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` AS BUILT SANITARY SYSTEM REPORT
';I N-IiIW
OWNER TOWNSHIP 1.1 SEC./
ADDRESS ST. CROIX COUNTY, WISCONSIN.
LOT LOT SIZE
SUBDIVISION
PLAN VIEW
Distances and dimensions to meet requirements of H63
r
X00
Int. EVLRYTHING WITHIN 100 F1,
5 - -
. I ~
I dt a ti or,thjA ro
SCAL AIQ
BENCHMARK: (Permanent reference Point) Des DD
Elevation of vertical reference point: Slope at site:
SEPTIC TANK: Manufacturer: - Liquid Capacity: 140
Number of rings on cover : Tan manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set or a cycle gallons; tots capacity o
distribution lines gallon: size o pump head;
gallon per minute horsepower bran name of pump
and model number
Type of warning device
HOLDING TANK: -Manufacturer Number of gallons
Elevation of manhole cover
Type of warning device
SEEPAGE PIT SIZE: um er o pits feet diameter feet liquid dept seepage pit in et pipe-elevation
bottom of seepage pit a evation feet.
SEEPAGE BED SIZE: number of lines wi th__1glengthS~tile depth_3p
SEEPAGE TRENCH: width lengit _
PERCOLATION RATE,i,;,~~E E U A RE BU LT
INSPECTOR
DATED PLUMBER ON JOB ,g~
LICENSE NUMBER
j
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 3969 BUREAU OF PLUMBING
MADISON, WI 53707
IX CONVENTIONAL ❑ALTERNATIVE State Planl.D.Number:
(If assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
MILES HOME MILE
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Richatc.d Git keu on RR# 1 , Somet z et, W1 110-1.9- Q~ v / e 30
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
SW SW, Section 14, Lot 3, T31N-R19W, Town of Someu et
Name of Plumber: MP/MPRSW No., County Sanitary Permit Number:
Cad. Poweu 1563 St. Ctcoix 43682
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WA NING LABEL jL0CKIbIQCC)FER
PR VID D: RO ED
3 ~O ES P
ONO YES ONO
BEDDING: VENT A.: VENT MATL. JH IGH WATER UMBER OF ROAD: P BERTV WELL: BUILDING: VENT TO FRESH
ALARM FEET FROM , A~ ~i AIR IT:
OYES NO ❑Y NO NEAREST Ujl /
DOSING CH ER:
MANUFACTURE : BEDDING: LIQUID CAPACITY. PUMP MODE / jPUMP/SIPH0>4Vr_A 6 1 WARNING LABEL JLOCKING COVER
PROVIDED: PROVIDED:
OYES ONO ' OYES ONO OYES ONO
GALLONS PER CYCLE: PUMP AND CONTRO OPERA IONA NIUMBER OF PROPERTY WELL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF) ❑Y NO EAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FN(, l H DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTf ILINGTH. 'OF DISTR. PIPE SPACING. COVER INSIDE CIA #PITS. LIQUID
BED/TRENCH 1 TRENCHES / MATERIAL: HNUMBEIR IT DEPTH.
DIMENSIONS I /Y
GRAVEL DEPTH FILL DEPTH UIS R. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. OF PROPERTY j WELL, BUILDING: VENT H
BELOW PIPE ABOV O R. ELEV. INLET. ELEV. END. PIPES' ROM LI AI ET
a G T-~
MOUND SYSTEM: 1`.
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
OYES NO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS.
DYES ONO OYES ONO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL: =SO DED. SEEDED: MULCHED-.
CENTER- EDGES.
OYES ONO DYES ONO OYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER:
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: [PIPES O. DISTR. ID ISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING.
ELEV.: ELEV.. DIA.. ELEV.: . DT:
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING. DRILLED CORRECTLY : COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED
OYES ONO OYES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: "NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LIN
❑ YES ❑ NO ❑ YES El NO NEAREST
t~S r2.68 915
5 It .5j
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-7, 7 a V. SZ
Sketch System on `Ret ' /ou file for audit.
