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HomeMy WebLinkAbout020-1144-80-000 STC 104 t AS BUILT SANITARY SYSTEM REPORT O b •E u , ~~?sJ . M, D SUBDIVISION J CSMI PMLC 1/1 177~~ LOT i SECTION T~ 9 N-R W,' Town of S m i ST. CROIX OUNTY, WISCONSIN ~j PLAN VIEW HAW EVERYTHING YS'EM 59 I 0 I 6A, i i t M INDICATE NORTH ARROW Provide setback and elevation information on reverse of this forma Provide 2 dimensions to center of septic tank manhole-cover. NCH 4ARK: S► ~C~7r ~l/T Qi~St ~~T +C7D x .,TERNATE BM. SEPTIC TANK / POMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: ck from: Well House Other Setb Pump; Manufacturer Model# Size 7- 71 Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM W ''dth : trjf Lengt ► Number of trenches t~tJ D~stAnce & Direction to nearest prop. line: D Setb~ackfrom well: 400► House _J0 , Other i ELEVATION,S t Bti i loing Sew Br - ST Inlet. ST outlet ^ s3 ~ ► y P i let PC bottom Pump Off Header/Manifold Bottom of system Z Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: ~G 1 t~ LICENSE NUMBER: /j7 O 2 /9 INSPECTOR: /~1LN JK//LAS 3/93: it _ g 10_ Cb ST. CROIX COUNTY ZONING OFF 6E PblJ V j ~i Cri(1t a CERTIFICATION STATEMENT S 7 IQQ COL 1Ty FOR UTILIZATION OF AN EXISTING SEPT 'K ~a 7 This is to certify that I have inspected the septic tank presently serving -the -jilLDU 104.,i©'_r-7ws'0 r sidence located-- at: ~1/4, /J L 1/4, Sec. ? T2a_N, 1 W, Town of /'ttA.DSen~ Upon inspec lion, I certify; that I have !found the 11 tank and baffles, to be in good condition, and it appeaks to be y functioning properly. Last time service Did flow back, occur from absorp-, ion system? Yes X No- (i no, skip n xt line) Approximate volume or length of time: ~2eo! gallons minutes Capacity: Construction: Pr~fab Concrete AC Steel Othe Manufacurer (if known): Age of Tank (if known): ig ture) (Name) plea a Print Title) (License Num er) (Date) Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR-83 Wis. Adm. Code (except for inspection opening over outlet baffle). ' Name L145 =Signature, P MPRS 5/88 Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX -Safety and Buildings Division . (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI o.. ANDERSON, JUDY X CST BM Elev.: Insp. BM Elev.: BM,Fescription: Parcel Tax No.: JC7, 7 4 r y 00) TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Vent irito ntake ROAD Dt Inlet TANK TO P/ L WELL BLDG. A Ar Septic NA Dt Bottom Dosing NA Header/ Man. ? 3 s 9 q7 3N Aeration NA Dist. Pipe g' -V 97 i-s 9 7, Holding Bot. System 9,3 2 aG- g a PUMP/ SIPHON INFORMATION Final Grade %g p4 Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Loss ead Forcemain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length _ No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 7-~ DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER Model Number: INFORMATION Type O System: ,,,,,G,JJ lb 410 1004 N// 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 4 xx Depth Of xx Seeded/ Sodded xx Mulched Bed/Tr nchCenter Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson.17.29.19W, SW, NE, Lot 64 t/ Plan revision required? ❑ Yes ❑ No Use other side for additional information. 