Sr (0 1Y
ubdivision Name
Owner's Name:
Mailing Address: U cA leJ S G-
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW ,_ ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS ? - Z7 PERCOLATION TESTS
SOIL MAP SHEET SOIL TYPE _S Z1VL o4o:f0en
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES AFTER INTERVAL
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN /IN
P I
a
P —A 3
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
1 16
3
y > —
G > - S, -
y
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. &is'Z Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
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PL State and County State Permit #�
Permit Application County Perm
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:
B. LOCATION: ,4�W] Y %J %, Sectio .3j , T,34 N, R LZ $ (or) ,L Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township SfAaJ1'dt/
C. TYPE OF OCCUPANCY: * Commercial *Industrial *Other (specify) Variance
Single family J_ Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete —,X Poured -in -Place Steel Fiberglass Other (specify)
New Installation X Replacement
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 X Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top No. of Trenches
Seepage Bed: _ Length S12 Width 4,Z Depth y c — Tile depth (top f No. of Line —Z
Seepage Pit: Inside diam ter Liquid Depth No. of Seepage Pits
Percent slope of land Distance from critical slope
WATER SUPPLY: Private K Joint ❑ Community ❑ Municipal ❑
Owners name as Iisted on EH 115 if other 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, S 3 T
NAME � 44exi e C.S.T. # and other information
obtained from 3v Y\ C (owner/builder).
Plumber's Signature MP /MPRSW# X4 s ' Phone
Plumber's Address A e.
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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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM county:
Safety and Buildings Division ST . CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary��r)nrr��:
Personal information you provice may be used for secondary purposes [Privacy La j, s.15.04 (1)(m)j.
Permit Holder's Name: ❑�ge F] Town of: State Plan ID No.:
KJOLSING, JERRY
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel T0306 -2006- 60
TANK INFORMATION ELEVATION DATA A9800147
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Air to
I ntake ROAD Dt Inlet
ir
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
-
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSION
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type Of mod Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STANTO 1.31.17 658, ,SE 1860 146TH STREET
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
Safety and
ofBuil Bui W a te r D
SANITARY PERMIT APPLICATION
Bureau of Buildin Water Systems
201 E - Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less Count
than 8 112 x 11 inches in size. r C /p/
• See reverse side for instructions for completing this application State Sanitary Permit Number
3o
The information you provide may be used by other government agency programs 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
" /V4,,1 S r 1/4, 5 3/ T 3/ , N, R/ 7 E (or) W
Property ner' ailing Address Lot Number Block Number
City, State Zip Code Phone Number Subdivision Name or CSM Number _ ` '
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cit Nearest Road
Village T/1
E] Public 1 or 2 Family Dwelling - No. of bedrooms Town OF /c/ 5'�,
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo 0 3 G z oo<° _ (Oo
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) PB ��
A) 1 E] New 2. ❑ Replacement 3 E] Replacementof 4 E] Reconnection of 5 g 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 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) Elevation
1 150 � 1 /3 � % , VZ� Feet ] Feet
_ Ca acit
VII INFORMATION in gallons Total # of Manufacturer's Name Prefab. Con steel Fiber- plastic Exper.
New Existin Gallons Tanks Concrete glass App.
strutted
Tanks Tanks
Septic Ta fTV- 41j Z -K ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ 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) Plum er' gnat e: (No Stamps) MP /MPRSW No.: Business Phone Number:
( Zee _ - � 7 /s — 5�
Plumber's Address (Sf City, State, Zip Code):
r
IX. COUNTY /DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue 21ss Signature (No Stamps)
Approved [ Given Initial , V 00 Surcharge fee) f Adverse Determination 0 L / / CE)
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
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SHD -6398 (R. 0 DISTRIBUTION: Original to Counly. One copy To: Safety & Ruildings Divi -ion, Owner, Plumber
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ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently serving
the f ,, residence located at: jVW ., '5C .,
Sec. , ;?l , T N, R Town of f, St. Croix
County, Wisconsin. Upon inspection, I certify that I have found the tank and
baffles to be in good condition, and it appears to be functioning properly.
Last time serviced
Did flow back occur from absorption system? Yes j No (if no, skip next
line.
