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4
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER Atf'j ~~t£ ~i r
ADDRESS J/~; O. Sax Fop
3~ 1 I
SUBDIVISION / CSM# t Lzoye/f 57,0 T/a-Q LOT 3
SECTION. & TT !~N-R >q W, Town of 52,y t~
ST. CROIX COUNTY, WISCONS
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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(1j, T H Se N S/V SEwg? (/.vim C..lt<e
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Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: )Ar ow G,C~7 ~~Nc' /00. oy'
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION
Manufacturer: Z,_", ~p Liquid Capacity:
Setback from: Well S' House Other
I
Pump: Manufacturer JL//-~ Model# /JAI Size /U.4
Float seperation AI A Gallons/cycle : A IA
Alarm Location A`I A
:SOIL ABSORPTION SYSTEM
Width: S Length DS' Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: House Other
ELEVATIONS
Building Sewer ST Inlet. ~S . S3' ST outlet y'S • ~2
PC inlet- A/4 PC bottom A/,4 Pump Off AM
Header/Manifold 95 .6 7' Bottom of system `7,51-00"
Existing Grade ~jC, ~$Final grade . 9S
DATE OF INSTALLATION:
PLUMBER ON JOB: LICENSE NUMBER:
~/Pjl
INSPECTOR:
3/93:jt
LQCMPKpar Q)9fl4Astr?8.19.1029
Labor and Human Relations PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) sanitar a mi
Permit Holder's Name: ❑ City ❑ Village XQ Town of: State AS n I o.:
M lev.: Insp. BM Elev.: BM Description: ~i Parcel Tax No.:
lem,
TANK INFORMATION ELEVATION DATA A9300280
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark o.
Dosin owy a, /D O
Aeration Bldg. Sewer
r
Holdin St/ Inlet S / 3
I
TANK SETBACK INFORMATION St/ F~Outlet S 95, ~.S
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing ~ - NA Header i Mon.
Z
Aeration Dist. Pipe 0(0' 9x'/
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Ma Demand 7all° S e
Model Number GPM
TDH Lift Friction Syste Ft
Forcemain Length 19_i a. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BEJU-TRENCH Width / Length No.Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
D MEN I N s DIMEN I N
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufactu
SETBACK
INFORMATION Type O ,~.JQul C,0 i / Moe Number:
System: ereo4',', >/G27 OR UNIT
DISTRIBUTION SYSTEM
Header''- Distribution Pipe(s) x Hole Size x Hole Spacing Vent T I take
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Syst s Only
Depth Over Depth Over xx Depth Of eeded / Sodded xx Mulched
Bed /4+j29%-Eenter 7 Bed /ice €dges Topsoil ❑ Yes El No E] Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) /
LOCATION : ROY 16.28.19.1029 _ /n( . ~ f kt
Plan revision required? ❑ Yes ~No
Use other side for additional information.
SBD-6710(R 05/91) Date Inspector's Signat a Cert. No.
ADDITIONAL COMMENTS AND SKETCH
y
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION
DLHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
STATE SA 7A P IT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑.JS
8% x 11 inches in size. c ec if r is ion to previous application
-S@@ reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROP TY OWNER PROPERTY LOCATION
7i1r e SSE ~ ~11`5 w %AJ C %a, S l TSB , N, R /7 E (or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
o_ ~3o gdr) 34
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
Aos. l" s of (::;7,4 n V c tr7-4-f 7 Owl/
CITY NEAREST ROAD
L:I
11. TYPE OF BUILDING: (Check one)
State Owned ❑ VILLAGE: w
❑ Public 01 or 2 Fam. Dwellin" of bedrooms PARCEL AX NU R( )
III. BUILDING USE: (If building type is public, check all that apply) O 4/0 -1,2-1'Y _ Y6
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
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 Im New 2. El Replacement 3. El Replacement of 4. ❑ 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,~Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
140 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
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 7Po I/$OSq.Ar• . .3 -dd~Feet 4 Feet
VII. TANK CAPACITY Site
INFORMATION in allons Total #of Manufacturer's Prefab. Fiber- Exper.
New xistin Gallons Tanks Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tanker /a50 ! !.~/iES~
Lift Pump Tank/Si hon Chamber
El I El I El 1 1:1
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name ((Print): Plumber' igna ure: (No Stamps) M,P//MPRSW No.: Business Phone Number:
APlumber's Address (Street, City, State, Zip Codyy
IX. UNTY/DEPARTMENT USE ONLY
A en o wompal
Disapproved Sanitary Permit Fee (includes Groundwater ;ate Issuing
Approved ❑ Owner Given Initial -X urcharge Fee) A v e Determinatio X. CONDITIONS OF APPROVAL/REASOMS FOR DISAPPROVA :
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
,r
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 (S3D 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 11 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.
