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Jan-11-2006 10:16 AM 3M 6517337100 3/4 ° 03 h h c c a O o 2 o 2 0) a) r- a~ m7 ~o0 b a) ~w cz tM LL I L ct m °a- I o rn~ o coo E y 2 .20, x CL o ' ' w 1 E O S } c oU))o 4)0) Coo i~ L a) O) ~ O 3 a) c c c I p c y a m ;Ct ~=:.oc°~ I 05C2 Oct NL U d MOL a)~L Oy•G.N I rnp)E C m SC yrn CcU y co U O co O m .y m f0 C CD = L Y L y'D a) y 0 00 O N D y o C O CL U O 'O Z L y 'O Z p CO m y N L m N m I 7 cv U d O v C C vi LL CO O N m a) U. Cp C C.) Lo p; N O O. E I C C C y a)>a)N L C. y y o,n g3 c E Q Lu.0 I Q co)tt U) :5 m m ~ I c ~ w E E U) = o I x o z ~ I I 0*4 am am N N I- cA I I N I O I O Z c c U M > > v a o w I o o (D z cA FZ- I 'O 2 I 'O 2 Cl) ` y N y y p CL Of Q u) (D w C (D 0 •Pft& LL C? L LL L o y Q I o a) Q z m z z co z o N Z aci m cC to E N E Y a) a+ S+ Its y m N a7 m •i m C w a. •~o r ~ I a r ~ c )n I N 47 ~6f C N H y V Is O °O G G a a N p G C a a 0 C N co i wo E L) U) cn '0 ~ n.S I aS o Z •N _ aaa IcF aaa IL i'',v Iv o m co (D 0 04 CN N J V m 01) Imo 0) co rn rn o z tr: C N N - y 0 C O O - ED O y O E N co co CD CD y ~ y p L (n N C Y m C p d Q} f!) d Q z co a) O fOA N NV) O N N C N y c ni O C I ` O O1 O O ` U N y U o y O T O rn d a) C C l a y d C o m N cn (6 E CM.i n f0 w ` a) a) r N C O y O n N_ N d W H N C N O u I~ C) N •C N Uy. Z' Z I •C Cl) m m o E o m '=V) m m co 0 (n • O N UJ CO 2 O Z w H I U) O Z _ z r2 ON i4 E I = E rA a; ~aa I da ~ U (L I C a m • e~ o d y y c y y c tt~~ L) IL 0 U) 0 0 U) ) ^ATION: EAU GALLE 27.28.16.415, SW, SE, 6a 0 7f- iisconsin.Departmentofindustry, PRIVATE SEWAGE SYSTEM 00g-,10 yy 9S~ 3d ` Labor and Human Relations INSPECTION REPORT Safety and Buildings Division -RT Sanitary Permit No.: (ATTACH TO PERMIT) GENERAL INFORMATION 171432 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: STANAITIS, PETER G & SHERAN EAU GALLE CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 24-7 LDS Atx_,,;_, 0 81078800110 INFORMATION ELEVATION DATA A9200197 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 ir Ito ntake ROAD Dt Inlet TANK TO P/ L WELL BLDG. A Air Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Head Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED / TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DI EN I N 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.) 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 t , SANITARY PERMIT NUMBER: _ I SANITARY PERMIT APPLICATION TDILHR COUNTY In accord with ILHR 83.05, Wis. Adm. Code 5--1 - C STATE SANITARY PERMIT # '-AttacKcomplete plans (to the county copy only) for the system, on paper not less than 1:1 8% x 11 inches in size. hrevision topre s 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 /1afn-i _ % $'off t/4, S 27 T , N, R 16W E (or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # ClSTATE ZIP CODE PHONE NUM ER SUBDIVISION NAME OR CSM NUMBER n lvT coo Z S Mh -28fS III. TYPE OF BUILDING: (Check one) ❑ State Owned VILLLLAGE NEAREST ROAD Q G NIM W: ❑ Public [K 1 or 2 Fam. Dwelling-# of bedrooms3 R Calm. # III. BUILDING USE: (If building type is public, check all that apply) ~ Z"'1 T R PARCEL ~l;0/Z7,8 ❑ Apt/Condo 1 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 100 Outdoor Recreational Facility 3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 90 Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) 1~ A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. l01 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 X 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 Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin 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. Plumber's Name (Print): Plumber's tg ture: (No Stam s) MP/MPRSW No.: Business Phone Number: HEM r au,f /4 /S 67?-YI?o lumber's Address (Street, City, State, Zip C e): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved S ary Permit Fee (Includes Groundwater g e)ssue issuing ent signature (No Stamps) A Surcharge Fee) Approved El Owner Given Initial Adverse Determination v~ X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Pib-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 renawdl 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 owncrship or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Ons1e sewage systems must be properly maintal'ned. 