HomeMy WebLinkAbout018-1003-40-000
J
STC 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS 1 1 L S UO t
SUBDIVISION / CSM#
#
SECTION 2 , LOT
----T-=LN-R W Town of l rp1 G 0/
ST. CROIX COUNTY, WISCONSIN
s:
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i
NS Coe I**
~ 's ~ J b RGr
s
Z
INDICATE NORTH AR OW
Provide setback and elevation information on re V
verse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: G G ra G ~d o 1 G U
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: C/c., t Ste ,$A Liquid Capacity: U
Setback from: Well ? House 3 Other
Pump: Manufacturer 2&e. Model# Size
Float seperation Gallons/cycle: (s~~
Alarm Location 1s H Xrle c t {S{, -
SOIL ABSORPTION SYSTEM
Width: Length C1 ? Number of trenches
i
Distance & Direction to nearest prop. line: /~o
Setback from: well: House f'U Other
ELEVATIONS /
Building Sewer ST Inlet: ST outlet:
PC inlet tG ~5 PC bottom Pump Off
Header/Manifold 7 d Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION*
PLUMBER ON JOB: j4p--t i~z ""i5
LICENSE NUMBER: j j~ G Gf
INSPECTOR:
3/93:jt
Wiscbnsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
'Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 284324
Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.:
KRAMER, DALE HA4MOND
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
018-1003-40-000
TANK INFORMATION ELEVATION DATA A9700092
HI FS ELEV.
TYPE MANUFACTURER CAPACITY STATION BS
Septic ✓ WFS ~r~ r~'t; Benchmark
Dosing
Aer Bldg. Sewer
Holding- St/ Inlet
TANK SETBACK INFORMATION St/ yet Outlet
j,
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom ~(~,l✓0
Dosing NA _ w / Man. 7
Aerati NA Dist. Pipe
Holdi Bot. Syltem 3 07 3. /Z
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift 3y5' Friction System 50/ TDH Ft
Loss H
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Liquid Depth
DIMENSION DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O CHAMBER Model 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: HAMMOND 02.29.17.20B,SE,NE BALDWIN C 9~ 9d~
J
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710(R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH '
SANITARY PERMIT NUMBER: +
I
I
Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building Water Systems
ri•~L.■7f1 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 County `
than 81/2 x 11 inches in size- - /x-
• See reverse side for instructions for completing this application State Sanitary Permit Num Sbef
The information you provide may be used by other government agency programs ❑ Check if revision in previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
Dale Kramer E1/4 NE 1/4, S 2 T 29 'N'R 17 8(or) W
Property Owner's Mailin Address Lot Number Block Number
1165 200~h. St.
City, State Zip Code Phone Number Subdivision Name or CSM Number
Baldwin, WI 54002 (715 )684-3642
est Road
II. TYPE F BUILDING: (check one) E] State Owned ❑ E] VII city age r200
t.
Public 1 or 2 Family Dwelling - No. of bedrooms -3- Iiti Town OF Hammond th. S
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
D18- ioa3
1 E] 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. g 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 [n 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 11 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
450 376 376 1.19 97.6 Feet 99 Feet
VII. TANK Capacity site
in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper.
p-
INFORMATION
New Existing Gallons Tanks concrete strutted glass App-
Tanks Tanks
Septic Tank or Holding Tank X 1000 1 Midwestern xx ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber X 750 1 Midwestern ❑ ❑ ❑ El
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: (No Stamps) MP/MPRSW No.: Business Phone Number:
Joe Stang Mp6646 (715) 698-2266
Plumber's Address (Street, City, State, Zip Code):
506 Willow Drive Woodville, WI. 54028
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue / ssuing ent Signat No Sta
Surcharge lee)
pproved ❑ Owner Given Initial ~/!y
Adverse Determination ~w
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05194) DISTRIBUTION: Original to County. One cupy To: Safety & Ruildings Divi ion, 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 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 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, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. 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.
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 8 112 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) 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 & BUILDINGS DIVISION
State of Wisconsin
Department of Commerce
aprli 1991 2226 Rose Street.
La. Crosse WI 546019,
^;EGERER SOIL TEST IXu
42' v MAIN STREET
PO BOX 74
RIVER FALLS WI 511022,
RE: PT AN 597-40215 FEE RECEIVED: 120.00
IIEh., DI-iLL
SE,114-E,2,29,17W
TOWN OF HAMMOND COtN'71 OF ST CROIX
MOUND SYSTEP1
The Department has reviewed the above-referenced submittal.
Conditional approval is hereby granted for t.he system plan submittal. All
rioted items muss be corrected. The review and approval. of the system is bases;
on chapter 145, Wisconsin Statutes, and chapters -omm, 2*3 and 24, Wisconsin
Administrative Code, and is colitingent upon compliance with any stipulations
shown on the plans. ibis system has not been reviewed for the code
requirements set forth in chapter CodAl 22 or in c;haptera ILHR 50-64, Wisconsin
Administrative Code.
This plan submittal approval will expire two yea.r6- fro{ll the approval late, or
if a sanitary permit is obtained, plan approval will expire on the day the
initial sanitary permit expires. The licensed p.iumber res'ponsible for this
installation shall k=eep one set of plans wit.ii the Department's stamp of
approval at the construction :rite. The installer shall notify the appropriate
inspector- when inspections can be made.