I
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 cumber(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 gallon 3, 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 81/2 x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; bui {tin sewers, wells; water nlsin:'I;`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 an(..s veit:ical elevation refer~.Ace points;
C) complete specifications for pumps and controls; Jose volume; elevation differences friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil abs?.orJtion 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 (!ees) for a num er -if
regulated practices which can effect groundwater.
The n.onie:s collected through these surcharges ar(' osf-I for monitoring groundwater, grour,cl-
water coniamination investigations and establishment oi' standards.
SBD-6398 (R,11/88)
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Cc'VEl 1ST?oR3UT~aV tf£~}/~EA~, PLB 67
=NC Nl?ARK- / Po.U DiGF oN PLOT & CROSS SECTION PLANS
~trr 4,AJt FLEV. /Ov,M' KAPPA BROS. Ef6JVAfiN$ INC
PLUMBING UNIT
$~gA 5 L, PROJECT
B\ E ! IJN l / Al
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AL -
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~SQECT/ J.cJ G",TN '1/P TGNr li~ ~n J OASa I~
Gt~ LL J~
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~iQoDrll ~Y r
sc~uTAr
:!5loL,t-ri-I ACifir ~o- NO
T ~y SCALE
F ESH AIR INLET AND OBS A
APPROVED VE14T CAP
MAXIMUM 12'
ABOVE FINAL GRADE
'+i/----Y-- 4' CAST IRON VENT PIPE
MAXIMUM OF 42• .ABOVE ~ I
PIPE TO FINAL GRADE II
SIGNED:
MARSH HAY OR SYNtHETIC COVERING I I LICENSE. S 33 9S
MINIMUM 2' AGGREGATE I ~7 I
- /D S
~ ~9 3
~1 I
OVER PIPE DATE:
I
DISTRIBUTION PIPE
OIL ESTING BY:
CYST 3 Q°
ELEVATION BED 6' AGGREGATE •
BOTTOM PER $OIL,, BENEATH PIPE PERFORATED PIPE BELOW
TEST IS • COUPLING TERMINATING
_ 9~ , _ FT. AT BOTTOM OF SYSTEM
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, 1 DIVISION
P.O. BOX 76
LABOR AND PERCOLATION TESTS (115) MADISO
N WI 53707
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION N PE:
/ /4 /TZVN/R/9E (or)W `I' 316 l~bv~,~ 4T16W
C UNTY: O ER'S BUYER'S NAME: MAILING ADDRESS:
~T C A61A ~~es ~~Ib l'►'1 5
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: I PROFILE DES I T NS: ER LATION TE Y
Residence UNK New ❑Replace Mxy /S Iq MO /7 ~9~
Ic z 2 -9,6, RATING: S= Site suitable for system U= Site unsuitable for systemS51 ~Y
CO ENTIO❑NAL: M[4S. ❑u IN GR] ROUND-POU RE: S EM-IN❑FILLHO❑LDING TANK
U : RECfd01V MENDE -Pa~~IL p s1~
DE
required If any portion of the tested area is in the
If Percolation Tests are NOT SIGN RATE:
under s. ILHR 83.09(5)(b), indicate: IQ vs ! Floodplain, indicate Floodplain elevation: N
W Pr PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH lpq ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 1 9 AZ CIS ,7S 40,j > 4.4Z n ">Bcc rs 13"8re-i-Sk 141&ge AS S'T'ea rv M5
B- Z 9.-63 46.92 Noru > 3 14"ALL7:5 26"81,5,G A ' &&^A5 CV 6,t o rl
/Z" 6LLTS zr 4 /$~1Qp&ju MS ` "949 N A_-S
B- 3 g.? S 9g.6a ~ > 4. 5
B- 9.75 . > 9.7 17'gi-cm /4"6A.S~L49"8RN04-S*& 6 37 "&,8e►ft4 le
B- S 9.41 99,46 8161gig > 9.4z 4A)B cTs ZV8AagtL 4a" 8&m M-S
B-
4L PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER10133 PER INCH
P_ Zd ".70 >Z > > <
P- Z. D N rlis 46.90 >2 > >2
P_ 4 AID -hjwf-
P_ L Al-i 1o AY
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 Q ScAt~
f
3 3
e
E
3
Liz
E
E _
o, ~ E
- , k
P`3
N
E
f A -t-
I
L iT I. ba/0Q -ZO
_
E
(irllL~u /FIL 24.66, _
I, the undersigned, hereby cerT71 thaT7he'svrt-tests reported on this form were made by me in ures and methods sp` fied in the Wisconsin
Administrative Code, and that the dat ecorded and the location of the tests are correct to the best of my knowledge and belief.
