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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER, 11,j,4zn Arnje
ADDRESS Z,p 9~ a?~~ .t SL ~2c z~r
SUBDIVISION / CSM# LOT
SECTION .A!2 N-R_ZZ_W, Town of L,4!/
dq 31. t ~h-f~ 65
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYST~M _
14
t Jot
vas ew 5w
I ` I INDICATE NORTH OW
Provide setbc-and elevation information on reverse of this -form.
Provide 2 cUnensions to center of septic tank manhole Cover.
BENCHMARK: ASi= a 6Z 17-2 Sr.Dc;- l~
ALTERNATE BM: r c i~pG ~'Zt`c ✓111CIC Sz,~~ ldS, i v
SEPTIC TANK / PUMP CHAMBER / HOLDING.TANK INFORMATION
/SIC
' Manufacturer: Liquid Capacity: ISQ06
Setback from: Well House Other
Pump: Manufacturer r Model# -"maize
i
Float seperationGallons/cycle:
Alarm Location
:SOIL ABSORPTION SYSTEM
Width: Length Number of trenches o~
7C'
Distance & Direction to nearest prop. line:
Setback from: well: House Other
s`
ELEVATIONS
r _W Building Seer ST Inlet;ST outlet
PGA inlet PC b4tom Pump Off
Header/Manifold (.3 $ Bottom of system 9".1Z
Existing Grade d vl, Final grade /x Ta 24
c --DATE OF INSTALLATION: 41, Au
PLUMBER ON JOB:
/E? ~uT?S
LICENSE NUMBER :
INSPECTOR:
3/93:1t
BENCHMARK: ASC e ~Zi7'J
ALTERNATE BM:- /l ~ C fG p~ ~G ZC`G 621,ie
SEPTIC TANK / PUMP CHAMBER / HOLDING.TANK INFORMATION IAJC
Manufacturer: yt Liquid Capacity: X0
6111
Setback from: Well House Other
Pump: Manufacturer Model# ~5ize -
Float seperation -Gallons/cycle:
Alarm Location
:SbIL ABSORPTION SYSTEM
Width: Length Number of trenches
Distance & Direction to nearest prop. line: '74~0)~
Setback from: well: M House other
s
ELEVATIONS
I%~J,q ST- outle
t
Building Suer /
Inlet
a ST
jI n
Pd inlet PC bAtom Pump Off
mv_
Header/Manifold ~.3 $ Bottom of system
Existing Grade Z.0 d wl, Final grade /,o
I
c --DATE OF INSTALLATION: Co 3
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR: 3/93:jt
gg_S 64 1
LQ"It~0k;rt WNdA,.31.16.44PRfVkrelf jrSYSTEM county:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division ST. ROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
193456
Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.:
BTVFElefi.: Insp. BM Elev.: BM Description: Parcel Tax No.:
l od . a' /dd, a 006-1064-95-000
~j%
TANK INFORMATION ELEVATION DATA A93001166
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic /I n
Benchmark
DosiQg,
DIX/
Aeration Bldg. Sewer
Holding St/APE Inlet Z/
TANK SETBACK INFORMATION St/ tit Outlet 3z'
Vent
TANK TO P/ L WELL BLDG. A
irIto ntake ROAD Dt In
Air
Septic ~D >7S r NA Dt Bottom - -
Dosi NA Header zZ~
Aeration NA Dist. Pipe Z.~ 3
Holding Bot. System /3,.7'1 qo?,
PUMP/ SIPHON INFORMATION Final Grade 1930,
,
/Y7a r.,, loly
MwMTa_'cturer Demand , (
Model Number GPM y s~x E '
TDH Lift Friction S e m TDH Ft
Forcemain Length Dia. Dist. To e
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Lengt i No. Of Trenches PIT NO. Inside Dia. Liquid Depth
DIMENSION s. DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING anufadurer:
SETBACK
INFORMATION Type O CHAMBER Model
System:-7_e. ry >OR UNIT
DISTRIBUTION SYSTEM
Header / hhwagW 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 / r „ Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
~Y/Trench Center 36 - 0143 BO/ Trench Edges ~ ~3 Topsoil E] Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: CYLON 29.31.16.449B,SE,SW, HWY 64
Plan revision required? ❑ Yes 2-1go U /
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
li
701 R SANITARY PERMIT APPLICATION F
In accord with ILHR 83.05, Wis. Adm. Code couNTY
ST TE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than El i'; Pp 8% x 11 inches in size. c k i revi n to rev ous
ation
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPE OWNER PROPERTY LOCATION
P ~ 36, Y" S v2- l , N, R CO E (orfV
,~J,,O,ft /Iktfo C_ PROPER OWNER'S MAILING ADDRESS, LOT # IBLOCK#
A1,17!r ca
f CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
OND Z _
II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE : NEAREST ROAD /
5 j4_ r/
Public 1:11 or 2 Fam. Dwelling-# of bedrooms - PARCEL AX NU (S) t~
III. BUILDING USE: (If building type is public, check all that apply) _L ~6)
1 ❑ Apt/Condo U~ 7
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. ❑ New 2. %Replacement 3. ❑ Replacement of 4.0 Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 El In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 El Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIR D (s . ft.) PROPOSED (sq. ft.) (Gals/da /sq ft.) (Min./inch) ELEVATION
,3o 0_ 3, Feet 7 r U Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con Steel glass Plastic App
Tanks Tanks structed
Se tic Tank or Holdin Tank G~ ev o dX e -fL
Lift Pump Tank/Si hon Chamber ! r 1 L1 L1__ [I I El
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system sho on the attached plans.
