HomeMy WebLinkAbout010-1016-90-300
NDEPAr4TMtNT 6US RY OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, , C DIVISION
LABOR AN P.O. BOX 76
HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707
(H63.090) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/CITY: LOT O.:BLK-NO.: SUBDIVISION NAME:
Std 1431,71/4 7 /T30 N/R16*(or) W Emerald n/a n/a
COUNTY: OWN-ffRPSIFADMAX NAME: MAILING ADDRESS:
St. Croix R. noornink & H. Hielkema 1841 220th. St., Bal win, Wi. 54002
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence 3 n/a [RQew ❑Replace I 5-9-92 5-11-92
RATING: S= Site suitable for system U= Site unsuitable for system 'no 1) 1 C
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING T : RECOMMENDED SYSTEM:(optional)
❑S [A I ~S ❑U ❑S E U ❑SEU ❑S ®U mound
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: n/a Floodplain, indicate Floodplain elevation: n/a
decimal' PROFILE DESCRIPTIONS page 30 AmC2
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTHS ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 1 4.16 97.50 none 2.66 1.00, 10yr4/3, 1.1 .83, 10yr4/4 sil., .83,-
7.5 4/4 s.l. 1.50 7.5 4/4, not. s.l.
B_ 2 4.50 97.50 3.00 2.50 •67, 10yr4/3, 1., .58, 10yr4/4, sil., 1.25,-
7.5)m414. mot., s.l. &
B- 5yr4/4, mot. sil.
B- 3 3.75 96.35 3.17 2.50 •83, 10yr4/3, 1., .67, 10yr4/4, sil 1.00,-
7.5 4 4 s.l. 1.25 7.5 4/4 mot s.l.
B_ 5yr4/4, mot. sil.
B-
PERCOLATION TESTS
TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P_ 1 24 none ?0 1-; 1<_ 1-- 2
P- 2 24 none 30 11-1 11 / 8 UP u
P_ 3 24 none 30 1_ 1 -
P-_
P_
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION 98.50
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I, the undersigned, hereby certify that t (&-I ests reported on th, o r ere made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data r r d and th cane pf the re correct to the best of my knowledge and belief.
NAME (print): To ~ TESTS WERE COMPLETED ON:
Cary L. Steel c cs~ 5-11-92
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
1554 200th. Ave., New c t clad, 4T 4017 2298 7CST SI A RE:
E Z
f
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
D I LH R-SB D-6395 (R. 02/82) - OVER -
L
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395
To be a complete and accurate soil test, your report must include;
1. Comp' legal description;
2. Tl- e on must clearly indicate whether this is a rf. idence or commercial project;
3. M." Y' M umber of bedrooms or commercial use J;
4, Is tl ' or replacement system;
b. Ccrrv suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHE STEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan;
7. MA :E A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A
r, *e Fheet may be used if desired;
8. N` su; your benchmark and vertical elevation reference point are clearly shown, and are permanent;
9. Cc I appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp-
tic . i
10. If f' i lsuch as flood elevation) does not apply, place N_A. in the appropriate box;
11. Sign t.. + d place your cur address and your certification number;
12. Make c~=pies and distrit as required. ALL SOIL TESTS MUST BE FILED VVITH THE
LOCAL A,_' ? HORITY WITHIN 30 MAYS OF COMPLETION.
ABBREVIATIONS 4 CERTIFIED SOIL TESTERS
parates and Textures Other Symbols
Stone (over 10") BR - Bedrock
cob - Cobble (3 - 10") SS Sandstone
gr - Gravel (under 3") LS Limestone
's - Sand HGW - High Groundwater
cs - Coa- , Perc - Percolation Bate
coed s - Me f iu W to el l
fs- Fir. Bldg - Building
Is - Loar,% 1 > - Greater Than
'sl Sandy oam < Less Than
~'I - Loam Bn - Brown
.sil - Silt Loam BI - Black
si - Silt Gy Gray
cl - Clay Loam Y - Yellow
scl - Sandy Clay Loam R - P--4
sicl - Silty Clay Loarn mot - M._.~
sc - Sandy Clay wl witia
sic - Silty Clay fff- few, fin; t
Ic - Clay cc con~_._
PI - Peat rnm - Many,
m - Muck d - distinct
p - promim
HWL - High rel,
Six general soil textures st, f ~r
for liquid waste disposal BM - Bell(:
VRP Vert nce Point
TO THE OWNER:
This soil test report is the first step in securing a sanitary permit. The county or the Depart^^^rnt may request
verification of this soil test in the field prior to permit. issuance. A complete set of plz=ns nor the private
sewage system and a permit application must be submitted to file appropriate local i ~ r n order to
obtain a pem5it. The sanitary permit must. be obtained and posted prior to the start of an}, -instruction.
QEPARtMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 539069
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/M42N§tDMITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
Std 1491,11/4 7 /j30 N/R16*(,,) W Fanerald in/a n/a n/a
COUNTY: OWNER'S MX25M NAME: MAILING ADDRESS:
St. Croix R. Poornink & H. Hielkema 841 220th. St., Baldwin, Ili. 54002
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: 1PERCOLATION TESTS:
Residence 3 n/a ItNew ❑Replace 5-9-92
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: iN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
❑ S Eis ❑u ^ s ®u ❑ s ~u I0 s ®u mound
If Percolation Tests are NOT required T ESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5) (b), indicate: n/a Floodplain, indicate Floodplain elevation: n/a
decimal' PROFILE DESCRIPTIONS page 30 AmC2
TH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
BORING TOTAL TON
NUMBER DEPTHS ELEVBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-1 4.16 97ne 2,66 1.00, 10y
r4/3, 1., .83, 10yr4/4 sil., .837.5 r4/4 s.l. 1.50 7.5 r4/4, mot. s.l.
B_ 2 4.50 97.00 2.50 .67, 10yr4/3, 1., .58, 10yr4/4, sil., 1.25,-
r4 4 not., s.l. &
B 5yr4/4, mot. sil.
B_ 3 3.75 96.35 3.17 2.50 .83, 10yr4/3, 1., .67, 10yr4/4, sil., 1.00,-
B- 4 s.l. 1.25 7.5 r4 4 mot s.l.
B 5yr4/4, mot. sil.
IB- I
PERCOLATIOTESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 P 100 2 PERIOD PER INCH
P-
P
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION 98.50
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I, the undersigned, 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 the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON:
Gary L. Steel
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
1554 200th. Ave., New Richmond, Wi.54017 2298 1715A,46-6200
CST SIG AJ RE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
l1ll_HR Sf's06395 (11 02/$2) - OVER -
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS
SUBDIVISION / CSM# LOT #
SECTION T_ 3~O N-R_IZ
Town of ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
815-,k44'W O )
f/AUSC Gd~E~
INDIC ORAL RO
Provide setback and elevation information on rev of s;° PQrm•~p
Provide 2 dimensions to center of septic tank
ta(
i
BENCHMARK'
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity:
Setback from: Well House ~-Other
Pump: Manufacturer Model#Size /
Float seperation_ Gallons/cycle: ~G
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length Number of trenches
Distance & Direction to nearest prop. line: 2A -.-l c-2-21
Setback from: well:- House Other
ELEVATIONS
Building Sewer ST Inlet, g7 7 ST outlet
PC inlet 2Zf_S~ PC bottom Pump Off
Header/Manifold 1,25j), 7Z Bottom of system / J.~2
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:5
INSPECTOR:,
3/93:jt
Wisconsin Qepartment of Industry, PRIVATE SEWAGE SYSTEM County:
Lpbor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION
PBODICK,S Name;- KEVIN El City El Village 1 l Town of: State Pan o.:
CST BM Elev.: Insp. BM Elev.: BM Description: X Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic (~J ~'orv Benchmark 102.9 2.1
Dosing $ '
Aeration Bldg. Sewer
Holding St/ Ht Inlet S.S3 ~I ?