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. ti. 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 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; (Jose 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 's+ SBD-6398 (R.11/88) I EXISI LNG TREES Qrn j 4b 146. -qw b tp r 'MOD J H KO'd '1013 TSiH JH-ld ianaidm 0Z:60 Z6/ST/S0 EXISTING TREES Y. / rn r' Y/ a i i Y' ! six av,+~~►a r. r.r wwr~r i 1 w is ..rr...... J /^ti I .en ( fir/ i t e- m 1 i N 7 ~ . i t ,j 'Y r= r~ z0'd '1013 T9iH 9H7d idnEidnH 0Z:60 Z6/ST/SO f ; ✓a'~F REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS DIVISION LABOR BOX h UMANE LATIONS PERCOLATION TESTS (115) MADISON WI 53707 (H63.09(1) & Chapter 145.045) LOCATIONS SECTION: TOWNSHIP/MUNICIAY: LOT NO.:BLK. NO.: SUBDIVISION,JVAME: 1/ a IT29N/RIZ H (or CS COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: Sf Coo ~if sf Qi' 2~~~GVi USE TES OBSERVATIONS MADE NO. BEDRMS,: COMMERCIAL DESCRIPTION: r~ PROFILE DESCRIPTIONS: PE A ION TESTS: (Residence ❑New _ Q, rJ/ RATING: S= Site suitable for system U= Site unsuitable for system a C, / / OCR r ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-11 LLHOLDING TANK: RECOMMENDED SYSTE__MLLloptional) ®S ❑U ❑S ❑U ❑S ®U ❑S CZU ❑S OU G'oy 'o'J/1*1771~ 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: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH 19. ELEVATION OBSEERV D ES HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) .1 V B- //10 9738 on e > B- B- B- PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER 44G464S- AFTER SWELLING INTERVAL-MIN. PERIOD 1 P I D 2 PERIOD3 PER INCH P- A/0 19 & 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 " " I i I 1-Ft i 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 : J TESTS WERE COMPLETED ON: -Dale u 7-9 - ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): CST SIC ,~ATURE DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - L HURLBURT HEATING, LIE LPEM W C~ cTRUSOMOTTQL :-;PLUMBING & ELECTRIC, INC. 1227 East Prospect St. DURAND, WISCONSIN 54736-1548 • DATE 2,(/g ~ JOB NO. Phone 672-8190 - MP-0001468 ATTEN ' I l / RE: TO i > WE ARE SENDING YOU ,Attached ❑ Under separate cover via the following items: ❑ Shop drawings ❑ Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order ❑ COPIES DATE NO. DESCRIPTION THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ Approved as submitted ❑ Resubmit copies for approval For your use ❑ Approved as noted ❑ Submit copies for distribution > ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ ❑ FOR BIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS COPY TO C~ SIGNED PRODUCT240-2 Nees Inc, smtm, Mm 0147. If enclosures are not as noted, kindly notify X-t once. r W .1`.yyII 1 r ~ y$ w Cie 3LL zLd H ©H ~m 7 ~ i t i 9 Y Z 9J m ~ IhY ~ ~ I k & t b i - F W 1 z U = I t t ~ 9 4 zV V > v, m ~ o0 h~ _ 1 Y i d a .9 i z i Z'd S83Q-lIfl QNUd G 9b:bS 26. ZZ AUW She c/ Fx~r/,n ~a Idw,'~ 9 \ , \ yODZ /,douse -1/0 i20o Ga 1, o 1 IN El- 9G•Z / 2.m. - Deho7es 1Re rl 112a r 8z - 97-,ea 1~ ~ 13 ~ ca ' 17erl0le s $o 83 - 97.38 P# o -Denafe5 Pee-e aenc~ /~o~ is Ile foP of I e I-o sS P,' r_ pe Aaweep /,vs~ 0f enc/ of -Denofes /?x70 GYri ve Gr>oy/9 NeXT f r7Q~f ~i os / • l3e~l sysferrl I No, . 150 X 6 I I SeC.2 7 i8m/nNo, 6 APR, z•;~.,.°;o~a;%a;~;o~4 Sy c I ~ 7-het sAB Co ve r I ~ ,i a 0 6• a e 0„ O o yo a 0jo0 o 00 /o Z Are stJYy sEl i "~o Z`f Pe ffo rate d T pN R 14W P%pe 8~ I I ~ 15 30 B3 o P3 ` ~ ~ ~ I ~ ~ ''Ven't ~ ~ 4'1• o~ ~ I I ~5 ~ ,Z°~'o 8Z1 $3 17 tJh : T r '70 57' MP ~~z 9 I a 8 . r~. ~I y~ S Form-STC- 104 AS BUILT SANITARY SYSTEM REPORT OWNER /efe~ .5~al7al/3- TOWNSHIP Z' a SEC. ,27 T 2d, N-R /o W ADDRESS 1i,/No ST. CROIX COUNTY, WISCONSIN 13a/~~' e- j , i?. - 3 'm z SUBDIVISION 41,4 LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I1I1R 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Ex "-5-7 "'r? /0 O I I I 1 I . I1 No II vc nt 1oi I ~y® INDICATE NORTH ARROW d BA BENCHMARK: Describe the vertical reference point used dp Crns~ ~~pe 4efwe,--/I A~~-< J Elevation of vertical reference point: Propose slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: /.200~2nl Number of rings used: X 0 Tank manhole