Ali permits required by the city, village, township or county shall be
obtained prior to installation.
Inquiries should be directed to me at the number listed below. Please refer
to tiie plan nmber shown above.
~J lIICer'Ciy,
1
` ~o,T:rENt0
Ge gird M. Swir l
Ian Reviewer
Section of Private Sewage
(602) 725-9342
SBD-7997 (R.11196)
Page of 6
MOUND SYSTEM g ,
1991 . .FOR 4 2
pQR `CGS, D`V • A 3 BEDROOM RESIDENCE
SP►FE~~
LOCATED IN THE 5 E 1/4 OF THE N E 1/4 OF SECTION Z , T Z`t N, R l7 W,
TOWN OF I~ W~ V~► O N , S~ . C~~ U UC COUNTY, WISCONSIN.
INDEX
PAGE l 'of 6 TITLE SHEET
PAGE 2 of 6 PLOT PLAN
.PAGE 3 of 6 PLAN VIEW-CROSS SECTION
PAGE 4 of 6 DISTRIBUTION PIPE LAYOUT
PAGE 5 of 6 PUMPING CHAMBER '
PAGE 6 of 6 PUMP PERFORMANCE CURVE
PREPARED FOR
~ A LF. ~c-R.-A t't Eli
1\65 Zoa 7TF ST•
~~LDti..►ily, ~vl 54ooZ
PREPARED BY
WEGEFZEFZ SQ I L . TEST I M(=-
AND . , '16S NS~y
77ES I GtV SEF2V I CE
A"HUR L
PRIVATE SEWAGE SYSTEfX0. BOX 74 421 M. KAKI ST. weaswoarN.
RIVET FALLS. MI 54022 ei~l
~
Conditionally 715-425-0165
wN.MM
Ack p 11 rl71 dAsIG~E4
IlEff. OF tl USTRY, LABOR & NUL IAH FELAT1,514S ~ i~ l L ~ v ~c-l cl -7
INVIS OF SAFETY Iii LU. : s
SEE COR
JOB NO. 7<Z
C. ~ ~A
a
' ~
5
s ~ `
PLOT PLAN
Page Z of
Scale 1 LLB '
3 a~~z-w1
o
0
zsoF y"~vc -D
D
ov PRauy E~J CU►Sv2.E, %Iv 1Tf'fl.,l- Ii
S yYp~a 8}ttNG Z~L\S"MJG Yb00 (Set, M kb jN IV
PQ sT
P `t` Q\r- 1►.ho DOE co*-tiP~ 1+ c L i
x ~ttSnN6 ~
`zm -41-. 1uo,p'.o►,i 'nil,
dos , of -TE.QVA V(101Qe cn
~ Q
a ~D FS TRH- M
Ile
~6
3l
>3 o QI
\ J
51
e i~ \ C
~Q~2 B3 0
NOTES:
-1. Elevations shown are existing ground elevations unless otherwise noted.
2. Install permanent markers at end of each lateral. ( ~A required)
3. Install-4" observation pipes with approved caps. ( 2 required)
4.-Septic tank to be %000 gallon capacity manufactured by
t'\ kpwzvzzN P►z.2RSTC eXISTivG'~ - PJw~P `S' ri `f0 $E 1Mt pt^I~j~~TttAl "1S0 GM-• `1*►~k.
5. Bench Mark
6. Divert surface water around system to. prevent.ponding at the uphill side.
Page 3 Of
Approved Synthetic Covering
rrs-r" c. 33 ,Distribution Pipe
Medium Sand
G
Topsoil F Elev.
,
3 E
u
b
3 % Slope
Bed Of i~ 2 (Force Main Plowed
Aggregate From Pump Layer
D Z-o Ft.
E z-ZY Ft.
Cross Section Of A Mound System Using
F o.$ Ft.
A Bed For The Absorption Area
G 1.O Ft.
A 8 Ft. H I- S Ft.
Linear Loading Rate= "'-'6 GPD/LN FT B (17 Ft.
Design 'Loading Rate= o.y -GPD/SQ FT j 1 6 Ft.
J ZD Ft.
K \3 Ft.
L ~3 Ft.
e~-.
For--e M-R'i - W 3 y Ft.
L
71-
j Observation Pipe
g K
A - -
W ~a ----------------------•I Force Main
E"Lvws ter
Distribution :ed Of ZM- 2 2 gip.
Pipe Aggregate
I
Observation Pipe Permanent Markers
(Anchor securely)
Plan View Of Mound Using A Bed For The Absorption Area
Page Of
Perforated Pipe Detail
0
End View
)Perforated
End Cop. PVC Pipe
onInstall permanent marker
at end of each lateral
Holes Located On Bottom,
Are EquoUy Spaced
Q S
PVC Force Main
Q
PVC
Manifold Pipe
piste ution
Pi e
Lost Hole Should Be I
Next To End Cop t
End Cap /J
- P 22 Ft.
Distribution Pipe Layout
S y Ft.