TANK SETBACK INFORMATION St/Ht Outlet S•G9 97.2/
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP / SIPHON INFORMATION Final Grade
Manufacturer Demand 'n y:(,y 93.2 6
Model Number GPM
TDH Lift Friction System TDH Ft
oss Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Di;. 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: Emera[[~~ld.7.30.16W, SW, SW, Lot 4, 160th Avenue
'DO d r S tAA 0~ zoOM~ C1 too
T~sp• g-30.9 ~ fio~w~. ~ W /
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
~ _ e sm
SANITARY PERMIT APPLICATION COUNTY
~'■~■'■■i In accord with ILHR 83.05, Wis. Adm. Code
STATES ARY MIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than A46 09
8% x 11 inches in size. ❑ Check if revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROP OWNE PROPERTY LOCATION
' i '/4 '/4, S T , N, R (or
PR PERTY OWNER'S MAILINSa DRESS LOT # BLOCK #
f' 1
C STAT IZIPCODE PHONE NUMBER SUBDIVISION AME OR UMBER
II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLA GE: NEAREST R
TOWN OF: a4b~d
EL TAX NUMBER( S)
❑ Public Z 1 or 2 Fam. Dwelling-#of bedrooms3 PARC
III. BUILDINGUSE: (If building type is public, check all that apply) 610 /01 '1o %(n 1 ❑ Apt/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 in line A. Check line B if applicable)
A) 1. 0 New 2. ❑ Replacement 3. ❑ Replacement of 4.E] Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit # Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ® Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 12. 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 Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumb 's Name (P inY • :71umer'sig =:(N :/mpso) MP/MPRSW No.: Business Phone Number:
9
PI mber' Address ( treet, City, State, Zip Code):
_ I
IX. COUNTY/DE ARTMENT USE ONLY
❑ Disapproved S itary Permit Fee (Includes Groundwater ate Issued Issuing Ag ture o Sta )
Approved F-1 Owner Given Initial 7 Surcharge Fee) 60
Adverse Determination
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 "uildings 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.
Vlll. 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.11188)
Wisconsin Department of Industry. PRIVATE SEWAGE SYSTEM satety:and Buildings Division
Labor•and Human Relations Bureau of Building Water Systems
REVIEW APPLICATION
Hayward Office La Crosse Office Madison Office Shawano Office i ` Waukesha Office
209 W 1 st Street 2226 Rose Street 201 E. Washington Ave. 1053A E. Green Say Street 401 Pilot Court, Suite C
Rt 8, Box 8072 LaCrosse, WI 54603 P.O. Box 7969 P.O. Box 434 Waukesha, WI 53188
Hayward, WI 54843 Phone (608) 785-9334. Madison, WI 53707 Shawano, WI 54166 Phone (414) 548-8606
Phone (715) 634-4804 Fax(608)785-9330 Phone (608) 267-5119 Phone (715) 524-3626 Fax (414) 548-8614
Fax (715) 634-5150 Fax (608) 267-0592 Fax (715) 524-3633
is
INSTRUCTIONS: To save time, schedule your review with one of the offices listed above prior to submi • 4l appl( a it th
fice
form together with fees and plans/information. Your submittal must be received at least one working day priorto the appoimAd
where your review was scheduled. Please call any of the listed offices if you need help filling out the form or have question on what ltttormation to
submit. PLEASE PRINT VERY CLEARLY. A sample of a completed form is on the reverse side for your reference. n is
7.
1. APPOINTMENT INFORMATION -if you have scheduled an appointment, fill in the information requested below to save time:
Appointment Date Revi er Name Plan Identification Number
9V
2. PROJECT INFORMATION If this review is a revision or extension to your existing
plan identification number, provide that number here:
Project N me
[]City n Village ® Town Of: County
Prol Ct Location
!t or
GOVT. LOT 1!41/4,S T N ,R
3. APPLICATION FOR 4. FEE COMPUTATIONS FEE SUBMITTED
System Type (check one): System Type I (include new and existing tanks)
Up To 1,500 gallon septic tank $110.00
A At-Grade 1,501 - 2,500 gallon septic tank $120.00
H Holding Tank 2,501- 5,000 gallon septic tank $160.00 .
M ® Mound 5,001 9,000 gallon septic tank $ 200.00
N n Non-Pressurized In-Ground(Conventional) 9,001-15,000 gallon septic tank $300.00
P Pressurized in-Ground over 15,000 gallon septic tank $500.00
O Other: Up To 1,000 gallon dose chamber $ 70.00 70
1,001 - 2,000gallondosechamber $ 80.00
Building Type (check one): 2,001 - 4,000 gallon dose chamber $100.00
4,001 - 8,000 gallon dose chamber $120.00
D ~ Dwelling, 1 or 2 Family 8,001 -12,000 gallon dose chamber $140.00
P C] Public Building Over 12,000 gallon dose chamber $160.00
S E] State-Owned Building Up To 5,000 gallon holding tank $ 60.00
5,001-10,000 gallon holding tank $100.00
Code Derived Daily Flow gRd Over 10,000 gallon holding tank $150.00
Check If Replacing Existing System Experimental System (additional onetime fee) $ 300.00
Revisions To Approved Plan 2 $ 60.00
Petition For Variance: Setback ~ $100.00
O1~1"~ ED $225.00
Petition For Variance Plumbing $225.00
JWn 1. fi..199§ $ 75.00
Groundwater Monitoring Ground a t arp opnitoring - Pe/r Site $ 60 00 .