Reverse Side. "
SIGNATURE../ TITLE:
DILHR SBD 6710 (R. 01/82)
~ wlsconsln APPLICATION FOR SANITARY PERMIT W
'D 1 L H R COUNTY A (PLB 67) UNIFORM SANITARY PERMIT #
I~ OEPRRTTEnT OF
InOUSTR 0, LROOR 6 HUMFIM RELRTIOnS Ym J O
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches lin size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PR ERTY OWNER MAI INGADDRESS
7 n rI
0 "
PAUPEFITY LOCATION CfTY:
V4.LLAGE:
1/4 4, S ,1 , N, R E (Or' TOWN OF: zz"
LOT NUMBER BLOCK NIlJMBER SUBDIVISION' NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED -~U
1 or 2 Family Number of Bedrooms: Public (Specify):
THIS PERMIT IS FOR A:
0 New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
Y Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued
❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: S a
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the pri to sewage system shown on the attached plans.
Na:of Plumber int): I Sign MP/MPRSW No.: Phone Number
Plumb is Address: Na of Designer: /
t
eae~~'a J" -S- I .
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
A /Q~ Q ❑ Owner Given Initial
Y Approved Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
D I LH R -SB D-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
i
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INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.);
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
r° e
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EH 115 Rev. 9/78
_ REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
j P.O. BOX 309, MADISON, WISCONSIN 53701 fir( $
Co
LOCATION:~w'/4," /a, SectionA,Tc3Z N,RZ71b(or)dj?Township or Municipality
Lot No. , Block No. Subdivision Name County D -
Owner's/Buyers Name: 01- •`N
Mailing Address: 1010A 999 A S er 7L c V
TYPE OF OCCUPANCY: Residence No. of Bedrooms 3 COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS S,__6 0. PERCOLATION TESTS 7 -S'A00
SOIL MAP SHEET ~O NAME OF SOIL MAP UNIT G04 Moll- 4o 1 lar#mY 65we_
PERCOLATION TESTS . ,70
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P- .Z S, e y 3 4
P-3 h t~ owe AA
'Y o 6
P-
P-
P-
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK
OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B- Z A&zee- 117"x'
B- 3 22 kS
B- 6" Q > frnol, 6 « o
113- 9P6 1 /4keA_-
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy -000' ' Indicate scale or distances.
Give horizontal and vertical referenc points. Indicate slope. / 'Ae -PI¢A
je-
E
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e
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Ix( sxs_y4c~-, 10911-019
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17
I, the undersigend, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods
specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my
knowledge and belief.
/
Name (print) S Certification No. SS 41w
c
Address e~ o S G~
Name of installer if known
Copy A -Local Authority CST Signat
Form - S T C 100
Owner of Property
Location of ProPert 1 1
y_S
, , lti?, ~~a, Section T N R W
Township mf ^S l-
Mailing Address Sopl-e ('-s-67-(,J SyC~25
Subdivision Name
r
Lot Number A_
Previous Owner of Property ~~iJARl7~i~A/~
Total Size of Parcel
.a'Date Parcel Was Created eeq/S*/'=/
Are all corners identifiable? Yes No
Include with this application one of the following:
x.Certified Survey Map
.Deed
.Land Contract, or
.Other Legal Document which describes the property
PROPERTY OWNER CERTIFICATION
I (We) certify that all statements on this form are tr o the best of my (our)
knowledge; that I (we) am (are) the owne rope described in this
information form, by virtue of a warran y deed recorde t e Office of the
County Register of Deeds as Document o. -j'~5387 nd that I (we)
presently own the proposed site for the se a disposal Sys m (or l (we) have
obtained an easement, to run with the above descn a operty, 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 OWNER SIGNATURE O O-OW R (IF APPLICABLE)
DATE SIGNED DATE SIGNED
UU(.UMEN i Ivq. STATE BAR OF WISCONSIN FORM 11_1982 ! THIS SPALt RESERVED FOR RECORDING OA1A
- LAND CONTRACT
Individual and Corporate
(TO BE USED FOR ALL TRANSACTIONS WHERE OVER
' J$25,000 IS FINANCED AND IN OTHER NON-CONSUMER
ACT TRANSACTIONS)
Contract by and between Edward E. Germain and
Arm Marie 6enllain,~ husband and wife,-•---------------------- ~
("Vendor
whether one or more) and
?azy__~A__Ca,lkex s a,--h s?~axxd..ara r f?, __as.. loins
-t:g------------------------------------- ("Purchaser", whether one or more). l~
Vendor sells and agrees to convey to Purchaser, upon the prompt and full per- f I
formance of this contract by Purchaser, the following property, together with the i'
rents, profits, fixtures and other appurtenant interests (all called the "Property"), in------------------------ St.___Qr_0• County, State of Wisconsin: RETURN To
Edward E. Germain
F3ox 66A, Somerset, WI 54025
Tax Parcel No.