cover elevation: //,21 0 Tank Inlet Elevation: //0, 1 Tank Outlet Elevation: 110,09 Number of feet from nearest Road: Front,O Side,O Rear, -3~20 feet From nearest property line Front, OSide0Rear, 0 30 0t feet Number of feet from: well F l , building: 17ZJ / (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER * • Manufacturer: Liquid Capacity: ,J Pump Model: Pump/Siphon/ nufacture Pump Size l Elevation of inlet: Otto of t k elevation: Pump off switch elevation: n per cycle: Alarm Manufacturer: A rm witch Type: Number of feet from nearest property line' Front, O Side, O Rear, Q Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: YES Trench: Width: /j Length: 70 Number of Lines: Area Built: Fill depth to top of pipe: ,2 O Number of feet from nearest property line: Front, O Side, © Rear,O Ft. D1' Number of feet from well: .5'330 Number of feet from building: (Include distances on plot plan). SEEPAGE PIT j. Size: Number of pi iameter: Liquid depth: Bot of seepage t elevation: / J Area Built: Has either a drop box O or di trib do box b e used on any of the above soil absorbtion sytems? (Check one . HOLDING TANK Manufacturer: Capacity: Number of rings used: lfaevat~6n of bottom of tank: Elevation of inlet: Number of feet from nearest o ert line: Zont, O Side, O Rear, 0Ft. Number o fe t f om well: Number of eet f o building- Number of fee from nearest road: Alarm Manufacturer: / p Inspector: Dated: -~v `O to Plumber on job: License Number : 0 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS DIVISION P.Q. Box 796s PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING -MADISON,*Wl 53707 UCONVENTIONAL ❑ALTERNATIVE Slate Plan I.D. Nu-1- a UI asvgnnfl ❑ Holding Tank D In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER. INSPECT N D E Peter Stanaitis Rt. 1, Baldwin, WI 54002 BENCH MARK Wermanenl reference point) DESCRIBE IF DIFFERENT FROM PLAN: R . PT. LEV. CST REF PT. ELEV SW SE, Section 27, T28N-R16W, Town of Eau Galle Na,n. 01 Plumt,er. JMPIMPRSW No.. ntSanitary Permit Numlter: Dale Hudson 6629 TS't. Croix 83823 SEPTIC TANK/HOLDING TANK: MANUFACTURER LIQUID CAPACITY TANK INLET ELEV. TANK OUTLET ELEV WARNING LABEL LOCKING COVER / PROVIDED PROVIDED 110,50 ( 0, OYES ONO OYES ONO BEDDING VE DIA. VENT MATL JHIGH WATER NUMBS OF ROAD: PROPERTY WELL BUILDING (VENT TO FRESH ALARM FEET FROM LINE AIR INLET DYES ONO C DYES ONO NEAREST DOSING CHAMBER: MANUFACTURER JBEDDING ILIOULD CAPACITY VUM1IP MUUEL PUMP. SIPHON MA NUF ACTUHEH WARNING LABEL LOCKING COVER PROVIDED PROVIDED OYES ONO OYES LINO OYES L_]NQ GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PHt Ulk IT IY WF LI JIIIILIIIINI~ VENT TOFHts" (DIFFERENCE BETWEEN FEET FROM LINE AIR INIFI PUMP ON AND OFF) DYES ONO NEAREST 10 SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing Lf NGTH JIlAMI I1 11 JILAII HIAI AND MARKIN(, or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: [LLDE LOTH LENGTH NO OF UISTR PIPE SPACING COVER INSIUI 111 1 sPI IS IJ UIIIO BED/TRENCH T THENCHFS NIATERIAU PIT )L 11 DIMENSIONS (,NAVEL DEPTH II I1ISflt Pp'kf U TR PIPE DISTR. PIPE MATERIAL NO DFSIH NUMBER OF PHOPEHIV WE'LL HUILOING VENT TIlIHf91 1NF LOW PIPES ABOVE COVER ! I F V INI I EL€ FNU PIPES FEET FROM , LINE AIR INLE I \C NEAREST MOUND SYSTEM: ' Mound site plowed perpendicular to slope C t~k of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems make certain that it ON REVERSE SIDE. SHOW ELEVA- OYES ONO meets the criteria f r medium sand. TIONS MEASURED. SOIL COVER TFXIUHE PFHMAN!N I MAHKI HS I I FiSI IfVA I TUN WI I I S - _ DYES ONO _ _O YES LINO DEPTH OVER TRENCH BEU DEPTH OVfH 1HENCH BED OEVTH OF TOPSOIL SODDED OFF [)I It MOLCHlD CENTER EDGES OYES ONO OYES ONO DYES E PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH TOE NCHES LATE HAL SPACING 11,11AVIL III PTII H! L(1W VIPb I It L OFPIH ABOVE COVI H DIMENSIONS MANIFOLD PI1MP MANIFOLO DISTR PIPE MANROLOMATEHIAL NO IIISIH UISIH PIPE 11IS11lIHIIIIf INVIIII MAIIHIAI KM1IAHKINI, ELEV. ELEV. CIA ELEV. PIPES UTA ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED COHHF CILY COVEN MATERIAL VFHtICAI L II T CORHFSPONOS TO APP14OVI1) PLANS OYES ONO OYES NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL BUIIUING FEET FROM LINE DYES ONO OYES ONO _ NEAREST 00 , 1~,0 ~J Sketch System on 1 Retain in county file for audit. Reverse Side. q ~ (f\ SIGNATURE TITLE DILHR SBD 6710 (R. 01/82) I r7!ILHR SANITARY PERMIT APPLICATION C~~ C,~a,X In accord with ILHR 83.05, Wis. Adm. Code ° STATE SANITARY PERMIT # !