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STC - 104
AS BUILT SANITARY SYSTEM REPORT
i
OWNER MO V ~ n (70 l
~a'°Ll
ADDRESS fy U Loe
SUBDIVISION / CSM# LOT
SECTION i _T "7)V N-RIZ.W, Town ofZei U~
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
E~~ysve
i
5
i
J
Q
E I
T7, t= i
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
1
a
BENCHMARK:
ALTERNATE BM: 4 y1 m ~~2 n l d (O
SEPTIC TANyyK~ / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity: f
1
Setback from: Well House 13Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: 5 Length ?5-
Number of trenches
Distance & Direction to nearest prop. line: '2 /-1b
Setback from: well: House 1/0 Other
ELEVATIONS
Building Sewer W14 ST Inlet. PE,6 4-1ST outlet
PC inlet PC bottom Pump Off
Header/Manifold g4,b,y Bottom of system
Existing Grade Final grade
DATE OF INSTALLATI E, / l S
PLUMBER ON JOB: D~ ~,1e G
LICENSE NUMBER:
INSPECTOR:
3/93:jt
.Wisconsin Department of industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations ST. CROIX
Safety and Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
PeGrmit OSSEL Holder's Name: ❑ City ❑ Village ❑ Town of: State PI
X
CST BM Elev.: Insp. BM Elev.: BM Description: G-A-1 LIE Parcel Tax No.:
TANK INFORMATION ELEVATION DATA -7
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
SepticS Benchmark
Dosing /
14
Aeration Bldg. Sewer p
Hold g St/. Inlet 6,316<3 w,
ANK SETBACK INFORMATION St/ Outlet (o (off' d-5
4jo TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Headers /~.3,P- Sir
Aeration NA Dist. Pipe 9 • 3j
/
Holdin Bot. System
PUMP/ SIPHON INFORMATION Final Grade G3 /
M acturer Demand '6:;yo "C ',5, -r
Model Number PM
TDH Lift Fric n System TDH Ft
Forcemain gth Dia. Ff Dist. To Well
SOIL SORPTION SYSTEM
BED/TRENCH Width Length / No. Of Trenches PIS No. Of Pits Inside D. Liq 'd Depth
DIMENSION S S .2 DIMEN I
SYSTEM TO P/L BLDG WELL LAKE/STREAM 9=~BER Manuacturer:
SETBACK INF
ORMATION TypeO /'~.(1 a,~- ~ a 3 ~A Model Number.
System: ; S OR UNIT
DISTRIBUTION SYSTEM
Header /Manifold ,i Distribution Pipe(s) x Hole Size x Hole Spacing Vent To
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Sys
Depth Over 01 Depth Ove xx Depth Of x ded / Sodded xx Mulched
Aod7trench Center /0 - V? Bed/ Trench Edges ~d - Vf Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: EAU GALLE.1.2~1.16W, NW? NW{ 60TH AVENUE
~ a-~ ~ ~ y ~ r • ~
/ a
O U
c?,2~GZ.J~ ~iC.~l~~i'/2 ' f~,,~, C~~ ° ! ~ • /jji~u.c={~
Plan r Sion required? ❑ Yes Q-No
Use other side for additional information.
SBD-67 Q (R 05/91) Date Inspector's Signature Cert - No.
^°ds° Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building Water System!
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 Co
than 8 112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
The information you provide may be used by other government agency ~3~
y y y programs ❑ Check if revision to 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
Marvin Gossel 1W/4NW 1/4,S 1 T 28 , N, R 16 R(or) W
Property Owner's Mailing Address Lot Number Block Number
2579 60th Ave.
City, State Zip Code F(P_',
one Number Subdivision Name or CSM Number jgQQdX7j 11 a 54n-)a )
I. TYPE U LDING: (check one) E] State Owned E' it Nearest Road 698 aw&g_ ❑ village
I
OF B ❑ Public 1 or 2 Family Dwelling - No. of bedrooms -2- Town OF Eau Galle 60 th. Ave,
411. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1❑ Apartment/ Condo d l c v r- U- oa 0
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash
5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1 _ Ej New 2. ❑ Replacement 1 ❑ 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 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) XeJkl, 5r Elevation
300 750 750 .40 30' ep Feet 101 Feet
VII. TANK Ca
in gallons Total # of Prefab. Site Fiber- Ex per.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank X 10013 1 Midwestern ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibili for insta ti f the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plu er's Signat r /MPRSW No.: 7 Business Phone Number:
Joe Stang MP 6646 1-715-698-2266
Plumber's Address (Street, City, State, Zip Code):
506 Willow Drive Woodvi e WI. 54028
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved sanixary P rmit Fee (Includes Groundwater Date Issue Iss g Agent Signature (No Stamps)
roved V x Surcharge Fee)
~44 pp roved Owner Given Initial U 3
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to) county, One copy To: Safety & Buildings Divwon, Owner, Plumber
Marvin Gossel
2579 60th.'Ave.