Plumber's Name (Print): Plumber' ignatu : (No Stamps) MP MPRSW No.: Business Phone Number:
~21,5~ 5V_
j-"40- j
Plumb 's Address (Street, City, ate, Zip Cod
# 19 - ~4 t~ Sl L~
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued allssuing Agent SI )
Surcharge Fee) A
❑ Approved ❑ Owner Given initial - j'
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-8398 (formerly Plb-87) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
i_ A sanitary permit is valid for two (2) years.
2. `Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested in ##1-7.
VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of
tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all
septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 81A 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.
i
I
SBD-6398 (R.11/88)
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rsann ~p _ o27 - `
fee.
3o x . I S x ltd - ,p
CROSS SECTION OF A BED OR TRENCH SYSTEM
(DELETE OUTSIDE LATERALS FOR A TRENCH SYSTEM)
Vll
TR'NLt4 r $ aI\A
r
C~~TF~£D
K sT
SOIL FILL
DISTRIBUTIOAI PIPE
APPROVED SyA1THETiC COVER
2" OF AGGREGATE '-MATERIAL OR 9" OF STRAW
OR MARSH HAy
6"OF%t-P,', AGGREGATE
yp.f(' ELEV. bF 9 3, 6 FEET_..
lower elegy. 43.3
DISTRIBUTIOU PIPE TO SE AT LEAST RICHES BELOW ORI&IWAL GRADE Gt~~~'~ TfF~)C ~t
AA1D AT LEASTLO IMCHES BUT Kio MORE THAW 42- ILICHES BELOW FIAIAL GRADE
as vy /OL<<er rentIi 1
svc,-(~~ pnQr~i"enc ~l LCL~~f ~rF~1C
MAXIMUM DEPTH OF EXCAVATIOAI FROM ORIGIWA.;WILL Y IWCHES ~01 i"(;5
MINIMUM DEPTH OF EXCAVATIOIJ FROM ORIGW~Lnn`+G'RA 6 INoN y,nctiy~
. l~ PN RE~A
s1~ uEO : ` ` pUS~~~ FE~ Abp gp~1A
pE SP
pEQpS~M~t~ p1 ~5`°N oeN~E
~LICEMSC IJUMBER: ~ SQ~N
DATE : /_7 ,--.4cjfGE G
Industry, SOIL AND SITE EVALUATION REPORT Page-Lof~
Labor and Human Relatio
" D,af,Safsty al Buildings in accord with 1LHR 83.05, Wis. Adm. Code
X~i
-!!~!►.t COUNTY
Croix Attscfrobmplete site plan on paper not less than 81/2 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. s
*dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: ; PROPERTY LOCATION
/ W
pedeJ C, k ' f O (C~dic, GOVT. LOT 114,5~j 1/4,S,;~q T 3 N,Fl
: PROPERTY OWNER':S MAILING ADQRESS~ LOT B ~N SUBD. NAM M If IV 4
( CITY, STATE ZIP CODE PHONE NUMBER []CITE ]VILLAGE SOWN NEA E T ROAD J `
(J New Construction Use [ J Residential / Number of bedrooms [ Addition to existing building
D4 Replacement [XJ Public or commercial describe L h rC of a c. f1-A GC e
r Code derived daily flow gpd Recommended design loading rate D `7 bed, gpdm2Q__trench, gpd19
Absorption area required 7?7 bed, 112 /edQ. 5 trench, ft2 Maximum design loading rate j2- -1 bed, gpd/0O 1 trench, gpol112
t Recommended infiltration surface elevation(s) e 3. ft (as referred to site plan benchmark)
Additional design / site nsiderations rent - 3 7- N ` low Tench 3 -kedh Parent material (ju tua' SA Flood plain elevation, if applicable Al d ft
s ■ suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U - Unsuitable for system (8I S El U [as ❑ U S ❑ U as ❑ U ❑ S ®U ❑ S 1 U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Bounfty Roots GPD/ft
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed mach
Boring # F3
3 l m sb s ~ ~ as
9- 3 S sb m u cto co 6 s 6 ~v
Nil Ground i 1614 3 a n1s Wt tcJ a m U.S 11,10
`s'ft. R S sC CL( l
14 Ly)-,-)~ 16 54, 102
e i
Depth to -3 i~ s S~ W, ( Cc~ _ 6.7
• ~ ,
' limiting f _J_
factor to - lal i ~ 5 S S~ rA
Nom'
1
Remarks: fca-) '90', cen 'o u ou S ir, xis m f e S
Boring # l
d
U -,E 3 f S S as
o
, 52 N3 o1rn sr k m y C/N - 0•5 € o-t
~10
Ground Yiz q h, S Crd 67 S
.