X Y6 Inches
Y LlInches
Hole Diameter Icy Inch
Lateral ) Inch(es)
Manifold Inches
Force Main " Z Inches
# of holes/pipe L
Invert Elevation of Laterals 98.1 Ft.
6YV1-)= Z$.o$ op"'-7
Place lst hole Z`Lifrom center of manifold with succeeding holes
at 4R`' intervals. Last hole to be next to the end cap.
PUMP CHAMBER CROSS SECTION ARID SPECIFICATIONS PAGE S OF C~
{
VEiJT CAP
4"C.L VENT PIPE
WEATHEK PROOF \APPROVED LOCKING MANHOLE
10' FROM DOOR, JUUCTIOW BOX OVER WITH. WARNING LABEL
WIWDOW OR FRESH I2~lMILI'
AIR INTAKE
GRADE
I y' Mlu_ _ ,
. ~ 18' MIN.
COWDUIT
Ib"MIAI.
PROVIDE I
INLET AIRTIGHT SEAL
_T II v
APPROVED JOINT/ A Tank construction shall comply I (I~ APPROVED JOINTS
with ILHR 83.17 and ILHR 83.20 i ICI
I I) ALARM
a 'i II
I i
i I ow
C I I
--LLE1C83`5~ FT PUMP-, _-J
OFF
0
9Z.SO COAICRETE BLOCK
3" APPROVED
RISER EXIT PERMITTED ONLY IF TANK MMJUFACTURER HAS SUCH APPROVAL. 000INQ
SPECIFICATIOMS
DOSE
TANKS MAIJUFACTURCR: P'1 l W N plZer-Alr NUMBER OF DOSES: 3 ` 6S PER DAU
TANK f,IZE: ,SO GALLOWS DOSE VOLUME z
ALARM MAWUFACTURER: SLIST INCLUDING 5ACKFLOW: \Sb' (,ALLOMS
MODEL I.IUM6ER: , 2" 1~w CAPACITIES: A= ~s ! tiIJCHE5 OR 30 Z.3 GALLONS
SWITCH TYPE: `r 5= Z INCHES OR 3 q ' O OQLLOU5
PUMP MANUFACTURER: S ca INCHES OR YS b' GALLOWS
MODEL NUMBER: 3a1~ SOS D= 13 2S3•S
INCHES OR GALLONS
SWITCH TYPE: Zc y~ ~I MOTE: PUMP AMD ALARM ARE TO Or a
MINIMUM DISCHARGE RATE 12-)"O b GPM INSTALLED ON 5EPARATE CIRCUITS
VERTICAL DIFFERENCE BETWEEN PUMP OFF AA1D_DISTRIBUTIOu PIPE.. IL - S Z FEET
+ MINIMUM NETWORK SUPPLY PRESSURE , , . . , 2.50 FEET
+ "Los FEET OF FORCE MAIN X V. b ~ FYcFLFRICTIOU FACTOR_ 3 •3o FEET
TOTAL ObIJAMIC HEAD = 2O-3ZFEET
DIAMETER
38 12 II
INTERNAL,. OIMEIJSION~ OF TANK: LENGTH ;WIDTH .~~;LIQU10 DEPTH
BOTTOM AREA - - 231= - GAL/INCH
AS PER MANUFACTURER = ~t:,5 GAL/INCH
Pie- ~ ~ F 6 ~
Goulds
Submersible
Effluent Pump
CE
3871 EP04
EP05
APPLICATIONS • Fasteners: 300 series • Fully submerged in high ■ Motor Housing: Cast iron
Specifically designed for the stainless steel. grade turbine oil for for efficient heat transfer,
following uses: • Capable of running lubrication and efficient strength, and durability.
• Effluent systems dry without damage to heat transfer. ■ Motor Cover: Thermoplas-
• Homes components. Available for automatic and tic cover with integral handle
• Farms Motor: and float switch attachment
manual operation. Automatic
• • EP04 Single phase. 0.4 HP, points.
Heavy duty sump 115 or 230 V, 60 Hz, 1550 models include Mechanical
• Water transfer Float Switch assembled and ■ Power Cable: Severe duty
• Dewatering RPM, built in overload with preset at the factory. rated oil and water resistant.
automatic reset. ■ Bearings: Upper and lower
SPECIFICATIONS • EP05 Single phase: 0.5 HP, FEATURES heavy duty ball bearing
115 V, 60 Hz, 1550 RPM, construction.
Pump: EP04 built in overload with ■ EP04 Impeller: Thermo-
• Solids handling capability: automatic reset. plastic Semi-open design
3/4" maximum. • Power cord: 10 foot with pump out vanes for AGENCY LISTING
• Capacities: up to 55 GPM. standard length, 16/3 SJTO mechanical seal protection. SP Canadian StandatdsAssociation
• • Total Discharge up to 24 feet. with three prong grounding
" NPT. plug. Optional 20 foot ■ Impeller: Thermo-
ga size: 1 '/i plastic stic enclosed design for (CSA listed model numbers
• Mechanical seal: carbon- length, 16/3 SJTW with improved performance. end in "F" or "AG".)
rotary/ceramic-stationary, three prong grounding plug
BUNA-N elastomers. (standard on EP05). ■ Casing and Base: Rugged
• Temperature: thermoplastic design provides
104°F (400C) continuous superior strength and
140°F (600C) intermittent. corrosion resistance.