-Attach 'complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8% x 11 inches in size. -See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES ❑ NO PROPERTY OWNER PROPERTY LOCATION f p CIS' 5W '/a S' (/o, S 27T , N, R 6 (o W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION DAME 104, I N/ /l///X /V14 CITY, STATE ) ZIP CODE IPHONENUMBER ),11179-471?-51 CITY NEAREST ROAD, LAKE OR LANDMARK _5 0Z)Z 715 O VILLAGE : uL7Q/t/~i l~~ ve o rR TOWN II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify): N,4 III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable) 1. a. ❑ New b. N Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit # Date Issued 3. ❑ An;Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreementto County Copy. IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2) 1. a. X Conventional b. ❑ Alternative c. ❑ Experimental 2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. 9 Seepage Bed b. ❑ seepage Trench c. ❑ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): 12""o 4~2'~e'Y2 Feet ® Private ❑ Joint ❑ Public CAPACITY VI. TANK in gallons Total # of Prefab. Site Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks l structed Septic Tank or Holding Tank DO 06 / e L° Lift Pump Tank/Si hon Chamber ❑ ❑ ❑ ❑ VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: .male f_', ~.~o~ •t'~a.~.~, t5~GZ9 45' Gay` r337? Plumber's Address (street, City, State, Zip Code): Name of Designer: VIII. SOIL TEST INFORMATION Certified Soil Tester (CST) Name CST # ~q/ ~4/uG~SO J CST's ADDRESS (Street, City, State, Zip Code) Phone Number: ~oX 'ell IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial y~i~I Surcharge Fee Adverse Determination /oto '0 X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT ' APPLICATION TO THE APPLICANT: 1. This 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 appr;~ved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have :questions concerning your private sewace sy_te? contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-381:3. To be complete and accurate this sanitary permit application must include: 1. Property owner's narne and mailing address. Pr;:ividc the legal description where the system is to be installed; II. Type of building -•r use served: L public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. 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. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than EY 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; dosing or pumping chambers; 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. GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Groundwater included the creation of surcharges (fees) for a number of regulated practices which Wiscorkin's can effect groundwater The surcharge took effect on July 1, 1984. All of the water that buried treasure is used in your building is returned to the groundwater throug'i your soil absorption system or the disposal site used byyour holding tank pumper. ~ The nonies collected through these surcharges are cred;ted to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for mor toring g -ou'?d-# v;:ater, groundwater contamination investigations and establishment of standards. Croindwatw s worth protecting. ;3D-6398 (R.63/86) APPLICATION FOR SANITARY PERMIT STC - 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 Location of Property s R/ h S 14Sec on 'V'j'-7 1"9TSB W Township 97,1C Mailing Address ~a /10)( 17~~ Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable?_ Yes No Is this property being developed for resale (spec house) ? Yes No Volume 96 0 and Page Number L13'L as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3.