Lot 3, Certified Survey Map filed December 8, 1978, in Volume 3,
Certified Survey Maps, page 746, as Document #353786, being
I' located in the SW. of the SW1k of Section 14-31-19. i
Subject to recorded easements, reservations, and rights of oray.
This land contract amends the land contract between these same ii
;a II parties, dated 16 Jul 80, recorded 28 Jul. 80, in Volume 614,
page 532, as Document #365387. This amended land contract shall
i~ change only those terms and conditions that are different from
the original land contract; otherwise the original land contract `i
shall remain in effect. '
This 1S.-nOt........ homestead property.
(is) (is not) (,i:
Box66A, Somerset, Wisconsin
Purchaser agrees to ur osthe Property and to pay to Vendor at
.
a in the following manner: (a) I
the sum of $-r-T-- h
s}t the exeeution of this fnntraet; and (b) the balance of $...._.2.30 ,.QQ together with interest from date
hsFe®f on the balance nbitstfintling from time to time At the rate of. --:lt_,...~~i1~ per cent per annum
I until paid in full, all follows :
There shall be monthly payments of principal and interest in the amount
of $63.41 per month, commencing on October 1, 1983, and continuing on
the lst_day of each month thereafter until September. 1, 1987, at which
time and date, all remaining principal and any accrued interest shall
be paid in one balloon payment.
* includes principal paid under original land contract.
Provided however, the entix outstanding balance shall be paid in full on or before the 1St . day of
---___-__September-----------_ the maturity date).
Following any default in payment, interest shall accrue at the rate of % per annum on the entire amount
in default (which shall include, without limitation, delinquent interest and, upon acceleration or maturity, the entire
principal balance).
II ~I
Purchaser, unless excused by Vendor, agrees to pay monthly to Vendor amounts sufficient to pay reasonably antici-
pated annual taxes, special assessments, fire and required insurance premiums when due. To the extent received by Vendor,
Vendor agrees to apply payments to these obligations when due. Such amounts received by the Vendor for payment of
taxes, assessments and insurance will be deposited into an escrow fund or trustee account, but shall riot bear interest
unless otherwise required by law.
Payments shall be applied first to interest on the unpaid balance at the rate specified and then to principal. Any
amount may be prepaid without premium or fee upon principal at any time after__ 4].a.C~ .4? _145$te......._ O
-tkere-rse}y-be-no- f+regnJ*n+entr-e•~~rialei~wl-~v,itkouL-pw~iseion-af-Yvwdor.~
In the event of any prepayment, this contract shall not be treated as in default with respect to payment so long
as the unpaid balance of principal, and interest (and in such case accruing interest from month to month shall be treated
as unpaid principal) is less than the amount that said indebtedness would have been had the monthly payments been
made as first specified above; provided that monthly payments shall be continued in the event of credit of any proceeds
of insurance or condemnation, the condemned premises being thereafter excluded herefrom.
Purchaser states that Purchaser is satisfied with the title as shown by the title evidence submitted to Purchaser
for examination except:
no exceptions
Purchaser agrees to pay the cost of future title evidence. If title evidence is in the form of ar
be retained by Vendor until the full purchase price is paid.
Purchaser shall be entitle to take possession of the Property on__._..date of. clos3Zg,___
*Cross Out One.
KQYIIInCOOlpry® STATE. BAR OF WISCONSIN
• • • FORM No. 11 - 1082
77`7` 7-
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NOV 17 1673
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ST. CROIX COUNTY
WISCONSIN
1' ti ZONING OFFICE
1 x x n x x x x■ mom"
~i ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680
February 15, 1996
Via Fax: Remax 247-3622
Attn: Mike Germain
RE: Septic Inspection for Richard Gilkerson
Address: 2109 - 60th Street, Somerset, WI 54025
Dear Mike:
An inspection of the septic system serving the Richard
Gilkerson residence located at 2109 - 60th Street, Somerset, WI
was conducted on December 21, 1995. This property is located in
the SW; of the SW, of Section 14, T31N-R19W, Lot 3, Town of
Somerset, St. Croix County, Wisconsin. At the time of the
inspection, this septic system was found to be code compliant for
a three (3) bedroom home.