• Fasteners: 300 series METERS FEET
stainless steel. 10-
• Capable of running-
dry without damage to s 30 h
components. k,
Pump: EP05 s - - - Fr -
• Solids handling capability: o z 25
maximum. w -
• Capacities: up to 60 GPM. s 20 I 2-
• Total heads: up to 31 feet.
• Discharge size: 11h" NPT. z 5-
• Mechanical seal: carbon- 0 15
rotary/ceramic-stationary, 4 j
BUNA-N elastomers. o
• Temperature: 3 10
104°F(400C)continuous
140°17 (600C) intermittent. 2- i
- -
5
1 I I
0 00 10 20 30 40 50 GPM
` L L
0 2 4 6 8 10 12 nr/h
CAPACITY
0 1995 Goulds Pumps, inc. Effective May. 1995
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER Dale Kramer
MAILING ADDRESS 1165 200th. St.
PROPERTY ADDRESS ! 1 G v v t s b.
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE Badlwin WI. 54002
PROPERTY LOCATION SE 1/4, NE 1/4, Section 2 , T 29 N-R 17 W
TOWN OF Hammond ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP -9 VOLUME , PAGE , LOT NUMBER
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 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 60% 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 system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater 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.
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 DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
l
SIGNED:
DATE: `f X14 7
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations
safety and nd buildings Division INSPECTION REPORT ST. CROIX
(ATTACH TO PERMIT) SanitaryPermitNo.:
GENERAL INFORMATION 284255
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
KRAMER DALE HAMMOND
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
018-1003-40-000
TANK INFORMATION ELEVATION DATA A9700011 IM-,
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic /0-V Benchmark
Dosi ng
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet
rl
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. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING manufacturer:
SETBACK
INFORMATION Type O CHAMBER Model 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: HAMMOND 02.29.17.20B.SE.NE 200TH STREET
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
i
Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building Water System!
201 E. Washington Ave.
In accord withiLHR 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 County
than 8112 x 11 inches in size. 0 l
0nit(ary Permit Number
• See reverse side for instructions for completing this application . State SaaQ
The information you provide may be used by other government agency programs ❑ Check if revision to pre- vious application
(Privacy Law, s. 15.04(1) (m)].
State Plan I.D. Number
APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Na a Property Location
'f , N, R ~E'(or) W
40 _
D,q sL 1/4 f1,6 1/4, S
Property Owner's Mailing Address Lot Number Block Number
1166 ~2 e, vCti sC
City, State Zip Code Phone Number Subdivision Name or C_SM Number
6 -7
II. TYPE F B ILD1NG: (check one) ❑ State Owned ❑ City Nearest Road
0 P- Vi Public 1 or 2 Family Dwelling- No. of bedrooms Town OF ~.4 rn ,v, o : p1 C%G 4 ~L
111. BUILDING USE: (If building type is public, check all that apply) arcel Tax Number(s)
1 ❑ Apartment/Condo / ~ - 10,-, 3 C
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/ Mbtel 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. p New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
-
System_______ System Tank Only ___Existing System
Exlsting 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 410 Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 R] 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
Feet Feet
VII. TANK Capacity gallons Total # of r Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass- Plastic App
/c? New Existing structed
Tanks Tanks
Spptar k 1v UL 1~'7 E InJ :5t IL, kk ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plum is Signature: tamps) PRSW No.: Business Phone Number:
c~ce Ste,iI G~_z Cr U/ C C ?41, t Z2G
Plumber's Address (Street, ty, State, Zip Code):: `
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
Approved F1 Owner Given Initial 1116 Surcharge Fee)
19 ~
Adverse Determination I
X. CONDITIONS OF APPROVAL / REASON FOR DISAPPROVAL:
SOD-6398 (R. 05/94). DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS '
E
I
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit rr ay be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrate Code will be applicable:
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership _,r 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 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, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
11. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
111. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one online 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.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone rumber. 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) 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.
PLOT PLAN Page 3 of 3
SCALE 1"= WD'
I"
o'
o
g o
o
N
4 0'
B
i
e
0
k wEL- $1Li - ZL. \,a Q p' orJ
(Z F "RTC-q,?. v J)Z
. 8.2 i3.3
3 S o' ro 9c
(715 ) 425-O1 f5 M00576
CST Signature Date Signed Telephone No. CST #
Owner's name San. Permit No.