• Other recordings filed with the Register of Deeds Office 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 the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (We) cvLti 6y that att. 4tatemen~- on .thia Bohm ane V,-ue to the boat o6 my (oun) hnowi'edge; that I (we) am (ate) the ownet (a) o6 the ptopehty de cAi.bed in .thi.a .in6otmation 6ohm, by vi tue o6 a waA arty deed h.eeoh.ded in the 066.iee o6 the County Reg.c.a.teA o6 Deeds as Document No. ; and that I (we) p.t entt.y o~twn the ~:opoae.d 4,1 to bon .he aevuwge ditz ; caa., sytzem, (ah 1 (we) have obtained an eaa emen t, to hun with the above deb c r ibed ptopet ty, bon the comtkucti,on o6 aa.id Aya.tem, and the tame has been duty Aeeoh.ded in the 066ice o6 the County Reg.i ateA o6 Deed6, as Document No. 3 q Z c1$c7 ) SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED .JCUMENT NO. STATE BAR OF WISCONSIN-FORM 1 • 11 r WARRANTY DEED VOL 560 pr:, 434 THIS SPACE RESERVED FOR RECORDING DATA W1 21 9C Iver Larson and Dorothy L. Larson REGISTERS OFFICE j 'f'tIIS DEED, made between ST. CRO~X CO., WAS. Husband and wife as tenants in Common Rec'd. for Record this-- -8t1i • Grantor y of 19a'ht A.D. 19 7? and Peter G. Strlnaitis and Sheran K. Stanaitis q $;30 A. husband and wife as tenants in common • _ Grantee, - btr of ~ W i t n e e s e t h, That the said Grantor for a valuable consideratio Forty ..d. } Three Thousand and qo/100 ($43,000.00) Doiiarf- conveys to Grantee the following described real estate in St Croix County, RETURN TO State of Wisconsin: Robert Richardson j' Southwest Quarter (SW4) of the Southeast Quarter (SE-k4) and Tax Key # South Half (S'-,) of the Northwest Quarter (NW-14) of the This is homestead property. Southeast Quarter (SEIQ All in Section Twenty-Seven,(27) Township Twenty-Eight (28) NorthRange Sixteen (16) West. i; &ER .0b FEE f! . Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining; And warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except Easements 0 record and will warrant and defend the same. Executed at Spring Valley, Wisconsin this- 6th day of September_, 1977 {i SIGNED AND SEALED IN PRESENCE OF (SEAL) Iver Larson (SEAL) Dorothy L. arson if l 1 ` (SEAL) Ei (SEAL) I Signatures of authenticated this day of 19-• i ii Title: Member State Bar of Wisconsin or Other Party Authorized under Sec. 706.06 viz. FATE OF WISCONSIN flerce ss. county. 6th Septemker 1 Personally came before me, this day of , 1977 the above named TVPr Larson & DnrothyL l arson - to me known to be the person- who executed the foregoing instrument and acknowled a same.' O { A. I % r• This instrument was drafted by ROb t J . lEIlalCdS(gr) ROBERT J. RICHARDSON u Attorney at Law _ Not y Public f~ • , . C-6~4k, W 8. Spring Valley, Wi. 54767 The use of witnesses is optional. My ommission (Expires) (Is) ne man t! Names of persons signing in any capacity should be typed or printed below their signatures. FlGMill.rCamprry® WARRANTY DEED--STATE BAR OF WISCONSIN, FORM NO. 1 H z N • y a ST C'-105 r r a • y SEPTIC TANK MAINTENANCE AGREEMENT 0 St. Croix County z d a OWNER/BUYER 10MO G•STA/E/~ ~1I5 ~'SN~RR~tI S%R/~h l7/S ROUTE/BOX NUMBER R1.1 17-1/;? Fire Number 630 t}QQ'~~ CITY/ STATE zip PROPERTY LOCATION: J V%1 5 E 14 Section, TN, R 16 _W, Town of r- V G_A/_ L & , St. Croix Countye Subdivision Lot number. Improper use and maintenance of your septic system could result in I its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into i the system can affect the function of the septic tank as a treat- ment 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 systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. H 0 E I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- •v ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. nJ,J SIGNED ~l DATE T-3) 0 --9,9 St. Croix County Zoning Office P.O. Box 98- Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. 1 ROIX COUNTY rS N" IN jar i i ;I I j ~ ~w t;F , 2-7 2-P /1e 9 3t i 0`_ 11.5-4 HUPLEILIP T F r.,!..~ HT!_~ _ U. i , F . 0 l ST. CROIX COUNTY t WISCONSIN ZONING OFFICE Za v~ ak; f7~tbi ST. CROIX COUNTY COURTHOUSE 911 FOURTH STRFE T 0 HUN)ON, W154016 - (715) 386-4680 ~ The exi ing s tic se"t er, wh' h ser.