If you have any questions, please give our office a call.
5;s ely,
K. T ompsaSn
Assistant Zoning Administrator
St. Croix County, Wisconsin
db
9
STC - 104 Cb
(r'
AS BUILT SANITARY SYSTEM REPORT RECEIVED r-'
n
JANe 3 L-6
OWNER ZT GR3t 1
006NTY
ADDRESS ZMN0OPPOE ~Ir
SUBDIVISION / CSM# LOT # S"
SECTION _T~N-R W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EV RYTHING WITHIN 100 FEET OF SYSTEM
~toc h
1
spy
I 6g
INDICATE JORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
n / D
BENCHMARK: S L
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: 2z-, 6 Liquid Capacity:
Setback from: Well House /
~SC- Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
-:SOIL ABSORPTION SYSTEM
Width:- . 2_ Length Number of trenches
Distance & Direction to nearest prop, line:
Setback from: well: 4M_ House-Z,!2X_ Other
ELEVATIONS
Building Sewer ST Inlet, ST outlet 9W,d
PC inlet PC bottom Pump Off
Header/Manifold 4 Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR: fZ~!
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and 8u.ildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI
GILKERSON, RICHARD X e' et CST BM Elev.: r Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic C'olr Benchmark Ig lee) ,C'6
Dosing
Aeration Bldg. Sewer
H g St/ Inlet
TANK SETBACK INFORMATION St/0 Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic ESQ ~2~- 3is ` NA Dt Bottom
r
Dosing NA Header / Man. jr 7v
Aeration NA Dist. Pipe f, v 9 3. o/'
Holding'" Bot. System 9 loan 9~, ~O
PUMP/ SIPHON INFORMATION Final Grade
Man cturer Demand
Model Number
TDH Lift Ion Sys e t
Forcem, ' 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 4,17 S DIM N I
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEA u acturer:
SETBACK CHAMB
INFORMATION TypeO / , Moe Num
System: ~ pbvn, r/30 fr OR U
DISTRIBUTION SYSTEM
Headers r Distribution Pipe(s) x Hole size x Hole Spacing Vent To Air Intake
Length J~- Dia. Length !~5_ Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Gr stems Only
Depth Over Depth Over xx Depth Of xx Seeded / d xx Mulched
;I
Bed /Trench Center Bed / Trench Edges Topsoil ❑ Yes ❑ No s ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Somerset.14.31.19W, SW, SE,,Lot 3, 60th Street
LLJI~/-<-~'~~CJ.("~~~3°`i.C..CI l/Y7 0 G/~.1=~. ~~~t-r,-, G.._.,-r v~7c" r,~x
Plan revision required? ❑ Yes 9_N
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signat re Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building Water Systems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit! Number
.25931,%
The information you provide may be used by other government agency programs, ❑ Check if revision to previous application
(Privacy Law, s. 15.04 (1) (m)J. State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION
Prope wner Name Property Location
1 /a cj 1/4, S T , N, R f~(or
Property Owner's MailingngAddres Lot Number Block Numb
I ate Zip Code Phone Number Subdivision Name or CSM Number
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ lay Nearest Road
❑ Village
Public 1 or 2 Family Dwellin - No. of bedrooms Town of
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ 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) ~J A Sanitary Permit was previously issued. Permit Number Date Issued 0- t?
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 S. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./i ch) Elevation
Feet Feet
VII. TANK Capacity
gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existin strutted
Tanks Tanks
Septic Tank or Holding Tank l ❑ ❑ ~ 1:1 ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ Ej VIII. RESPONSIBILITY STATEMENT
I, th ndersi ne , a ume responsibility for insta ion a onsite sewage system shown on the attached plans-
Plumbe " Na r Plum t ( S p MP/MPRSW No.: Business Phone Number:
Plumbe sAdd Mt ity, Zip Co
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing A ent Signature ps)
roved Surcharge Fee)
op~App ❑ Owner Given Initial j?Jj %
zx~
Adverse Determination O(/~ <
CONDITIONS OF APPR AL / RE SONS FOR DISAPPROVAL:
I - //,/dam
.4 -66
SOD-6398 (R. 05/94) 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 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. On site 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.
ll. 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 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) fora 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.