H63.05 PLOT PLAN
Show:
F71
l1SE Location of building served NA Dosing chamber
Septic tank ® Vertical/horizontal reference point
Building sewer N.e System elevation is
Effluent system VRULT VV-W4 Well
O-R Replacement system area Property lines w/in 50' of system
Distribution boxes Scale LOCp , or dimensioned
E^ Pump and controls:
Mfr. & Model No. Vertical Lift Size Force Main
Friction Loss T. D. H. Vol. Dist. Pipe Gal. per Min. Gal. per Cycle
Place check mark in appropriate box, indicating item is shown on plot plan below:
,O
Ln
a
.o ~
DLO' PRUPo4Pp
WvvSN
0
5' t~
R, ?r ~
i- RU7
J ~'Vyx WLTI l
O Lo cfrVaw ~wi - L°t . 100 . o Ow lti P o F
i
3 S O' 1-0 ~
By the granting or approving of the above plan, or upon the event of a subsequent
permit being issued, St. CroixCounty and theSt.CroixCounty Zoning Administrator, does
not assume or hold itself liable for any defects in plans or specifications, plan
omission, examination oversight, construction, or any damage that may result in or
afte) instal i n.
um r s signa u icense o. Date
C.,`?,. 5- - G`~7 UN
scQ%"E1JON
v asr +,waw 11`~s thL.~. N" IAJ T P R r-1
1 X3 SEC.T PR•ooF
~ucuosu 2~
DAR
G
~NLtT
M~.nwES`~-~ ~+t3r ~oov ~-.s~anc L~~UE
T~k w / f FFLCS t2`7%%j ou
8 1 ~v t~wq ovY vE T P l G cr~p
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page t of 3
Labor and Human Relations -
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but SZ"• C-1Z O. 1 X
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. C) 18
- ) O6 3 - y Q
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
L ~R A M eov -oT S 1/4 OEE 1/4,S Z T Z 9 N,R 1-7 E (oi
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM If
1165 Zop ~ ST, - _ _
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE OrOWN NEAREST ROAD
Y3 PrL1~bv11~J, ►tiJl SQL oZ (~15) 68y-36~LZ Ni- orte,U zoo Tb 5T.
(~Q New Construction Use p(J Residential / Number of bedrooms 3 [ ] Addition to existing building
[ j Replacement [ j Public or commercial describe
Code derived daily flow 50 gpd Recommended design loading rate ` bed, gpd/ft2 trench, gpd1(t2
Absorption area required - bed, ft2 trench, ft2 Mabmum design loading rate - bed, gpd/ftt2 trench, gIXW
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design /site considerations s v ~ 'g T=oR 1r ~ YI- p OF 5rat t- PM S orz-P T) W S'-1 S'CQ14
Parent material S t Lry s e%\"er JT WL~ C ` 'I-ILL Flood plain elevation, if applicable tv A It
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN RLL HOLDUVG TANK
U= Unsuitable for stem ❑ S O U ❑ S O U Os ,O U ❑ S ®U ❑ S O U ❑ S Elul
SOIL DESCRIPTION REPORT 1-3y'3sIj`l"'Ir~Le ~°~z +3t'w»vc 'Titre
PrS PCF, C.uw y OROtf\JkrjC_e
Depth Dominant Color Mottles Texture Structure Consistence BottTdaly Roots GPD/ft
Boring# Horizon
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed reach
{ ] 0-6 10`1 tz Z.S /1 sl I z'FSbh `FI- C,,S . 5 . t,
6-k t o ~Z y - s I I Z bb M ~F~ c S - s
Ground 3 17-30 -7-SLI2 Sly lo~~ G SIC-1
ow, M
elev. ~
.
ft
Depth to
limiting
factor
Rt`t
Remarks:
Boring # ,
~_q l~`lR2•S~I ~ S\~ Z`FSb>T M~h a-S .S ,~a
Z Z C) S to ~ rz V t s 1 I Z 'Fs 117 'ft- c S - s.
3 \S -32 ~-S ~ R 3t cl -~.Sy~z s/g - -
Ground y 10 `tkz 613 Sicl o~ M`F{ _
elev.
CIV-Z ft.
Depth to
limiting
factor 91
Ate" Eg
Remarks:"
T Name.-Please Print Phone:
Arthur L. We erer 715-425-0165
Address: Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022
Signature: C /14, ' L Date: - 1 1 CST Number
M00576
PROPERTY OWNER Y'--?-12-1 E2 SOIL DESCRIPTION REPORT Page Z Pr 3
PARCEL I.D.# 018`- ~Oy3- 40 *R
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Ba.rdary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
M. D-8 lOy2 Z•5lI Sl~ Z`~S~iIZ wt~'~- a.S _ 5 •Li
Y
Ground c~ -)_Svc? Ve S ~c Ow,
13-3 7•S`/R 3/
~1-
elev.
CIS D ft.
Depth to
limiting
factor ft17 S"
Remarks:
Boring #
L
fV0 R'bD1 ~FILT~s ► jE~ E t1~ V ~i
12S /\J G l Ml 0 Q O L
C3
Ground IN O '
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:
SBD-8330(8.05/92)
S T C - 100
This application form is to be completed in full and signed by the
owner(s) of the property 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 y L~ V-c.\-LjNv vl L1?
Location of property ' ~ 1/4 NL 1/4, Section Z , T Z cj N-R L7 W
Township Vyty-l " y~ N--) Mailing address 116 S 100 17f 57--
Address of site l ) _L00 T* S -r- ~~c ~w env, w 1 S(4OO Z
Subdivision name - Lot no.