~s the d elling h~' ng adde on to mu ep~ be i petted G l,isensed /et pla,ance ith high group water nd/or eclr. oc er7Fnts set fo - h in ILF1R hapter 83.10 The rep alts of t at ins ection ust n1adP avai.fice. If t xisti septi st these emc -s, tjn is grope y fun ionan ~.dition y o Ie dw ing wit ut upd ting at syem. t.ts addOlt ; Evenen oa th on tho e iir - septa _ n,yaeITI setfo h in HR Cha er 83,10(1). II Property Owners ~ •r ~G~~~/l C1 i T ,`S Fropor. ty Ma i. l i ng Addrnrr - r•r.opertyLegg1 Dc-script-..ion: (J s 1/4, Sec. , Z l T. N. , rt, w. , rn. of E~liu C~/fe 'T, nr:. t:ho owriot- of t_.hc al--ovo <iir:u: Y 1t;rr~i jtr l.:rt.y, hc rf~hy :ift ir.ni t-h;it. the septic system serving this dwelling meats the above referenced state private sewage system cod,-f;. T rr.ali.zo that th.s addition may cause the existing septic. :system to become undersa.zed for a dwelling of the resulting si.a,e, and 1 will riake this, information available to any future parties interested in purchasing this property. Notary Public subscribed and sworn to before me on this date: u Signed:. Date:. Z Ii ~~rrlr~~-_ My commission expires: County Approval: y Date f AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SECTION T N-R W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM INDICATE NORTH ARROW BENCHMARK:Elevation and description: Alternate benchmark SEPTIC TANK:Manufacturer: Liquid Cap. Rings used: Manhole cover elev: Final grade elev: Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front , Side , Rear Ft. From nearest prop. line:Front Side , Rear Ft. No. of feet from: Well , Building: (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufact.: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.: Pump off elev.: Gallons/cycle: Alarm: Man.: Switch Type: Location Distance from nearest prop. line: Front, Side_, Rear_Ft. Distance from: Well Building SOIL ABSORPTION SYSTEM Bed: Trench: Seepage Pit: Width: Length Number of Lines: Area Built Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top of pipe: No. feet from nearest prop. line:Front , Side Rear Ft. No. feet from well: No. feet from building HOLDING TANK Manufacturer: Capacity: No. of rings used: Elevation of bottom tank: Elevation of inlet: No. feet from nearest prop, line:Front , Side Rear Ft. No. feet from: Well , building , nearest road Alarm Manufacturer: INSPECTOR: DATE: PLUMBER ON JOB: LICENSE NUMBER: 6/90:cj DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY 5_~ STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than El / 4113-2- 8% x 11 inches in size. cec If evili/sn 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 ' r 0N /a E %a, S T 2 8j N, R E (or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # Vii. -1 I._ CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER oo Z h y CITY NEAREST ROAD 171 II. TYPE OF BUILDING: Check one ( ) ❑ State Owned VILLAGE ❑ Public N 1 or 2 Fam. Dwelling-#~ of bedrooms ~ PARCEL AX NUM" RO t III. BUILDING USE: (If building type is public, check all that apply) f 'T 2-6 Z , Z G 8.1 , L145 1 El Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 70 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. R 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 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 Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. INFORMATION Fiber- Exper. New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank 171 1 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. Plumber's Name (Print): Plumber's Sig , ture: (No Stamps) 1P/MPRSW No.: Business Phone Number: 17 n / " 'r a" " fi "-y ff Y 5, 72 - 1// o lumber's Address (Street, City, State, Zip C e ~211 IX. COUNTY/DEPARTMENT USE ONLY 7 ❑ Disapproved Sanitary Permit Fee (Includes Groundwater [ate Issued Issuing Agent Signature (No 3tarn Surcharge Fee) i [~rApprved ❑ Owner Given Initial s 1 Advers Determination ^ X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: / SBD-6398 (formerly Plb-67) (R. 11 /68) DISTRIBUTION: Original to County, One Copy To: Safety B Buildings Division, Owner, Plumber INSTRUCTIONS a. 1. A sanitary permit is valid for two (2) years. 2. You sanitary.pirmit may be renewed before the expiration (late, and at the time of rene,.vgl any new criteria in the Vi;s:,onsin Administrative Code will be applicaCe.. 3. All evisions ;o J ,is permit must be approved by the permit issuing authority. 4. Changes in ow e .nip or plumber requires a. Sanitary Permit 'transfer/Renewal Form (SE31) 6399) to be submitted to the Gounty prior to installation. 