S~.,,~~ ~J.r sus,
,62- hf-9-,~J
t-
I ,os
JD~
'a
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of
Labor and•Fluman Relations
Division of'Safety & Buildings in accord with ILHR 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
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.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROP OWNER: PROPERTY LOCATION
GOVT. LOT 1/4~ 1/4,S/ T AR 9'(orer
P 0 ERN OWN R': TILADDRESS L0 BLOCK # SUED. NAME OR CSM #
TATE H ZIP CODE PHONE NUMBER ❑sCITY VILLAGE WOWN NEAREST ROAp I-e
[ ] New Construction Use V] Residential / Number of bedrooms [ ] Addition to existing building
JA Replacement [ ] Public or commercial describe
Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2_,2__trench, gpd/ft2
Absorption area required bed, ft2, i];< s trench, ft2 Maximum design loading rate :Z bed, gpd/ft2__,k_trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material ' s Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem ®S ❑ U 10S El U ® S El U JZ S❑ U ❑ S 54 U 1:1 S R U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boulrdary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. C t. Color Gr. Sz. Sh. Bed Trench
772
/
s. - s
Ground s - 9j .9
elev.
ft.
Depth to
limiting
factor
a
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
CST Name:-Please Print Phone:
Address: _
Signature: L Date: CST Number:
PROPERTY OWNER SOIL DESCRIPTION REPORT Page~of
PARCEL I.D. #
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. nt. Color Gr. Sz. Sh. Bed Trench
Ground s - -
elev.
2L ft.
Depth to
limiting
fact
I
Remarks:
Boring #
Ground
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)
~lop ~ ~Jcll
81
I
3G' '
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER i
MAI LNG ADDRESS
PROPERTY ADDRESS
(location of septic s stem) Please obtain from the Planning Dept.
CITY/STATE " zA
PROPERTY LOCATION _561 1/4, Section T _N-R_ 1 W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER -'g:'
CERTIFIED SURVEY MAP,2 , VOLUME E , PAGE LOT NUMBER _3
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
ri 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 A
Location of property!2' 1/4 Ily9 1/4, Section"
ection T,,~, N-R- W
Township - ailin address -2 e~
Address of site ~C~GJ pC,o~h
Subdivision name Lot no.
Other homes on property? Yes_ / No
Previous owner of property "-^='Q~-'~~* _
Total size of property 7,-27 '
Total size of parcel
Date parcel was created - - 7VV
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes No
Volume ~~Z - 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 in the office of the County Register of
Deeds as Document No. _1/Ij~SS 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/
6 / - /Z
Date of S'gna ire Date of Signature
FORM NO. 985-A
/LCMi'I.rCmprry~
353'786
W1 /4 corner Lot 1 CSM CERTIFIED SURVEY MAP
I Section 14 Vol. 12, Page 487
T 31 N , R 19W Doc. #344068
I 33-~`~--- 1 4U-----x---
i N 87°48'40"W
I 438'
I I
I
j 6 6'
I I
U N PLATTED LAN DS
I l i 8 9
I a
I f
o FILED
DEC ~8 1078
rA a comft
1! fir, ASSUMED BEARING
I 1 '
I
I
I
j 33' 405.00'
I
900 _ S8704814011E 900 1201 2401 3 0'
438.00'
I =
I ~
I 0
4
c f '~I 3.25 acres including right-of-way °o.
c 3. 00 acres excluding right-of-way 'N SW-SW
M
0) i N APPROVAL OF THIS MINOR SUBDIVISION
U DOES NOT MEAN APPROVAL FOR
- I w p I BUILDING SITE OR SEPTIC SYSTEM.
CI-
f0 I N Z I REFER TO H62.20.
I _
I ~ ~ QI
r- I
I
can N I 405.001
Z 900_ N87°48'40"W 9 APPROVES
a~ I 438.00' N p
c I _ wl
= I NOV 17 1978
En I o X 4 F-I
I~0 w 3 Q I ST. C. O+X L,.:U,, I Y
C 3.27 acres including right-of-way M JI COMP2EHENSIVE PARKS PLANNING
AND ZONING COMMITTEE
c I lO ; 3.03 acres excluding right-of-way ZI
M M M
= I ~I
I
s?
