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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER__,(1,-'''1-a
ADDRESS
SUBDIVISION / CSM# LOT
SECTION TY_N-R q W, Town of ~6 rrf~
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
,2 c/
3 /
Ile
r
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: I
ALTERNATE BM:
SEPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacture . I,clez 6 Liquid Capacity:
Setback from: Well House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: /,P2 Length Number of trenches
Distance & Direction to nearest prop. line: :-;y
i
Setback from well: Housed Other
ELEVATIONS
Building Sewer ST Inlet. ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing-Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
Permit Holder's Name: ❑ City ❑ Village p Town of: State PI
RABOIN, VERA X
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic s goo Benchmark Cb7~5/~ `QQ
Dosi ng
Aeration Bldg. Sewer C'r Jf 2,0
Holding St/Ht Inlet a 7 93
TANK SETBACK INFORMATION St/ Ht Outlet q6 i std ,2S
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header/ Man. /0, 61 q/, 7 7
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
r a 9/ 9~ . S S
Model Number GPM
TDH Lift Friction System TDH Ft
Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Len th No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type O 3 D a 5 Jr 3 OR UNIT Moe Number:
System:
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length ~1' Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over 0 Depth Over 4 I 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: SOMo~ERSET.3.30.19W, NW, NE, PARENT STREET
!3
a: yeti
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. 151 /U G '6 V
g c~.
SBD-6710(R 05/91) Date In pector' Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: _
I
i
J
SANITARY PERMIT APPLICATION COUNTY _
Y
v~IliL!71n In accord with ILHR 83.05, Wis. Adm. Code TY oko j
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ a v? 8 ~Gf
8% X 11 inches in size. Check if revision to pre ious application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOOC~ATION
i' Wet ~ /a/~~~, S T,7V, N, R E (o
PROPERTY OWNER'S MAILIN DDRESS LOT # BLOCK #
a -e /-0,- 1»
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: Check one CITY EAREST AD
nn ( ) State Owned VILLAGE 0~72Ci je
4OWN OF.
❑ Public I~i-1 or 2 Fam. Dwelling-## of bedrooms AR
EL TAX NUMBER(S) ~7
III. BUILDING USE: (If building type is public, check all that apply) a~p~ ~ap~b.-gyp
1 ❑ Apt/Condo
2 ❑ Assembly Hall 60 Medical Facility/Nursing Home 100 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. Replacement 3. ❑ Replacement of 4.0 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 V9 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 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. RAjE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch))) ~ELEVATION
J" Y110 1, Feet 7 .5 Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exp 'r.
INFORMATION Manufacturer's Name Con- Steel Plastic
New istin Gallons Tanks Concrete structed glass A
Tanks Tanks
Septic Tank or Holdin Tank
Lift Pump Tank/Si hon 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): Plumber's . ture: (No Stamps) MP/MPRSW No.: Business Phone Number:
- 76 6
lu r 's Address (Street, City, State, Zip Code):
l 7~' m
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Iss 'ng Agent Signature (No Stamps)
Approved ❑ Owner( [ surcharge Fee)
iven initial V~.~}r
14 Adverse Determination 1 J
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, 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 the 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 & 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 in 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 in ##1-7.
VII. Tank information. Fill in the capacity of every new and/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% 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, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
PROJECT_ ADDRESS
S C~ ,
1/4 1/4/S /j3o N/Rl W TOWN COUNTY w jYa
MPRS Byron Bird Jr. 3318 DATE'
°
BEDROOM CLASS PERC
.,.;_ZCONVENTIONAL_ IN GROUN ESSURE
CONVENTIONAL LIFT_ MOUND HOLDING TANK k
'SEPTIC TANK SIZE--~,j; f,
IFT TANK SIZE . .