Other homes on property? Yes 1- No
Previous owner of property 1~5-WeZ-' ftryvt) 'LLL-h Mhe L 1NTH
Total size of property q-S Fie,
Total size of parcel L{. S P~ e
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes I---- No
Volume 85 Z and Page Number SIBS 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
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner (s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. _ q 6 Z a 9 y , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No_
Signature of Applicant Co-Applicant
Date of Signature Date of Signature
02/17S'97 MON 14:42 FAX 715 ash 4637 REGISTER OF DEEDS 1~J001
` A Vu '9-pprf, r~ lypd~
'Document Number
ocumcat tle -
67 QAcix (.110, wl
J ked for Roo"
_ i
FEB 1,7, 199T
.s 10: 35 A. y
LA s
Reaotding Area
Name and Rebus Addrtss
C/21 No. olain Ali 7y
pairet Yden65catiou Ntmtber (PIN)
"THIS PAGE IS PART OF THIS LEGAL DOCUMENT - DO NOT ItEMOE"
"Phis idfocaution must be coWleted by subminer: doeumetu ti[k- ME LA return address and PIN (f req dyed). Odter peormacen such
- dte g-fL+t eZ--, legal descripft, uc. may be placed on d-& first page f&, document or may be placrd on addiamai pages of the
doctauru. Norc: Urr of des cover page adds one page ro your doc ane a and $100 to the rceou& kr-. Wutetsv+ Saw-r, 59.5I7- WADA 2196
02/17'97 MON 14:43 FAX 715 386 4687 REGISTER OF DEEDS 002
STC - 106
PRIVY INSTALLATION AGREEMENT
St. Croix County, Wisconsin
PRIVY INSTALLATION AGREEMENT -COPY TO BEATTACHED TO THE SANITARY PERMITAPPLICATION.
PrtyQwner(s): Reserved For Recording Oara
S_3 I M L.QC: b , P. I (Z ML
Maihog(Ad(drC~ss:
Location:
51~t Ne 5 Z T Z 9 N, R E or W
44ty.aUUage. Township of:
1r}-R wt ~ one ~j
Parcel TaX Number!
O l 9 L'Q) Q
Legal Descopuon: ~g b Q
4z ifv VbC ,8Z oc7
ai>
1. No plumbing will be installed in the privy.
2. No plumbing will be installed in the premises served by the privy unless a code compliant soil absorption system or
holding tank exists, or a valid sanitary permii to install such a system has been issued.
3. A privy vault/ pit shall maintain minimum setbacks as specified in Table 1.
Tables Well Building Lake/Stream Additional County Setbacks
Open Pit 50 Ft 25 Ft Min. 75 Ft
Sealed Vault 25 Ft 25 Ft Min. 75 Ft
4. Privies for public buildings shall comply with ILHR 52.63. Wit Adm. Code, .
S. Privies used for one- and two4amily purposes shall be constructed in such a manner so as to exclude flies, rats and
other vermin. Doors should be self-hosing and vault ventilators should terminate at least one foot above the roof.
6. A privy vault shall be constructed of watertight plastic, fiberglass, coated steel or monolithic concrete. Materials shall
comply the intent with 11.1-111 83.20, Wis. Adm. Code. Counties may, by ordinance, establish minimum sealed vault sizes
and type or construction within the guidelines of 1LHR 83,20, Wis. Adm. Code.
7. The privy shall be kept clean and sanitary. The contents of the pit or vault shall be disposed in accordance with NR
113. Wis. Adm. Code.
Z. • This agreement shait'be'binoirlg on tH"e'ffwni it, their heirs and assignees. This document Shail be nRorded by th'e
register of deeds in a manner which allows its existence Lobe determined by reference to the property where the
privy is installed,
PoAte owner(s) ame s :
Yr-1N h~ d and sworn to before me on this date:
Notary Public-Slate of W IISonsin
owners tgna Vr t ori;lfpission cPites Match 22, "0"'
i,.r` ^NOLaryPubl,c
19 A My commis :'-Xo; esp
r .L
NOTE: This document was drafted by the State Departrne + :1ndu' ry~.Cabor and,Numan Relations.
Bureau of Building water Systems.'" . '
`0 /17x'9 Tt MON 14:44 Fat 715 386 4687 REGISTER OF DEEDS f~ 003
. ❑O c u ra 6 h17 N t~ WARRANTY
rJER r..~s aracW Re~aav FO ~aT ,Y900a0040 oAtw
STATE BAR OF WISCONSIN FORM 9 low
OFFICE
sre /q VIIj~/. W Ern-P-st Lathe, -.and- ,M~q..~~~k~~.....x .....~.7. I k9~'d for R~~d
w.~ e
_
U ~ IM I
cunVes$ and WZ[Tranta to ..17kk~, ..►T xaxtlex ..dz~t3 . W~zts3 ! ' f 30 ~1
I:
. - . • .
-
tko......wix~ • ,.t.........., lQ MI _ I
g deocr0nA real estate is .a,4 ...c 1«.-X M! MM 11
4TH _ ...County, + I
State of WiGeowin.
Part of 51; of NEB Of 5 Tax ftn l rho; I;
ectivn 2, Township 29
North, of Range 17 West, described.-as fo_tjowsj_z
- f
Commencing at the center of Town toad at the
Northeast corner of said SEh of NEB; South 600 'I
feet; thence West 350 .feet; thence north 254 feet; jl
thence East 40 feet; thence; North 350 feety thence I
East 310 feet to the point of beginning, subject DVS'
easements, right of ways and privileges of
record.