4,. 6' LEGEND
E
0
I ~~~`~o N87°21'W (990 32'd COUNTY SECTION CORNER MONUMENT,
0 I 33 405.01' FOUND
I 438.01' • EXISTING 1" IRON PIPE
UNPLAT_T_ED LAND
•W corne 274'--- EXISTING
ection 14 FENCE LINE
31N 1:19 1"x24" IRON PIPE, WEIGHING
O 1.68#/LINEAL FOOT, SET.
UN PLATTED L_A__ND
Vol. 516, Page 340
Doc. #324316
Volume 3 Page 746
THIS SPACE RESERVED FOR RECORDING DATA
DOCUMENT No. STATE BAR OF WISCONSIN FORM 1-1982
WARRANTY DEED
1 RE-GISf RS OFFICE
wa d E` Ge""~....._.rmain ST. CROIX CO., WIS.
This Deed, made between Ed r 16th
Ric d for Record this
_and -Ana Mari _e_Germai_ni-fe-
Grantor, day of July A.D. 19$5 300
and Ri_chaxd. lice.r-5Qn and Miry-_.D... G .'-.kzrs-on_, ? : p 17
h..usbalid. a_nd..wi.fe_,- as._.j.Qint...tenants.,----
- - - - -•-c.... Wir1a N Oi~t
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration-
J
RETURN TO
t..... s.Q......------
conve•s to Grantee the following described real estate in
County, State of Wisconsin:
Lot 3, Certified Survey Map filed December 8, 1978, in Volume 3, Certified Survey Maps, Page 746, TaxParcelNo------------------------------------
asDocument No. 353786, being located in theSw4 of SW;)
Southwest quarter of the Southwest (31), North,
Section Fourteen (14 Vest, subject to recorded easements,
Range Nineteen (19)
reservations, and rights of way.
This Warranty Deed is given in satisfaction of that Land Contract
between Grantor and Grantee dated July 16, 1980, in
28, 1980, in the St. Croix County Register of Deeds office,
July as Document No. 365387, and.subsequent
Volume 614 of Records on Page 532, ust 23,
Land Contract amending certain terms and conand1Oeco~dedhor.LAand ug Contract
dated July 16, 1980, dated August 23, 1983, i Volume 671 of
1983, in the St. Croix County Register of Deeds office,
Records on Page 394, as Document No. 387195. ^
This ....zs...not homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
and grantors title - g e
warrants that the title i° good, indefeasible in fee simple and tree and clear of encumbrances exet:pt
and will warrant and defend the same. 19 g 5
2 7th - day of June...
Dated this /
/r L FL._~EQ<~ \ (SEAL)
Ann Marie Germain
Edward E. Germain ~ -
(SEAL1
-(SEAL)
ACKNOWLEDGMENT
AUTHENTICATION
' STATE OF WISCONSIN `
Si-nature(s) o.f..Fdward...E.•._. .ermain.. ~ Ss.
and Ann Marie Germain County r.t
- -
- - -
authenticated this day of 19 _8_1) Personally came before 'tie this -day -
13 the above Par. d
• y~ -
- .
Cherrill Hirst
TITLE. N1F-NTB•EIZ51ilL!pCKOP~,'1cr6NS`Eti
GIiERRIIL HSRSi . ca
y Public
a O t a r NovnY PubuD: - State OL _ t n• ~,-c ttcd i r e
uthonotri zed by ?06.06, Wis. Stat,.L. ~ cGlres to ' 76 he the per'on -
au ; Da7l
fore,oinL, instrument and acknoaledgm the une.
T4IS ; J,TR',;S'ENT WAS CR? FT: BY
DOAR, DRILL F; SKMr, S. C.