W
96.E G iDYe.S m ( Q.~ Y
Depth to
limiting
Remarks, is I U ~3 a- ca' -
F11 Name:-Please Print G • , 0 2~ c 1hon rJ 13 Sr
i
&n A, t rkl
+tg r 7S`
ess:. iber:
ud ure:
Da \ 0 _q3 CST Num 7o/
r ,
PROPERTY OWNER _a~acdd Acyoi d SOIL DESCRIPTION REPORT Pagea of J
PARCEL I.D. ff
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/f4
in. Munsell 11u. Sz. Cont. Color Gr. Sz. Sh. Bed Tmnch
t b,1,;L /~Y~e 3 ~ m 'd rri ~ S dm C3-s"
Ground i0 ~(l~ Y S S rvl u~ - 6-7 9-
elev.
~ft D-rb~" lU~(~s - s s~ m 7
Depth to
limiting
factor
?.syi2 Ylys
Remarks: Ve+o nonC,enlinkeas lavndS W
Boring #
I
Ground
elev.
IL
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
IT
Remarks:
Boring #
E3
Ground
elev.
IL
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
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'piilmeni of industry, SOIL AND SITE EVALUATION REPORT Pegs of
labor and HtNnen Relations
~k Division of Safety A Bdldrps in accord with ILHR 83.05, Wis. Adm. Code
,fi^M!!!r►4 j COUNTY
• . si. Cry;
j Attach complete site plan on paper not lose 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. 0
dinrensioned, north arrow, and location and distance to nearest road.
' t APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
# PHOP'el OWNER:(- ` 1 C k f o fit c, PROPERTY .S ON 3 / ,R W
GOVT. LOT 114 1i4,S ` T N
N AN SUBD. NAME ,4 M II
i P ERTY OWNERS MAID ADQRESS~ LyA BLOCK
} CITY. STATE ZIP CODE PHONE NUMBER []CI []VILLAGE (MOWN NEAT ST ROAD
I New Constnxlion Use j j Residential / Number of bedrooms j J Addition to existing building
D4 Replacement b(I Public or commercial describe Chirp G
Code derived dally Now qS gpd Recommended design loading rate C `1 bed, gpd/1t2 8 bench, 90MI
Absorption area requited 3,7'7 bed, N2lcjo • J bench, N2 Maximum design loading rate --I-bed, gpd/tt2 n• bench, gpol(t2
} Recommended Infiltration surface elevation(s) . enc h %1twe r : q 3. 3 It (as referred to site plan benchmark)
Adddonal design I site gonsideradons renc - 3~ = y lOu,' ranch a. 7' - 3,1S'
N
i! Parent material ~u &rLSA &A Flood plain elevation, if applicable 1164
S a Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
s U a Unsuitable for stem ®S ❑ U 1A.S ❑ U ®S U ®S U 0S ®U L ]S 1@11
I . SOIL DESCRIPTION REPORT
.Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BDunday Roots GPD/it
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
3 r AmSb t S `~co OS d (v
C clJ ~~co 0 S Q 1
11) YK_ -3/ 3
,Ground 1- 4 3 - r ~mS m y u./ M v.S l~•%
Slav
tl
-7 Li'
16 S S~ 6~f
Depth to '3 /U S S 101 Cw 6.7 oy? ng
factor , -160 iv 4-5 s .sue I - - k7 .6
ry
. 'Remarks: ~cc1 ion Crrn 'tea ous (,r~s v~' /DY,e y~Y s
Boring # r U k- a S b
r
IV IU 2 q13
s ~ am k m ~ Cc~-l os o ~
tGround:.,.. 7~SYj_ y ~m D.
q 0 ad
~ to .5 p ib e.5 ~O s m ~ -
Imtting'
fox"
s:
3
•
l U ~3 3- "
Remarks: :6!% Ks
T Name-Pleae Print G• S Phone: IS S~ 13 V 1 4, &x 4w 4by,,n
Date: , . CST Number:
Spnaturr. - /D - et 3 C170/
PROPERTY OWNER aA , 1d A(ujd SOIL DESCRIPTION REPORT Page,zZ ofd
PARCEL I.D. / A
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPDYYt
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed rends
soon= o J,~- ~UY.e 3 s b ✓ S a cs s'
Ground io ~f `1 ( - S S vh y) 0-7 .8
elev.
Depth to
'
limiting i
factor
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S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER- A-z s L
ADDRESS &9X S~ S FIRE NUMBER
CITY/STATE_ ~T)1L~i2.,~tz.~ Syd/2 ZIP
PROPERTY LOCATION:c<-7C- 1/4,,Sa) 1/4, SECTION, TjLN-R Zh W
TOWN OF , St. Croix*County,
SUBDIVISION , LOT NUMBER
Improper use and maintenance of your septic system could
result in its premature failure to hand
le wastes.
Proper
maintenance
consists of pumping out the septic tank every three
years or sooner, if needed by a 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/Ile, 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 Co. Zoning officer within
30 days of the three year expiration ate.
0
SIGNED: q
DATE:-
St.
Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
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