5. Onsite sewage systems must be properly maintained. The see tic tank(s) must be, pumped by a licenged pumper wherever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system; contact your local code administrator or the Mlr& 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, --connection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all informat on requested in ##1-7. VII. Tank informatic n F!i in the capacity of every new and/or existing tank, list the tctal gallons. number of tanks and mam^ f .cturer's name. Indicate prefab or site constructed and tank material. Com).,iete for all septic. pump!sip on and holding tanks for this system. Check experimental approval only if tanks received experimental preduct_approval from DILHR. VIII. Responsibility st=.tement. Installing plumber is to fill in name, license number with appropriate prefix (e:g. MP, ef.c.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Comp ete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include tine following: A) plot plan, drawn to scaly! or with complete dimensicns, location of holdings F~ p 'rank(s) or other treatment tanks; built'.+^g sewers; walls; water r n; rater service; stream n o r, p '•rlp cr siphon tanks; distribution boxes soil absorption sysie^is, replacement system areas, and .he k, atio of the building served; B) horizontal and vertical elevations reforenre points; C) complete spe( ifications for pumps and controls; close 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) SANITARY PERMIT APPLICATION B-1 L H R In accord with ILHR 83.05, Wis. Adm. Code COUNTY _ STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8tiz X 11 Iftch@S In SIZ@. El Ch~ck f r visa n to previous application 7l y~2- -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. C PROPERTY OWNER PROPERTY LOCATION /U ft l . ; 0 ; '/a : '/a, S 7 T N, R Cep E (or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ff~~11 ❑ State Owned VILLAGE ❑ Public EJ 1 or 2 Fam. Dwellin of bedrooms PARCEL TAX NUMBER ) III. BUILDING USE: (If building type is public, check all that apply) 7 T ~ P_ I 1 ❑ Apt/Condo 20 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School S ❑ 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.E1 New 2. ❑ Replacement 3. ❑ Replacement of 4. Reconnection of 5.E] 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 gallons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank F1 I [I F-1 El 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. Plumber's Name (Print): Plumber's Signature: (No Stamps) ® MP/MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): . T IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) - y Lpp*r_1ved r7 Owner Given Initial Surcharge Fee) ~ . r-, f•' Adverse Determination i 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 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 'ranks 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 3'% 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; close 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) •JF REPORT ON SOIL BORINGS -AND SAFETY & BUILDINGS DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS \ 1 MADISON, W1 53707 (H63.09(1) & Chapter 145.045) LOCATIONS SECTION: TOWNSHIP/MUNICIAY: LOT NO.: QLK. NO.: SUBDIVISION,JVAME: • O '/a Z1 IT29N/R/Z H (or 6? HIV//Y/J 1,14 1 Nr/,J COUNTY: OWN/E~R'S BUYER'S NAME: MAILING ADDRESS: Z6;/". _T/ 1 C.0-6 e7 / USE COATES OBSERVATIONS MADE NO. BEDRMS.: ICOMMERCIAL DESCRIPTION: 2T Replace DESCRIPTIONS: PERCOLATION TESTS: Residence Z74 A174 ONew ,TReplace 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 DU DS DU DS ®U DS oU DS L~U c0VC12, 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 Il Floodplain, indicate Floodplain elevation: y~ PROFILE DESCRIPTIONS BORING TOTAL -DEPTH T GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH 19, ELEVATION OBSERVED ES I H TO BEDROCK IF OBSERVED (SEE ABBRV, ON BACK.) B-2 -1,,6 9'~72,23 A10176 La/' f B- B- B• PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INGH66 AFTERSWELLING INTERVAL-MIN. PERIOD 1 P R O PER1003 PER INCH P_ 111"k P- P 2 • (~j i~ i 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 i t N 17 -I - - - I i 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 : J TESTS WERE COMPLETED ON: male ~ , ~ ~ 7-9 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): 2~1 1715 ON / CST SIC ,A,TURE CI CL l~ . l~~~ DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) OVER - v w n e s e~ ~ e fc° r SfQhQ~►f ~s dcX,.