Approximate volume or length of time: 2 = gallons minutes
Capacity: /moo
Construction: Prefab Concrete _ Steel Other
Manufacturer (if known):
Age of Tank ( if known) :
(Signature) (Name) Please Print
(Title) (Li ense 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
ce, tify that the tank, to the best of my knowledge, will conform to the
requirements of ILHR 83, Wis. Adm. Code (except fgr inspection opening over
outlet baf le)
;,
Name Signature
2� 8S:!Z9
Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page —L of
Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and S , C r o
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
03�• -a b- b
APPLICANT INFORMATION - Please print all information. Rev wed y; Date `
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). J c�
Property Owner Property Location
Y ID V L ' Govt. Lot 4) 1/4 St 1 /4,S 3' T31 ,N,R 7 E (o W
Property Owner's Mailing Address Lot # I Block# I Subd. Name or CSM# ..r
8 t� 5 -f . 3 6 tsar.V, R, E s,4e-
City State Zip Code Phone Number Nearest Road
L +rte ❑City ❑ village
.} (� Town
V V s a � h l 1 J V
❑ New Construction Use: m Residential / Number of bedrooms 3 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow q5O gpd cc Recommended design loading rate _ bed, gpd/f? _ trench, gpd/ft
A orption area required �$ bed, ft2 �'' `` ttrench, ft Maximum design loading rate #1 bed, gpd /ft r trench, gpd/ft
�t � 'nfiltration surface elevation(s) 9 (0 , Y;k 1 ft (as referred to site plan benchmark) -
Additional design /site considerations !x">�.• ra?'!E [� CJ's 42!t v -
Parent material c 0 't Cd Flood plain elevation, if applicable ft
S
U TUnsuitable Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
for system fiA S ❑ U K S ❑ U 59.S ❑ U I NS [- ❑ S ®U I ❑ S 19 11 1
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD /ft
g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench
o_ o y
3 1 2 s:L a In (0 r as av .s
W4 - L Qm W- 1M r W . 'S r
Ground 3 Q -IS 1 1>1p q/ C !� +"� w1 Sb k I"r�Fr c F r s
elev.
q9, 91—ft. 4 6- 151K
Depth to L
limiting �+ -fig 7,5`t i2 �/ H� L.r o�M I,� Fr Gt2
factor LS Q S L C+w —s t
IR 'Qin. 7 -3S 7.6 y ��{
3S - 70 7.5 yftN y
Remarks:
Boring #
Ground
Depth ing o
factor
in. Remarks:
CST Name (Please Print) Signature l Ncr6 / Q
Address i h Date CST Number
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer, Pr ✓ti ►�r�S�:, s�
Mailing Address
Property Address
(Verification required from Planning Department for new construction)
City/Stat ,L?.ti,4aad Parcel Identification Number 63e; 2crr
LEGAL DESCRIPTION
� r
Property Location < <
d[� Y, s /., Sec. 31 . TAN R Town of .S'�i rl
Subdivision Lot #
-— _•
Certified Survey Map # Volume . Page #
Warranty Deed # .?)5d y a3 Volume
. Page #
Spec house ❑ yes 0 no Lot lines identifiable i? yes ❑. no
SYSTEM :IVLATrr�JANCE
oomsists mak t th e= = ofyourseptiesystemcouldmsnItmitsp i Ia Rm t0handlewastes .Pcnpermaiatenanoe
can a sts o the ping n of Sue every roe Years or sooner, if needed by a licensed pmq=. What you put into Sue system
�c tank - as. a ftftnent stage in Sue waste disposai_sysrem,
The proPaW owner agrees to submit m St. C�+oac Z�iag a
oa form, signed by the owner and by a
ts1? opeia condition �ctodphmrberar a Iiexasedpumperverifymg Scat (1) the on -site wastewaterdisposal system.
and/or (2) after inspection and pu�p�g (if nece�aiy), the septic -tank is less .than 1/3 i'irll of sledge.
Ywr the Undersigned have read Sue above requkements and ag to maiabi, die m sewn
set forth, herein, as set by She Delm mcnt of Commerce and flue P� 8e �t with th a standards
dating that Y septic system has ban of Natural Resources; State of Wisconsin.. Certification
ys of the three must be completed and returned to the St, Ckoix.Couaty Zoaiug Office
within 30
year expiration date.
SI �PU�CANT
DATE
O CERTIITCAITON
I (we) certify that all statements oa this form are true to the best of my (our) knowledge.' I (we) am (are) the owner(s) of
P described above, by virtue of a warranty deed recorded in Register of Deeds Office.
S ATURE APPL14CANT
DATE
« « « « «« Any information that is misted ma result m the sanitary permit being revoked by the Zoning Department.'` « * « 4
«« Include with this application: a stamped `w9maty deed from the
_ of the Reeder of Deeds office
a copy certified survey map if reference is made in the warranty deed
g MIT. YLE.9. 6ANRS. "ouy o [i. �•ua• ►Ewlf1 or
NON TN UN( Or i[ Iq uroN ar Rr UTl•agM• tCGMNK (afT fr{,; COtY(s,
. G " faa••i 2o'w axT iCCT "tf
Y x••) • 0. ♦ lie $6 i TLM �Ir•
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+. 6
P At �
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TIC
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LEGEND
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eN n SCALE ' �? xs°' noel nrc 32 - - f • s W - s
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arena+ RJ R O + > +t
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• I t CURVE DATA TABLE `� ' � - 2 1
[�•v[ ou c.e,o cNralo «N. J . ESTATES
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