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HomeMy WebLinkAbout020-1119-80-000 y j (D 00 N O0 o O O ova ao v-; a d 0. 0 0 c II ~ c I M o 0 0 nl U N '0 N N N C O H CLOt0 c M wO Co d C X V 0 - Q N C a C O 'a C=C N N N L .0+ V m N d ( i' Nam a z 0Mi Z a E N 00 c _ rn c - N O 7 C0 LL c LL c (O 820 O ~ N C' C O 3 c or a~ a~ 6 E Q E Q nccco4) m U I 3 a M v a) w Z z E E O = O ~ V I, E L E I Z a m a m n H Z j 0 0 O z d c U v r O N 7 N U O O i O !n F- N z 0 N z c E a c E 2 M 2 M (D CD a) (D :3 N m O N O ~IJJ N Q7 C N w Q N R co 0) Q) C: d L 0 2 L O ~ O 'o O Z m Z b z m Z w N N z z o ~ aci E al 1 E ~ m E N N _ O ~ O L O w (D 4) 0 C) C. w ee Ur C (O O C. w w N C (D 21V11 CO U-) N G7 O 0 N G! i N O Q O j D O d 0 a C'4 D CS a 'm N F- m 04 0 t-- 04 0 3r • W a a a z o N a a a z o in O N 'O L = i +0 N 1~- 00 U) Q) Cl) It V1 J L) ~ Y C O0i rn Z AV N .O O N O N O O O O .n E O a o 0 0 c Y 3 o m N CL YO m N CO N N 2 N N car N Q} m m p Q} U' ((3 CD = O Yy~ O 0 E N c N C IV O C O C5 E c Q C E f~ a, I co i :3 6 Lo 3: 0 0) Q 0) p of oo c m N c c c o o N rn t v Z a cc o L N O Q) 0 3 O C 0) .e 00 0 c H c C L • o T co no N w o u a~ rn O N E o E U y o 2 0- Cl) Z_ 2 H U) z o z_ Z v) l~ v d R £ a CL ° a a T • a c, m v rrV~y E L c c "~1 A u a 2 0 m v 0 N V i BENCHMARK: _r. D Ek t ~:JP y,c f k VQ 0N rAl Qj ~4j see tl_~ ALTERNATE BM: SEPTIC TANK / PUMT-CTUUMM / HOL RMATION Manufacturer: Liquid Capacity: ~U U OV Q~ 5~~ Setback from: Well House U Other _ Pum,_____~• ~ Fl Gallons .cyc e-: Ala at;nn_ Q -:SOIL ABSORPTION SYSTEM Width: ~C7 Length 3/b Number of trenFhes 3 Distance & Direction to nearest prop. line: a~ over 7-6 ~ Setback from: well: House ► Other ELEVATIONS t~ Building Sewer ST Inlet; S. ST outlet Pump tiff _ _ C oaV f 9 9 s~ a Header/Manifold Bottom of system-13,33 Existing Grade 3 Final grade I~~p DATE OF INSTALLATION: y PLUMBER ON JOB: t~O (,y7} _e 4D 4~ LICENSE NUMBER: 3y Vy INSPECTOR: 3/93:jt I STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER _1U ►1 N E 6d ti-P, ADDRESS '01 10AWOOD I K Upsop 1,51s<" S y01(0 SUBDIVISION / CSM# IKOUA BROA oof)s LOT # N SECTION. 1 Ta_N-RW, Town of H u o~ o dJ ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 3 ~D~bal~'1 i a, S~ ~d {MJ0 . d t N 1ZA'I'E NORTH ARROW Wesj PRu IINe Provide setback and elevation information on reverse of this -form. Provide 2 dimensions to center of septic tank manhole cover. LOO> TKDNoartId MMMusIY7.29.19.5]FIRIMEkAVWJMTig1 W WOODS County: Labor and Human Relations INSPECTION REPORT Safety*and Buildings Division (ATTACH TO PERMIT) Sanitar rmit GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI X s . @ v.. BVfM sc do Parcel Tax No.: e2e lti1ill so 000 TANK INFORMATION ELEVATION DATA A9300205 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 TANKTO P/L WELL BLDG. A Ar Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP / SIPHON INFORMATION Final Grade Manufacturer Demand I Model Number GPM TDH Lift Friction System TDH Ft Loss Forcemain 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 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: HUDSON 17.29.19.515 LOT 12 'ROUT BROOK WOODS ©~x.-mss ,c2~~~c. f.~~ ,~~~~~z •rt-~-~-~~ Plan revision required? ❑ Yes ❑ No Use other side for additional information. I F SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY R .,,.:....,...~.,e_ STATE SANITARY PERMIT# -Attach complete plans (to the county copy only) for the system, on paper not less than / QQ 8% x 11 inches in size. E3 check if revision to 5vlous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PR ERTY OWNER PROPERTY LOCATION © I- Eju Ne, LA) Me- /1/1(. h, 541'/4, S T , N, R E (or) PROPERTY OWN AILI G DDRESS LOT # BLOCK # CITY STATE ZIP CODE PHONE NUMBER SUBDIVI N NAME O SM NUMBER I1. TYPE OF BUILDING: (Check one) 11 State Owned + O VILLAG N OF: E * NE i ROAD ❑ Public X1 or 2 Fam. Dwelling-~# of bedrooms .L PA LTAX N RO III. BUILDING USE: (If building type is public, check all that apply) 0C200_/1/?