Site Evaluation in Lieu of
Groundwater Monitoring Site Evaluation in Lieu of Groundwater Monitoring' $ 60.00
av
Subtotal: /¢1
Priority Review: Enter same amount as Subtotal: ':.L4-
MAKE ALL CHECKS PAYABLE TO: SAFETY AND BUILDINGS DIVISION Total. Fee: 5. SUBMITTING PARTY INFORMATION
Telephone No. (include area code & extension) Comp ny Na Cont ct Pers n
( )
No. & S eet d ess Or P.O. Box City, T wn or Vil ge, State, Zip ode
S Z :2
1 Aerobic or prepackaged treatment system fees are calculated based on equivalent size septic tanks and dose chambers.
2 Revision fees are not applicable to temporary holding tanks or extensions to existing approvals.
NOTE: Fees are pursuant to Wis. Adm. Code, Chapter ILHR 2, and are subject to change annually.
SBD-6748 (R. 07/93) OVER, P
f
WORKSHEET - MOUND SYSTEM DESIGN
S94-40331
PROBLEM:
Design a mound system for a
The site characteristics are:
Depth to groundwater or bedrocks in.
Landslope %
Percolation rate _ min./in.
Distance from dose chamber to distribution system ft.
Elevation difference between Dump and distribution systern _ ft.
Step 1. WASTEWATER LOAD 16-V3,IX 3 = c~~~ gal.'
Step 2. SIZE THE ABSOQPTION AREA
A) Area required sq. ft.
B) Bed or trench length (B) ft.
C) Bed or trench width (A) ft.
-D) Trench spacing (C) _
r",~Wastewater load .24 cal ft2 /day B = ft.
tr`enc "ms
Step 3. MOUND HEIGHT
A) Fill depth (D) _ i ft.
B) Fill depth (E) = D + slope (Ay" p) ft.
C) Bed or trench depth (F) _ ,t.
D) Cap and topsoil depth (G) ft.
E) Cap and topsoil depth'(H) _ Zs- ft.
ti i P,n
f 10._
Step 4. MOUND LENGTH 894 4 0 3 3
A) End slope (K) _ CDR/ + F + IT 3 ft.
6) Total mound length (L) = B + 2(K) _ ~~•L•ft.
~o,3~;
~bJ,sf7
Step 5. MOUND WIDTH j '
Al) Upslope correction factor
A2) Upslope width (J) (D + F + G)(3)(factor) ft.
81) Downslope correction factor - /p
82) Downslope width (I) _ (E + F + G)(3)(factor) = lQ,,,,_ ft.
9, 93.?
Cl) Total mound width (W) for bed - J + A + I 2 Y Z ft.
y8f&~/Qz
C2) Total mound width (W) for trenches;
J + + (no. trenches -1)(c) + A + I/= ft.
Step 6. BASAL AREA
A) Infiltrative capacity of natural soil = gal./ft2/day
B) Basal area required = wastewater flow
natural soil infiltrative-c pacity - sq. ft.
Z08 'leg .2,,V C1) Basal area available for bed for sloping sites -
B x (A + I) sq. ft.
/d) = JDao, o
C2) Bas are~y avail le for trench for sloping sites =
B W IJ + A sq. ft.
C3) Basal area available for trench or bed for level
tes B x W sq. ft.
Sit;
Liconsc h:u:
Date: a- -
Pa. of
Step 7. DISTRIBUTION SYSTEM
7A) SIZE DISTRIBUTION SYSTEM S94-40331
1) Hole size = in.
2) Hole spacing in.••n
3) Distribution pipe length =ri,y T
4) Distribution pipe diameter = in.
5) Spacing between distribution pipes in.
6) Distance from sidewall to distribution pipe _ in.
18) DISTRIBUTION PIPE DISCHARGE RATE ~fL ft.