Woodville, WI. 54028
2 Trench 5x75
NW! NW! S 1 T28N,R 16W
4 4
System Elev. 30" below groung level
BM. top of 1" P.V.C. pipe 100'
Drawn by:
Joe Stang U
MP 6646
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Wi cgnsin Depman artment Relations, Industry,
Relati SOIL AND SITE E V A L 6 ..R E P.-(ART Page I of
,Labor artd Hu
.Division of Safety & Buildings in accord with ILHR is. Am. Co 1but
NTY
At
tach complete site plan on paper not less than 81/2 x 11 inchi Pannot limited to vertical and horizontal reference point (BM), direction of slona- o. GEL I.D. #
dimensioned, north arrow, and location and distance to nearest ro t f' 1Dsl ZO
APPLICANT INFORMATION-PLEASE PRINT ALL INFOR sT c;HOix IEWEDBY DATE
COW NTY
PROPERTY OWNER: 1v
r-- NV-U1N Gos 1/ 1/4,S l T Z$ N,R I& E(ow
PROPERTY OWNER':S MAILING ADDRESS SUED. NAME OR CSM #
Z S p `fit Iwe- • - -
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE ®rOWN NEAREST ROAD
wbo~vt~tt;,wt Suo'Lb um) 698- Z-is3 v Gf~l1 Fs 60 ` * hug
QQ New Consirh don Use [>4 Residential / Number of bedrooms Z [ ] Adult to existing building
j ] Replacement [ ] Public or commercial describe
Code derived dally flow 3 0O gpd Recommended design loading rate - bed, gpd/ft2 y trench, gpd/ft2
Absorption area required bed, ft2 trench, ft2 Maximum design bading rate 0.23 bed, gpcw 0 • Y trench, gPcw
Recommended infiltration surface elevation(s) S L' Ffr6 E L/ o F V it (as referred to site plan benchmark)
Additional design / site considerations ~ iw1M'@J0 Z `ME>\J Ctf eT5 MH S 'K 7 S ' LOry G .
Parent material G t_ h\ -L PrL "w l FT Flood plain elevation, if applicable A , ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SM-EMI IN FILL HOLDING TANK
U= Unsuitable fors stem HS ❑ U MS ❑ U C?S ❑ U IRS ❑ U ®S E U O HOLD DING 911
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed reach
vC
i ) 0-9 1OL1R- 313 5 ~~I Sbk mu
<1 -Z8 ►oLl tz 3~6 - 1~ \esbtz >~tv~►- cw - o.~ a.8
Ground 3 Z$ _7$ 7-S `ft - Y/6 I S o S rn o o. S
elev.
%b . S It
Depth to
limiting
factor
7 8
Remarks:
Boring #
o_~z `0~~3l3 - sl 1~►sbh w►v'Fr cS o.V €o.S
Z Z ~z-3o lost cL 3J b _ s ~ ~ e.sbk rH v~, erg 0.1 a. ~ II
3 30-)$ ~•s~tV-- VfL
Ground
elev.
48 . S ft
Depth to
limiting
factor
G7 Remarks:
T Name:-Please Print Phone:
Arthur L. We erer 715-425-0165
V egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022
Signature: 9 S_ 8 9 Date: ~ Iu L LO I H `sT Number: M00576
PROPERTY OWNER C='SOIL DESCRIPTION REPORT Page?-of,
PARCEL I.D. # C70 ~ - L W) I - ?-Z
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BaxxJary Roots GPD/ft
in. Munsell . Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trerxh
a_8 ~o~t~ 3!3 s > sbk V,U'Vj, 6-S
13 ~ ~_~l3 10`ti\Z 3A
Ground 3 U3?9 '~~S`t tz 6 - s 1 ~s~h wt u ~V- o , 3 a, y
elev. _
\O~..b ft. N Div ti S 1 S k R- Vrl tRsS t V LS 3 MtiD S
Depth to
limiting
factor
>F-I
Remarks:
Boring #
o _8 ~o`-1R- !3 S~ Z.~w, 3 b m'F1• eS e.S o, l
S\~ds1cl Z~~bk~,
L (Z CW r O.Y iO S
Ground
elev. S Ll R ~r16 _ 1 g 1 s ~01-~ >n u'4 r o 3 o y
tos ft.
Co n~ S . S `i ! 1n fm-stu% Wt v s B S .