_ 80 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. ❑ New 2. 4 Replacement . 3. ❑ Replacement of 4.E] Reconnection of 511 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 KSeepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground - 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY. 2. ABSORP. AREA 3. ABSORP AREA 4: LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE q,5 RE E D (sq. ft.) PROPOSED (sqft.) (Gals/day/sq. ft.) (Mi inch) ~E7LEVATION oJUJ . 1 - ~3 Feet IT ' Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks T ks strutted Septic Tank or Holdin Tank Lift Pump Tank/Siphon Chamber I 7*_ El 0 Vlll. 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 Signature: (No Sta ps) TMPRSW No.: Business Phone Number: Tim gy_,~ . Plum b~r' Addless (Street,c~p State~Z~ Code): fi~ fi~ 1r`Yl v h >J ✓ o IX. C NTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing A nt Si a tamps Approved ❑ Owner Given Initial ~ Surcharge fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber-requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must-be properly maintained. The septic tank(s) must be`pumped by.a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings, Division, 608-266-3815. To be complete,and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to-b6jnptpIJed., 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. 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'f 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 curv , pump model and pump manufacturer; D) cross seption of the soil absorption systernAf r~quired by the county; E) soil test data on a 115 form; and F) all sizisd 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 colld~led through these'surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-8398 (R.11/88) S T C - 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 hou ,(spec se), then a second the property isSO d form and shoul be to this a office when appropriate ice with the deed recording.. owner of property ()/~A/ ~Y - 4" Location of property4/4j 1/4 '5~1/4, Section T~N-R /10 Township 1144 -2> SO /l,/ Mailing address _ Z6:9 q aok,&)C O AV-t4 2) Sd Al Lv /a l Address of site _ q-0 rj' Subdivision name iCacc7-Aeca,*. G040 DS Lot no. Other homes on property? yes No Previous owner of property Alid y'a 7--S , Arb .961,r£ ///C T' Total size of parcel ~Q~'S Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes 4-'No volune 75~ and Page Number _l8 3 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 & 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(~e, certify that all statements on this form are true to the bes of my ((~D-) knowledge that I ~ the property described in this information f~orrmj, bthe y virtue ~of oa warranty deed recorded in the office of 'the County Register of Deeds as Document No. x/63/-"14/ own the and that I (we) presently proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described the construction of said system, and the same has been duly p recorded in the office of County Register of deeds as Document N/ gn ture of appli ant Co-applicant F 161 11 1,95 Date of Signature Date of Signature DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 THIS SN.CIE RESERVED FOR RECOROINO DATA WARRANTY DEEttDpp 900r 152Pa;E 1C~•~ ftF~ISTERS OFFICE This Deed, made between dice... ST. CROIX CO., WIS. A...Hilt,..a .;pint. tenants..and..each..in..his. or. het..owr,....... Reed, $or Record ibis 29th ri.ght.......... _ _ Grantor, aY AugA.D. - 19 8 6 and John E.. Narbonne., .Jr.