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HomeMy WebLinkAbout042-1077-80-100 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 159 GENERAL INFORMATION State Plan ID No Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Hil ert, James & Betty Warren, Town of 042- 1077 -80 -100 CST BM Elev: Insp. BM Elev: BM Description: Section /Town /Range /Map No: 28.29.19.442c TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark x Dosing Alt. BM Aeration Bldg. Sewer Holding SUHt Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing t T t Header /Man. XI / Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length I Dia. T SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO / BLD LAKE /$TREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header / Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) 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 discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 722 Highway 65 Roberts, WI 54023 (SE 1/4 SE 1/ T29N R1 9W) NA Lot 1 Parcel No: 28.29.19.442c 1.) Alt BM Description = _ 1 l 2.) Bldg sewer length - amount of cover = O J �-- - 4- G 4-Q w + _ n � W ' J se 3 _ 1 Required? Yes o i de for additional information. L...' I I '_ __ _ J< 3/97) Date Insepctor' ignature Cert No RECEIVED P A I II OA4 q y �I C unty Sanita a ion ST. CROIX COUNTY WISCONSIN I L u 1 1 In acc d with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT O��Iy Personal i ormation you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER G p9 , t. CROI COUNTY (Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road PLANNING& ZDNING OFFICE Hudson, WI 54016-7710 (715)386 -4680 Fax (715)386 -4686 Attach complete plans for the system on paper not less than 8 -1/2 x 11 inches in size. County Sanitary Permit # ❑ Check if revision to previous application I. Application Information - Please Print all Information Location: Property Owner Name /� S t= 1/4 $ E 1/4, Sec OAS - 5 , -r H r _ ) /� Ar 05 N, R /Q E(o W Property Owner's Mailing Address Lot Number Block Number ` 12. Nwy to City, State Zip Code Phone Numer Subdivision Name or CSM Number s e - u 0 4 P / 11 Type of Building: (check one) amity ❑ Village MTown of 1 or 2 Family Dwelling - No. of Bedrooms: ❑ Public /Commercial (describe use): W R /Z. A 5 /v ❑ State -owned Nearest Road II. Type of P t: (Check only one box on line A. Check box on line B if applicable) /� Lj �' S Parcel Tax Number(s) 1 U Repair ❑ Reconnection 3. ❑Non plumbing 4. ❑Rejuvenation 0Y oZ 1 (p ?7 - �° ! O O .. Sanitation J614 B) / :7 - J o -- Cl o Permit Number aa Date Issued i a State Sanitary Permit was previously issued P / a /O -� D IV. Type of POWT System: (Check all that apply) Non - p r e ssurized In- ground ❑ Mound Z 24 in. suitable soil ❑ Mound <_ 24 in. suitable soil ❑ Mound A +0 ❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Other ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating V. Dispersal/Treatment Area Information: ` 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soi Application Rate 5. Percolation Rate 6. System Elevatio�r 7. Final Grade Required Proposed (Gals. day /sq.ft.) (Min. /inch) Elevation I,o 00 4. r 8 &.4.J-:X 8R.4 4,2.4 Vi. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks i/ / ptDb l (o. I3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ VII. Responsibility Statement I, the undersigned, assume responsibility for repair / reconnenction /rejuvenation/installation of non - plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installation of non - plumbing sanitation system. Plumber's Name (print) Plumber's Signature (no stamps): MP /MPRS No. Business Phone Number Plumber's A�� s (Street, City, State, Zip Code) V-_7 e 4o: Yefr 3 VIII. County Use On-ly A0 Disapproved Sanitary Permit Fee D e Iss ed Issui gent Spatuostam >< ' Approved wner iv erse etermi n IX. Condi i ons of Approval /Reasons for Disapproval: ,, n Ped t- f :r at, MCC J 4b drof kibx- FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER c1'+ �; .. TOWNSHIP to �'�t. -r,� — /1 --t , SECTION ? 2 N -R ADDRESS ST. CROIX COUNTY, WISCONSIN 64 S SUBDIVISION LOT LOT SIZE A �d �' .fi �' ` •f PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM \&} V 40L �. NDIC TE NORTH ARROW H � s BENCHMARK: Elevation and description: Alternate benchmark SEPTIC TANK: Manuf acturer : Liquid Cap. 1 Rings used:,/ cover elev: ,/-? grade elev: Tank inlet elev.:�2 P l Tank outlet elev.: C' i _eN, 2 sr :E q M 0 ? _M \� M rr 2 / / 3 / } \ / / \ / \ \ § \\ q, j , CD § { / \ } 2 4 - ) S E 2 ) q % 'p. $ cu e , a o � /� /I (D a / (n ¢ E /3 k co . e e = § § « C : } e \� ° / ) 0 \� § E Cl k� g � \ 0 0 0 \ - 0 CO) § § k � 7 \ E D e \ « § � _ > / E \ / \} f / 1 $ ] \ Lo \ CD \ 2 z CO . \ CL \ j;: % g U) w ! w -W m § co 0 % [ m 7 # f I n > 2 � / § a ; � \ { � \ \ \ � � $ . ¥ � � \ � � K 0 < ƒ § 7/ /2 oa 4 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS INDUS TRY,• � DIVISION LABOR AND HUMAN RELATIONS PERCOLATION TESTS (115 MADISON WI 7969 (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: r OWNSHIP /roltmltCrPZtt : OT NO.:BLK. NO.: SUBDIVISION NAME: s{ Vi sE '/ 2 ,? /Tz9 N/R /FE (or) W allf)e,eE� / cs COUNTY: T MAILING ADDRESS: 6T � JI BC '-T y lf1 LPE12T 7272- w 4s �oa��rs �1r sy© Z3 USE DATES OBSERVATIONS MADE NO. B DRMS.: ICOMMERCIAL DESCRIPTION: PROFI DESCRIPTIONS: PERCOLATION TESTS Residence - N . �} ❑New Replace 1 v L V RATING: S= Site suitable for system U- Site unsuitable for system acs e /s ONVENTI NAL: MOUND: IN- GRO RESSUR UNDP E: SYSTEM -IN -FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) © S CCU 'l S DU I S ❑� ❑ S ©U CJ S ©U C o.0 v�.v -✓,q L— Tit -uc,�s DESIGN RATE: D OX l V O If Percolation Tests are NOT required [loodplain, f any portion of the tested area is in the under s. ILHR 83.0915 ►(b), indicate: G `s4 S $� indicate Floodplain elevation: !' 1 .iJOT / PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GR UNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED H TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- O S �L� > `1: O 40 , ( ly1.� s� /, 0 ' a� �ti . /• S ' T�v Si' 7..S S/� XS /. O B-2- , T �✓ GS � B- B- B- - PERCOLATION TESTS DEPTH , WATER IN HOLE TEST TIME DR I WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL - MIN. PERIOD t P RI PER INCH P- P- oe P z n/ CS �1/ �'L S P- GG�_ 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. 7135 114 1�'P `� ��'`�`'�`' - (p f, 0 s -a IE7 P L-0 P &, A-) TN r rv�- ro.�l�c€.v0�-T�� °.a — �(.S�' 3 �i �•c��S . ys s^` j 4 FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SECTION — ° S TN -R ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION /U l LOT 164LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 1, - r � o i N 3,NDIC4XTE NORTH ARROW p• D S 4 BENCHMARK: Elevation zjnd description: 8 " Alternate benchmark �i SEPTIC TANK: Manufacturer: U)," _,d..,. /� Liquid Cap. / 9,0 O Rings used: cover elev: ,/ Final grade elev: Hilpert, Jim �Z /G ? -� - e ('722 Hwy. 65 SE4,SE,, Sec.28.,T29 -R19 Town of Warren Roberts WI Hwy. 65 Location of site: Same Permit No. 128871 12 -10 -90 Henry Nechville replacement -- trench � t DEPARTMENT OF INDUSTRY LABOR &HUMAN RELATIONS INSPECTION REPORT FOR SAFETY & BUILDING P.O. BOX 7969 ON -SITE SEWAGE SYSTEMS D IVISION MADISON WI 53707 OFFICE OF DIVISION CODES & APPLICATION SE 4 SE4, Sec . 