=
1) Number of holes per pipe _
2) Flow per pipe = ,~C GPM,
7C) SIZE MANIFOLD
1) Manifold is central/ end
2) Manifold length ft.
3) Number of distribution lines =
4) Manifold diameter =
in.
1D) SIZE FORCE MAIN
1) Minimum dosing rate = 3 7,5!'~GPM
2) Force main diameter = 2 in.
3) Friction loss = ft.
goo ~ is ~ s`~ y l
7E) TOTAL DYNAMIC HEAD
1) Vertical lift = _So ft.
2) Friction loss, ft.
3) System head 2.5 ft. ft.
4) -Total dynamic head ft.
Ucer:
Date _..11
S94-40331
7F) PUMP SELECTION
1) Pump selected will discharge, GPM at /,S ft.
total dynamic head.
2) Pump model and manufacturer
7G) DOSE VOLUME
1) 10 time void/ Vol of di tribution lines 11,7 gal./cycle
2) Daily wasteyvate~olu 4 doses/24 hrs. gal./cycle
3) Minimum Ise volume gal./cycle
7
s y~ /,Dra..~ ttc?~- //,j o iazcc ata~.~/13 s?G f
7H) DOSE CHAMBER
1) Minimum capacity required ~ gal .
Sign:
Licunso
Date
~c~ of xr
/ c ~oo,o, S94-40331
/r
,~~Va L),-JI
0
All
41
~.~d s 2b IWA/
k ~ .u.
ID
t~F lS S~SY
S
77
. Page~_u~ ire
Straw, Marsh Hay, or S 9 4 40 r~
Synthetic Covering Distribution Pipe .
Medium Sand H G
s
Topsoil F
-3 E D
3
3 $ Force Main Plowed Layer
Slope
Bed of )j"-2)S"
Aggregate
Cross Section of a Mound System Using D~Ft.
A Bed For The Absorption Area E Ft.
F ~ A.4 Ft .
A -Ft. G Ft.
H f Ft.
Signed: K
C~
License JC
Date:
Alternate Position of
z~ F
Force Main
L I
I
observation Pipe
J B Imo-- K
IP I- - - _ _
-
A Forc Main
I
W -
Distribution Pipe IBed of 12"-2~"
Aggregate
observation
I .Pipe Permanent Marker
.Plan View of Mound Using a Bed'For the Absorption Area
• . r
. 5
p4ge z at .Lr1
S94-40331.
Perforated Pip. Detail
t
n
nd View
Perfaohd
End Cop ' PVC Pipe
ao~d'tio Holes Located On Bottom,
J Are Equally Spaced
60
Q I
I
PVC Force Mairy
Q PVC
Manifold Pipe
Alternate Position Of
DisfriD•ition Force Main
Pipe
Lost Mole Should Be
Neat To End Cop
End Cop Distribution Pipe Layout P c ( Ft.
R
S'
X -i/(?_ Inches
1 Y Z2 Inches
Signed: Hole Diameter Inch
- Lateral " Inch(es)
License Number: Manifold Inches
S
Date: Force Main "Inches
of- holes/pi pe
Invert Elevation of Laterals 92o ,Ft.
ia. Rov
xt ~ B `;3iQNS
'DEPT. Of INDUSTRY, LAB r,.,
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S-94-40331
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PAGE OF
PUMP CHAMBER CROSS SECTIOIJ AND SPECIFICATIONS
VENT CAP 4 p 403c% 4'.,4 VENT PIPE WEATHER PROOF APPROVED LOCKING-'
25' FRAM ODOR JUWCTION BOX MAIJHOLE COVER
,
WtUDOW OR FRESH 12"MIU.
AIR INTAKE
GRADE I , y°M(AJ.
I
18' MIIJ.