-.and-F-val.ya-.L...Xerbonne-,- a_&-.------- I :1 P ~ h"-band. and ..wife-,...Survi-vor.ship aari.taL..Property................ Grantee, Witnesse,`1, That the slid Grantor, for a valuable consideration...... .n.~: 1 RETWkN TO conveys to Grantee the following described real estate in _ 5t. .,roix jG EMU CLtt4 :V I S'".iET County, State of Wisconsin: n S~nlf Lot 12, Trout Brook Woods in the Town of Hudson, St. Croix County, Wisconsin. e Tax Parcel No; TnANSFAR FEE This is homestead property. (is) {.iixdbT) Together with all and singular the hereditaments and appurtenances thereunto belonging; And..... r-antors..NJcholas._E....H.ilt..and.Alice 1...Hilx warrants that-the title is good, indefEasible in fee simple and free and clear of encumbrances except easements, covenants and restrictions of record, if any, and will warrant and defend/ the same. Dated this _........a3_ day of August 19.$6.... ..(SEAL)-C.G. .-(SEAL) ICHOLAS E. HILT (SEAL) C ~ (SEAL) . ALICE A. HILT AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ss. St.---Ccni.x.................... County. _s~,~ authenticated this ........day of 19...... Personally came before me this ........day of August 19..515_ tW ri ova' named • .........,Nichnias..E,...HzJ,t..an~~~3.•ic~--A..::;tz~,.t.. • TITLE: MEMBER STATE BAR OF WISCONSIN (If not . authorized by § 706.06, Wis. Stats.) to me known to be the person s ..wecuted the foregoing instrument and acknowlecLge the amp.• ~J. THIS INSTRUMENT WAS DRAFTED BY . ) HEY'.~OOD, CARI, HURRAY S SHERBURNE ` - . ~ t . . . . by Samuel R. Carl - - . . P-:(}:- $ox•-229;..{-hrdso. ;--{•FI------ 5441b............. Notary Public - ..S.t... .4zQ.t.•X County,.wia. (Signatures may be authenticated or acknowledged. Both Vii!' Commission is permanent. ~If not, state expiration are not necessary.i date: 19:.1.....) •Na- of peraons sianing in any capacity 9h„u!d be typed or printed helox :hair nn h; rev. WARRANTY DEED STATE. BAR OF WISCONSIN Leval Blank Co. Inc. FORM No. I - 1912 Ati. -kee. Wu. , dog ~iL' oaGuoo ~.e~ _ 'C 1'9(Wl 1/4, 1/4, SE S-. -R(AX COUNTY S I CAN : _7;ioGLT 4V_eo,,I< _ Z.4)_aD v s__. _ LOT ,;;-j -..a- your sf?7t_.C JS' t?! e~C~L11.C1 T.'( ? ~U? t i. ~ ntenance of r_'Tiic t'17 E'_ : "t lure to handle waste'. CJ 1E: T' i _i t E:I,a'. ' E' o l_, ,L) ; ep t ic_ at r4 ri,_ c~,rr ye cr v 1. `pp r,~:"--_dedl, by a, lIC~c;Sl:`aed septic septic `:c:?'ik -cit.p, 2: What you s ia, [Aliie CxJl :r, ca , affect the function of wr, s, eP t+,~ tank ars ~:,at~ e xt Cage in the waste disposal system St Croix County residents may be eligible to receive a grant to ..e i0 with the cos+- of the replacement of a failing system, which We; era.tion prior to July 1, 197f3. St Croix County accepted this prcgrare in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The u- zTty agrees to submit to the St. Croix County Zcning a certa:tiuation form, signed by the owner and by a master plunger, journeyman plumber, restricted plumber or a licensed punter verj. yi.ng 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. Certification from. will be sent approximately . 30 nays prior to `-three year expiration. I'll e ixnders igned have read the above requirements and agree the private sewage disposal system in accordance with tI fi c' th , herein, as set by the Wisconsin DNR. be completed and returned to the St < Office, wit,,, 30 days of 4 . the tree year ' J Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page / of 3 Labor and Human Relations _ Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete 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. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROP RTY OWNER: PROPERTY LOCATION Can nJ /Ugh d AJ ~j 0- GOVT. LOT A/jt/ 1/4 5()1/4,S /7 T ~ N,R /f E (or)o PROP OW :S MAILING AD RE D LOT # BLOCK # SUBD. NAME 0 CSM # / CITY S )FATE 1-ro-Vroo4 rL , ZIP CODE PHONE NUMBER []CITY QVILLAGE OWN N EST ROAD uG~S ,S ( 16I M 6 roo ku~ Br ,Aew Construction Use ~p Residential / Number of bedrooms 3 [ ] Addition to existing building D4Replacement Public or commercial desaibe Code derived daily flow ~v gpd Recommended design loading rate -:2--bed, gpd/ft2 ~trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2. I trench, gpolft2 Recommended infiltration surface elevation g3. (s) 33 It (as referred to site plan benchmark Additional design / site con iderations Parent material a /Y S~ _ /!7 3r6 -y ood plain elevation, if applicable It S = Suitable for system CONVENTIONAL RS IN GROUND PRESSURE AT GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem us O U S❑ U ®S O U S❑ U O S J9 U 0S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bound ry Roots GPD/ft . in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed rertdt +xatv.4 /0 yt Ground 3 Z7_~$ D Y)e t ,c ! S v s 1 r+ 7 Depth to , G~ 15.1 tai limitin Ct0 ~r+ iki W -dtS DH e3~ sr~i/ HO` Glo ~c~c Remarks: Boring # J /0 yt /-✓1 y 7 Y 3 yz - /0 Y1414 s r 54 t- Ground elev- W Z Depth to limiting fcstgt_.. Remarks: CST Name:-Please P, / Phone: 7/5' Address: /O Signature: Date: CST Number: ~~/f3 00 3yyj ncrvn r Page_2Lof 3 PARCEL I.D. v, Boring # Horizon in. Depth Dominant Munsell Color Qu. Sz. Mottles Cont. Color Texture Structure GPD/ft Gr. Sz. Sh. Consistence Roots Bed Tmnch Boundary j 2 2- -k 7 2~ s Z Ground 3 Z D SL Z s 05 Depth to limiting Remarks: Boring # . 4?rS ~t Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor F-1-.- Remarks: .Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R•05/92) JoP-3 roo W, CL IY- Hoe- Back roc,,qle-Y ©h s; /fr Meq ~N1 G 37' 130" Cr,•~.;~.1 sJo W 6 7 P -'0 S 5 F C T L OTA 14 1) 7r P R0 J EC ICI ...~V_C ENS E=// L C ` A T 10 I LO • e - l,? D } I /d ~ Y, r ~ ~ r, . J c J J. r. v~ 1 \Jj FRESH All! INLETS AND ORSERVA;r" iP: PIVE C1t0SS SECTION Appj,:) v e d Vent P Minimum 12" Above 7 mwk Gxb 4" Cast Iron aae Above Pipe Vent Pipe To Final Grade Marsh Hay Or Synthetic Covcri.n~, Min. 2" Aggr.cylo l Over Pipe \V Distribut-io~ Tee Pipe Aggregate ! Pe><foraLed Pipe Uelow Beneath Pipe i~~--.j--'oupJing Ter-minat-Ancj rI RoL tom of Sys kern to fo i l .S r149 i • I AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP QjrU SEC. TZ_N, R W P.O. AM MS? 1t.' ST. CROIX COUNTY, WISCONSIN. SUBDIVISIObi=0 O-T- (,~©c1 t LOT~~LOT SIZE 40 / DC Lc o / PLAN VIEW Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I 1~ N Q x% SEPTIC TANK(S) 1 ~[1 MFGR. S CONCRETE X STEEL NO. of rings on cover 2?_ Depth DRY WELL TRENCHES NO. of width length area BED no. of lines width lengthy area depth to top of pipe AGGREGATE U1 A/1` @C _ PERK RATE - AREA REQUIRED /,t 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 SYSTEM. INSPECT i l DATED S PLUMBER ON JOB LICENSE NUMBER RRPORT OF ITTSPECTIO11--INDIVIDUAL SE14AGE DISPOSAL YSTEM Snnitary Permit X7 r State Septic IE 12J TOt•IJISHIP St. Croix, County SEPTIC TA77K r•x • .~ze _ / j 1 gallons. ""umber of Compartments Distance From: Well C4 ~ _ ft. 12% or greater slope ft. r Building ft. Wetlands Highw3ter ✓ r ~ f t . DISPOSAL SYSTE3 Tile Field or Seepage Pit(s) Distance From: T7e1 ft, 12%. or greater slope ft Building Wetlands _ L f FIELD Highwater ft, Total length of lines f ft. Humber of lines Length of each line ) ft. Distance between lines ft. Width of the trench l ft. Total absorption area sq, ft. Dept:: of rock below tile.