28, T29 -R19 State PlanLD Number Town of Warren � < CONVENTIONAL ❑ ALTERATIVE (If assigned) Hw 6 5 ❑ Holding Tank ❑ In- Ground Pressure ❑ Mound NAM OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION A E: Jim Hil ert 722 Hw 5 Rob r s WI BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FR M PLAN: 4z REF. PT. V.: UST EF. PT. ELEV.: f ` re?' y 1 10 Name of Plumber: MP /MPRSW No. County: Sanitary Permit Number: Henry Nechville 3258 S r SEPTIC TANK /HOLDING TANK MANUFACTURER: LIQUID CAPACITY: TANK INLET /: TAN ELEV.: WARNING LABEL LOCKING COV �/ % PROVIDED: PR OVIDED: 9 / � 9YES ❑ NO ❑YES NO BEDDING: DIA.: VIENT MATL.: HIGH WATER I UMBER OF ROAD: PROPERT WELL BUILDING: VENT TO FRESH C, 0, ALARM: ❑ O FEET FROM LINE: YES N iE , AIR I ETy ❑YES NO NEAREST —b- v �- MANUFACTURER : BEDDINQ, PACITY: PUMP MODEL: PUMP /SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER 11 YES ❑ NO PROVIDED: PROVDED: GALLONS PER CYCLE: PUMP AND CONTROLS ATIONAL: ❑ YES ❑ NO ❑ YES ❑ NO (DIFFERENCE BETWEEN NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH FEET FROM LINE: AIR INLET: PUMP ON AND OFF ❑ YES ❑ NO NEAREST —♦ SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: BED /TRENCH WIDTH: LEN NO. OF DISTR. PIPE SPACING: COVER PITS: INSIDE DIA.: # S 7/ TRENCHES: MATERIAL LIQUID DIMENSIONS ' �j 11:512 % P PTH: GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. PROPERTY BUIL I R. NUMBER OF WELL: DING: VENT TO FRESH BELOW PIPV' ABOVE COVE/ ELE LET: ELE ND: cf. " � Q .� -,�. , PIP Stine S: FEET FROM LINE:' *VIa, Q AIR INLET: % �' I� ✓�- a7 0`1 NEAREST �� v c./�. � 7p�S MOUND SYSTEM: Mound site plowed perpendicular to slope and furro Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTHS OF SOIL: SODDED: ❑ YES ❑ NO ❑ YES El NO CENTER: EDGES: S EEDED: MULCHED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED /TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: G L DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: PUMP DIMENSIONS TRENCHES: MANIFOLD MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. PIPE DISTRIBUTION PIPE M ERIAL &MARKING: ELEVATION AND ELEV.: PUMP ELEV. DIA.: ELEV.: PIPES: IA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY COVER MATERIAL: CORRESPONDS TO E YES ❑ NO APPROVED PLANS 1 YES E NO A CO ME TS' PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: s r" f t c rletdAj DYES ❑ NO FEET FROM LINE: ❑ YES ❑ NO NEA EST —� , , st . Elm ✓o -�;��5 � t�C.� �- �t� ��-��..� Sketch System on n in county file for audit. Reverse Side. SIGN URE: � TITLE: j1 � SBD -6710 (R. 06/88) � ; * i W47. S ANITARY PERMIT APPLICATION �, �, � In accord with ILHR 83.05, Wis. Adm. Code -5r. sT. c,e — Attach complete plans (to the county copy only) for the system, on paper not less than STATE SANITARY PERMIT # 8'f x 11 inches in size. ❑ &.Z -See rev erse side for instructions for completing this application. cheo if vlous application STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION PROPERTY OWNER PROPERTY LOCATION 2 7 ,0 Ll `L NG E '/ 515 %4, S J-? T�� , N, R /0 E (or) W PROPERTY OWNER'S MAILI AD RESS LOT BLOCK ? z Z "_ CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER or &0,2/-S ZIP O ff 3 0O es" II. TYPE OF BUILDING (Check on State Owned CITY NEAREST ROAD 4 ❑VILLAGE: W A s?4 7'E- ❑ Public 0 1 or 2 Fam. Dwelling- # of bedrooms _ A ELT NUM ER (S) _ `t III. BUILDING USE: If building d off 7 ( g type is public, check all that apply) 1 ❑ Apt/Condo _ G 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 in line A. Check line B if applicable) A) 1. ❑ New 2. �K 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## _ 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 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 14 El System-in-Fill 43 ❑Vault Privy VI. ABSORPTION SYSTEM INFORMATION: 4 5 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM E FINAL GRADE / REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/ ay/sq. ft.) (Mindinch (DOD / Glf)$S Ql. 3� ELEVATION ( . d Feet V TANK CAPACITY INFORMATION in allons Total # of Prefab. Site Fiber - New istin Gallons Tanks Manufacturer's Name Con- Steel Plastic Exper. Tanks Tanks oncrete strutted glass APP• Septic Tank or Holdin Tank ?y00 Lift Pump Tank/Siphon Chamber Gdv VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: �ta!) MP PRSW No.: Business Phone Number: (115 7 Plumber's Address (Street, City, State, Zip Code): nApproved DEPARTMENT USE ONLY ❑ DisapproveLinitial Sanitary Per it Fee (includes Groundwater a e ssue Issuing A nt Signa re No Sta s ❑ Owner Giv eSur Advers De arge Fee) n / p '1L.A. X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb -67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber APPLICATION FOR SANITARY PERMIT STC -100 his application form is to be completed in full and signed by the owner(s) of the roperty being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor, ( "spec house "), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of Property Location of Property �� _ !� _ S ! Section , T _22_ N -R W Township Q Nailing Address 7 Address of Site , Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? !/ Yes No Is this property being developed for resale (spec house) ? Yes No Volume -�-� and Page Number _7/ L as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and page number and the Seal of the Register of Deeds In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. DOCUMENT NO. S'. E BAR OF WISCONSIN FORM 1 1982 — THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED `--' ��.3Fs�8+G BOOK .15$PAGE,,��� REMSMS OFFICE This Deed made between _- _- .--- `Tam e S H , Schwa 1 en , _ SIT, CROIX ()0,0 WIS., a sing -le man ---------- - - - - -- •w `u`s. roe Rew this 29th - - - - - - -- - - - - -- - - - - - - -- --- - - -- - - -' - -- - - - - -- -- ----------- ` -- 0 1 6 - - James E Hit 30 A and_.... - -... ' ' . -.. -, Grantor, 4 ..... pert _and_ Bet -t JH' - .p . 8 :30 A hus - • - - " band and wife _,____as --- su-rv"ivorshi_p - __ _. marital .prope.rty - - - - - -- ---------- araa as tamod ------- - - - - -- - - - - - - -- ---- - - - - -- - -- --- ----- -- ---- --- - - --- -- Grantee, Witnesseth That the said Grantor, for a valuable consideration_.. -__ ---- - ----- - - - - - -- ______ conveys to Grantee the following described real estate in ....... Cr0 iX RETUR TO County, State of Wisconsin: 'i''IB R INK Off° RUBERT� Roberts, Lot One (1) of Certified Survey Map Tax Parcel No_ __ __ ....................... recorded in Volume 6, page 1655; being a part of the SEk of the SE, of Section 28, Township 29 North, Range 18 West, r, SF W o 1 o tl 4/ FEE I This .. l.S - ... -- " - - " - -- homestead (is) (is not) Property. Together with all and singular the hereditaments and appurtenances "thereunto belonging; And ..... James _ H, Schwalen_ warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements and rights of way of record, if any, and will warrant and defend the same. Dated this --------- ...