1/0y.. 6 SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION L'~L~7■~ In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE 1)IT PE RMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than v) (j/~/ 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. PROPERTY OWNER PROPERTY LOCATION .J Gf ~ f D C-7t s SC(~ 1/41( '/4, S T27 , N, R / E (or W PROPERTY O NER'S MAILING ADDR LOT # BLOCK # CITY, TATE ZIP CO PHONE NUMBER SUBDIVISION NAME OR CSM UMBER II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned El-VILLAGE: . d ! I E ]Public 111 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX UMBER(S) W 111. BUILDING USE: (If building type is public, check all that apply) Q 1 ❑ Apt/Condo j 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash 50 Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1.0 New 2. %Replacement 3.E] Replacement of 4.0 Reconnection of 5.0 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 9?Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill %zc~L / KJ G 17~~~n --14 ox)e, VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4, LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day sq. ft.) (Min./inch) ELEVATION szz, <M _~s S~ 9601 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 Holdin Tank /'dw D~ c7 Lift Pum Tank/Si hon Chamber Ll El 1 1-1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's ' nature: (No Stamps) P/ IPRSW No.: Business Phone Number: t S 74 r 7 Plum is Address (Street, City, Plate, Zip Code . I 14 Z C er- IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signat a (No Stamps)- proved El El Owner Given Initial Surcharge Fee) Adverse Determination M 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 a0proved 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. Ill. 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. Vill. 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) i ~ rl r ~ 1r ~ _ .f J v iA { V L ~ a l ti t i 44 c. Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page Labor and Human Relations / Of Division of Safety & Buildings in accord with ILHR ,~3.A5, W' Adm. Code ~l'~~• COUNTY S7: G'POi'X Attach complete site plan on paper not less than 81/2 x 11 i s~rr`size. Plan i de, but not limited to vertical and horizontal reference point (BM), n ands, of,salope, 4Qt PARCEL I.D. # dimensioned, north arrow, and location and distance to n aT~ road~~~ APPLICANT INFORMATION-PLEASE PRINT AL, OR ION, REVIEWED BY DATE PROPERTY OWNER: ` F.~pPERTY LQCA ION V : ,1 t J y /4 N D C R 50.0 1,~01fT. LaT , 5_W 1 /4 V E 1/4,S 7 T 2y N,R ! 9 E (a) W PROPERTY OWNER':S MAILING ADDRESS x, 4~0 # BLOCK # SUBD. NAME OR CSM # CITY, STATE ZIP CODE PHONE NUMBER',-' OCITY. OVILLAGE OWN NEAREST ROAD #VPSO..) 'V/s , SY0i4 (7/5) 3P6 -&71vOSo-J w~S . GuE~T ~f> [ j New Construction Use [kJ-liesidential / Number of bedrooms .3 [ J Addition to existing building jtj'lieplacement [ J Public or commercial describe r Code derived daily flow y~-o gpd Recommended design loading rate bed, gpd/ft2 • trench, gpolft2 Absorption area required bed, ft2 SG 3 trench, ft2 Maximum design loading rate bed, gpd/ft 2 ' trench, gpd/ft2 Recommended infiltration surface elevation(s) 5-,w-_e • 3 ft (as referred to site plan benchmark) Additional design / site considerations Se-e- A4--C* o w Parent material Sr-S 57 - Pl¢ecr4- 1 /3 09,4i}- 7- Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND INN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable for s stem 3110 ❑ U 13-S ❑ U 0S ❑ U as ❑ U 9-s- ❑ U ❑ S 2t1-- 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 Tmnch o',9 /oy/e '27 Ijf s sd~ ~+vfR s 3f . .fI 4G 8-2-0 o file a /s - .8 00 LI/I .24 Ground C / 'Y /o yle 7Ce - s D, 5 cP~Q S . 