This seed is given in satisfaction of the terms
of a contract, the vendor therein being Della Mae E
Lathe a.Ad with the sane grantees as herein, said
contract recorded with the Office of the Aogiater
of Deeds, St.. Croix County, Wisconsin, on 1-17-86
in 07300, page 484, 4408526.
I;
rni3 ..,..,e1. „ h6MeStead prapatrty,
(is) (IN not) '
Exception to waAr mUcs.
Dated this •--------...1....... day of o G,!__..-----
r A
.....................(SF~iL) (SEAL)
Erpe.st..Zathe
c1(
SEAL)
(SEAL)
AV TIERMTYCATION ,A,CENO W Ll3DGMUNiT
Signature sI CSf rn S • 12~t 1 , b STATIC OF WISCONSIN
.da off" ~ ~ .Cottssty. •
it -1-~ 7 - c-----~ $giagplip enaoe lretore me thin
18._.- tli8 a1~OVh tls~CE'~
estzn +en
Ti'iCL : 14I AlBEE STATE BAR ~YiSCpNSIN----....__
..l{-..r. ui T_ k .rrie ne'-na a••''.:'T":
aWisconsin Deparbnt of boraW ~edustry,
La9or and HuurmmmanRelladonations SOIL AND SITE EVALUATION REPORT Page I of 3
j Division of Safety & BuilIngs in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on ST• C-R. o: X
Paper not less than 81/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (B", direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. O L 8 - ) O6 3 - y Q
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
R L'~!: A )''I ev. eevFL&T S e- 1/4 NL? 1/4,S Z T Z 9 .,N,R 1-7 E (all
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM tt
1165 Zoo r»- S--, - _ _
CITY, STATE ZIP CODE PHONE NUMBER []CITY OVILLAGE ®rOWN NEAREST ROAD
3~~DwIAJ, k1I Sq6oZ (-)1S) 68y-3CgZ . ~}~wl~ o►~,~ zov TjJ 5--.
[ ] New Construction Use pQ Residential / Number of bedrooms 3 [ ] Addi kn to e)asdq building
Pd Replacement [ ] Public or commercial describe
Code derived daily flow Ll 50 gpd Recommended design loading rate • `1 bed, gpd/ft2 trench,
9W
Absorption area required 31 S bed, ft2 31 S trench, ft2 Mabmum design loading rate . 5 bed, gpd/ft2 • 6 trench, gpdA12
Recommended infiltration surface elevation(s) q, • 6' It (as referred to site plan benchmark)
Additional design / site considerations "o Q i,,p w / 8'x y.-)' (Aex.) . r-, IN., _ Z ` OF SR i.,p FILL
.
Parent material - S t L` N s t%X r teN,T WVZ C ~ Tt LL Rood plain elevation, if applicable Iy q _ ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE T SYSTEM IN RLL HOLDING TANK
U= Unsuitable for stem O S 0U 0 S [I U 11 S ,I U ❑ S ®U ❑ S DaU ❑ S U
SOIL DESCRIPTION REPORT
Boring # [Horizon Depth Dominant Color Mottles Texture Structure GPD/ft
in. Munsell QU. Sz. Cont. Color Gr. Sz. Sh. Consis6ence Bound3y Roots
Bed rends
' [-a 1o`t R z.s /t - si I Z ~sbh `F►- a.S - , S
I~.... Z 5-11 10 `t2~!!cf - sl[ Z~3bb Mkt CS •S .6
Ground 3 t.1-3o S'~ 2 3! -"svrt s!8
elev. y t o-i R" b 13 S i e i o wt wi `F h
°tb.o It
Depth to
limiting
factor
hgi-01
Remarks:
Boring #
I 13-9 t~~2 Z s ! I - 511 Z`Fs~1T ~~h a-S - .s 6
Z 9-~s 113`1tz y[ st I Z~s~ V,'f'►- cs _ .5 . 6
13
cl SyR S/g - ,
Ground 3 1S -32 -)-S Lt R Sly 1p ~t R 6t3 S r cl o ti, h►`t^1--=° - _
Gel~lyev.7
17
Depth to limiting [ -
factor
Ate"
Remarks:' 9 - =
T Name:-Please Print Phone:
Arthur L. We erer 715-42 - 5,
g rer Soil Testing & Design Service-P.O.,Box 74 River Falls,WI 54022
Sgnature. r 7~{ q - z) Date)P,! L '1,1 ~'7 csT N 0 5 76
PROPERTY OWNER SOIL DESCRIPTION REPORT Page ' of--I,
PARCEL I.D. # O t 8- MQ 3- 4 O
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounds Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
3 o-8 10`12 Z.s /I Si Z* sbvc V,-, 'R. a-S - 5
Z`Fs~~ rn'f~►- cS • S •6
Z l3 ,oM R Y!`/ S) 'j
13-3~( ~-S`7R 3 ~ c1 ~-sYl~ sIg i - -
Ground 3 y O Y R 6 /3 S C r1 ~N `
elev.