__.2 7th - --- --. - - -- '- ...._ day of .-. -- ------ ----- -- Oc- to— ber ......... . .. ........ - -- - - -- -- - - -- _ ------ - -- - -- (SEAL) .. .�. J �����-- -� - -- -- � /��` -J -- (SEAL) ------------ ---- -- ---------- - - - - -- - James H. Sc -' - - -- - - - - -- - - - - - -- - ----- - - - - -- - - - -- - -- -- -- ---- - -- --- - - - - -- -- ---- --- (SEAL) - - - -- - --' -..._--- --- - -- - -- -- -- - ' -- -- -(SEAL) ..... ............ --- ---- - - - - -- AUTHENTICATION ACKNOWLEDGMENT Signatures) _ __ ___J . .. .......... STATE OF WISCONSIN --- - - -••- - � -••-•---•----- ---- .................................... -- County. au' en is a s 2 7 thday of _C tober 19.1_ all" en � 7 Personally camp hr�fnra ,,,o *i,;� STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNS /BUYER ROUTE /BOX NUMBER `/ ��- !� ��Y �` FIRE NO. CITY /STATE ��1_ /�� r ZIP PROPERTY LOCATION: 5 1/4 s 17 1/4, Section , T ;�; N, R W, Town of Z,[> h A ja� , St. Croix County, Subdivision W/W , Lot No � . 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 SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I /WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE �, J St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386 -4680 Sign, Date, and Return to above address DEPARTMENT OF INDUSTRY, REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS ' DIVISION 'HUMAN AND � PERCOLATION TESTS ( 115 ) P.O. Box 7969 HUMAN RELATIONS 1 (ILHR 83.09(11 & Chapter 145) MADISON, WI 53707 LOCATION: Stt" � TOWNSHIP /Ib►t7ftItCIPR'tiTy OT NO.: LK NO.: SUBDIVISION , /Tz9 N/R 11E (or,W Grirt�e�eE.v csy COUNTY: , MAILING ADDR S: sr c2a IX TtM B c n y If L PEI? -r- 72 �`wr 4 S o RtiPrs' G�lr ssyo z3 USE : CO A E RI TION: DATES OBSERVATIONS MADE Residence �- � ❑ J/ L� New Replace ' To / V r/ �'t' p J�. y RATING: S- Site suitable for system U- Site unsuitable for system ONVENTI NAL: MOON : IN- GROUNDPRESSURE: S TEM•IN - FILL O J�o � 6 g �7 1,6 � DED SYSTEM: (optional) © S ❑u S ❑u ®$ ❑� ❑ $ 4 �9 [— �' o o x v c If Per7s.ILHR on Tests are NOT required DESIGN RATE: If an under 83.09(5)(b), indicate: f � y portion of the tested area is in the r''�T s S 2_ Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL P H T R NUMBER DEPTH IN, ELEVATION UMDWATER-INCHES CHARA TER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH OBSERVED TO BEDROCK IF OBSERVED (SEE AB BRV. ON BACK.) S p �1( S / d ' Of' /� d �S' Tf/ B- z y D 9y s y' yam- > o B- B- PERCOLATION TESTS TEST DEPTH NUMBER INCHES FTERSWEL INTERVAL -MIN. DR I WA L V INCHES RATE INUTES TEST T Rl D t P RI o PER INCH P- P• `f CS ST O .v T �E P. P- P• / GIn . / S L s P_ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or of land slope. 74—' ��� distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevatio all borings and the direction and percent � SYSTEM ELEVATION p' 9� S n l �'�'�' `� �'�` - - Sa- d / w s r TiF ,o Coe, p AJ N T I� C ` 11 2 � J 0 - J � o a 0 U Nn LL ,a OD r1 � lu 2 1 1 1 Q � 1 u i 1 0 1 ► I A , N 00 F10 W N IV � � V '� � � ` a � T �f'TG/►�Os � Fresh Air Inlets And Observation Pipe N, y, Qom--- Approved Vent Cap Minimum 12 °Above Final Grade :j ti ;j 34 " Above Pipe — 4 " Cast Iron 10 Final Grade Vent Pipe' Synthetic Covering Min. 2" Aggregate Over Pipe Distribution 94ti • z7iy Tee I ,1 Pipe "'' 0 0 0 0 0 , G Aggregate Beneath Pipe _ 0 Pertbrated Pipe Below V 0 Coupling Terminating At 7yS ,. Bottom Of System haw &R T"R'eA) C.- Fresh Air Inlets And Observation Pipe � h J 0 Q - - ^ Approved Vent Cap is Minimum 12" Above ?. Final Grade �i;v 3C& 4" Cast Iran