7 elev. ft. C y Y/P 9( /d y,e~ -s' S cP-~ • d Depth to limiting factor IKI Remarks: Boring # K 0--7 /o ye 2-12- ~s 2.,r", sh& v~.e s 3~ • 0 7. S' yve 2141 C► -5 -7 s YAP y~ S o,~, s ~,e S 7 Ground elev. G Z U /0 y/? C•, S G~,~ 7 r ft. Depth to limiting factor Remarks: CST Name:-Please Print 8013"7-- Phone: -7/7` 3 daress: GSS O'NP.G /c0p• 111v9s0•✓ GJ/• S-IVO,.6 Y-/- f ~tC3 r f 2f/ 2- Signature: I Date: CST Number: . ~ ,.Z~1~ ~ f> C Tt S AOT4UA 17- 7o SX115 ri;O6 S yS 7-e.y • Sods 4'E" ~Q,ZIo w $ s -l- S y S ~-f'~t G~ A.) LEFT Gp,vv EG E4 V l ~ /E' UA• ~l9 E' PROPERTY OWNER SOIL DESCRIPTION REPORT Page Of 3 PARCEL I.D. # GO i Y AI AW 111Z-~ Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourxiary Roots GPD/ft in. Munsell Qu. Sz. Coat Color Gr. Sz. Sh. Bed ranch b-3/ 10YR A/ 7, f e v7 2-F N 6`31 /0 YA ~1,ql 2-f [2 Ground C 31- 3 /0YX 6 S D, C S GQ~2 , Q elev. ft. ' Depth to limiting factor > Remarks: Boring # z Ground elev. ft. Depth to limiting factor Remarks: Boring # 4 ~~a x Y vk k ~r"~ ~ .i Ground elev. ft Depth to limiting factor Remarks: Boring # Ground elev. ft Depth to limiting factor Remarks: con o~oroo ncinn~ • o -~i D ~ ~ i 9,S' , 70 . Z N ~ ~ th Z 70 70 w Z LA (A ~ t m t- ~ N I` CO rn W d o~> m rn Q G re o - A 0 L OTC A N r o m o D m %A I £ o (r m IT, r a O 1 O U"7 V~ r ~0 L a > IN 1'' c ~ Q o Q ~o C w r m rr) m ~ G ~ UN I L d u m -Z 117 D 1 a u D G I 76 '10 u c M) m h m O 7 Q I O mM m W ~v T ~'t7 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ~f/1~ci ~7 / MAILING ADDRESS e 1 l SD PROPERTY ADDRESS ti~ cr i 7 z ~i Z9-- Id (location of septic system) Please obtain from the Planning Dept. CITY/STATE 4_,P_Soj PROPERTY LOCATION _S UJ 1/4, /V C 1/4, Section f T_2_9_N-R lW TOWN OF D S e 4-) ST. CROIX COUNTY, WI SUBDIVISION Pi47z.le -u%-~ LOT NUMBER .O S PAGE 5Z, I.OT NUMBER CERTIFIED SURVEY MAP , VOLUMF/ 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 y expiration date. SIGNED: DATE: `7` St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 i 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 V D Location of property--"LL) 1/4t1 1/4, Section /7 ,T 2-4 N-R W TownshipQpp'- y n r/ Mailing address Address of site Subdivision name yi to vVic.-,j 2~s Lot no. _ Other homes on ProPertY Yes No Previous owner of property z;, Total size of property Total size of parcel r'' Date parcel was created Are all corners and lot lines identifiable? V~ Yes No Is this property being developed for (spec house)? Yes No Volume AQ7~and Page Number ,J?Z 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. y 9'~ , 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. gnat e of Applicant Co-Applicant f -3°> / Date of Signature Date of Signature UOLUNIENT NC STATE, BA1,, OF WISCONSIN FOf.Nf 3-1982 R~. ERv.:~ .a FeC.'HD:•.~ DATA QUIT CLAIM DEEO i" 107rPA'E 512 John V And a sin le person - - - F?ec'tl 15r fis~: 7 -quit-claims to Judy. K Anderson, a single person APR z 7 1994 - - -F; - - - - . t 2 30 P. - - - . the fol!ow inn described real estate in St . Croix County. State of W sconsin : n runv vo K Bartholomew Law Office, S.C. P.O. Box 27 Nr Hudson, WI 54016 4 A Tax Parcel No:.... - 2 i. i Lot 64, Park View Estates Secon,i Addition to the Town of Hudson. ~ <.i This deed is given pursuant to a judgment of divorce granted on 00 February 9, 1994, St. Croix County Case No. 92-FA-182. (3-8 C: - CA .Z o~ i m 17 s ,4. O (7) m rrrt n This 1S.