CONDUIT--
11~
IAJLET PROVIDE 1
~~,L~r~~,~z~• '~IRTIGHT SEAL
APPROVED JOINT ' A t~f ; ; I III APPROVED JOWTS
wl7~, PIPE W/./4."PIP£
EXTENDIU(p 3' " I I I ALARM EXTEIJDIAI(. 3
O►JTO SOLID SOIL B r I I I OWTO SOLID SOIL
~'atC1'+~S I I
R HUTS, , ( I GN
too
cam, ors
u ® j I
ukv
t' PUMP OFF
D
SEE C
CONCRETE 5LOC4t
RISER EXIT PERMITTED ONLY IF `TAWK MAULWACTURE.R HAS SUCH APPROVAL
SPECIFI•CAT IOUS
:.PtlC AND
)SE TAM MANUFACTURER: IJUMBER OF DOSES: PER DAy
TANK' SIZE: /GALLOWS DOSE VOLUME: GALLOWS
ALARM MANUFACTURER: - - I• /Fnr~re • SS~Pr« . CAPACITIES: A+~ INCHES OR GALLOUS
MODEL WUMBER: B=- s~_IMCHES OR GALLOUS
SWITCH TYPE: C~~ IIJCHES OR° GALLONS
PUMP MAMUFACTURER: ~i 1 D-__,L„IAIGHES OR .1aQ_ GALLOWS
MODEL NUMBER: MOTE. PUMP AND ALARM ARE TO BE
DW11CH TYPE: INSTALLED ON SEPARATE CIRCUITS
PUMP DISCHARGE. RATE GPM
0 PM M t At .
VE.RTICAL•DI►FEKENCE bETWEEN PUMP OFF ARID DISTRIBUTION PIPE.. FEET
+ MINIMUM NETWORK SUPPLY PRESSURE 2,5 FEET
+ . l•5 FEET OF FORCE MAIM X FY100FLFRICTIOU FAC70R.. FEET 3,~5
'~DS
'TOTAL Ob)JAMIC. HEAD = =fM - FEET t3 /
Q
IIJTERtJAL. DIME SIONS OF TAIJK: LENGTH ;WIDTH -;LIQUID DEPTH
gIGIJED: LICCUSE IJUMBER:
Y y.~;'tr
Performance u u
Curves Pumps
S9.4-4033-1
METERS FEET
90
MODEL 3885
25 80 SIZE 3/4" Solids
WE15H
70
= 20 WE10H
-Z I
- W E07H
15 50
WE05H
40 ::p
10 30 WE03M
20 WE03L
5
10
0 0
0 10 20 30 40 50 60 70 80 90 100 110 120 GPM
t i i
0 10 20 30 m'/h
CAPACITY
MGOULDS PUMPS, INC.
S8*CA FALLS NEW YpCM 1314B
METERS FEET
120 MODEL 3885
35 SIZE 3/4" Solids
110 WE15HH
100
30
90
25 80
70
20
60
O
50 WEOSHH
15
40
10 30
20
5
10 '
0 0
0 10 20 30 40 50 60 70 80 90 100 110 120 GPM
L ~I I I
0 10 20 30 m'/h
CAPACITY
01985 Goulds Pumps. Inc. Effective July, 1985
C3885
DEPA.QTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
I,AE30R AND
PERCOLATION TESTS (115) MADISOP.O. BOX N WI 7969
W MAN RELATIONS
(H63.090) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/ ITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
SW 1/4S1.11/4 7 /T30 N/R16)f (or) W Emeral r / ,n/21
COUNTY: OWNER'S M NAME: MAILING ADDRESS:
St. Croix R. Doornin;.c & 11. Hielkema 841 220th. St., Baldwin, Wi. 54002
ISE DATES OBSERVATIONS MADE
NO. BEDRMS.: t,UMN1EN TA L D[5CR PTIO I PR Z P - DNS: f I TESTS:
KNResidence 3 n/a UNew ❑Replace L 5-9-92 I -5-11-92
RATING: S- Site suitable for system U= Site unsuitable for system
CQNV--ENTM A MOUND: IN-GROUND~fi U §Y3" M- N-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
❑S®U IDS U I ❑S®U mound
❑S LAS❑U ~
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: n /a Floodplain, indicate Floodplain elevation: n/a
decimal' PROFILE DESCRIPTIONS page 30 AmC2
IORING TOTAL DEPTH T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
VUMBER DEPTH= ELEVATION OBSERVED EST. HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
3- 1 4.16 97.50 none 2.66 1.00, 10yr4/3, 1., .83, 10yr4/4 sil., .83,-
7.5 r4/4 s.l. 1.50 7.5 r4/4, mot. s.l.
2 4.50 97.50 3.00 2.50 •67, 10yr4/3, 1., .58, 10yr4/4, sil., 1.25,-
13 [ < < 4 m s.1. &
5yr4/4, mot. sil.
B-
3 3.75 96.35 3.17 2.50 •83, 10yr4/3, 1., .67, 10yr4/4, sil., 1.00,-
13 7.5 r4 4 s.l. 1.25 7.5 rzt 4 mot s.1.