, ►S.Uft.
Depth to
limiting
factor
\3'
E}t S"
Remarks:
Boring #
Iv oy~ Lj R-D D 1 *T7 QV.JA-L_ ~l'rs w E~ E ki ~ IV L ll. 0 ~ Q O L
'I
Ground
elev.
ft.
Depth to
limiting
factor
i
i
Remarks:
Boring # i
E3
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
i
i
13
I
Ground =
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
PLOT PLAN Page 3 of 3
SCALE 1"= 4 p '
3 80\Z►"1
~vsE I
E-
o
0
.D O
D
~x\sl~u6 PR~v~ N
x ex.~S~NG ~
eM -(F-L. Ioo.~ o1.1 '01' £
OF -M_U' ftkle N
0 r I
a a•~
3l
~N
a
s•z ~
e:3
t
M- all,
35Q' ~ ~ i
(715 ) 425-0165 M00576
CST Signature Date Sign Telephone No. CST #
d Depadmnt stry.
Lab" a SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor and Human Rel geladons tions
Division of Safety Buildrgs in accord with ILHR 83.05, WS. Adm. Code
COUNTY
Attach complete site plan on ST• C-RQ-1 X
paper not less than 81/2 x 11 inches in size. Plan must include, but
not firnited 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. 01.8-
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
d
PROPERTY OWNER: PROPERTY LOCATION
N L ~R A wt e. e0V`F-LOT S E 1/4 NE 1/4,S Z T Z °I . N,R 1') E (ar~l
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM If
ll6S Zoo r* ST. - - _
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE ®fOWN NEAREST ROAD
3NLDwIN,h1[ Sg6al CVS)68y-36yZ l-}flr'►h'Io►~~~ Zo(3 ST•
[ 1 New Construction Use PQ Residential / Number of bedrooms 3 [ ] A" to existing building
Pd Replacement [ ] Public or commercial describe
Code derived daily flow L) SO gpd Recommended design loading rate • y bed, gpd/R2 trench, gpol(t2
Absorption area required 3-1 S bed, 112 31 S trench, 112 Maximum design loading rate • S bed, gpd/112 • 6 trench, gpd/ft2
Recommended infiltration surface elevation(s) a -I. (0 ft (as referred to site plan benchmark)
Additional design / site considerations "o v i.,O w / S'X W)' t3eZ . " t _ Z ' of S A up FILL
.
Parent material S t L`N s M\ w►evT W \EiZ 0- ` T\ LL Flood plain elevation, if applicable ►y . A - It
S = Suitable for system CONVefnONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM W FILL HOLDING TANK
U= Unsuitable for stem ❑ S Ou 0S ❑ U ❑ S OU ❑ S O U ❑ S OU OS E111
SOIL DESCRIPTION REPORT
I . - 7
Boring # [Horizon Depth Dominant Color Mottles Texture Structure Consistenoe Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh.
Bed rends
] x o-a Irwl R Z.S /I s1 I Z'~Sb~t `~I- 0..S
Z S-\1 ti0`t 2t!!~ 31 1 Z ~3bb h~ ~t CS • S
Ground 3 \1-30 -).S `2 2 31y
14,i IZ 613 S 1 C } o VVI Y+'1 Fh
elev.
qb•o it
Depth to
limiting
factor
R+-9 "
Remarks:
Boring # •
-9 1131R 2•S 11 Sly Z.`FS6T
13 Z 9- s 1p ti 2 y/ s 1 1 Z -Fs b 'f'1- c s - • s 6
3 1S -3Z -S `t R 3/ Q1 ~'SyR s/t3 -
Ground Y i O R 613 S! C I o
elev.
gq•Zft
Depth to
timitirig
fa`br
L
A•r 6 "
d
Remarks: ' -
T Name.-Please Print Phone:
Arthur L. We erer 715-425-0165
Addraftr
egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022
Sgrratue:
LJ~ 91_Z) Date: 1L'1~1~~~ CSTN M0057.
PROPERTY OWNER Y'Z?-fN I EAR SOIL DESCRIPTION REPORT Page Z- of
PARCEL I.D. # O t 8 - 100 3 - L4 O
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BotxxJary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trey
3 o _ 8 1 p`-I R a.5 ! I - S t Z, `F S ? wm 'Fl- a. S _ , 5 •
Z s- l3 1o-. tz V/Y Z~a~k w, 'G ~s _ • s •L
►3-3 c1 ~-sYa sie
Ground 3 y -)-S `712 9/y /pym. to t3
elev.
°15.D ft.
Depth to
limiting
factor
3 ,
E}t S"
Remarks:
Boring # s L4 L lv u R~D p t l w E U w i
IV L 0 O L
Ground v
elev. {
ft.
i
Depth to '
limiting
factor
Remarks:
Boring #
s
1
Ground i
elev.
ft. }
Depth to
limiting f
factor
Remarks:
Boring #
t
f
Ground
elev.
f t.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
• PLOT PLAN Page. 3 of 3
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k4 j [9q7_ (715 ~ 425-0165 L_ H00576
CST Signature Date Sign Telephone No. CST #