-4-in- Depth of rock over the /'Z in-. Cover over. rock Depth of tile below grade - - in. Slope of trench in per 100 ft. Depth to Bedrock P-lq ft. Depth to ground water ft. PITS Number of pits Outside diameter ft. Depth below inlet ft. Gravel around pit: `yes no. :Total absorption area sq. ft. Square feet of seepage trench bottom area required vquare feet of seepap. t ar required , Inspected` Title: c Approved - - Date 197LU Rejected Date 197 I 1 EH 115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 ' MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TES S , LOCATION:..~~'/4, Section L_.~, RW(or)~ownship or Municipality ~s Lot No.4(2_, Bloc No. w Z4. Tulk County CAd♦ ubdivision Name Owner's Name: 0: X-14 Mailing Address: TYPE OF OCCUPANCY: Residence _ X No. of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW X ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS /2_-/y-,77 PERCOLATION TESTS /4r_/Q-77 SOIL MAP SHEET SOIL TYPE IY2n-1 /IVsIeo~ 4,01, 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 BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN P- ! 3 l .Sew z- k o 12 Z 21Z 4? P-2 74 Se Q,.e_ v C) v P .7-e~ ore ~L v S v2 .2 i. /2 Z' SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) e- B_ 3 916 >Y6'' 36 " ivy Z B- S_ 96" A4we 1-5., 3 -x A/ 9/ y Z AYzw-e.- d ,.s PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location andsquare feet of suitable areas. ,Lndi to nu~mbg7pf sqare fde of absorption area needed for building type and occupancy. Q.2~°' Oddcc.'9`rsb(~ 07 l or distances. Give horizontal and vertical reference nts c slope. •VY. _,9` ~ 1~. I t e- i` \ 1 it ~ ~ / ll i Q digs- ~l 3 . ~6 -5* Ito Y AA, Cifr^ Y I, the undersigned, hereby certify that the soil tests reported on this orm 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) j Certification No. 7 7 1,42 ula j Address Name of installer if known 2.111- ZA6 CST Signature COPY A -LOCAL AUTHORITY ilk 0 State and County State Permit ■ 7 Permit Application County Perini # - 7 for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailin A dr ss: 9/ G~~,,, 4-so'041 7 IP (or) Lot# City B. LOCATION: X70 Yom Section LZ, Tqg~j N, Rj Subdivision Name, nearest road, lake or landmark Blk# Village T Lc SOit/ !I / Township 75t-ga L91.0c.-k G~c 0 dS C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance Single family _)C,_ Duplex No. of Bedrooms No. of Persons D. TYPE OF APPLIANCES: Dishwasher_,&_YES NO Food Waste Grinder_YES_,&NO # of Bathrooms 2 Automatic Washer _,K_YES NO Other (specify) E. SEPTIC TANK CAPACITY .120c.> Total gallons No. of tanks / *Holding tank capacity Total gallons No. of tanks New Installation ~C Addition Replacement _ Prefab Concrete X *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2 2)_,3_3) 2 Total Absorb Area s ft. NewC Addition Replacement *Fill System S~~vi wBut!, Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches Seepage Bed: Length y6, Width Depth y "Tile Depth 49 " No. of Lines_ 101 Seepage Pit: Inside diameeter- }-Liquid Depth Tile Size Percent slope of land leue- Distance from critical slope~- 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 C ' 'ed Soil T ster, NAME A!d C.S.T. # ? and other information obtained from ( uild Plumber's Signature MP/MPR W# (v Phone *,21&A_:: "S[Z_ Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). 3 T N Ord /r'uv _ 2 y X z N' 6Ar, 3T 114~1 26 ` A(o WGS, WeAAc a I A B- e Yv, c to Q8~ ~ loo. 3 3 0' Do Not Write in Space Below FOR DEPARTMENT USE ONLY Date of Application r Fees Paid: State /Z' cr Count D e Permit Issued/R~Oled•-(d te) A9 /-A !Zlssuing Agent Name Inspection Yes__J`~No Valid# Date Recd 1. county (white 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 6/'1/76