Now R1Cnmond, `otar- PIhlic f- not
..i-~ion is pc~rman,,. -
1
(Si,•r,ntIrr, may he authentie•ate,i or acl.m,v.IcS,~•d. E/,Ith (•nm data: ~
are not n,.o• -ary.)
r.i 1..,.I ..v •h..:r ,gnat re
-r'+„n3 s.xnlnR in ar; PAPA°'•:% `h'•;:.1 b~ •
srAre RAR OF w17;C0N1IN Stock No. 130Q1
F() utt4 N. 1 -13,42
H G Mau e• Gx^a~`t ~ -
ErdRItIA , o t11~'•'1#
AS BUILT SANITARY SYSTEM REPORT
TTN-F&W
OWNER _ TOWNSHIP r- SEC./
ADDRESS,6 ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requireinenLs of 1-163
W. EVERYTHING WITHIN 100 OF SYS'1 E14 leo
S BO -
I di a or, thl A row I
SCALE : I I I
BENCHMARK: (Permanent reference Point) Des °i~ 'Elm~
Elevation of vertical reference point: Slope at site: m
SEPTIC TANK: Manufacturer: - Liquid Capacity: fi~ l
Number of rings on cover Tan manhole cover elevation: 12 _
Tank Inlet Elevation: X4;9 Z Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set or a cycle gallons; tots capacity of-
distribution lines gallon: size o pump head;
gallon per minute horsepower ran name of pump
and model number ;
Type of warning device
HOLDING TANK: -Manufacturer Number of gallons
Elevation of manhole cover
Type of warning device
SEEPAGE PIT SIZE: Number o pits feet diameter
feet liquid dept seepage pit in epe-elevation
bottom of seepage pit elevation feet.
SEEPAGE BED SIZE: number of lines wi th)X_lengtl tile depth ,
SEEPAGE TRENCH: width length
PERCOLATION RATE AREA REQUIRED/,/(-- AREA AS BUILT
_T
i
INSPECTOR
DATED /o PLUMBER ON JOB di,j ),ems
LICENSE NUMBER
i
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P_0. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
State Plan I.D. Number:
CX~ CONVENTIONAL ❑ ALTERNATIVE
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (1l assigned)
MILES HOME MILES 116ME
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Richand Gitk.enzon RR# 1, Somendet, wI /D -1.9_p_? - / 1,T0
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.:
SW SW, Section 14, Lot 3, T31N-R19W, Town o4 Somenset
Name of Plumber: 7__7RSW No.: County Sanitary Permit Number:
Cat Poweu 1563 St. Cnoix 43682
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: 17TANK INLET ELEV.: TANK OUTLET ELEV.: JWA NING LABEL )CKIbIQ CO ER
A / / / PR VI PRO EO
3 03. A
. to ES LINO YES LINO
BEDDING: VENT A.: VENT MATL HIGH WATER TIMBER OF ROAD: P RTV WELL: BUILDING: VENT TO FRESH
ALARM FEET FROM , / ~i Al. IT
❑YES NO ❑ Y NO NEAREST t✓ I
DOSING CH ER:
MANUFACTURE BEDDING. LIQUID CAPACITY PUMP MODE PAN 81ER 1 WARN I NG LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES LINO ❑YES LINO ❑YES LINO
GALLONS PER CYCLE: PUMP AND CON OPERA IoNA MBER OF PROPERTY WELL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN rEIET FROM LINE AIR wLEr
PUMP ON AND OFF) Y TRO NO AREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDT (((~~t LENGTH INOOF DISTR. PIPE SPACING. COVER INSIUE CI A. =PITS LIQUID
BED/TRENCH THE N-C H ES / MATERIAL PIT DEPTH
DIMENSIONS (y"
GRAVEL DEPTH FILL DEPTH UIS H. PIPF DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING VENT H
BELOW PIPE ABOV O R ELEV. INLET ELEV. END. I I PIPES. FEET FROM a AI Et- I
NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
❑ meets the criteria for medium sand. TIONS MEASURED.
YES LINO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
❑YES LINO ❑YES LINO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED.
CENTER EDGES.
❑YES LINO ❑YES LINO ❑YES LINO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH. NO. OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER:
BED/TRENCH TRENCHES.
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEV_ ELEV. DIA. ELEV.. PIPES. OI A.:
.
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES NO ❑YES LINO
COMMENTS' PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LIN
0_7 ❑ YES 1:1 NO ❑ YES El NO NEAREST
TO r Z 9 9I
l a,w 1o~ 1r.5
.~3 ~r II .S,
d V. SZ
Sketch System on Ret ' in ounty file for audit.
Reverse Side. Z.- '7
SIGNATURE s~ TITLE.