Depth to
limiting
factor
Remarks:
Boring #
o-le l,o~,~ 3l3 ~ s l 1 ZrnSb1z vv►-~`t~ ~S - o-So. C
S Z 1o Z~ ! 0 R l L s 1 J Z S b~ vn `F 1- 0- S - o. S o. C
3 ~g ~•SyfZ y~6 - S L\S \azbh rnQ'~i- - Q. 3 Iu.y
Ground
elev. 3 C-a wS 7- Sit 31V, 1k1 If-5'3I u VIA U s $ s .
\ob-S ft.
Depth to
limiting
factor
Remarks:
Boring #
0-10 WKt? 3l3 S 2-`4'3~1z vbru`F~. ag _ 'I'S o.
Z \0 3b lv`-!R 3~6 S) Z Sb12 vnU'F cw
3 3C-7~ ~•s `1 R Y/~ ~S a sg - 0.3 m,Y
Ground
ibfl 5 ft U e-d►v N S LO SLY ~'1 S IU bY1 V S
Depth to
limiting
factor
C-S
Remarks: L 0 L4 O S b
cnn o~~nrn nrro~`
` PLOT PLAN Page y of
F~r~i2 v~~ GQsYTO-
SCALE 1"= 30 ' t~, KJv 008-too'-1-0
6 0 `N NFU ,
o.SS m To
~tousF_ `CD _ 8 E f T ~l ~T z S ~t `l- EN WtVs , -
0
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0`x'1 - ~.IA0.0 c N a"WISH, 3/v4p~jC
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4 - A
~~pv:J`~pv~L. LL►vE -S~'4G!!I`1.. ~1f[~`_`_I'~Ec. v~?:~~4 : _ ~f
_ ? . ` 0!^!11 S LD[ _ , _ U J4
Ly_ _ PMTZJL Ll~i, lctl S ( 715 ) 42.5-oi 65 M00576
CST Signature Date Signed Telephone No. CST #
PROPERTY OWNER ~oSSt~, SOIL DESCRIPTION REPORT Page 3 'of. L
PARCELI.D.# 00$- `t)0l- ZCl
Depth Dominant Color Mottles Texture Structure Consistenoe BouryJay Roots GPD/ft
Boring # Horizon in. Munsell . Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trerch
r3 l0`1 R c3 s Z stilt \3 c.S - o.s 4-
2 C.S S
Ground 3 ~8 ~8 -)-,3 (Z- YI6
elev.
1q0 ft
Depth to
limiting
factor ~y
Remarks:
Boring #
1,3%' 3 Pip b ito Y- fig- B u w e w N S
W
LS G 1Zk` f C )NY L~
E3
Ground b~" ~ ~.11v G utU S l~ L ~ ~0 Z
elev. C
ft.
Depth to
limiting
factor
Remarks:
Boring #
t-tZ M )Eb ~v - "'O - sSLU = Std Q Lo
E3
L Stvtl ` f S 1Qti S ` w
Ground
elev. ' S Z
fL
Depth to
limiting
I J
factor
Remarks:
Boring #
E3
Ground
elev.
ft.
Depth to
limiting
factor
Remarks: al"U BR-LL 0 L CI`t S CS t t, S? b
cqn a~aMp nSm~
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNEWBUYER Marvin Gossel
MAILING ADDRESS 2579 60th- AvP_
PROPERTY ADDRESS oC6oo 7 6 0
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE Woodville, WI.
PROPERTY LOCATION NW 1/4, NW 1/4, Section 1 T 2S N_R 16 W
TOWN OF Eau Gal.-le ST. CROIX COUNTY, WI
SUBDMSION LOT NU 13ER
CERTIFIED SURVEY MAP , VOLUMEO~1,/PAGE S , 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.
U\kle, 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 retumed to the St Croix
County Zoning Officer within 30 days of the three year expiration date
SIGNED
DATE:
St Croix County Zoning Office
Govenuncnt Ccntcr
1101 Carmichael Road 1 1;9
Hudson. Wi 51016
+ 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 Marvin Gossel
Location of property 1/4 NW 1/4, Section 1 T 28 N-R 16 W
Township Eau Galle Mailing address 2579 60th. Ave.
Woodville, WI. 54028
Address of site
Subdivision name Lot no.
Other homes on property? Yes. No
Previous owner of property 2 G( ~T~ e~~- ~~~/l l~-
Total size of property
Total size of parcel y J c emeS
Date parcel was created
Are all corners and lot lines identifiable? v Yes No
Is this property being developed for (spec house) ? Yes C-----No
L
Volume ~S and Page Number 13 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. 2 q 7 ~cf Z 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
tq ~QfLc e of the County Register of Deeds as Document No.
Signature of Applicant Co-Applicant
Date of Signature Date of Signature