B 5yr4/4, mot. sil.
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATER INCH ES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. t P RI D2 PER1003
P_ 1 2.4 none 30 ~112 1' 1,; 2.4
P_ 2 24 none 30 1 1J 8 J J f'
P- 3 A none 30 1~~ 1
P-
P-_
LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
)ntal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
f land slope.
98.50
SYSTEM ELEVATION_
Qd ! I
I
a f
h r ~ I l
I
!
.
the undersigned, 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 the location of the tests are correct to the best of my knowledge and belief.
JAME (print : TESTS WERE COMPLETED ON:
Gary L. Steel 5-11-92
ADDRESS CERTIFICATION NUMBER: PHONE NUMBER (optionai►:
1554 200th. Ave., New Richmond, Wi.54017 2298 715 46-6200
CSTSI A 'RE:
,
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. `
1IAR-SSD-6395 (R. 02/82) -OVER -
• O~
FILED
9 JUL 4119920
4853'74 JAMEg n'/:~`NNELL
Regi
ueedS
St c x Co., W1
CERTIFIED SURVEY MAP
HARVEY HIFIJ<EMA AND FEIUEN DOORNTW
Part of the South 1/2 of the Southwest Fractional 1/4 of Section 7, Township 3Q-North,
Range 16 West, Town of Emerald, St. Croix County, Wisconsin.
W//4 COR. SEC. 7, T30N, R 16 W,
h / P. K. NAIL FOUNOI O Indicates P X ?411 iron pipe weighing
m 1.13 lbs./lin, ft. set.
h
3 a ~_NPcA rrEO 4 4 NOS •,PPROVED
W S B5• 49' 25
1T E / 002. 6o'
( Q
J 284.83 280. 00• i,`Ul 2
340, 00•
3 I ~ 382, Co.
,
,
` 53, I S OO -17'00 "E 164.99'
cti CROIX, (~OU*T-Y
4I b N 89/Of 00.0 "E Golri-wphenslYe`Pl*nning
N too,--' Zoning and
Q 3 rL o r: 2 a LOT 3 L o r 4 Parks Comrr.:itea
_j O
Q I ^ N I , 5.J87ACRES b 4.436 ACRES N 6.062 ACRES .lot recordad
~ 234,662 SO, FT. /9 J, 25/ SO. FT. q 264, 064 S0. FT. 0 imn 30 d*dya Of
O q 4.184 ACRES 4.224 ACRES qO 5.772 ACRES EXC.ROAD. N "`lll
I~ I = 0 I q EXC. ROAD °O C, EXC. ROAD W 25/, 438 SOFT, 0` N III+tXUOVaI data
QI to/82,24/SOFT. ^ 184,01/S0,F7, o b b tt4jKNAV8k5I18~6@
v 33' 65' W I p h "Id rvow
y
JI
- jI I ~~I I o ' ° ° Q
r H/GNWAY S TBACk L/NE • I
I O = WATER COURSE °
h S 85. 49.25 "E - 9J7. 4 H
O 2_ 7480 • S L /NE SW FRAC. 1I4
O-~ 280.00' O
r3L/40.^00 • M rDao _382. Co • -
N 85' 49 O M J82.60• /T9.64.
25 "W 1182.
Z41 b
SW COR. SEC. 7, TJON, R/6W, -
NAIL FOLINDI UNPL q rrFD 4 AND N
S /14 COR, SEC. 7, r JON, R/6 W,
18ERNTSEN MON. FOUNDI
W
SCALE I" m 200'
O O 30' /00' 130'200' 300' 400' 500' 600'
W 3
k to
v ~
W Router 1 Address: ,0&114801'.44 ,
`
%
W M Hammond, WI 54015 ,'s"_
Z \SC' NS' 0%
.r
Phone No. 1-715-796-5584
y •
O S
o
~ ' LAURE E'•
W CC
r' M
ti o • Oated : May 29 , 1992 j'~
° a o V RIVER f-ALLS:•:',~
Z \ = Revised: June 29, 1992 WISC. Q.
e4O
~ J 1111111
Q " Q Laurence W. Murphy
Registered Land Surveyor
Vol. 9 Page 2498
Certified Survey Maps
St. Croix County, Wisconsin. This instrument drafted by Laurence W. Murphy
SHEET / OF 2
r
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER U 1 N f
~odlG~
MAILING ADDRESS 2 L/ 4y t,,
PROPERTY ADDRESS y. ° '
(location of septic system) ~ Please obtain from the Planning Dept.