DOSE TANK SIZE'
HOLDING ,TANK SIZE' '
ABSORPTION AREA' D
PERC RATE: ~BED SIZE- ,
Benchmark V.R.P. Assume Elevation 100'; ;
:g i,
Location of Bench V
mark t
* N.R.P._ lr~v~^i••~
1:3 Borehole Q Well 'Scale
'Feetti,
O Perc Hole w srv- _
System Elevation
h 1 Uent ( f
12"
Grarlp
Z T,
TYPAR COVERING
1 y Y~
1
t 2"
i
12" 3- 4 s, ® 3'
Sewer Rock ~r12
r}~ , x k s,. ~ ,
,wh 1
s rw ~k Leh mlviry,rv ft~ ;
. r ~ JJ j
1 4 fir. V F
v 1 et.; y 1 , I
a r
V P
jP'% r{( a~i)yAytM ta" r
/r
Ile-
Y H `
F r )y£ i^
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page _ of
labor and Human Relations
Division of Safety & Buildings in accord with I LH R 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but K eO
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. 67
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNE : PROPERTY LOCATION
Lle r14- O/ h GOVT. LOT " 1/4,4a1/4,S T N,RI E
PROPERTY OWNER': MAILING ADD ESS LOT # BLOCK # SUBD. NAME OR CSM #
(p' R h C/7 7-
CITY, STATE , ZIP CODE PHONE NUMBER ❑CITY VILLAGE MOWN NEA ST ROAD
5,5 urt
r i OaS 7.3f
[ ] New Construction Use Residential / Number of bedrooms .2 [ ] Addition to existing building
Replacement [ ] Public or commercial describe
Code derived daily flow YOV gpd Recommended design loading rate _ 7 ed, gpd/ft2yTtrench, gpd/ft2
Absorption area required bed, ft2 7 trench, ft2 Maximum design loading rate ,~7 bed, gpd/ft2-,trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material K T~ ar Flood plain elevation, if applicable It
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem ®S ❑ U ❑ S 12 4J ~S ❑ U ❑ S [RU ❑ S ~J ❑ S 5n
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 Tmr& Z -3 5,
D G-
Jva 1-2
Ground 'le
elev.
ft.
Depth to
limiting
factor
7
Remarks:
Boring #
/o
.v M1ti .v.. ^i'? o -
&
Ground
elev.
Depth to ° _ .
limiting W
factor L
Remarks:
CST Name: Please Print Phone_
ram
ddress:
dv
Signature: Date:~ CST Number:
7
PROPERTY OWNER 00~ SOIL DESCRIPTION REPORT Page . of
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
:k
7~~4ooe le r==:; r $
Ground
or Za (410f
y~~ft.
Depth to
limiting
factor _
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
tip:.........
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
~a h'•:i:Y\: i::::::i i
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
L
Soil Test Plot Plan
Project Name 4,4o /h Byron Bird Jr.
Address rz ~rcf sue.
//f ®s~ o _ 577 CST 479
Lot `"Subdivision Date
A/1/4/P~1/4 S_,J TZ.LN/R/V W Township
❑ Boring O Well PL Property Line County
L BM or VRP Assume Elevation 100 ft. IZo o_ 4Co ~h le~/oclr X6`60'7
System Elevation *HRP f4d, G a /~``s ~
~o
B / .
o'
c
Scale 1/4" c 10 Ft. When dimensions aren't stated
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNMUYER/~`'a
MAILING ADDRESS
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION 1/4, Section T_. 3_N-R~W
TOWN OF rah-`cam ST. CROIX COUNTY, WI
s
SUBDIVISION LOT NUMBER
VOLUME PAGE LOT NUMBER
CERTI)H'IEDSURVEYMAP
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.
SIGNED:
DATE: -
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
I
s
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 Ne /ixv ~h
Location of property mil(/ 1/4_1/4 , Section N-RW
Township Mailing address
Address of site
Subdivision name Lot no.
Other homes on property? -Yes No
`
Previous owner of property To ~1~c a
Total size of property
Total size of parcel ado X o
Date parcel was created ~JGc~ 7 ~l~ y~
Are all corners and lot lines identifiable? lrYes No
Is this property being developed for (spec house) ? Yes yZ No
Volume and Page Number 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 i the _o fice of the County Register of
Deeds as Document No..6 S~5 3 , 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 ffi e of the County Register of Deeds as Document No.
~ dA3'S~ 3
Signature of pplicant Co-Applicant
Date of Signature Date of Signature