-_-- - homestead property. A (is) (is not) C Dated this -day of 19 art: - ,(SEAL) (SEA L) ohn V. Anderson r (SEAL) (SEALI f. Fi • y IF - - AUTHENTICATION ACKNOWLEDGMENT Signature (s) _ STATE, OF WISCONSIN - - - ss. 15f _ercr- - -County. ` authenticated this day of 19 Personally came before me this ..,day of s« - Li 19 the above nained J L - - TITLE: MFMPER STATE BAR OF WISCONSIN - (If not, - - - authorized by ~ 706.06, Wis. Stats.) to me known to be the person e foreg-oing instrument an acknowledg, s I}~. THIS INSTRUMENT WAS DRAFTED BV ary OUWCi : s l , ~Jnsin . BARTHOLOMEW LAW, OFFICE, S.C. State of Wis A ; , - 516 Secpnd- Street, Hudson, WI 54016 kki --5 L KY _ E'. tiatj public SF (Y County, Wis. (S:9natarc 11aY be authenticated or ackniw!cd~ed. P,oth 1I_; ce!n ili _IOr is p r~:a wn ,If noF state expiration are not aatt , is 91~ 7UIT CLAIM DEED STA1 E N.%1Z OF w "ON:IN w «„r..in ircal Rank Cn. 1 FOR%I N.,. t - 11.2 AS BUILT SANITARY SYSTEM REPORT YOWNER TOWNSHIP SEC. T N, R W ADDRESS ST. CROIX COUNTY WISCONSIN. SUBDIVISION LOT L 7~-- LOT SIZE PLAN VIEW Distances & dimensions to meet requirements of H62.20 SNOW EVERYTHING WITHIN 100 FEET OF SYSTEM l v ~ 1 ~ TTr' I- T r 1 i M, I di a e o#h Ar - ow SCALE: SEPTIC TANK(S) I ' f O"` MFGR. Imo; y ~e CONCRETE c/ STEEL N0. oT rings on cover Depth L NO. PUMPING CHAMBER SIZE PUMP MFGR. GALLONS Per Cycle TRENCHES NO. of wiat length area BED NO. of lines 2 width 12-" length ' area ~F- dept to top o pipe. NUMBER OF SEEPAGE PITS Outside diameter total pit area AGGREGATE PERK RATE ARE REQUIRED AREA AS BUILT Disclaimer: The inspection of this system by St. Croix County, does not imply complete compliance with State Administrative Codes. There are other areas that it is not possible to inspect at this point of construction. St. Croix County assumes no liability for system operation. However, if failure is noted the County will make every effort to determine cause of failure. GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYTEM. INSPECTOR. DATED PLUMBER ON JOB LICENSE NUMBER '4A • AS BUILT SANITARY SYSTEM REPORT PMR , TOWNSHIP SEQ. 0. ADDRESS T N' R .1~ ` k , ST. CROIX COUNTY, WISCONSIN. , :BDIVISIOy , LOT LOT SIZE . PLAN VIEW -Distances b dimensions to meet requirements of H62.20 _ SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM x I d i c a t e I r h -Arroo j~a--~~---}. SC AL i I I I I -I ,tPTIC TANK(S) MFGR. CONCRETE STEEL NO. of rings on cover Depth DRY WELL INCHES NO. of width length area no. of lines width length area depth to top of pipe AGREGATE '(ZK RATE AREA REQUIRED AREA AS BUILT lisclaimer: The inspection of this system by St. Croix County does not imply complete .ipliance with State Administrative Codes. There are other areas that it is not possible ,Q inspect at this point of construction. St. Croix County assumes no liability for Istem operation. However, if failure is noted the County will make every effort to :ttermine cause of failure. ,,EASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. *-INSPECTOR DATED PLU:iBER ON JOB LICENSE NUMBER 9 MFVREPORT OF INSPECTION-INDIVIDUAL SEWAGE SYSTEM • San.itaxy Pexm.it/-S~ ' State Septic __5 NAME Township St. Cno.ix County I'I t. Locat.iox 1, 6.' Section _ SEPTIC `TANK Size ga.Z.Zons. Number 96 Compaxtments 1 ` Distance From: We.Z.Z t,. 