~t,n9 ~a Idw,'~~ douse S yD~Z A1o" ~2oDGo). o a/~- /00. D Se-- . n 1 /rla~~ I 82 - 9 7, ,613 ll Ic. 8 ~ ~ ' 1761 rJ0/e s 83. 97.38 Bore 1101c :5 Poo -Dcnafes Pert aene~ AIOd is 1_41e fop o f //ales- r_ I ei-oss Qf ego/ o~ 'Denotes PX70 P11Ae bfween wsf I've c~.- Gvay~ ~ex~ f r~Q~f~i dos/. /3eol syserr/ I I yso X SeC.,27 ll?r"4771 6 / Not Z'~ ► r. 0.04. n -h 3 Ca ve r S,fie • dog(.-00061, 00 lv 0°~'c► 0;o0 0 00 /OLA Ave sIJ% SE % ~ "~o ZZ'' Pe rf a rate of I I T8N RiG~v A99~'e~ P:p~ I I ~ Pao c~~ n r B3 ~op3 \ II ~5 " z°1Q 81I ton l3l ~ T 83 70 S7' I. d8 / SAFETY&BUILDIN DEPARTMENT OF REPORT ON SOIL BORINGS AND DIVISION INDUSTRY , N LABOR P.O. BOX 769 HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707 (1-163.090) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/MLITY: Ln/a T NOBLK. NO.: SUBDI VISION NAME: S4 N~ 3 /T31 N/R17)t(or) W Stanton n/a n/a COUNTY: OWN R NAME: . St. Croix Wayne Ausen R.R.#l, Star Prarie, Wi. 54026 USE DATES OBSERVATIONS MADE NO. BEDRMS.: 1COMMERCIAL S RIPTION: PROFILE S: O TESTS: L&Resiclence._. 3 n/a ~lew ❑Replace 2-25-92 n/a RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESS ESTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) ®s ❑U ®J'❑u]S Ty0s gU ❑S ®U conventional If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the n/a under s.H63.09151(b), indicate: class 2 Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS a e 5 JsB BORING TOTAL DEPTH R N ATER-INCHES CHARACTER 0 SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERV D EST. T TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- 1 86 99.0 none >86 -13 10yr3/31.,13-3510yr4/4sil.,35-867.5yr4/4s.1. 2 85 98.35 none >85 -1010yr3/31.,10-3010yr4/4sil.,30-857.5yr4/4s.1. B- B3 90 98.60 none >90 -13-10yr3/2,1.,13-3210yr4/4,sil.,32-90-7.5yr4/4,s 1. - B- 4 83 98.45 none >83 -12-10yr3/3,1.,12-29-10yr4/4,sil.,29-837.5yr4/4,s 1. B. 5 82 99.25 none >82 -1410yr3/2,1.,14-2810yr4/4,sil.,28-827.5yr4/4,s.1 B- PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 P RI PERIOD 3 PER INCH P- P_ P-ee de 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 95.35 = >g; mss.. _ 1 i Irv ' ,00 bi 5 b .___L 1. 1 _ _ __._~.__1.._. ► 1, the undersigned, hereby certify that the soil tests reported on this f e accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of t le correcf 4"b,.' "b of my knowledge and belief. NAME (print : rr* ,r TESTS WERE COMPLETED ON: Gary L. Steel 2-25-92 ADDRESS: ERTIFICATION NUMBER: PHONE NUMBER (optional): 1554 200th. He.,-New Richmond, Wi. 17 2298 1715;7246-6200 ST SIGN RE: U 11 C- zorv NG OAF CIS w rZ '41&4~' I t `-f DISTRIBUTION: Original and one copy to Local Authority, Property 9 r n 1 e DILHR-SBD-6395 (R. 02/82) -OVER - INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this 'a new or replacement system; 5- Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; ]I. Sign the form and place your current address and your certification number; 12. Make legible copies and distribute' as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st - Stone (over 10") BR Bedrock cols - Cobble (3 - 10") SS - Sandstone gr Gravel (under 3'_;) LS - Limestone *s - Sand HGW - High GV0U1)dW0te1 cs Coarse Sand Perc - Percolation Rate rued s - Medium Sand W - Well fs - Fine'Sand Bldg - Building Is - Loamy Sand > - Greater Than *sl - Sandy Loam < - Less Than *1 - Loam Bn Brown *sil - Silt Loam BI Black si Silt Gy Gray *cl - Clay Loam Y Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay wj - with sic - Silty Clay fff - few, fine, faint *c - Clay cc common, coarse t ` Pt Peat r,. mm - Many, rnedium ,,r n, - Muck d - distinct C.,p - prominent t. WIVL - High water level, &)'t. general soil textures ` surface water t for Iiquid waste gi~posal; ; BM - Bench Mark VRP - Vertical Reference Point 'j - ~ <CI ~1 - . r J. 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 applic ipa must be submitted to the appropriate local authority in order to abtgin a perrnit. The sanitary permit muo be obtained and posted prior to tho start of ~.iny ct~trstrt~clisn.