F,& Aj~.
NAME rint : TESTS WERE COMPLETED ON: 'S M 4y vE Jau sue, o ,Nc, TZ
ADDau S: CERTIFIC TION NUMBER: JPUONE N MBER(optional):
W~ S~o~6 3 Z oFsa
CST MU RE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
INSTRUCTIONS FOR COMPLETING 115 - S - 6395
To be a 'i fete and accurate your, report cle:
I. Gorr, description;
2. The use ,,c _i-,n must clearly br,, :nether this is a rr, a oi- commercial project;
3. MAXIIY'll!M nurnt: c)f bedroorns ~ corninercial use
4. Is this a nesn° c, re anent system;
S. Complete the s 'i rating boxes. A SITES IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYS RULE[) OUT BASED ON SOIL CONDITIONS;
6. PLEASE u,, , ins s (rt here for vo-iting profile descriptions and completing the plot plan;
7. MAKE. . i ,,tely locating your test locations. Drawing to scale is preferred. A
separaE". a~ ,y 1" , _ . ,E " ?'i.
8. Make sure birch tf,, k and v£ i reference point ate clearly shown, and are permanent;
9. Complete a ap, opriate boxes as to da names, addresses, floool plain data, percolation test exenip-
tion, i`
103 If the ` is flood plain, -j does not apply, }dace N,Ain the appropJate box;
11. Sign th-,; ' .,.e your cu r -rt your certification number;
12. Make legi. and distribute as ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL. Ate "Y WITHIN 30 DAYc "_)1,;'LETION,
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
aces and Textures Other Symbols
st. S'tc>r€e lover 1[J") BR Bedrock
cob - Cobble (3 - 10") SS Sandstone
- Gravel (under 3'-> Li€ iestoi,
r-lic;h Grp: er
ail w ;r£. Black
si Gray
c> ;any Yellovv
scl - ` rJy Clay Loarn Red
sicl - r"ilty Clay Loam, ~t ~lottles
sc - Sandy Clay "xT? Vp'€th
sic - Silty Clay - few, fine, faint.
*c _ Clay £,ommor;, cc,
pt Peat Many, rnedi~,,n
rn lbrUCk - (Distinct:
P t.)rornineo
i..i V" High v
Six pene€al soil textue£~s SLW,~,
for lictwd waste disposal I Bench EJ
V, Vet €ical Reference Point
TO THE OWNER:
This soil test report is the first step in securing a sanitary permit. The county or the Department may request
verification of this soil test in the field prior to permit issuance. A complete set of plans for the private
sewage system and a permit application must be submitted to the appropriate local authority in order to
obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction.
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S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER /,ti~4 ,el,
3 5"7 SovT/1-4,1e ' _ ALY
-
ADDRESS CDT S6- -4-'0J0-A? ST•~71,ZV FIRE NUMBER _2 y 2
CITY/STATE- _'eli 2 /`i?GG-S ZIP- _S`li'v~dc ~
PROPERTY LOCATION : 1/4 , AL-571/4, SECTION-[, , T_,?r N-R ~g W
TOWN OF 220 V , st. Croix County,
SUBDIVISION- gjZLci I/f Q ~T.4T~dl/ , LOT NUMBER_,Zj~,_.
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 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/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 Co. Zoning officer within
30 days of the three year expiration date-
SIGNED:
DATE: St. Croix co. Zoning Office
911 4th St.
Hudson, 111 54016
STC - no
This application form is to be completed in full and signed by
fthe owner(s) of the property being developed. Any inadequacies
will only result ~n delays of the permit issuance. ,Should this
development be intended for resale by owner/contractor,(spec
house), thenta 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 _ Z~d 7' `ele,,~
Location of property.5,5U-)1/4 /U 1/4, Section _14, T2N-R_7 W
Township
Mailing address
Address of site r/ c--- ~y,re AGG~
Subdivision name (='Gfil/~~' S/'r,9 r-?•Y~,~ of no. Other homes on property? yes_ X No
Previous owner of property _1S6fdIlS le, :Q,61 -2
Total size of parcel 3. 2 46,2e~-s
Date parcel-was created
'Are all corners and lot lines identifiable? Z.__Yes No
Is this
/V r perty being developed for (spec house)? Yes No
volum and.Page Number as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER & 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
Count
Register.
Y ' of
Deeds as Document No.
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 propertY for
the construction of said system, and the same has been
duly
recorded in the office of County Register of deeds as Document
No. .
Signatu a of apPlicant
C -applicant
Date of Signature - 9~
Date of Signature.
i
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