DILHR SBD 6710 (R. 01/82)
wgconson APPLICATION FOR SANITARY PERMIT
C' L H C COUNTY
i~ oEVRRimenTOC (PLB 67) UNIFORM SANITARY PERMIT #
InOUSTRV. LRBOR & HUrrW:kn RELRTIOns
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/zx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PR ERTY OWNER MAI ING. ADDRESS
11 L7 i,
PR PE LOCATION CITY:
114 1/4, S , N, R E (or) To TOWN OF7
LOT NUMBER BLOCK N11MBER JSUBDIVISION' NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
-
TYPE OF BUILDING OR USE SERVED -.'Oeo C77 -*'6-00
rj~ 1 or 2 Family Number of Bedrooms: Public (Specify):
THIS PERMIT IS FOR A:
2) New System ❑ Tank Replacement ❑ Repair
FA Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
~-q Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
EA System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued
❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total *of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity Z4 0a
Lift Pump Tank/Siphon Chamber
Holding Tank capacity ?
Manufacturer: F S
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total *of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the pri to sewage system shown on the attached plans.
Na/p7of Plumber Pint): I Sign u : MP/MPRSW No.: Phone Number-
('L a ( )
Plumb is Address: Na of Designer: /
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: [Fee: Date:
Disapproved
/~3 ,w, ~ /~j~ _ ❑ Owner Given Initial
/~~'f Approved Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
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EH •J15 Rev. 9/78
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
' y WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
LOCATION:S_/4,~W'1/4, Section_ZY,T3Z N,RZ?1115(or)C~2Township or Municipality
Lot No.- Block No. County
Subdivision ame+
Owner's/Buyers Name: o .`N
Mailing Address: BD )I2 All
TYPE OF OCCUPANCY: Residence No. of Bedrooms -3 COMMERCIAL I i Lf g
EFFLUENT DISPOSAL SYSTEM: NEW~REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS ,S=0a6. PERCOLATION TESTS r?
SOIL MAP SHEET /0 NAME OF SOIL MAP UNIT 6048 6-0r//A'f'1 1a,4 MX A;5we-
PERCOLATION TESTS S/oAl
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTE INTERVAL MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P- / a e ~~re y
Wo 3 (0 (0 IS'-
P_ Sim Ap"e y AID 3 4 07 vgp is P-_3
P-
P-
P-
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK
OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
sss
B- " 4 - st J;e-kc
B- 6-~ Q ? 6 L o "LS 6t°.t
B- 6., Alay e. O" S Q us
B- >246 " 6 « ]z e)j It S
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy P~ BDOiOl Indicate scale or distances
Give horizontal and vertical referenc points. Indicate slope. / / Its P/4v w
/t[0 JQ,B~ - ~`a oer _ ,f ,vI/ led 5-7~4e , 1e
B3 - Fl, 64
All
G'
n A-/fenws~,~e ,9rr,9 c1 y r'l
~a o x r'o o p o ~3
/ P*,+ -y Ar Arm
4 ao xsr~
O Q b'oo'
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feoo
x rc )cx x *x vt x
\ Ct9r t1- SL& 1'/T3 / Al / cJ :c
I, the undersigend, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods
specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my
knowledge and belief. m
Name (print) s Certitication No. S`S T 9
c
Address !/2, o S Cj~
.Name of installer if known
Copy A -Local Authority CST Signat
J
I
ST. CROIX COUNTY ZONING..OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certif that I have inspected the septic tank presently
serving the residence located at:
Siva 1/9, ,Sly! 1/4, Sec., TLN, RW, Town of
Upon inspection, I certify that I have found the
tank and baffles to be in good condition, and it appears to be
functioning properly.
Last time serviced
i
Did flow back occur from absorption system? Yes No_,2!L(1f no, skip
next line)
Approximate volume or length of time: gallons minutes
Capacity:
Construction: Prefab Concrete-Steel Other
~>~~~s
Manufacurer (if known):
Age of n ( i f ry'own)
(Signa ure (Name) lease Print
(Title) (License Number)
(Date)
Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes)
or Licensed Disposer (NR 113 Wisconsin Administrative Code)
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Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
my knowledge will
condition, I certify that the tank 2MMP/MPRS
conform to the requirements of ILCode (except for
inspection op nine over outlet bafflNam Signatur 75
5/88