6t. 12% on gxeaten s.Zope 6t Bu.i.Zd.i.ng it. Wet.Zands ~ • H.ighwaten it. DISPOSAL SYSTEM Distance Fxom: We.Z.Z CPJ 12% on gxeatex s.Zope jt. Bu.i.Cd.ing_ it. Wet.Zands Ft. Highwatex it. FIELD DIMENSIONS: W.i d-th o j txen ch l 6t. Depth o 6 no ck b e.Zow t i.Ze_Z_j~_.in . Length o6 each tine 6z. Depth o6 rock oven t.i.Ze .in. Depth o6 tite below gxadel-Lin. Numbex o6 tines '7 Tota.Z .length o6 tines it. Stope o6 trench Z' in pen 100 it. Distance between tines it. Depth to bedrock , / Tota.Z abs dxbt.ion axea 6A~_6t2 Depth to gxoundwaten .s 2 Requited axea ( Type o6 Coven: Pape ox Straw PIT DIMENSIONS: Number o6 piOat Ghavet around pits yes no Outside diamDepth below inlet it. Totat absoxb6t 2 A 2 Area qu.ixed 6t INSPECTED BY TITLE APPROVED t~ DATE Z l9k . ~~c:.I , REJECTED DATE 197 S r4 cam., Imp Rev. 9/78 REPORT ON SOIL BORINGS AND PERCOLATION TESTS ( ~;t WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309, MADISON, WISCONSIN 53701 p df; LOCATION:'/a,eV_0 '/a, Section (or) yl ownship or Municipality Lot No.Block No. ~ - County Owner's/Buyers Name: ub ivisio n ame d'/ Mailing Address: ~hdv~ dso GcJ/S S®l'6 t l:• TYPE OF OCCUPANCY: Residence X No. of Bedrooms COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW cA REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS 45~ -,2.3 `7f PERCOLATION TESTS (O'•2-3 ~ 7 9 SOIL MAP SHEET JV NAME OF SOIL MAP UNIT At B .A"__ PERCOLATION TESTS 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 ~o ( ,S P- See Are At A P- Seems e 3 • P-3 qdpr See BOr-L D q ~ © 3 6 la r-S P- P- P- SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B_ e c pen ~`~IC fe 01F106-1a s B- E e_ ?/,M- 12 SIC " 60 se S B- o ti 6" /6" lo-S~ d„ v se S B- 41 13 fy1/-, B- tt g_ 1/3-- 2 3 &Z n V t S PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on theplan the location and square feet of suitable areas. A" jo, Indicate number of square feet of absorption area needed for building type and occupancy 6/3 ;0 0Z Sacs / In icate scale or distances. Give horizontal and vertical reference points. Indij~ate slope. * A'*14 . E j k F ~ , .~e~c s ~a~ryy - `~,~s E Till F Tv v 4 1 i . tr r i g I3I 'n = ~ Y I : E I 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) 6_4 Y Certification No. ~s , Address ~C. S eell~ Name of installer if known Copy A -Local Authority CST Signatur k 4F State Permit B67 State and County Permit Application County Per t for Private Domestic Sewage Systems Count *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY (f Mailing /Address: 7, B. LOCATION: w'/4 Section U, T N, 1R E (or) W Lot# City Sub ision Name, nearest road, lake or landmark Blk# Village Township u C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) Variance Single family Duplex No. of Bedrooms No. of Persons D. SEPTIC TANK CAPACITY 006' Total gallons No. of tanks Z HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete Poured-in-Place Steel Fiberglass Other (specify) New Installation Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENToISPOSAL SYSTEM: Percolation Rate `l Total Absorb Area sq. ft. New r Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) -No. of Trenc es Seepage Bed: r~ Length Z Width.1_Depth -Tile depth (top) No. of Line Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land :7 OL7,' Distance from critical slope WATER SUPPLY: Private Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the . effluent disposal system from the EH-115 prepared by the Certified Soil Tester, ` _ _ NAME p / P / S /i C.S.T. # - ` j_ a/ and other information obtained from 5 11 c , (owner/build . Plumber's Signature - P/MPR W# •~r S 3 Z Phone ~7 3~ 3 Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. f S x ~ I F % q7 y F 4e u . F , Do Not Write in Space Below F R COUNTY AND STATE DEPARTMENT USE 0 LYE Date of Application r Fees Pai`d[: State AW D Co nt mate Permit Issued/RsjQSted' (date) -/f- Z/ Issuing_ Agent Name Inspection Yes No State Valid# Date Recd 1. county (w to copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1 /7