CITY/STATE N(W /LC1h1M0#VW Vl1!S
PROPERTY LOCATION_ 1/4, 1/4, Section T_ Z N-R A6 W
TOWN OF ' t _4t / ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP S 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 yeas 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 T C r loo .
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 -11 e u v/V 60 dj'C/~ '
Location of property Z:L1/4 SW 1/4, Section' T_~d N-R~W
.Township - tler4
Hailing address_. (ale) NCO 1164 MoAol A
Address of site Saf M
Subdivision name Lot no.
Other homes on property? yes_ No
Previous owner of property &OW10k
Total size of parcel C !
Date parcel was created 2 9 TZ '
Are all corners and lot lines identifiable? eyes No
Is thin property being developed for (spec house)? Yes -4No
volume and page Number as recorded. with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARIUUITY DEED which includes a DOCUMENT NUILDER, VOLUME AND PAGP,
NUMBER & THE SEAL of THE IZEGISTLI 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 Nap
shall also be required.
PROPERTY OWNER CERTIFICATION
I(wc) certify that all statements on this form are true to the
best . of ray (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. and that I (we) presently
own the proposed site for the sewage disposal system or I we)
oUta' (
lned an easement to
run the above' described property,
for
the construction of said system, and the same tae been duly
recorded in the office of county Re ister o
No. Y g of
deeds as Document
signature of'ap~l cant Co-appl cant
Date of Signature( Date of s gnature
THIS SPACE RESEMMO FOR RE~ORDIHG DATA
0oCUMtNI tip- WARRANTY DkED
STATE BAR of WISCONSIN FORM 2--1942
• r VOL -~.OUMGE3_ REGISTE S OFFICE
500441
- Hielkema, ST. CROIXCO-,
Reuben Doornink and Harvey N• WdOx Re d
-.a..k~a.: HarveX..Helkeina JUN 8 1993
- 11:2 t PA M
at
conveys and warrants to ....)C~X.Y1_.kC,s_.1~5?d-~.Ck~...21...&~X~$~~-....-.... .
p~etsrdDssOs
.
Fexson
RETURN T
_
' County,
the following described real estate in Tax Parcel No:
state of Wiseorsin:
tb Half of Southwest Fractional Quarter (S# of
Part of the Sou Township Thirty (30) North,
. ) of Section Seven M v Wisconsin described
S Stange FracSixteen (io West, St. Croix County. filed July urvey SW as follows: Lot Four (4)o2498, Doc_ No. 4853?4p
1992 in Volume 9 . Page
*SF
EM
This $_:n4 homestead property.
7CbtK (is not)
.
ricti
gxceptioia to warranties: Easements and restons of record
. 19... .-3.
- day of (SEAL)
-4 -
Dated this
(SEAL)
.
. __g~uben..Do4~i(~ini5---_.---------
~tso --•(SEAL)
(SEAL)
- _Har ey N. Hielkema
ACHNOW LSDGMZNT
AlUT1919I9TICATION
STATE OF WISCONSIN
se
- - - - - -
St. Croix . county.
~Y of
Personall y tame before me this -
19
19 93 the above named
anthentiest~ this --------d~Y of •
Reub ])oornink-and-HareHielkema
- Hielkema,-_a k a arv
e--------
TITLE: ][EMBER STATT BAR OF WISCONSIN _ Ir.
me known to be the person r v ry
Gutho by 7~6 08, Wis Stets.) ! re instrument an cknowle
- F
_
THIS IN -MUMBNT WAS DRAFTED By
A. McCormack - ` -
Thomas
-•--------•------------•--•-•-t. 3
54002
WI
- a ent.
Baldwin Notary Public
My commission is pew
Lad or aekao S------- Both K
t ~e sntheaties # ' .
. sate- ~ a~.._
-
are Mt neEe"a
or printed below their 519"1 1n am "Deelt9 ehoaid tYDed Wisconsin Legal Blank Co-. Inc-
. of ptwoo ftsing gaing STA Milwaikee. Wisconsin
~ or ; ~1982~
WASRANTY DEED
- S2
_r
~7• z' 97-03
v~
L-1 I